Effects of third-generation aromatase inhibitors on bone

Ovarian Suppression: Early Menopause and Late Effects

OPINION STATEMENT

Around 90% of breast tumours are diagnosed in the early stage, with approximately 70% being hormone receptor-positive. The cornerstone of adjuvant therapy for early-stage hormone receptor-positive breast cancer is endocrine therapy, tailored according to disease stage, biological characteristics of the tumour, patient's comorbidities, preferences and age. In premenopausal patients with hormone receptor-positive breast cancer, ovarian function suppression is a key component of the adjuvant endocrine treatment in combination with an aromatase inhibitor or tamoxifen. Moreover, it can be used during chemotherapy as a standard strategy for ovarian function preservation in all breast cancer subtypes. In the metastatic setting, ovarian function suppression should be used in all premenopausal patients with hormone receptor-positive breast cancer to achieve a post-menopausal status. Despite its efficacy, ovarian function suppression may lead to several side effects that can have a major negative impact on patients' quality of life if not properly managed (e.g. hot flashes, depression, cognitive impairment, osteoporosis, sexual dysfunction, weight gain). A deep knowledge of the side effects of ovarian function suppression is necessary for clinicians. A correct counselling in this regard and proactive management should be considered a fundamental part of survivorship care to improve treatment adherence and patients' quality of life.

CDK4/6 Inhibitors and Arthralgia: A Single Institution Experience

Background: Aromatase inhibitors (AIs) are associated with musculoskeletal pain in one third (20–47%) of breast cancer patients. Recently, CDK4/6 inhibitors have emerged as a new therapeutic approach in hormone receptor (HR)-positive breast cancer. While hematological and gastrointestinal toxicities are frequently reported during treatment with CDK4/6 inhibitors, musculoskeletal symptoms are less commonly encountered. Methods: Herein, we present a retrospective study of 47 breast cancer patients who received CDK4/6 inhibitors along with endocrine therapy in our department between 01/01/2018 and 01/09/2020. Results: Median age at diagnosis was 58 years (29–81). Median duration of treatment was 8.76 months (SD: 7.68; 0.47–30.13 months). Median PFS was 24.33 months (95% CI; 1.71–46.96). Overall, toxicity was reported in 61.7% of the cases (29/47). Arthralgia was reported in 6.4% (3/47) of the patients. Hematological toxicity was reported in 51.1% (24/47) of the patients. Neutropenia was the main hematological toxicity observed (86.8%; 22/47) along with anemia (4.3%; 2/47), thrombocytopenia (2.1%; 1/47), and leukopenia (4.2%; 1/24). Conclusions: Though our data reflect a small sample size, we report a reduced arthralgia rate (6.4%) during treatment with CDK4/6 inhibitors compared with that reported in studies of AIs (20–47%).

The associations of CYP19A1 rs700518 polymorphism with bone mineral density and risk of osteoporosis: a meta-analysis

Osteoporosis is now a worldwide public health problem that seriously endangers human health, but its causes have not yet been fully clarified. Recently, increasing evidence suggested that polymorphisms in CYP19A1 gene were associated with osteoporosis risk and bone mineral density (BMD), but results remained conflicting. We herein performed a meta-analysis based on evidence currently available from the literature to make a more precise estimation of these relationships. The PubMed, Embase, Cochrane library, CNKI (China National Knowledge Infrastructure), and Wan Fang databases were searched for eligible studies. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were applied to assess the strength of these relationships. A total of 8 studies involving 2632 subjects were included in our meta-analysis. We observed that the AG genotype of CYP19A1 rs700518 was significantly associated with lower BMD values of lumbar spine and femoral neck (AG vs. GG: p = .001 and.01, respectively). However, this polymorphism had no obvious impacts on osteoporosis risk according to current available data. In conclusion, the present meta-analysis showed that CYP19A1 rs700518 polymorphism may be a potential candidate biomarker for osteoporosis screening, early diagnosis, and treatment, which will help improve individualized therapy of osteoporosis patients in clinics.

Bone health consequence of adjuvant Anastrozole in monotherapy or associated with biochanin-A in ovariectomized rat model

AIMS

We investigate the consequence of adjuvant anastrozole (ANA) in monotherapy or associated with biochanin A (BCA) in ovariectomized (OVX) rat model and the degree of developing bone loss in both conditions.

MATERIALS AND METHODS

Sixty female rats were assigned to six groups. Five groups were bilaterally OVX, and one was sham operated. The five groups were; ANA group (0.5 mg/kg b.wt orally), BCA (5 mg/kg b.wt intraperitoneally (I/P), co-treated group (BCA + ANA), two control groups receiving even distilled water orally or DMSO I/P for twenty weeks. Bone turnover biomarkers BALP, OC, PTH, TRAP and TNFα were determined in serum. Bone mineral content, histological and morphometric measurements on rat femurs were performed. BMD by X-ray technique on tibias of rats and CT analysis of lumbar vertebrae of all treated and sham groups were applied.

KEY FINDINGS

There was marked elevation in bone turnover biomarkers with high serum Ca and P content in the ANA-treated rats. Moreover marked elevation of TNFα, PTH, TC and TG, ANA caused severe changes in the BMD detected by X-ray in tibial bones and CT analysis of lumbar vertebrae of OVX rats. While I/P injection of BCA ameliorated the adverse bone health decrements caused by ANA.

SIGNIFICANCE

The study highlights the importance of the BCA supplementation in accordance with the ANA therapy in case of ovariectomized rat model of osteoporosis which is clinically presented in Postmenopausal women with breast cancer during which considerable risk of developing osteoporosis is predicted during treatment.

Adverse bone effects of medications used to treat non-skeletal disorders

There is a growing list of medications used to treat non-skeletal disorders that cause bone loss and/or increase fracture risk. This review discusses glucocorticoids, drugs that reduce sex steroids, antidiabetic agents, acid-reducing drugs, selective serotonin reuptake inhibitors, and heparin. A number of drugs are known to cause bone loss, increase fracture risk, or both. These drugs should be used in the lowest dose necessary to achieve the desired benefit and for the shortest time necessary, but in many cases, long-term treatment is required. Effective countermeasures are available for some.

