Osteopenia and osteoporosis in women with breast cancer

Prevention and Co-Management of Breast Cancer-Related Osteoporosis Using Resveratrol

Breast cancer (BC) is currently one of the most common cancers in women worldwide with a rising tendency. Epigenetics, generally inherited variations in gene expression that occur independently of changes in DNA sequence, and their disruption could be one of the main causes of BC due to inflammatory processes often associated with different lifestyle habits. In particular, hormone therapies are often indicated for hormone-positive BC, which accounts for more than 50-80% of all BC subtypes. Although the cure rate in the early stage is more than 70%, serious negative side effects such as secondary osteoporosis (OP) due to induced estrogen deficiency and chemotherapy are increasingly reported. Approaches to the management of secondary OP in BC patients comprise adjunctive therapy with bisphosphonates, non-steroidal anti-inflammatory drugs (NSAIDs), and cortisone, which partially reduce bone resorption and musculoskeletal pain but which are not capable of stimulating the necessary intrinsic bone regeneration. Therefore, there is a great therapeutic need for novel multitarget treatment strategies for BC which hold back the risk of secondary OP. In this review, resveratrol, a multitargeting polyphenol that has been discussed as a phytoestrogen with anti-inflammatory and anti-tumor effects at the epigenetic level, is presented as a potential adjunct to both support BC therapy and prevent osteoporotic risks by positively promoting intrinsic regeneration. In this context, resveratrol is also known for its unique role as an epigenetic modifier in the regulation of essential signaling processes-both due to its catabolic effect on BC and its anabolic effect on bone tissue.

Impact of obesity, lifestyle factors and health interventions on breast cancer survivors

The incidences of both breast cancer and obesity are rising in the UK. Obesity increases the risk of developing breast cancer in the postmenopausal population and leads to worse outcomes in those of all ages treated for early-stage breast cancer. In this review we explore the multifactorial reasons behind this association and the clinical trial evidence for the benefits of physical activity and dietary interventions in the early and metastatic patient groups. As more people with breast cancer are cured, and those with metastatic disease are living longer, cancer survivorship is becoming increasingly important. Therefore, ensuring the long-term implications of cancer and cancer treatment are addressed is vital. Although there remains a lack of definitive evidence that deliberate weight loss after a diagnosis of breast cancer reduces disease recurrence, a number of studies have reported benefits of weight loss and of physical activity. However, the limited data currently available mean that clinicians remain unclear on the optimal lifestyle advice to give their patients. Further high-quality research is needed to provide this evidence base, which will be required to optimise clinical care and for the commissioning of lifestyle interventions in the UK in breast cancer survivors.

Osteoporosis, fracture and survival: Application of machine learning in breast cancer prediction models

The risk of osteoporosis in breast cancer patients is higher than that in healthy populations. The fracture and death rates increase after patients are diagnosed with osteoporosis. We aimed to develop machine learning-based models to predict the risk of osteoporosis as well as the relative fracture occurrence and prognosis. We selected 749 breast cancer patients from two independent Chinese centers and applied six different methods of machine learning to develop osteoporosis, fracture and survival risk assessment models. The performance of the models was compared with that of current models, such as FRAX, OSTA and TNM, by applying ROC, DCA curve analysis, and the calculation of accuracy and sensitivity in both internal and independent external cohorts. Three models were developed. The XGB model demonstrated the best discriminatory performance among the models. Internal and external validation revealed that the AUCs of the osteoporosis model were 0.86 and 0.87, compared with the FRAX model (0.84 and 0.72)/OSTA model (0.77 and 0.66), respectively. The fracture model had high AUCs in the internal and external cohorts of 0.93 and 0.92, which were higher than those of the FRAX model (0.89 and 0.86). The survival model was also assessed and showed high reliability via internal and external validation (AUC of 0.96 and 0.95), which was better than that of the TNM model (AUCs of 0.87 and 0.87). Our models offer a solid approach to help improve decision making.

Cancer Treatment-Induced Bone Loss: Role of Denosumab in Non-Metastatic Breast Cancer

Chemotherapeutic agents, endocrine therapy and radiotherapy used in the management of breast cancer are known to cause decreased bone mineral density, and thus, increased incidence of fractures. A majority (~60%) of the breast cancer patients in India are either estrogen (ER) or progesterone hormone receptor (PR) positive. Adjuvant treatment with aromatase inhibitors (AIs) is the treatment mainstay for hormone-sensitive disease in postmenopausal (PM) women, with reduced bone mineral density (BMD), which results in increased fracture rates. Zoledronic acid, alendronate, risedronate and denosumab have been the agents of choice for managing bone loss. Denosumab 60 mg is approved for gaining bone mass in women with breast cancer who are at high risk for fracture following adjuvant AI treatment. The phase III HALT-BC data indicate an improvement in BMD with denosumab and a 50% reduction in clinical fractures, with significant improvements seen at the lumbar spine, distal third of the radius, and total hip. Denosumab has several advantages over other bone modifying agents such as subcutaneous self-administration by the patient themselves, no requirement of hospitalization, no dose modifications in renal impairment, and low incidence of acute phase anaphylactic reactions. We review the available evidence of denosumab for managing bone loss in non-metastatic breast cancer patients.

Diet impacts triple-negative breast cancer growth, metastatic potential, chemotherapy responsiveness, and doxorubicin-mediated cardiac dysfunction

Anthracyclines are standard-of-care chemotherapy for the treatment of triple-negative breast cancer (TNBC). However, high anthracyclines cumulative doses increase heart failure risk. Designing therapeutic strategies that ameliorate cardiac toxicities without compromising oncologic efficacy are important to improve TNBC outcomes and survivorship. The purpose of this study was to determine the impact of diet on TNBC chemotherapeutic responsiveness and development of chemotherapy-induced cardiac damage. Female BALB/c mice fed a control, Western, Mediterranean, or Western + fish oil diet were injected with 1 × 106 4T1-luciferase TNBC into the mammary fat pad. Tumors grew for 21 days before surgical tumor resection, then mice were treated with 3.3 mg/kg i.v. doxorubicin for 3 weeks. Vevo (R) cardiac ultrasound was performed. Female nu/nu mice were placed on diets before 1 × 105  MDA-MB-231-luciferase TNBC were injected via the tail vein to induce the development of lung metastases. Mice were treated with saline or 3.3 mg/kg i.v. doxorubicin for 3 weeks, and the development of metastases visualized by IVIS (R). Consumption of a high-fat diet increased TNBC growth regardless of dietary pattern. Western diet-fed mice developed lung metastases sooner and displayed increased lung metastatic lesion formation, which was not observed in Mediterranean diet-fed mice. Western diet-fed animals displayed worse cardiac function when compared with Mediterranean diet-fed animals. Hearts from Western diet-fed animals displayed increased fibrosis. Diet represents a modifiable component directly impacting tumor growth, antitumor chemotherapy efficacy, and cardiac toxicities. Our data suggest that the Mediterranean diet may reduce lung metastatic lesions formation and prevent the development of cardiac toxicities.

Effect of cytotoxic chemotherapy on bone health among breast cancer patients. Does it require intervention?

BACKGROUND

Breast cancer (BC) is one of the most common malignancies worldwide. Although the burden and mechanisms of endocrine therapy-related bone loss are known, the evidence is scanty regarding the impact of cytotoxic chemotherapy on bone health. We have attempted to summarize the effect of cytotoxic chemotherapy on bone health in BC patients.