Elevated incidence of fractures in women with invasive breast cancer

This study evaluates the incidence of bone fractures in women with BC.We found that women with invasive breast cancer are at an increased risk for bone fractures, with fractures most commonly occurring at lower extremity and vertebral sites. The risk is further increased in women undergoing cancer therapy.

INTRODUCTION

Bone loss and fractures in breast cancer have generally been attributed to aromatase inhibitor use. This study assessed the incidence of fractures after invasive breast cancer diagnosis and evaluated bone density and FRAX risk calculation at time of fracture occurrence.

METHODS

Retrospective cohort study of women with invasive breast cancer [June 2003-December 2011] who participated in an academic hospital based genetic biobank. Demographic and clinical characteristics were abstracted from the electronic medical record (EMR).

RESULTS

A total of 422 women with invasive breast cancer were assessed; 79 (28 %) sustained fractures during the observation period; fractures occurred at multiple skeletal sites in 27 cases (116 fractures). The incidence of fractures was 40 per 1000 person-years. Women who sustained fractures were mostly white and had a family history of osteoporosis (36.9 %, p = 0.03) or history of a prior fracture (6/79, p = 0.004). Fractures occurred 4.0 years (range 0-12 years) after cancer diagnosis. Fracture cases had femoral neck bone mineral density (BMD) of 0.72 + 0.12 g/cm(2), T-score of -1.2, that is, within the low bone mass range. Fractures most commonly occurred in lower extremities, vertebral, and wrist sites. Hip fractures accounted for 11 % of fractures, occurring at a median age of 61 years.

CONCLUSIONS

Fractures occur shortly after commencing cancer therapy. Rapid bone loss associated with cancer therapy may precipitate fractures. Fractures occur at relatively higher BMD in BC. Occurrence of fractures in invasive breast cancer raises the possibility of cancer-induced impairment in bone quality.

Effectiveness of aromatase inhibitors in the treatment of advanced endometrial adenocarcinoma

PURPOSE

Type I endometrial cancer is a common tumor of the female genital tract. Since in post-menopausal women aromatase enzyme can stimulate the endometrial tissue neoplastic growth, the use of aromatase inhibitors may have a therapeutic effect, especially in patients not eligible for surgery.

METHODS

A systematic review has been performed, with a very specific scope, i.e., the use of aromatase inhibitors in the treatment of advanced or recurrent endometrial cancer, as a single agent or in combination with others drugs.

RESULTS

On the basis of the 117 records retrieved from the bibliographic search, the rationale for the use of aromatase inhibitors in endometrial cancer therapy is discussed. Six papers fall within the scope of our systematic review and their results are thoroughly analyzed. Moreover, we report our experience on the clinical effectiveness of anastrozole in the post-chemotherapy treatment of a patient affected by advanced-stage endometrial cancer.

CONCLUSION

In general, aromatase inhibitors seem to have limited clinical benefit in the treatment of advanced and recurrent endometrial cancer, although further clinical trials are necessary to investigate more in depth their role. In our case, we experienced a positive feedback in terms of control of an advanced-stage disease.

Prevention and treatment of bone fragility in cancer patient

It is well known that fractures increase the risk of morbidity and mortality. The various mechanisms responsible for bone loss in cancer patients may have a different impact depending on the characteristics of the clinical case and correlates with the therapies used, or caused by the therapies used against cancer. Some hormonal treatments cause hypogonadism, event which contributes to the progressive loss of bone mass. This is detectable in patients with breast cancer receiving determines that estrogen-deprivation and in men with prostate cancer with therapies that determine androgen deprivation. Chemotherapy treatments used in cancer patients have reduced bone mass. In addition, low bone mass is detectable in patients with lymphoma treated with corticosteroids or radiation or alkylating agents. In premenopausal patients suffering from breast cancer, treatment with cytotoxic therapy or ablation of ovarian function, can lead to an 8% reduction in bone mineral density at the spine and 4% in the femur. With a chemotherapy regimen in CMF, the reduction of BMD is 6.5%; this bone loss is not recovered after discontinuation of therapy. Tamoxifen given for five years reduces bone remodeling and cause a 32% increase in the risk of osteoporotic fractures when used in premenopausal. After menopause, tamoxifen has a protective effect on bone mass, with a reduced risk of new fractures. Aromatase inhibitors in post-menopausal women, depending on the formulation can cause different effects on the reduction of BMD and fracture risk. We have in fact steroids, exemestane and nonsteroidal, letrozole and anastrozole. Patients at increased risk of fragility fractures should undergo preventive therapies as soon as possible after tests performed for the study of bone health. They can be used DEXA and the FRAX algorithm, which can define a secondary osteoporosis. Prevention and treatment of the increased risk of osteoporotic fracture is to maintain adequate levels of calcium and vitamin D. Bisphosphonates and denosumab are used for the management of bone remodeling and bone loss induced by cancer treatments. Bisphosphonates also have anti-tumor effects per se, which are expressed in potentially prevent the development of bone metastases. In men with metastatic prostate cancer and which is induced androgen deprivation, it is usefully used denosumab 120 mg monthly or zoledronic acid 4 mg monthly.

Effects of modified Shu-Gan-Liang-Xue decoction combined with anastrozole on osteoblastic proliferation and differentiation of MC3T3-E1 cells