METHODS

A comprehensive literature search was performed via MEDLINE and Cochrane library databases to evaluate the effect of chemotherapy on bone health among women with BC. We included articles related to skeletal-related events, bone mineral density, bone turnover markers, osteoporosis-specific quality of life, bisphosphonate, and other bone-directed therapy. We excluded articles that included patients with metastatic breast cancer and patients receiving hormonal therapy.

DISCUSSION

Bone microenvironment in cancer is directly or indirectly influenced by clinical, hormonal, nutritional, and treatment factors. Calcitonin, parathyroid hormone, calcitriol, and estrogen are the major hormonal regulators. Bone turnover markers, namely bone formation and resorption markers, have been used to predict bone loss, fracture risk, and monitoring treatment response. Chemotherapeutic drugs such as anthracyclines and taxanes synergistically affect BMD and quality of life. Calcium, vitamin D, bisphosphonates, and denosumab are supplemented to prevent excess bone resorption. Bone-targeted anti-resorptive agents have been studied as potential anticancer agents in the adjuvant treatment of breast cancer.

CONCLUSION

This review summarizes the negative effect of chemotherapy on bone health of BC patients and the importance of preventing or treating bone loss.

Bone-modifying Agents (BMAs) in Breast Cancer

Bone-modifying agents (BMAs) are mainstays in breast cancer and prevent and treat osteoporosis in early-stage disease and reduce skeletal metastases complications in advanced disease. There is some evidence to support that BMA also prevents skeletal metastases and improves overall survival. Bone loss occurs with chemotherapy-induced ovarian failure, gonadotrophin-releasing hormone (GnRH) agonists, and aromatase inhibitors. In some women, the bone loss will be of sufficient magnitude to increase the risks of osteoporosis or fractures. Recommended steps in osteoporosis prevention or treatment include risk factor assessment, taking adequate amounts of calcium and vitamin D3, and periodic evaluations with dual-energy x-ray absorptiometry scanning. If clinically indicated by the T-scores and fracture-risk prediction algorithms treat with oral, IV bisphosphonates or subcutaneous denosumab (DEN). Zoledronic acid (ZA) or DEN reduces skeletal metastases complications, including pathological fracture, spinal cord compression, or the necessity for radiation or surgery to bone. Also, both of these drugs have the side-effect of osteonecrosis at a similar incidence. Monthly administration of ZA or DEN is standard, but several recent randomized trials show noninferiority between ZA monthly and every 3-month ZA. Every 3-month ZA is a new standard of care. Similar trials of the schedule of DEN are ongoing. ZA anticancer effect is only in postmenopausal women or premenopausal women rendered postmenopausal by GnRH agonists or bilateral oopherectomy. High-risk women, either postmenopausal or premenopausal, receiving GnRH/oopherctomy should consider adjuvant ZA. There are insufficient data to support DEN in this setting. Herein, this narrative review covers the mechanism of action of BMA, randomized clinical trials, and adverse events, both common and rare.

MYLK and PTGS1 Genetic Variations Associated with Osteoporosis and Benign Breast Tumors in Korean Women

Osteoporosis, characterized by reduced bone mass and increased bone fragility, is a disease prevalent in women. Likewise, breast cancer is a multifactorial disease and considered the major cause of mortality in premenopausal and postmenopausal women worldwide. Our data demonstrated the association of the MYLK gene and PTGS1 gene variants with osteoporosis and benign breast tumor risk and the impact of ovariectomy on osteoporosis in Korean women. We performed a genome-wide association study (GWAS) of women with osteoporosis and benign breast tumors. There were 60 single nucleotide polymorphisms (SNPs) and 12 SNPs in the MYLK and PTGS1 genes, associated with benign breast tumors and osteoporosis. Our study showed that women with homozygous MYLK rs12163585 major alleles had an increased risk of osteoporosis following ovariectomy compared to those with minor alleles. Women carrying the minor PTGS1 rs1213265 allele and not treated via ovariectomy carried a higher risk of osteoporosis than those who underwent ovariectomy with a homozygous genotype at the major alleles. Our results suggest that both the MYLK and PTGS1 genes are genetic factors associated with the phenotypes, and these associations appear to be modulated by ovariectomy.

A Network Pharmacology Study on the Molecular Mechanisms of FDY003 for Breast Cancer Treatment

Herbal medicines have drawn considerable attention with regard to their potential applications in breast cancer (BC) treatment, a frequently diagnosed malignant disease, considering their anticancer efficacy with relatively less adverse effects. However, their mechanisms of systemic action have not been understood comprehensively. Based on network pharmacology approaches, we attempted to unveil the mechanisms of FDY003, an herbal drug comprised of Lonicera japonica Thunberg, Artemisia capillaris Thunberg, and Cordyceps militaris, against BC at a systemic level. We found that FDY003 exhibited pharmacological effects on human BC cells. Subsequently, detailed data regarding the biochemical components contained in FDY003 were obtained from comprehensive herbal medicine-related databases, including TCMSP and CancerHSP. By evaluating their pharmacokinetic properties, 18 chemical compounds in FDY003 were shown to be potentially active constituents interacting with 140 BC-associated therapeutic targets to produce the pharmacological activity. Gene ontology enrichment analysis using g:Profiler indicated that the FDY003 targets were involved in the modulation of cellular processes, involving the cell proliferation, cell cycle process, and cell apoptosis. Based on a KEGG pathway enrichment analysis, we further revealed that a variety of oncogenic pathways that play key roles in the pathology of BC were significantly enriched with the therapeutic targets of FDY003; these included PI3K-Akt, MAPK, focal adhesion, FoxO, TNF, and estrogen signaling pathways. Here, we present a network-perspective of the molecular mechanisms via which herbal drugs treat BC.

Update on the Role of Neuropeptide Y and Other Related Factors in Breast Cancer and Osteoporosis

Breast cancer and osteoporosis are common diseases that affect the survival and quality of life in postmenopausal women. Women with breast cancer are more likely to develop osteoporosis than women without breast cancer due to certain factors that can affect both diseases simultaneously. For instance, estrogen and the receptor activator of nuclear factor-κB ligand (RANKL) play important roles in the occurrence and development of these two diseases. Moreover, chemotherapy and hormone therapy administered to breast cancer patients also increase the incidence of osteoporosis, and in recent years, neuropeptide Y (NPY) has also been found to impact breast cancer and osteoporosis.Y1 and Y5 receptors are highly expressed in breast cancer, and Y1 and Y2 receptors affect osteogenic response, thus potentially highlighting a potential new direction for treatment strategies. In this paper, the relationship between breast cancer and osteoporosis, the influence of NPY on both diseases, and the recent progress in the research and treatment of these diseases are reviewed.

Correlation between bone mineral density and endometrial thickness over time in women with breast cancer history

As the efficacy of chemotherapy and adjuvant endocrine therapy for breast cancer increase, the quality-of-life to cancer survivors could be more important issue in strategies of breast cancer treatment. Bone health has become more compelling in care of breast cancer survivor than ever before. This retrospective study was aimed to evaluate factors relating to the change in BMD and to ascertain the correlation between changes in BMD and EMT of women with breast cancer in follow-up. Records of 164 women who underwent surgery for breast cancer were reviewed in this study. The basal characteristics included parity, menopausal state, medication with vitamin D, bisphosphonate, selective estrogen modulator (SERM), aromatase inhibitor (AI), gonadotrophin releasing hormone agonist (GnRHa), chemotherapy, radiotherapy, cancer type including positivity of estrogen receptor, progesterone receptor and HER2, combined the other gynecologic disease or the other origin cancer. At initial and follow-up visit, all subjective were checked with BMD, endometrial thickness (EMT). The mean age was 52.1 ± 8.5 years old and overall interval between initial and follow-up visits were 17.6 ± 7.5 month in this study. The BMDs of L1-4 (1.040 ± 0.166 g/cm2 vs 1.070 ± 0.181 g/cm2, p < 0.001), femur neck (0.850 ± 0.121 g/cm2 vs 0.870 ± 0.136 g/cm2, p < 0.001), and femur total (0.902 ± 0.132 g/cm2 vs 0.915 ± 0.138 g/cm2, p < 0.001) at follow-up visit were significantly lower than those at initial visit. The change in BMDs of L1-4 (ΔBMDL1-4, r = 0.353, p < 0.001, and r = 0.228, p = 0.003), femur neck (ΔBMDNeck, r = 0.198, p = 0.011, and r = 0.282, p < 0.001), femur total (ΔBMDTotal, r = 0.294, p < 0.001, and r = 0.327, p < 0.001) had positive correlation with age and the change in EMT (ΔEMT). After age correction, ΔEMT had positive correlation with ΔBMDNeck (r = 0.245, p = 0.002) and ΔBMDTotal (r = 0.273, p < 0.001). ΔBMDL1-4 and ΔBMDNeck differed according to menopausal state (p < 0.001 and p = 0.035), bisphosphonate (p < 0.001 and p < 0.001), and GnRHa (p < 0.001 and p < 0.001). In follow-up of women with history of breast cancer, ΔEMT could be an alternative screening marker for BMD decrease.

Osteoporosis: A Long-Term and Late-Effect of Breast Cancer Treatments

Simple Summary

Osteoporosis is a prevalent condition affecting 200 million individuals world-wide. Estimates are about one in three women will experience a fragility fracture of hip, spine or wrist. Common breast cancer treatments, such as aromatase inhibitors in postmenopausal women and chemotherapy-induced ovarian failure in premenopausal women, cause bone loss that in some women will lead to osteoporosis and fragility fractures. Fragility fractures cause morbidity and mortality and are entirely preventable. Prevention or treatment of osteoporosis includes lifestyle modifications (e.g., reducing smoking and excessive alcohol consumption, and increasing physical activity), taking calcium and vitamin D3, screening for osteoporosis with dual-energy absorptiometry, and treatment, if clinically indicated, with ether oral bisphosphonates, intravenous zoledronic acid, or subcutaneous denosumab. This chapter reviews the pathogenesis of osteoporosis, the magnitude of bone loss related to common breast cancer treatments, osteoporosis risk factor assessment and screening, and the specific drugs to treat or prevent osteoporosis.

Abstract

Osteoporosis is both a long-term effect (occurs during treatment and extends after treatment) and a late-effect (occurs after treatment ends) of breast cancer treatments. The worldwide prevalence of osteoporosis is estimated to be some 200 million patients. About one in three postmenopausal women will experience an osteoporotic (or fragility) fracture of the hip, spine, or wrist. breast cancer treatments, including gonadotropin-releasing hormone (GnRH) agonists, chemotherapy-induced ovarian failure (CIOF), and aromatase inhibitors (AIs), cause bone loss and increase the risks of osteoporosis. Also, breast cancer is a disease of aging, and most of the “one in eight” lifetime risks of breast cancer are in women in their sixth, seventh, and eighth decades. The majority of women diagnosed with breast cancers today will be long-term survivors and experience personal cures. It is the coalescence of osteoporosis with breast cancer, two common and age-related conditions that make osteoporosis relevant in women with breast cancer throughout the continuum from diagnosis, treatment, and survivorship. It is critical to remember that women (and men) will lose bone after age thirty years. However, only certain women will lose bone of sufficient magnitude to merit treatment with anti-osteoporosis drugs. The narrative review is intended for medical, surgical, radiation oncologists, and other mid-level providers, and provides an overview of bone loss and the prevention and treatment of osteoporosis.

Management of osteoporosis in women with breast cancer

The screening, prevention and treatment of osteoporosis are similar in women with or without breast cancer. Breast cancer treatments, such as aromatase inhibitors, chemotherapy-induced ovarian failure and gonadotropin-releasing hormone antagonists all decrease estrogen levels, which in turn causes net bone resorption and bone loss. Bone loss over time will be of sufficient magnitude to cause some women to experience fractures. Thus, osteoporosis is an equation; the peak bone mass achieved by age 30 years minus the age-related and menopausal bone loss. Women should have their bone density measured by dual x-ray absorptiometry scans every 2 years. As clinically indicated, women should receive anti-osteoporosis drugs such as zoledronic acid, denosumab or oral bisphosphonates.

Changes in Bone Mineral Density in Women With Breast Cancer: A Prospective Cohort Study

BACKGROUND

Cancer treatment-induced bone loss is an important long-term effect among breast cancer survivors. Little is known, however, about the pattern of bone loss and the factors associated with it.

OBJECTIVE

The aim of this study was to examine annual bone health changes and factors associated with bone loss for 3 years after diagnosis among women with breast cancer.

METHODS

Ninety-nine newly diagnosed women with breast cancer (mean age, 51.1 years) were enrolled in a prospective longitudinal study. Bone mineral density (BMD) was measured with dual-energy x-ray absorptiometry at baseline and yearly for 3 years.

RESULTS

During the 3-year follow-up, the proportion of women who had osteopenia or osteoporosis increased from 33.3% to 62.5%. The BMD of the participants significantly decreased 6.8% in the lumbar spine, 4.6% in the femur neck, and 3.5% in the total hip, with bone loss the greatest in the first year. In multiple linear regression analysis, chemotherapy was significantly associated with bone loss at all sites, and premenopausal status at diagnosis was significantly related to bone loss at the lumbar spine. We found no significant relationship between health behavior status and BMD change at any site.

CONCLUSION

Women newly diagnosed with breast cancer can lose up to 6.8% of BMD during a 3-year follow-up. Chemotherapy and premenopausal status are important risk factors for bone loss.

IMPLICATIONS FOR PRACTICE

Identification of premenopausal women at diagnosis and monitoring BMD before and after chemotherapy are key for promoting bone health in women with breast cancer.

Assessment of paraspinal muscle characteristics, lumbar BMD, and their associations in routine multi-detector CT of patients with and without osteoporotic vertebral fractures

PURPOSE

To investigate paraspinal muscle characteristics and lumbar bone mineral density (BMD) and their associations in routine abdominal multi-detector computed tomography (MDCT) as well as the impact of osteoporotic vertebral fractures on such associations.

METHOD

116 patients (69.7 ± 8.1 years, 72 males) who underwent routine abdominal MDCT (oncological staging and/or follow-up for tumor recurrence) were retrospectively included and assigned to a fracture and control group (age- and gender-matched), depending on the presence or absence of lumbar osteoporotic vertebral fractures. BMD was derived from lumbar vertebrae using a conversion equation, and the cross-sectional area (CSA), CSA ratio (CSA psoas muscles divided by CSA erector spinae muscles), and muscle attenuation were measured for the psoas and erector spinae muscles at the levels L2 and L4/5 without dedicated software.

RESULTS

Males showed significantly higher BMD, CSA, and CSA ratios at the levels L2 and L4/5, while females had decreased erector spinae muscle attenuation at L4/5 (p < 0.05). No significant differences between patients with versus without fractures were observed except for BMD (68.5 ± 37.2 mg/ml vs. 91.4 ± 26.8 mg/ml; p < 0.01). Age-adjusted partial correlation testing revealed significant correlations of BMD and the CSA ratio at level L4/5 (r = 0.20; p = 0.03), but not with muscle attenuation (p > 0.05).