Aromatase inhibitors (AIs) are widely used in the treatment of hormone-dependent breast cancer and as a result, aromatase inhibitor-associated bone loss (AIBL) has become a major concern amongst patients receiving AI treatment. Modified Shu-Gan-Liang-Xue decoction (mSGLXD), a clinical prescription, has been used for ameliorating AIBL in patients with breast cancer for decades and has achieved good clinical efficacy. However, the mechanism underlying how mSGLXD influences bone homeostasis and alleviates AIBL has remained elusive. In the present study, mSGLXD was supplemented with Rhizoma Drynariae containing phytoestrogens, and the safety of mSGLXD was evaluated. mSGLXD did not possess estrogenic activity and significantly inhibited the proliferation of estrogen receptor-positive breast cancer cell line MCF-7, which suggested that mSGLXD was safe for postmenopausal patients with breast cancer. Subsequently, the effects of mSGLXD alone or in combination with anastrozole on osteoblastic MC3T3-E1 cell proliferation and differentiation were investigated. Cell counting kit-8, reverse transcription-polymerase chain reaction and biochemical methods, such as ELISA and alizarin red S staining, were used in the present study. It was revealed that mSGLXD not only stimulated MC3T3-E1 cell proliferation, but also upregulated alkaline phosphatase and osteocalcin gene and protein expression levels. High concentrations of anastrozole (10 or 100 μmol/l) markedly inhibited MC3T3-E1 cell proliferation, but this inhibitory effect was attenuated by mSGLXD. Furthermore, mSGLXD increased MC3T3-E1 cell mineralization following β-glycerophosphate and ascorbic acid induction. Therefore, the results of the present study suggested that mSGLXD may be a promising adjuvant therapy, with high safety and efficacy, for the prevention and treatment of AIBL in patients with breast cancer who receive AI treatment.

Aromatase inhibitors associated musculoskeletal disorders and bone fractures in postmenopausal breast cancer patients: a result from Chinese population

As the prognosis of early breast cancer patients improves, the long-term safety of aromatase inhibitors (AIs) is increasingly important. In the present study, we retrospectively investigated the incidences of musculoskeletal disorders (MSDs) and bone fractures in a cohort of Chinese postmenopausal patients with breast cancer. Data of postmenopausal patients with breast cancer were collected. Among which, 70 patients received AIs therapy (median follow-up of 32.5 months), 52 patients received tamoxifen (TAM), and 89 patients received no endocrine therapy (NE). Baseline characteristics, incidence of MSDs and bone fractures were analyzed and compared. When compared with NE group (40.4 %, 36/89), more patients in AIs group developed MSDs (72.9 %, 51/70, adjusted odds ratio (AOR) = 3.30, 95 % confidence interval (CI) = 1.59-6.88, P = 0.001). But no difference was found between TAM group (36.5 %, 19/52, AOR = 0.70, 95 % CI = 0.32-1.52, P = 0.372) and NE group. About 39.7 months after initial AIs therapy, nine patients in AI group developed bone fractures in different sites, and the bone fracture rate was significantly increased (12.9 %, 9/70, adjusted hazard ratio (AHR) = 20.08, 95 % CI = 1.72-234.08, P = 0.017) in comparison with NE group (1.1 %, 1/89). Moreover, the bone fracture rate of TAM group was not different from NE group (1.9 %, 1/52, AHR = 2.64, 95 % CI = 0.14-48.73, P = 0.513). AIs therapy may induce increased rates of MSDs and bone fractures in Chinese population of postmenopausal breast cancer patients, whereas TAM therapy did not help reduce the incidences of MSDs and bone fractures.

Cancer-associated bone disease

Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.

Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper

Aromatase inhibitors (AIs) are widely used in women with breast cancer, but they are known to increase bone loss and risk of fractures. Based on available evidence and recommendations, an ESCEO working group proposes specific guidance for the prevention of AIs-induced bone loss and fragility fractures.

INTRODUCTION

Aromatase inhibitors (AIs) are now the standard treatment for hormone receptor-positive breast cancer. However, deleterious effects of AIs on bone health have been reported. An ESCEO working group proposes guidance for the prevention of bone loss and fragility fractures in post-menopausal women with breast cancer receiving AIs.

METHODS

A panel of experts addressed the issue of skeletal effects of AIs and effectiveness of antifracture therapies for the prevention of AI-induced bone loss and fractures. Recommendations by national and international organizations, and experts' opinions on this topic were evaluated.

RESULTS

All aromatase inhibitors are associated with negative effects on the skeleton, resulting in bone loss and increased risk of fragility fractures. Current guidelines suggest approaches that differ both in terms of drugs proposed for fracture prevention and duration of treatment.

CONCLUSION

The ESCEO working group recommends that all AI-treated women should be evaluated for fracture risk. Besides general recommendations, zoledronic acid 4 mg i.v. every 6 months, denosumab s.c., or possibly oral bisphosphonates should be administered for the entire period of AI treatment to all osteoporotic women (T-score hip/spine <-2.5 or ≥ 1 prevalent fragility fracture), to women aged ≥ 75 irrespective of BMD, and to patients with T-score <-1.5 + ≥ 1 clinical risk factor or T-score <-1.0 + ≥ 2 clinical risk factors. Alternatively, therapy could be considered in patients with a FRAX-determined 10-year hip fracture probability ≥ 3%.

Unrecognized and unappreciated secondary causes of osteoporosis

There are a substantial number of secondary causes of osteoporosis that can be identified through appropriate evaluation. Unrecognized celiac disease, Monoclonal gamopathy of undetermined significance (MGUS), impaired renal function, diabetes mellitus, and renal tubular acidosis are just a few of the more common secondary causes of osteoporosis. Through targeted laboratory tests, many secondary causes of osteoporosis can be identified.

Prevention and treatment of side-effects of systemic treatment: bone loss

Cancer treatment-induced bone loss (CTIBL) is generally more rapid and severe than bone loss associated with menopause in women or ageing in men and women. In premenopausal women with breast cancer, CTIBL is mainly caused by chemotherapy with resultant ovarian failure, by GnRH agonists or by tamoxifen. In postmenopausal women, steroidal and non-steroidal aromatase inhibitors (AIs) increase bone turnover, decrease bone mass and increase fracture rate (hazard ratio increased to 1.38-1.55 compared with tamoxifen). Zoledronic acid can prevent bone loss in premenopausal women receiving adjuvant therapy with goserelin in combination with either anastrozole or tamoxifen and in postmenopausal women receiving AIs. Denosumab has been shown in a placebo-controlled study to significantly increase bone mineral density in postmenopausal women under AIs. More limited studies indicate that oral bisphosphonates used at licensed doses for the treatment of postmenopausal osteoporosis can also prevent AI-induced bone loss. In prostate cancer, bone loss that occurs with androgen deprivation therapy (ADT) also leads to an increased fracture rate. The bisphosphonates pamidronate and alendronate can prevent bone loss whereas zoledronic acid can increase bone mass under ADT. As for breast cancer, delay in bisphosphonate therapy is detrimental to bone health. The protective effects of denosumab on bone loss and incidental vertebral fractures have been demonstrated in a 3-year placebo-controlled trial.