CONCLUSIONS

Paraspinal muscle characteristics and lumbar BMD can be assessed seamlessly in routine abdominal MDCT without dedicated software. There are level-dependent interactions between paraspinal muscle characteristics as well as lumbar BMD. Vertebral fracture status was independent of paraspinal muscle characteristics.

Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline

PURPOSE

The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer.

METHODS

ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature.

RESULTS

The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline.

RECOMMENDATIONS

Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.

Disease Progression Modeling Analysis of the Change of Bone Mineral Density by Postoperative Hormone Therapies in Postmenopausal Patients With Early Breast Cancer

The osteoporosis incidence in postmenopausal patients on aromatase inhibitors (AI) is much higher than in those on tamoxifen, and adverse effects other than musculoskeletal disorders are less on AI than on tamoxifen. In this study we performed disease-progression modeling in postmenopausal patients with early breast cancer who had received 5 years of postoperative hormone therapy. Clinical data from postmenopausal patients who had received postoperative hormonal therapy and met the predefined selection criteria were retrospectively collected in an anonymized way. Disease-progression modeling and simulations were performed using NONMEM version 7.42. A first-order deterioration model with a combination of a symptomatic model (when a drug effect provides a transient bad effect by offsetting the severity of the disease) and a disease-modifying model (when a drug affects the disease progression rate) was used. Vitamin D supplementation was found to have a disease-modifying effect in osteoporosis, whereas AI decreased the bone mineral density by a t score of -0.21. However, after stopping the AI, the estrogen level reverted to normal, thereby reexercising protective effects against bone loss. In the simulation the probability of osteoporosis increased by 10% in the AI group compared with the other groups (tamoxifen, no-treatment group) during the medication period. Tamoxifen showed no significant effects in the final model.

Long-Term Treatment of Tamoxifen and Raloxifene Alleviates Dystrophic Phenotype and Enhances Muscle Functions of FKRP Dystroglycanopathy

The third most common form of limb-girdle muscular dystrophies is caused by mutations of the Fukutin-related protein (FKRP) gene, with no effective therapy available. Selective estrogen receptor modulators, tamoxifen and raloxifene, have been widely used for human conditions for their anti-inflammatory, antifibrosis, prevention of bone loss, and muscle building effects (essential features for muscular dystrophy therapies). We evaluated therapeutic values of tamoxifen and raloxifene in FKRPP448L mutant mouse with severe dystrophic phenotype. The mice were treated with the drugs for 1 year through daily gavage. We demonstrate that tamoxifen and raloxifene significantly ameliorated the disease progression. The improvement includes increase in grip force production, extended running time and distance in treadmill test, and enhancement in cardiac and respiratory functions. Significant reduction in muscle pathology includes diminished fibrosis and fiber degeneration. Tamoxifen and raloxifene also significantly mitigated bone loss. Tamoxifen, but not raloxifene, caused severe adverse effects on male reproductive organs. The results demonstrate that tamoxifen and raloxifene hold significant potential for treating FKRP-related muscular dystrophy and probably other muscular dystrophies. Sex-related differential effects of the drugs call for a careful consideration for the drug and dosage selection in male and female patient populations.

CYP2D6 as a treatment decision aid for ER-positive non-metastatic breast cancer patients: a systematic review with accompanying clinical practice guidelines

PURPOSE

Tamoxifen is one of the principal treatments for estrogen receptor (ER)-positive breast cancer. Unfortunately, between 30 and 50% of patients receiving this hormonal therapy relapse. Since CYP2D6 genetic variants have been reported to play an important role in survival outcomes after treatment with tamoxifen, this study sought to summarize and critically appraise the available scientific evidence on this topic.

METHODS

A systematic literature review was conducted to identify studies investigating associations between CYP2D6 genetic variation and survival outcomes after tamoxifen treatment. Critical appraisal of the retrieved scientific evidence was performed, and recommendations were developed for CYP2D6 genetic testing in the context of tamoxifen therapy.

RESULTS

Although conflicting literature exists, the majority of the current evidence points toward CYP2D6 genetic variation affecting survival outcomes after tamoxifen treatment. Of note, review of the CYP2D6 genotyping assays used in each of the studies revealed the importance of comprehensive genotyping strategies to accurately predict CYP2D6 metabolizer phenotypes.

CONCLUSIONS AND RECOMMENDATIONS

Critical appraisal of the literature provided evidence for the value of comprehensive CYP2D6 genotyping panels in guiding treatment decisions for non-metastatic ER-positive breast cancer patients. Based on this information, it is recommended that alternatives to standard tamoxifen treatments may be considered in CYP2D6 poor or intermediate metabolizers.

Osteoporosis and musculoskeletal complications related to therapy of breast cancer

Aromatase inhibitors (AIs) are the treatment of choice for the majority of postmenopausal women with estrogen receptor (ER) positive breast cancers in early and advanced stage settings. One of most frequent side effects of AIs is bone loss that is of sufficient magnitude to increase risk of osteoporotic fractures. Osteoporosis is primarily a complex genetic disease with few modifiable risk factors. As the lifespan increases, and breast mortality decreases, more women with breast cancer will be at risk of osteoporotic fractures, or falls that result in fractures. The screening, prevention, and treatment of osteoporosis do not differ in women with or without breast cancer. Rather, breast cancer treatments, including AIs, chemotherapy-induced ovarian failure, and gonadotropin-releasing hormone (GnRH) agonists, all decrease estrogen, which causes net bone resorption, leading some women to experience fracture. Occurring in about fifty-percent of women, AI-induced arthralgia is one of the most common side effects, and causes of nonadherence and discontinuation. Registry studies show that nonadherence and discontinuation may contribute to higher breast cancer mortality. Thus, understanding the mechanisms, risk factors, and interventions to mitigate symptoms of AI-induced arthralgia is a high priority.

The Case for Prehabilitation Prior to Breast Cancer Treatment

Cancer rehabilitation in breast cancer survivors is well established, and there are many studies that focus on interventions to treat impairments as well as therapeutic exercise. However, very little is known about the role of prehabilitation for people with breast cancer. In this narrative review, we describe contemporary clinical management of breast cancer and associated treatment-related morbidity and mortality considerations. Knowing the common short- and long-term sequelae, as well as less frequent but serious sequelae, informs our rationale for multimodal breast cancer prehabilitation. We suggest 5 core components that may help to mitigate short- and long-term sequelae that align with consensus opinion of prehabilitation experts: total body exercise; locoregional exercise pertinent to treatment-related deficits; nutritional optimization; stress reduction/psychosocial support; and smoking cessation. In each of these categories, we review the literature and discuss how they may affect outcomes for women with breast cancer.

A Bayesian network and heuristic approach for systematic characterization of radiotherapy receipt after breast-conservation surgery

BACKGROUND

Breast-conservation surgery with radiotherapy is a treatment highly recommended by the guidelines from the National Comprehensive Cancer Network. However, several variables influence the final receipt of radiotherapy and it might not be administered to breast cancer patients. Our objective is to propose a systematic framework to identify the clinical and non-clinical variables that influence the receipt of unexpected radiotherapy treatment by means of Bayesian networks and a proposed heuristic approach.

METHODS

We used cancer registry data of Detroit, San Francisco-Oakland, and Atlanta from years 2007-2012 downloaded from the Surveillance, Epidemiology, and End Results Program. The samples had patients diagnosed with in situ and early invasive cancer with 14 clinical and non-clinical variables. Bayesian networks were fitted to the data of each region and systematically analyzed through the proposed Zoom-in heuristic. A comparative analysis with logistic regressions is also presented.

RESULTS

For Detroit, patients under stage 0, grade undetermined, histology lobular carcinoma in situ, and age between 26-50 were found more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients with age between 51-75, and grade II were found to be more likely to receive breast-conservation surgery with radiotherapy. For San Francisco-Oakland, patients under stage 0, grade undetermined, and age >75 are more likely to receive BCS. For stages I, IIA, and IIB patients with age >75 are more likely to receive breast-conservation surgery without radiotherapy. For Atlanta, patients under stage 0, grade undetermined, year 2011, and primary site C509 are more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients in year 2011, and grade III are more likely to receive breast-conservation surgery without radiotherapy.

CONCLUSION

For in situ breast cancer and early invasive breast cancer, the results are in accordance with the guidelines and very well demonstrates the usefulness of the Zoom-in heuristic in systematically characterizing a group receiving a treatment. We found a subset of the population from Detroit with ductal carcinoma in situ for which breast-conservation surgery without radiotherapy was received, but potential reasons for this treatment are still unknown.

Long-term oral bisphosphonate use in relation to fracture risk in postmenopausal women with breast cancer: findings from the Women's Health Initiative

OBJECTIVE

The aim of the study was to examine the association of long-term oral bisphosphonate use, compared with short-term use, with fracture risk among postmenopausal women with breast cancer.

METHODS

We studied 887 postmenopausal women who were enrolled to the Women's Health Initiative from 1993 to 1998, diagnosed with breast cancer after enrollment, and reported current oral bisphosphonate use of 2 years or more on a medication inventory administered in 2008 to 2009. The outcome of any clinical fracture was ascertained by self-report on an annual study form; a subset of fractures was confirmed with medical records. Women were followed from completion of the medication inventory until 2014. The association between duration of bisphosphonate use reported on the medication inventory and fracture was estimated using multivariate Cox proportional hazards survival models that compared 4 to 7 years and 8 or more years of bisphosphonate use with 2 to 3 years of use.

RESULTS

On average, women were 76 years of age and were followed for 3.7 (SD 1.1) years. There were 142 clinical fractures. In the multivariate-adjusted analysis for fracture risk factors, 8 or more years of bisphosphonate use was associated with higher risk of fracture compared with 2 to 3 years of use (hazard ratio, 1.67 [95% CI, 1.06-2.62]). There was no significant association of 4 to 7 years of use with fracture.

CONCLUSIONS

Bisphosphonate use of 8 or more years was associated with higher risk of any clinical fracture compared with 2 to 3 years of use. Our findings raise concern about potential harm or decreased effectiveness of long-term bisphosphonate use on fracture risk. The findings warrant confirmatory studies.

Assessment of ovarian failure and osteoporosis in premenopausal breast cancer survivors

Premenopausal women who develop ovarian failure after receiving chemotherapy are at a higher risk of rapid bone loss. Pharmacists have successfully implemented osteoporosis screening programmes in the general population and thus, assessment of breast cancer survivors for ovarian failure and osteopenia could represent a novel focus for oncology pharmacists. Therefore, we conducted a retrospective chart review to determine the adequacy of ovarian failure and osteoporosis assessment and management in premenopausal breast cancer survivors.

Methods and results. The charts of 20 women diagnosed with early stage breast cancer treated with cyclophosphamide over a 4.5-year timespan were included. Their median age was 36.7 years (range 29.8-41). The median cyclophosphamide cumulative dose was 9 g/m2 (range 2.4-14.45), with a median duration of follow-up being 4.62 years. The assessment of ovarian failure mainly occurred by documenting menstrual periods, which has been questioned as a reliable method for assessing ovarian failure. Menses stopped while or shortly after receiving chemotherapy in 11 women. Prior to and during cyclophosphamide administration, osteoporosis screening or counselling was not documented for any patient. After completion of chemotherapy administration, eight patients were counselled regarding osteoporosis and seven women were screened for osteoporosis with a dual X-ray absorptimetry (DXA) scan. Five women had DXA scans indicative of osteopenia according to World Health Organization guidelines.

Conclusions. Improvements are needed in the documentation and potentially also the management of ovarian failure and osteoporosis in premenopausal breast cancer survivors receiving cyclophosphamide-based regimens. This represents a potential opportunity for pharmacists to manage long-term chemotherapy toxicity.

Low intensity vibration mitigates tumor progression and protects bone quantity and quality in a murine model of myeloma

Myeloma facilitates destruction of bone and marrow. Since physical activity encourages musculoskeletal preservation we evaluated whether low-intensity vibration (LIV), a means to deliver mechanical signals, could protect bone and marrow during myeloma progression. Immunocompromised-mice (n=25) were injected with human-myeloma cells, while 8 (AC) were saline-injected. Myeloma-injected mice (LIV; n=13) were subjected to daily-mechanical loading (15min/d; 0.3g @ 90Hz) while 12 (MM) were sham-handled. At 8w, femurs had 86% less trabecular bone volume fraction (BV/TV) in MM than in AC, yet only a 21% decrease in LIV was observed in comparison to AC, reflecting a 76% increase versus MM. Cortical BV was 21% and 15% lower in MM and LIV, respectively, than in AC; LIV showing 30% improvement over MM. Similar outcomes were observed in the axial skeleton, showing a 35% loss in MM with a 27% improved retention of bone in the L5 of LIV-treated mice as compared to MM. Transcortical-perforations in the femur from myeloma-induced osteolysis were 9× higher in MM versus AC, reduced by 57% in LIV. Serum-TRACP5b, 61% greater in MM versus AC, rose by 33% in LIV compared to AC, a 45% reduction in activity when compared to MM. Histomorphometric analyses of femoral trabecular bone demonstrated a 70% elevation in eroded surfaces of MM versus AC, while measures in LIV were 58% below those in MM. 72% of marrow in the femur of MM mice contained tumor, contrasted by a 31% lower burden in LIV. MM mice (42%) presented advanced-stage necrosis of tibial marrow while present in just 8% of LIV. Myeloma infiltration inversely correlated to measures of bone quality, while LIV slowed the systemic, myeloma-associated decline in bone quality and inhibited tumor progression through the hindlimbs.

Navigating the Challenges of Endocrine Treatments in Premenopausal Women with ER-Positive Early Breast Cancer

Endocrine therapy is a key component of adjuvant treatment for premenopausal patients with endocrine-responsive tumors. It is commonly well tolerated, although side effects are a main concern in the selection of treatment options. Tamoxifen is still considered an adequate endocrine therapy in a large group of premenopausal patients (e.g. lower-risk patient, presence of co-morbidities, patient preference). Results of the SOFT and TEXT trials addressing new adjuvant endocrine treatment options in premenopausal patients were recently presented. Overall, in the SOFT study the premenopausal population did not benefit from the addition of ovarian function suppression (OFS). Nevertheless, for women at sufficient risk of recurrence to receive adjuvant chemotherapy and who maintained premenopausal estradiol, the addition of OFS to tamoxifen reduced the risk of recurrence. The magnitude of the effect was larger in younger patients. Moreover, in the SOFT and TEXT trials, adjuvant treatment with exemestane plus OFS, as compared with tamoxifen plus OFS, significantly improved disease-free survival, breast cancer-free interval and distant disease-free survival. However, premenopausal patients include heterogeneous subsets of women and tumors where costs and benefits of adjuvant endocrine therapy should be properly weighted. Issues specific for premenopausal patients, related to desire for pregnancy, family planning, safety, quality of life and subjective side effects, should be a priority in the therapeutic algorithm. Therefore, selecting the best-tolerated agent can enhance adherence to therapies and reduce the impact on quality of life and health status for these younger patients.