Triazole ring-opening leads to the discovery of potent nonsteroidal 17β-hydroxysteroid dehydrogenase type 2 inhibitors

17β-Hydroxysteroid dehydrogenase type 2 (17β-HSD2) catalyzes the oxidation of the highly potent steroids: the estrogen estradiol (E2) and the androgen testosterone (T) to the less active estrone and androstenedione, respectively. Inhibition of this enzyme may help maintain the local E2 level in bone tissue when the circulating E2 level drops and is therefore a novel and promising approach for the treatment of osteoporosis. In this work, a series of new nonsteroidal and achiral 17β-HSD2 inhibitors, namely N-benzyl-diphenyl-3(or 4)-carboxamide and N-benzyl-5-phenyl-thiophene-2-carboxamide was designed and the compounds were synthesized in a two to three steps reaction. A small library was built applying parallel synthesis. Highly potent 17β-HSD2 inhibitors could be identified in the thiophene-2-carboxamide class with IC(50) in the low nanomolar range. These compounds also showed a good selectivity profile toward 17β-HSD1 and toward the estrogen receptors α and β. The most interesting 17β-HSD2 inhibitor identified in this study is the 5-(2-fluoro-3-methoxyphenyl)-N-(3-hydroxybenzyl)-N-methylthiophene-2-carboxamide 6w displaying an IC(50) of 61 nM and a selectivity factor of 73 toward 17β-HSD1.

Prevention of osteoporosis as a consequence of aromatase inhibitor therapy in postmenopausal women with early breast cancer: rationale and design of a randomized controlled trial

BACKGROUND

Aromatase inhibitors (AIs) have improved the prognosis for breast cancer survivors and are now standard of care for postmenopausal women with hormone receptor positive early stage breast cancer. One side-effect, however, is a decrease in bone mineral density (BMD) and increased fracture risk. Since hormone replacement therapy (HRT) is contraindicated in these women, one prevention option is exercise combined with vitamin D and calcium. The effect of this intervention on drug-induced osteoporosis is unknown.

METHODS

A single-blind randomized controlled trial will be undertaken to test the hypothesis that exercise combined with vitamin D and calcium can prevent the decrease in BMD associated with the use of AIs. Sixty postmenopausal women prescribed an AI for the treatment of breast cancer will be randomized into either an exercise or control group. Participants randomized to the exercise group will undertake a 12-month gym-based exercise program, 3 times per week involving resistance and impact training. Participants in the control group will be advised on the benefits of exercise for preventing osteoporosis, but not prescribed exercise. Both groups will receive vitamin D and calcium supplements. The primary outcome will be total hip bone mineral density measured via dual energy X-ray absorptiometry (DXA). Study outcomes will be compared between groups at baseline, 6months and 12months.

SUMMARY

This study will investigate the effect of exercise in combination with vitamin D and calcium on prevention of drug-induced osteoporosis in postmenopausal women prescribed AIs for the treatment of breast cancer.

Bone metabolism and quality-of-life of postmenopausal women with invasive breast cancer receiving neoadjuvant hormonal therapy: sub-analyses from celecoxib anti-aromatase neoadjuvant (CAAN) trial

OBJECTIVE

Anti-aromatase therapy is important in the treatment of breast cancer in postmenopausal women but they have effects on the bone mineral density (BMD) and osteoporosis. Cyclooxygenase-2 (COX-2) inhibitors have been shown to be effective in chemoprevention in animal and clinical studies. A proof of principle study was performed to investigate the efficacy of combing anti-aromatase therapy (exemestane) and COX-2 inhibitors neoadjuvantly. The changes in the BMD, bone turnover proteins and quality-of-life (QoL) were analyzed and presented here.

METHOD

82 postmenopausal patients with histologically confirmed invasive hormone-sensitive breast cancers were included for the neoadjuvant therapy (NHT). 30 patients received exemestane (EXE) 25 mg daily and celecoxib (CXB) 400 mg twice daily (group A), 24 patients received EXE 25 mg daily (group B) and 28 patients received letrozole (LET) 2.5 mg daily (group C). The same assigned treatment was intended to continue for 2 years to study the changes in the bone metabolism. BMD of 48 patients were analyzed; 23 belongs to group A, 10 to group B and 15 to group C. The serum bone turnover proteins bone-specific alkaline phosphatase (BAP) and carboxyterminal crosslinked telopeptide of type I collagen (ICTP), were measured with commercially available test kits before treatment, 3 months and 15 months after treatment. Functional Assessment of Cancer Therapy core questionnaire (FACT-G) with its additional breast cancer subscale were performed at baseline, 4, 8, and 12 weeks after NHT.

RESULT

Difference between groups (p=0.007) for BMD at femur was significant. The changes of BMD in group B patients were significantly greater than patients in group A (p=0.011, CI=0.063-0.437), and group C (p=0.003, CI=0.146-0.620). The mean BAP increased from baseline in group B patients but decreased from baseline in group C patients at 3 months and 15 months. No statistical significance was found in the FACT-G scores and FACT-B scores among different groups at baseline, week 4, week 8 and week 12 after NHT. The Breast Cancer Subscale scores in group A patients were significantly higher than that of group C patients (p=0.021). After 4 weeks of NHT, negative changes of FACT-B and FACT-G scores were found in group B and C patients, but there were positive changes in group A patients. Significant differences of FACT-B score (p=0.008) and FACT-G score (p=0.019) were observed at that time point. Article from the Special issue on Targeted Inhibitors.

The use of bisphosphonates in cancer treatment

Bone metastases result in considerable morbidity and exert complex demands on health care resources. Additionally, for many patients, metastatic bone disease is a chronic condition affecting quality of life and independence over years rather than months. The bisphosphonates, notably zoledronic acid, have been shown to reduce skeletal morbidity in multiple myeloma, as well as a wide range of solid tumors affecting bone, by 30-50%. Quite appropriately, the bisphosphonates are increasingly used alongside anticancer treatments to prevent skeletal complications and relieve bone pain. In addition, they are increasingly used to prevent cancer treatment-induced bone loss and show promise in the adjuvant setting to prevent metastasis from breast cancer.