Effects of Yogasanas on osteoporosis in postmenopausal women

Background:

Osteoporosis is commonly encountered by postmenopausal women. There is an increased need for a low cost and efficient treatment alternative to address this population.

Aims:

To study the effects of integrated yoga on bone mineral density (BMD) in postmenopausal women with osteoporosis.

Settings and Designs:

Experimental pre-post study conducted in a community setting.

Materials and Methods:

30 females in the age group of 45–62 years suffering from postmenopausal osteoporosis with a dual-energy X-ray absorptiometry (DEXA) score of ≤−2.5 underwent a 6 months fully supervised yoga session. All the participants completed the study. Pretraining and posttraining BMD was calculated. Outcome measure: DEXA score at the lumbar spine.

Statistical Analysis:

The study was statistically analyzed using paired t-test to see the significance of pretraining and posttraining effects of a yoga session.

Results:

Improvement in T-score of DEXA scan of −2.55 ± 0.25 at posttraining as compared to a pretraining score of −2.69 ± 0.17.

Conclusions:

Integrated yoga is a safe mode of physical activity which includes weight bearing as well as not weight bearing asanas, Pranayama, and suryanamaskar, all of which helps induce improvement in BMD in postmenopausal osteoporotic females.

The Modern Landscape of Endocrine Therapy for Premenopausal Women with Breast Cancer

The optimal endocrine therapy for premenopausal women with early and advanced breast cancer still remains an important and controversial issue. For over 30 years, tamoxifen has been the gold standard in the adjuvant setting. New therapeutic options, such as the addition of ovarian function suppression to oral endocrine therapy (either tamoxifen or aromatase inhibitors), can improve outcomes over tamoxifen alone in well-selected patients. Treatment duration has also been revisited, and extended therapy is becoming a new standard of care, especially in high-risk patients. Endocrine therapy for advanced disease still represents a challenge and a research priority. New drugs and combinations able to overcome endocrine resistance are at the horizon, and their role in premenopausal women should be better elucidated. Side effects and quality of life (including family planning considerations) play an important role in treatment selection and in the patients' treatment adherence and should always be discussed before start of treatment. The paper will specifically focus on how to integrate all new treatment options in the current armamentarium of endocrine therapy of premenopausal women, with the aim of best fine-tuning treatment selections according to the individual risk/benefit evaluation.

Picking the optimal endocrine adjuvant treatment for pre-menopausal women

Endocrine treatments are key component of the adjuvant strategy for pre-menopausal patients with luminal tumors. Treatment options should be based not only upon the risk of relapse and level of endocrine responsiveness, but also on co-morbidities, preferences of the patient and degree of side effects. Tamoxifen should still be considered as an appropriate endocrine therapy in a large group of premenopausal patients (e.g. lower risk patient, presence of co-morbidities, patient preference). However, the results of the SOFT and TEXT trials, evaluating the value of ovarian function suppression (OFS) as well as the role of adjuvant aromatase inhibitor (AI), raised questions about the use of tamoxifen alone in selected higher risk patient. In the SOFT study, premenopausal patients did not benefit from the addition of OFS, but for those women at sufficient risk of recurrence to deserve adjuvant chemotherapy and who maintained pre-menopausal estradiol, the addition of OFS to tamoxifen reduced the risk of recurrence. Moreover, in the TEXT trial, adjuvant treatment with exemestane plus OFS, as compared with tamoxifen plus OFS, significantly improved disease-free survival, breast cancer-free interval and distant disease-free survival, thus representing a new treatment option. Recent available information on endocrine options for younger patients with luminal tumors support the use of tailored endocrine treatments. Issues specific for younger patients related to pregnancies desire, family planning, safety, quality of life and subjective side effects should be a priority in the therapeutic algorithm.

Tamoxifen use reduces the risk of osteoporotic fractures in women with breast cancer in Asia: a nationwide population-based cohort study

Purpose

Bone mineral density changes with tamoxifen treatment have been reported in pre- and post-menopausal women with breast cancer. However, there remains controversy as to whether tamoxifen significantly reduces fracture rates in different age groups. Breast cancer occurs at 10-20 years younger in Asian women compared with Western women. Therefore we conducted this population-based case-control study to determine whether or not tamoxifen use is associated with osteoporotic fractures.

Patients and methods

We selected 75488 women with breast cancer with no prior history of fractures from the Longitudinal Health Insurance Database for Catastrophic Illness Patients in 2000-2011. They were followed from the date of the diagnosis of breast cancer to the date a hip, vertebral or wrist fracture occurred. Because the use of tamoxifen was a time-dependent variable, we used a Cox proportional hazard model with time-dependent exposure covariates to estimate the risk of a fracture.

Results

There were 50257 and 25231 women with breast cancer who did and did not receive tamoxifen treatment, respectively. The tamoxifen users had lower risks for overall fractures with hazard ratios (HRs) of 0.52 and 0.59 in the crude and adjusted models (95 % CI = 0.45-0.61 and 0.51-0.69), respectively. They also had lower risks for hip (HR = 0.55, 95 % CI = 0.45-0.67) and vertebral (HR = 0.64, 95 % CI = 0.50-0.82) fractures in the adjusted model. The risk of fractures decreased with an increasing dosage of tamoxifen. Regardless of the age group, the tamoxifen users had a lower risk of fractures than the non-users.

Conclusion

In this Asian population-based case-control study, tamoxifen use was associated with a reduction in osteoporotic fractures, especially in hip fractures.

Control of Inflammatory Responses: a New Paradigm for the Treatment of Chronic Neuronal Diseases

The term 'inflammation' was first introduced by Celsus almost 2000 years ago. Biological and medical researchers have shown increasing interest in inflammation over the past few decades, in part due to the emerging burden of chronic and degenerative diseases resulting from the increased longevity that has arisen thanks to modern medicine. Inflammation is believed to play critical roles in the pathogenesis of degenerative brain diseases, including Alzheimer's disease and Parkinson's disease. Accordingly, researchers have sought to combat such diseases by controlling inflammatory responses. In this review, we describe the endogenous inflammatory stimulators and signaling pathways in the brain. In particular, our group has focused on the JAK-STAT pathway, identifying anti-inflammatory targets and testing the effects of various anti-inflammatory drugs. This work has shown that the JAK-STAT pathway and its downstream are negatively regulated by phosphatases (SHP2 and MKP-1), inhibitory proteins (SOCS1 and SOCS3) and a nuclear receptor (LXR). These negative regulators are controlled at various levels (e.g. transcriptional, post-transcriptional and post-translational). Future study of these proteins could facilitate the manipulation of the inflammatory response, which plays ubiquitous, diverse and ambivalent roles under physiological and pathological conditions.

Effect of neoadjuvant chemotherapy on the serum levels of bone turnover markers in women with early-stage breast cancer

Background

To evaluate effects of neoadjuvant chemotherapy on the bone turnover markers of preoperational breast cancer patients.

Methods

Forty-one breast cancer patients (29 premenopausal and 12 postmenopausal) and 60 healthy women (30 premenopausal and 30 postmenopausal) aged 30-64 years, were evaluated for their bone status. Serum levels of the bone formation markers PINP and BAP, as well as the resorption markers ICTP and β-Crosslaps in addition to E2, FSH, 25(OH)D and PTH were measured at the initial diagnosis and at 24 hours after each four chemotherapy cycles. BMD T-scores were determined in 12 patients 6 months after the neoadjuvant chemotherapies.