Osteoporosis: social and economic impact

The epidemiology of osteoporosis is reviewed, with a discussion of secular changes in incidence, geographical variation, and economic costs. The morbidity and mortality associated with hip, vertebral, and forearm fractures are outlined. The main pathogenetic factors contributing to age-related bone loss and osteoporosis are reviewed. Finally, there is a discussion of the recent advances in fracture risk prediction and the use of independent clinical risk factors to improve bone mineral density-based prediction.

Common variations in estrogen-related genes are associated with severe large-joint osteoarthritis: a multicenter genetic and functional study

OBJECTIVE

Several lines of evidence suggest that estrogens influence the development of osteoarthritis (OA). The aim of this study was to explore the association of two common polymorphisms within the aromatase (CYP19A1) and estrogen receptor (ER) alpha (ESR1) genes with severe OA of the lower limbs.

METHODS

The rs1062033 (CYP19A1) and rs2234693 (ESR1) single nucleotide polymorphisms were genotyped in 5528 individuals (3147 patients with severe hip or knee OA, and 2381 controls) from four centres in Spain and the United Kingdom. Gene expression was measured in femoral bone samples from a group of patients.

RESULTS

In the global analysis, both polymorphisms were associated with OA, but there was a significant sex interaction. The GG genotype at rs1062033 was associated with an increased risk of knee OA in women [odds ratio (OR) 1.23; P=0.04]. The CC genotype at rs2234693 tended to be associated with reduced OA risk in women (OR 0.76, P=0.028, for knee OA; OR=0.84, P=0.076 for hip OA), but with increased risk of hip OA in men (OR 1.28; P=0.029). Women with unfavourable genotypes at both loci had an OR of 1.61 for knee OA (P=0.006). The rs1062033 genotype associated with higher OA risk was also associated with reduced expression of the aromatase gene in bone.

CONCLUSIONS

Common genetic variations of the aromatase and ER genes are associated with the risk of severe OA of the large joints of the lower limb in a sex-specific manner. These results are consistent with the hypothesis that estrogen activity may influence the development of large-joint OA.

Women's health, breast health: a review of the gynecologic effects of breast cancer

Breast cancer is very common and seen in both premenopausal and postmenopausal women. Research into prevention, better screening, and more effective treatments is occurring continually, and changes are translated into clinical practice relatively quickly. It is important for women's health care providers to have an understanding of breast cancer treatments and the gynecologic side effects. For premenopausal women interested in fertility, options should be discussed prior to chemotherapy. Issues pertaining to pregnancy after breast cancer should be discussed in a multidisciplinary fashion, involving the obstetrician/gynecologist, breast surgeon, and oncologist. Ovarian suppression is often used as part of breast cancer treatment in premenopausal women with hormone positive disease, and menopausal symptoms may be severe. Hormonal therapies including tamoxifen and the aromatase inhibitors are used in the treatment of hormone positive breast cancers. Each of these drugs has a variety of gynecologic implications. Understanding the options for treatment for menopausal complaints in breast cancer patients is important for women's health providers. Although most breast cancers are sporadic, a small percentage will be due to mutations in the BRCA genes. It is important for women's health providers to take an appropriate family history and refer to genetic counselors for possible testing when hereditary cancer is suspected. This review focuses on the various women's health issues pertaining to breast cancer and treatment.

Risks of osteoporosis associated with breast cancer treatment: the need to access to preventive treatment

The results of available clinical studies suggest that breast cancer treatment significantly affect bone turnover, BMD and fracture risk. This is for instance the case for all third-generation aromatase inhibitors. For these reasons it is recommended that breast cancer patients exercise regularly and take daily calcium (1500 mg) and vitamin D (800UI) supplements. Most experts recommend that all women starting medical castration or aromatase inhibitor therapy should be assessed for their risk of osteoporosis and undergo bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry (DEXA). Patients with pre-existing osteopenia and osteoporosis should be evaluated for conditions which worsen skeletal health, such as vitamin D deficiency, hyperparathyroidism, hyperthyroidism and hyper-calcuria. If these patients have a BMD score of -2.5 or lower, a low BMD (T-score between -1 and -2.5) and additional risk factors for osteoporosis or fragility fractures, bisphosphonate therapy should be considered. The optimal duration of bisphosphonate therapy is unknown. It should probably be given for as long as aromatase inhibitor therapy is continued. In addition, bisphosphonate therapy may also reduce the risk of bone metastases. This approach seems to be cost effective based on an economic evaluation model.

Safety of adjuvant endocrine therapies in hormone receptor-positive early breast cancer

Postmenopausal patients with hormone-sensitive early breast cancer are typically treated with adjuvant endocrine therapy, which significantly reduces the risk of recurrence. Because treatment is of a long duration, side effects from adjuvant therapy can be problematic. The aromatase inhibitors (AIS) are replacing tamoxifen as first-line treatment agents for early breast cancer. Here, we present the side-effect data associated with AIS in relation to bone, gynecologic, and cardiovascular health and to arthralgia and myalgia. Although AIS have been shown to decrease bone density, increase arthralgia, and affect vaginal health, these adverse events are usually manageable, and several strategies can be followed to improve quality of life in women on AI treatment. To optimize adherence to therapy. It is important that these issues are addressed so that women can benefit from treatment.

Aromatase inhibitors, efficacy and metabolic risk in the treatment of postmenopausal women with early breast cancer

The third-generation aromatase inhibitors (AIs), letrozole, anastrozole and exemestane, are becoming the first choice endocrine drugs for post-menopausal women with breast cancer, since they present greater efficacy when compared with tamoxifen in both adjuvant and metastatic setting. In particular, several large and well designed trials have suggested an important role for AIs in the adjuvant treatment of postmenopausal women with estrogen-receptor positive breast cancer either in the upfront, sequential or extended adjuvant mode. Overall, AIs are associated with a small but significant improvement in disease free survival. The expanding use of AIs in the treatment of early breast cancer means that individual patients will be exposed to the agents for longer durations, making it increasingly important to establish their long-term safety. This review focused on the effects of AIs on bone metabolism, serum lipids and cardiovascular risk. AIs have adverse effects on bone turnover with a reduction of bone mineral density and an increase in the rate of fragility fractures. With respect to tamoxifen AIs present lower thrombotic risk and a less favorable impact on lipid profile, whereas the true effects on cardiovascular risk still remain to be clarified. An adequate monitoring of bone mineral density (BMD) and lipid profile could be recommended for post-menopausal women candidate to AIs.

Genetics of osteoporosis

Osteoporosis is a frequent skeletal disorder, particularly among postmenopausal women. It affects approximately 30% of women and 12% of men above 50 years of age. It is characterized by reduced bone mass and alterations in bone microarchitecture that result in impaired bone strength and a propensity to fracture. Decreased bone mass is the consequence of an imbalance in the bone remodeling process, resulting from complex interactions between acquired and genetic factors. The former include physical activity, nutrition and other lifestyle habits, as well as the skeletal effects of some diseases and drug therapies. Genetic factors have been extensively studied during the past 15 years. We will review some important studies that exemplify the advances and the difficulties in this research field.

Aromatase inhibitors for breast cancer: proven efficacy across the spectrum of disease

For more than 100 years, hormonal therapy has been known to be effective in the treatment of breast cancer. Initially, this therapy was dominated by the selective estrogen receptor antagonists such as tamoxifen. Aromatase inhibitors (AIs) are a distinct drug class with demonstrated activity in the treatment of hormone-sensitive breast cancer. All 3 third-generation AIs, exemestane, anastrozole, and letrozole, have been studied in multiple lines of therapy in advanced breast cancer and have demonstrated equivalence or superiority compared with tamoxifen. While initially developed as a treatment option for advanced disease, the AIs have also shown efficacy in the treatment of curable disease, including the neoadjuvant and adjuvant settings. In addition, the AIs demonstrate a tolerable side effect profile in comparison with tamoxifen, and this has led to their early incorporation as standard of care therapy. Given the proven efficacy of AIs across the spectrum of breast cancer, the remaining questions include definitive sequencing strategy, timing, and duration of use. Ongoing trials include head-to-head comparisons between the AIs in early-stage breast cancer; the results of these trials are eagerly anticipated and should further optimize the use of AIs.

Association of aromatase and estrogen receptor gene polymorphisms with hip fractures

Two polymorphisms of the aromatase and estrogen receptor genes appeared to interact to influence the risk of hip fractures in women.

INTRODUCTION

Allelic variants of the aromatase gene have been associated with bone mineral density and vertebral fractures. Our objective was to analyze the relationship between two polymorphisms of the aromatase and estrogen receptor genes and hip fractures.

METHODS

We studied 498 women with hip fractures and 356 controls. A C/G polymorphism of the aromatase gene and a T/C polymorphism of the estrogen receptor alpha gene were analyzed using Taqman assays. Aromatase gene expression was determined in 43 femoral neck samples by real-time RT-PCR.

RESULTS

There were no significant differences in the overall distribution of genotypes between the fracture and control groups. However, among women with a TT genotype of the estrogen receptor, the CC aromatase genotype was more frequent in women with fractures than in controls (39 vs. 23%, p = 0.009). Thus, women homozygous for T alleles of estrogen receptor and C alleles of aromatase were at increased risk of fracture (odds ratio 2.0; 95% confidence interval 1.2-3.4). The aromatase polymorphism was associated with RNA levels in bone tissue, which were three times lower in samples with a CC genotype (p = 0.009).

CONCLUSIONS

These common polymorphisms of the aromatase and estrogen receptor genes appear to interact, influencing the risk of hip fractures in women.

Cancer treatment-induced bone loss: pathophysiology and clinical perspectives

Hormone-ablative therapies for breast or prostate cancer can cause marked and rapid reductions in circulating estrogen or testosterone levels, resulting in significant effects on bone metabolism and cancer treatment-induced bone loss (CTIBL). Most patients with cancer are over the age of 65 and are already at risk for osteoporosis. Thus, accelerated bone loss from CTIBL is especially concerning in this population. Although there are currently no approved therapies for the treatment or prevention of CTIBL, oral bisphosphonates have been used in settings other than oncology to treat bone loss. New-generation i.v. bisphosphonates have demonstrated promising activity in preventing CTIBL in patients receiving hormonal therapy for breast or prostate cancer. In particular, zoledronic acid not only prevents CTIBL in both breast and prostate cancer patients but also increases bone mineral density above baseline. Such agents have the potential to delay or prevent CTIBL in patients receiving hormonal therapies.

Effects of steroidal and nonsteroidal aromatase inhibitors on markers of bone turnover in healthy postmenopausal women

Introduction

In contrast to nonsteroidal aromatase inhibitors, the steroidal aromatase inactivator exemestane does not have detrimental effects on bone in animal models. This study was designed to compare the effects of exemestane with the nonsteroidal aromatase inhibitors anastrozole and letrozole on serum and urine levels of biomarkers of bone turnover in healthy postmenopausal women.

Methods

Changes in the concentrations of bone-turnover markers, estrogens, and lipids were assessed after daily administration of exemestane (25 mg), letrozole (2.5 mg), anastrozole (1 mg), or placebo for 24 weeks in healthy postmenopausal women. The primary end point was the percentage change from baseline in bone-turnover-marker levels at week 24. The baseline-adjusted area under the curve (AUC) for weeks 0–12 and 0–24 was calculated to evaluate changes in bone turnover over time, rather than at discrete time points.

Results

Seventy-four (88%) of 84 randomized subjects were evaluable for bone-marker assays. Reductions in plasma estrogen levels and increases in bone-resorption markers were comparable for each aromatase inhibitor. Uniquely, exemestane consistently increased the percentage change from baseline in the level of serum procollagen type I N-terminal propeptide (PINP), a marker of bone formation, at week 24. In the active-treatment groups, the baseline-adjusted AUC at weeks 0–12 and 0–24 for PINP was significantly greater for exemestane than the other aromatase inhibitors.