Results

The baseline levels of both bone formation and resorption markers in premenopausal patients were higher than in premenopausal healthy women (p<0.05), while no statistic difference was observed between postmenopausal patients and postmenopausal healthy women. Regardless of the menopausal status, chemotherapy increased the ICTP and β-Crosslaps levels (p<0.05), but decreased the BAP and PINP levels (p<0.05), the later one significantly more with Taxane medication (p<0.01, p<0.05). Chemotherapy caused significant decreases of 25(OH)D levels in premenopausal (p<0.01) and postmenopausal (p<0.05) patients, however, did not affect the PTH concentrations. In premenopausal patients the E2 level decreased, while the FSH level increased after chemotherapy (p<0.05). Patients with pronounced ICTP and β-Crosslaps combined with reduced BAP and PINP serum concentrations after neoadjuvant chemotherapies were prone to develop osteoporosis 6 month later.

Conclusions

Neoadjuvant chemotherapy appeared to promote bone resorption and inhibit bone formation in both postmenopausal and premenopausal early-stage breast patients.

Soy isoflavone intake and bone mineral density in breast cancer survivors

PURPOSE

Low bone mineral density (BMD) is common among breast cancer survivors due to acute estrogen deprivation. Soy food is a rich source of phytoestrogens, namely isoflavones, known to have both estrogenic and anti-estrogenic effects. The objective of the study was to assess the association between soy consumption and BMD in breast cancer survivors, which has not previously been evaluated.

METHODS

Forearm BMD was evaluated using dual-energy X-ray absorptiometry at 60 months post-diagnosis for 1,587 participants of the Shanghai Breast Cancer Survival Study. Soy intakes collected at 6, 18, and 36 months post-diagnosis were averaged, and the association with BMD, osteopenia, and osteoporosis was evaluated using linear and logistic regression.

RESULTS

The mean (standard deviation) intake of isoflavones was 48.1 (28.0) mg/day. Soy intake was inversely associated with BMD and positively associated with osteoporosis. Compared with the lowest quartile, the highest quartile of soy isoflavone intake, ≥ 62.64 mg/day, was associated with a reduction of BMD by 1.95% [95% confidence interval (CI) -3.54, -0.36%] and an increased odds ratio of 1.69 for osteoporosis (95% CI 1.09, 2.61). The inverse association was predominantly seen among women who recently entered menopause (≤ 5 years).

CONCLUSION

In contrast to observations from general populations, high soy intake (≥ 62.64 mg of soy isoflavone/day) was associated with lower proximal forearm BMD among breast cancer survivors, particularly during the early years of menopause. Our finding needs to be replicated, particularly in studies with more comprehensive bone density evaluation.

Mitochondria: the gateway for tamoxifen-induced liver injury

Tamoxifen (TAM) is routinely used in the treatment of breast carcinoma. TAM-induced liver injury remains a major concern, as TAM causes hepatic steatosis in a significant number of patients, which can progress toward steatohepatitis. Liver toxicity is generally believed to involve mitochondrial dysfunction and TAM exerts multiple deleterious effects on mitochondria, which may account for the hepatotoxicity observed in patients treated with TAM. Endoxifen (EDX), a key active metabolite of TAM that is being investigated as an alternative to TAM in breast cancer therapy, slightly affects mitochondria in comparison with TAM and this demonstration well correlates with the absence of alterations in the clinical parameters of individuals taking EDX. The steady-state plasma concentrations of TAM and its active metabolites EDX and 4-hydroxytamoxifen (OHTAM) in patients taking TAM are highly variable, reflecting genetic variants of CYP2D6 involved in TAM metabolism. Besides de genetic polymorphisms, the intake of drugs that influence the enzymatic activity of CYP2D6 compromises the therapeutic efficiency of TAM. The knowledge of the impact of the variability of TAM metabolism in the breast cancer treatment explains the discrepant outcomes observed in patients taking TAM, as well as the individual variability of idiosyncratic liver injury and other sides effects observed. Therefore, and contrarily to the clinical use of EDX, the need of therapeutic drug monitoring and a regular assessment of liver function biomarkers should be considered in patients under therapies with TAM. In this review we focus on the mitochondrial effects of TAM and its metabolites and on the role played by mitochondria in the initiating events leading to TAM-induced hepatotoxicity, as well as the clinical implications.

The effects of a 6-month resistance training and dried plum consumption intervention on strength, body composition, blood markers of bone turnover, and inflammation in breast cancer survivors

The purpose of this study was to examine the effects of resistance training (RT) and dried plum (DP) consumption on strength, body composition, blood markers of bone, and inflammation in breast cancer survivors (BCS). Twenty-three BCS (RT, n = 12; RT+DP, n = 11), aged 64 ± 7 years, were evaluated at baseline and after 6 months of intervention on the following: muscular strength (chest press and leg extension) via 1-repetition maximums (1RMs); body composition, specifically bone mineral density (BMD) by dual energy X-ray absorptiometry; biochemical markers of bone turnover (bone-specific alkaline phosphatase (BAP), tartrate resistant acid phosphatase (TRAP-5b)); and inflammation (C-reactive protein (CRP)). Target RT prescription was 2 days/week of 10 exercises, including 2 sets of 8–12 repetitions at ∼60%–80% of 1RM. RT+DP also consumed 90 g of DP daily. There were no baseline differences between groups or any group-by-time interactions for any of the variables. BCS increased upper (p < 0.05) (RT: 64 ± 14 to 80 ± 17 kg; RT+DP: 72 ± 23 to 91 ± 20 kg) and lower (p < 0.05) (RT: 69 ± 20 to 87 ± 28 kg; RT+DP: 78 ± 19 to 100 ± 21 kg) body strength. Body composition and BMD improvements were not observed. TRAP-5b decreased in the RT group (p < 0.05) (4.55 ± 1.57 to 4.04 ± 1.63 U/L) and the RT+DP group (p = 0.07) (5.10 ± 2.75 to 4.27 ± 2.03 U/L). Changes in BAP and CRP were not observed. RT was effective for improving biochemical markers of bone turnover and muscular strength in BCS. A longer and higher intensity intervention may be needed to reveal the true effects of RT and DP on body composition and biochemical markers of inflammation.

Treatment options for older woman with early breast cancer

Breast cancer is the most common cancer in women and its incidence increases with age. Older women are not often offered optimal treatment compared with younger women for any particular stage. This is due to various reasons, including the lack of evidence for older women from well-conducted clinical trials. In this paper, the currently available evidences from clinical trials are reviewed and the various treatment options for older women with early breast cancer are discussed.

The effect of ovarian dysfunction on bone mineral density in breast cancer patients 10 years after adjuvant chemotherapy

BACKGROUND

Premenopausal patients treated with adjuvant chemotherapy often develop early menopause and thus, may encounter significant bone loss. We studied the long-term effects of chemotherapy-induced ovarian dysfunction on bone mineral density in breast cancer patients.

MATERIAL AND METHODS

The effect of menstrual status after adjuvant chemotherapy on bone mineral density (BMD) was examined in 29 premenopausal breast cancer patients.