Conclusion

Exemestane increased serum levels of the bone-formation marker PINP after 24 weeks, suggesting a specific bone-formation effect related to its androgenic structure. Potential effects on cortical bone and reduced fracture risk must be verified in a comparative clinical trial.

Effect of Anastrozole on Bone Mineral Density: 5-Year Results From the Anastrozole, Tamoxifen, Alone or in Combination Trial 18233230

Purpose

The Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial (median follow-up, 68 months) has shown that adjuvant anastrozole has superior efficacy and better tolerability than tamoxifen. However, anastrozole reduces circulating estrogen, and low estradiol levels are associated with decreased bone mineral density (BMD) and increased fracture risk. It is therefore important to understand the effects of long-term aromatase inhibitor therapy on BMD.

Patients and Methods

This prospective substudy of the ATAC trial assessed BMD changes in postmenopausal women with invasive primary breast cancer receiving anastrozole (1 mg/d) or tamoxifen (20 mg/d) as adjuvant therapy for 5 years. Lumbar spine and total hip BMD were assessed at baseline and after 1, 2, and 5 years.

Results

One hundred ninety-seven women from the monotherapy arms of the ATAC trial were recruited onto the bone substudy, and 108 were included in the primary analysis. Among anastrozole-treated patients, there was a decrease in median BMD from baseline to 5 years in lumbar spine (−6.08%) and total hip (−7.24%) compared with the tamoxifen group (lumbar spine, +2.77%; total hip, +0.74%). No patients with normal BMD at baseline became osteoporotic at 5 years.

Conclusion

Anastrozole is associated with accelerated bone loss over the 5-year treatment period. However, although patients with pre-existing osteopenia are likely to require monitoring and bone-protection strategies, patients with normal BMD would not appear to require monitoring beyond the recommendation for healthy postmenopausal women. The effect of anastrozole on bone should be weighed against its superior efficacy and better tolerability profile versus tamoxifen in the main ATAC trial.

Immunohistochemical expression of estrogen receptors in chondrosarcomas and enchondromas

Immunohistochemical expression of estrogen receptors alpha and beta was studied in chondrosarcomas and enchondromas and was correlated with chondrosarcoma grade, type, and dedifferentiation. Estrogen receptor alpha was studied in 37 chondrosarcomas, 10 enchondromas, and 2 extraskeletal myxoid chondrosarcomas. Estrogen receptor beta was studied in 23 chondrosarcomas, 6 enchondromas, and 2 extraskeletal myxoid chondrosarcomas. Ventana prediluted monoclonal anti-ER alpha (clone 6F11) and Biogenex prediluted polyclonal anti-ER beta were used on the Ventana ES autostainer and BenchMark XT IHC/ISH, respectively. Percent of cell staining and intensity (+, ++, or +++) was evaluated. Overall, 61% of conventional chondrosarcoma and 60% of enchondroma were positive for estrogen receptor alpha. Low-grade chondrosarcoma expressed estrogen receptor alpha more frequently than high-grade chondrosarcoma (P<or=.001). Extraskeletal myxoid chondrosarcomas expressed estrogen receptor alpha; it was not expressed in dedifferentiated chondrosarcoma. Overall, 89% of conventional chondrosarcomas and 83% of enchondromas were positive for estrogen receptor beta. Low-grade chondrosarcomas expressed estrogen receptor beta more frequently than high-grade chondrosarcomas (P<or=.05). Extraskeletal myxoid chondrosarcomas expressed estrogen receptor beta; it was frequently lost in dedifferentiated chondrosarcoma.

Effects of third generation aromatase inhibitors on bone health and other safety parameters: results of an open, randomised, multi-centre study of letrozole, exemestane and anastrozole in healthy postmenopausal women

Given potential differences between the skeletal and other effects of the third generation aromatase inhibitors (AIs), we conducted an open, randomised Phase I study, comparing the effects of three licensed AIs on bone turnover markers, lipid profiles and adrenal function. Treatment comparisons were undertaken in 90 healthy postmenopausal women with normal bone mineral density who received once daily oral anastrozole (1mg, n=29), letrozole (2.5mg, n=29) or exemestane (25mg, n=32) for 24weeks with a subsequent 12week washout period. All three AIs induced increases in bone resorption markers, but no significant differences were observed in their effects on bone turnover markers. Greater differences were observed in lipid metabolism. Notably, exemestane, but not anastrozole or letrozole, significantly increased the LDL:HDL cholesterol ratio by 12weeks, largely mediated by a decrease in HDL-cholesterol. Further, long-term clinical studies are required to determine the impact, if any, of the differences observed between the AIs

Cancer treatment-related bone loss: a review and synthesis of the literature

Cancer therapy can result in significant bone loss and increased risk of fragility fracture. Chemotherapy, aromatase inhibitors, and gonadotropin-releasing hormone analogues contribute to increases in the rate of bone remodelling and reduce bone mineral density. Patients with prostate cancer on androgen deprivation therapy experience an increase in the risk of fracture. New research has demonstrated the key role played by bisphosphonates in preventing declines in bone density and increases in bone remodelling. Novel antiresorptive agents targeting receptor activator of nuclear factor κB ligand have great potential in skeletal protection and prevention of bone loss related to cancer therapy. Early assessment of skeletal health, followed by initiation of calcium, vitamin D, and an exercise program are valuable in the prevention and treatment of osteoporosis. In addition, individuals at increased risk for fracture should be offered antiresorptive therapy. Early data have demonstrated that bisphosphonates are able to prevent the bone loss and increased bone remodelling associated with cancer therapy, including aromatase inhibition and androgen deprivation therapy. The present paper reviews the new research and advances in the management of bone loss associated with both cancer therapy and estrogen deficiency in the postmenopausal female.