RESULTS

During 10 years of follow-up, nearly 90% of women developed menstrual irregularities or amenorrhea. The total bone loss at the lumbar spine was -5.4% in women with preserved menstruation, -15.3% in those with irregular menses and -13.2% in amenorrheic women 10 years after adjuvant chemotherapy. The changes in lumbar spine BMD correlated significantly with menstrual function. Both amenorrhea and menstrual irregularities shortly after chemotherapy increased the risk of osteoporosis later on: one third of women with ovarian dysfunction developed osteoporosis of the lumbar spine during the follow-up. Osteopenia before adjuvant therapy predicted an increased risk for osteoporosis.

CONCLUSION

The present study with a unique follow-up period of 10 years shows that ovarian dysfunction leads to long-term deleterious BMD changes and predisposes breast cancer survivors to osteoporosis.

Skeletal manifestations of treatment of breast cancer on premenopausal women

With increasing use of screening mammography and more effective adjuvant systemic therapies, the majority of women diagnosed with early stage breast cancer will be long-term survivors and experience personal cures. Among the common side effects of adjuvant therapies is treatment-related bone loss, primarily as a result of estrogen deprivation. Whereas this occurs in both postmenopausal and premenopausal women, this brief review will focus on pre- or perimenopausal women when initially diagnosed with breast cancer. An important distinction is between those women who retain ovarian function despite cancer or preventative treatments and the more common situation of premenopausal women who as result of cancer treatments undergo ovarian failure or early menopause. Some women with treatment-related ovarian failure will have sufficient treatment-related bone loss to be at increased risks of subsequent nontraumatic fractures and/or osteoporosis and will be candidates for antiresorptive treatments. The noncancer treatment risk factors, screening and treatments for the management of osteopenia and osteoporosis are generally the same in postmenopausal women with and without breast cancer. However, premenopausal women with relatively rapid onset of treatment-related ovarian failure and bone loss pose several challenges. Awareness of treatment-related bone loss and risks of subsequent osteoporosis is a high priority in an ever-increasing population of breast cancer survivors.

Fracture in asian women with breast cancer occurs at younger age

Background

Western breast cancer survivors have an increased risk of osteoporosis and bone fracture. Breast cancer occurs 10 to 20 years earlier in Asian women than in Western women. We investigated if younger Asian women with breast cancer also have increased risk of fracture.

Methods

We used the universal insurance claims data from 2000 to 2003 to identify 22,076 patients with breast cancer and 88,304 women without cancer, frequency matched with age and index date (the date for a health care visit). The incidence of fracture in both cohorts and the hazard ratios (HRs) of fracture in the cancer cohort were estimated by the end of 2009.

Results

The incidence of all types of fracture was higher in the breast cancer cohort than in the comparison cohort (46.72 vs. 42.52 per 10,000 person-years), with adjusted HRs (aHRs) of 1.18 (95% confidence intervals [CI], 1.03–1.35) for hip fractures, 1.12 (95% CI, 0.98–1.28) for forearm fractures and 1.24 (95% CI, 1.04–1.48) for vertebral fractures. The aHRs were significant in both non-traumatic fractures (1.29; 95% CI, 1.11–1.51) and traumatic fractures (1.12; 95% CI, 1.01–1.23). The age-specific aHR was higher for younger breast cancer patients, and was significant for <50 years old patients in both traumatic (aHR 1.35; 95% CI 1.08–1.68) and non-traumatic (aHR, 1.72; 95% CI, 1.21–2.44) fractures.

Conclusion

This study suggests that Asian women with breast cancer might have an increased risk of fracture.

A study to evaluate the cause of bone demineralization in gynecological cancer survivors

BACKGROUND

An association between treatment for gynecological cancers and risk of osteoporosis has never been formally evaluated. Women treated for these cancers are now living longer than ever before, and prevention of treatment-induced morbidities is important. We aimed to distinguish, in gynecological cancer survivors, whether cancer therapy has additional detrimental effects on bone health above those attributable to hormone withdrawal.

METHODS

We performed a retrospective cross-sectional analysis of dual energy x-ray absorptiometry (DEXA) scan results from 105 women; 64 had undergone bilateral salpingo-oophorectomy (BSO) followed by chemotherapy or radiotherapy for gynecological malignancies, and 41 age-matched women had undergone BSO for benign etiologies. All were premenopausal prior to surgery.

RESULTS

The median age at DEXA scan for the cancer group was 42 years, and 66% had received hormonal replacement therapy (HRT) following their cancer treatment. For the benign group, the median age was 40 years, and 87% had received HRT. Thirty-nine percent of cancer survivors had abnormal DEXA scan results compared to 15% of the control group, with the majority demonstrating osteopenia. The mean lumbar spine and femoral neck bone mineral densities (BMDs) were significantly lower in cancer patients. A history of gynecological cancer treatment was associated with significantly lower BMD in a multivariate logistic regression.

CONCLUSIONS

Women treated for gynecological malignancies with surgery and adjuvant chemotherapy have significantly lower BMDs than age-matched women who have undergone oophorectomy for noncancer indications. Prospective evaluation of BMD in gynecological cancer patients is recommended to facilitate interventions that will reduce the risk of subsequent fragility fractures.

Low bone density in breast cancer survivors in Korea: prevalence, risk factors and associations with health-related quality of life

PURPOSE

To examine the prevalence and risk factors of low bone density and identify associations with health-related quality of life (HRQOL) in breast cancer survivors in Korea.

METHODS

This study was a cross-sectional descriptive study design. A total of 136 women with breast cancer who had completed their therapy were recruited at one university-based cancer center in Korea. Bone mineral density (BMD), health behaviors (physical activity, diet/nutrition behaviors, smoking, alcohol consumption, sunlight exposure), and HRQOL were measured.

RESULTS

Among the 136 breast cancer survivors, 49 women (36.0%) had osteopenia and six women (4.4%) had osteoporosis. Univariate analyses revealed that older age, low education level, low monthly income, tamoxifen therapy, aromatase inhibitor therapy, calcium supplement intake, and past or current smoking were associated with low bone density (BMD T-score < -1.0). In multivariate analyses, low economic status (OR = 2.22, p = 0.050) and past or current smoking (OR = 3.77, p = 0.039) were final risk factors of low bone density. In addition, women who had low bone density reported worse role function (p = 0.022) than women who did not.

CONCLUSIONS

Women of lower economic status or who are past or current smokers warrant monitoring and treatment strategies to reduce bone loss risk. Nurses may play a crucial role in screening this high-risk group for low bone density and in educating patients on the importance of healthy lifestyle changes.

Benefits and adverse effects of endocrine therapy

Endocrine-responsive tumors that are small and without nodal involvement (i.e. tumors classified as pT1 pN0) are a heterogeneous group of tumors that are associated with a low risk of relapse in the majority of the cases. Therefore, the costs and benefits of adjuvant endocrine therapy should be carefully considered within this subgroup of patients. Treatment decisions should take into consideration co-morbidities as well as the presence of other classical risk factors such as HER2 overexpression or extensive peritumoral vascular invasion. Tamoxifen or tamoxifen plus ovarian function suppression should be considered as proper endocrine therapies in premenopausal patients. Ovarian function suppression alone or ovarian ablation might also be considered adequate in selected patients (e.g. very low-risk patients, in the presence of co-morbidities or patient preference). An aromatase inhibitor should form part of standard endocrine therapy for most postmenopausal women with receptor-positive breast cancer, although patients at low risk or with co-morbid musculoskeletal or cardiovascular risk factors may be considered suitable for tamoxifen alone. Tailored endocrine treatments should be considered in patients with endocrine-responsive tumors classified as pT1 pN0. Issues focusing on safety, quality of life and subjective side effects should be routinely discussed.