Polymorphisms in the CYP19 gene that influence bone mineral density

Osteoporosis is a prevalent disease with a strong genetic component. Estrogens play a critical role in bone homeostasis. The aromatization of androgenic precursors is the main source of estrogens in men and postmenopausal women. Thus, aromatase is an attractive osteoporosis candidate gene. In this paper the influence of aromatase activity and aromatase gene variants on skeletal homeostasis is reviewed. The results of studies regarding the association between some common polymorphisms of the aromatase gene and bone mineral density and the risk of osteoporotic fractures are described. The mechanisms involved and the potential usefulness of those genetic data in the prevention and management of osteoporosis are discussed.

Management of cancer treatment-induced bone loss in early breast and prostate cancer -- a consensus paper of the Belgian Bone Club

Cancer treatment-induced bone loss (CTIBL) is one of the most important side effects of adjuvant antineoplastic treatment in hormone-dependent neoplasms. Chemotherapy, GnRH analogs and tamoxifen can induce marked bone loss in premenopausal women with early breast cancer. Aromatase inhibitors (AIs) are replacing tamoxifen as the preferred treatment for postmenopausal women. As a class effect, steroidal (exemestane) and non-steroidal (anastrozole and letrozole) AIs increase bone turnover and cause bone loss (4%-5% over 2 years). When compared to tamoxifen, the risk of getting a clinical fracture under AI treatment is increased by 35%-50%. In patients with prostate cancer, androgen deprivation therapy (ADT) increases bone turnover, reduces bone mass (4%-5% per year) and increases the fracture rate depending on the duration of therapy. Zoledronic acid can prevent accelerated bone loss induced by goserelin in premenopausal women, by letrozole in postmenopausal women and by ADT in men. More limited data indicate that weekly alendronate or risedronate could also be effective for preventing CTIBL. Initiation of therapy early, prior to the occurrence of severe osteoporosis, rather than after, may be more effective. Bisphosphonate treatment should be considered in osteoporotic but also in osteopenic patients if other risk factor(s) for fractures are present.

Aromatase inhibitor-induced bone mineral loss and its prevention by bisphosphonate administration in postmenopausal breast cancer patients

AIM

To investigate aromatase inhibitor-induced bone mineral loss and its prevention by bisphosphonate administration in postmenopausal breast cancer patients.

METHODS

Subjects were 17 postmenopausal breast cancer patients (mean age, 63.3 +/- 9.9 years) receiving non-steroidal aromatase inhibitor (AI; anastrozole, 1 mg daily) only and 10 such patients (mean age, 65.0 +/- 5.1 years) receiving AI + bisphosphonate (risedronate sodium, 2.5 mg daily) for 6 months. All of the subjects had undergone surgical resection and had positive estrogen receptor tumor status. Age, age at menopause, years since menopause, height, weight, and body mass index (Wt/Ht(2)) were recorded. Lumbar spine (L2-4) bone mineral density (BMD), T-, and Z-scores were assessed on dual-energy X-ray absorptiometry before and after therapy.

RESULTS

In the AI-only group BMD, T-, and Z-scores significantly decreased from the baseline during the 6-month therapy period (P < 0.05). Mean decreases in L2-4 BMD and Z-score were 2.5% and 3.0%, respectively. In the AI + bisphosphonate group, however, BMD, T-, and Z-scores significantly increased from the baseline values (P < 0.01). Mean increases in L2-4 BMD and Z-score were 4.5% and 3.3%, respectively.

CONCLUSION

AI carries a potential risk of bone mineral loss despite the short therapy duration. Bisphosphonate has a preventive effect on this loss.

Effects of aromatase inhibitors letrozole and anastrazole on bone metabolism and steroid hormone levels in intact female rats

AIM

The present study was designed to investigate the effects of two aromatase inhibitors on steroid hormone levels, bone mineral density (BMD) and bone turnover markers in intact female rats.

METHODS

Letrozole and anastrazole at two different dose levels were investigated for their effect on serum levels of estradiol, androstenedione, testosterone, dehydroepiandrosterone and dehydroepiandrosterone sulfate, BMD of femur and dorsal spine, and osteocalcin and pyridinoline levels as bone turnover markers. Fifty intact female rats were randomly divided in five groups (group 1 (n = 10): control, 2 ml saline; group 2 (n = 10): letrozole 1 mg/kg; group 3 (n = 10): letrozole 2 mg/kg; group 4 (n = 10): anastrazole 0.1 mg/kg; group 5 (n = 10): anastrazole 0.2 mg/kg, and oral gavages were applied for a period of 16 weeks.

RESULTS

Both doses of letrozole and anastrazole did not change femoral and vertebral BMD. Serum estradiol levels were reduced significantly at all dose levels by both agents (p < 0.001); all androgen levels were significantly elevated by letrozole (p < 0.05), although anastrazole increased only androstenedione (p < 0.05). The higher dose of letrozole increased osteocalcin levels (p < 0.05), while pyridinoline levels were increased (p < 0.05) by the higher dose of anastrazole.

CONCLUSION

Our results indicate that short-term use of letrozole and anastrazole had no clear effects on BMD in intact rats. Further investigations are needed to understand their effects on bone metabolism in intact females.

Recognition and management of treatment-related side effects for breast cancer patients receiving adjuvant endocrine therapy

In postmenopausal women with hormone receptor-positive early-stage breast cancer, the use of aromatase inhibitors (AIs) to suppress estrogen is associated with improved clinical outcomes compared with tamoxifen therapy. Women receiving such endocrine therapy may experience treatment-related side effects that negatively affect health-related quality of life (QoL) and adherence to therapy. In published clinical trials and in clinical practice, adverse events (AEs) constitute the main reason for nonadherence to endocrine treatment. Serious AEs are sometimes resolved by switching to a different agent, whereas other side effects can often be managed to allow patients to remain on therapy without sacrificing QoL. Across all adjuvant endocrine trials, regardless of the treatment received, vasomotor symptoms such as hot flashes are the most common side effects. Other frequently reported side effects, such as vaginal discharge, vaginal dryness, dyspareunia, and arthralgia, vary in prevalence between tamoxifen and AIs. Here we provide an overview of reported AEs of adjuvant endocrine therapy, focusing on those that are amenable to pharmacologic or nonpharmacologic management without treatment discontinuation. Also highlighted are specific management strategies that may improve patient QoL and thereby optimize adherence to therapy, which in turn might improve patient outcomes.