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Ouchi Y, Nakatsukasa K, Sakaguchi K, Morita M, Koyama H, Matsuda T, Kato M, Konishi E, Ono H, Taguchi T. The effect of denosumab in breast cancer patients receiving adjuvant aromatase inhibitors: 36-month results. J Bone Miner Metab 2021; 39:224-229. [PMID: 32889575 DOI: 10.1007/s00774-020-01138-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Aromatase inhibitor (AI)-associated bone loss increases the risk of bone fracture and reduces patients' quality of life, making it a critical issue worldwide. We conducted a prospective non-randomized clinical trial (UMIN-CTR, UMIN 000016173) to assess the effect of denosumab on bone loss in patients treated with adjuvant AI and have previously reported the results at 12 and 24 months. This study aimed to present the results at 36 months of treatment with denosumab for osteopenia in breast cancer patients who were undergoing treatment with adjuvant AI; 36 months is the longest denosumab treatment period reported so far. MATERIALS AND METHODS Patients received 60-mg denosumab subcutaneously every 6 months. Daily supplements containing 500-mg elemental calcium and at least 400 international units of vitamin D were highly recommended throughout the study period. The levels of bone mineral density (BMD) and bone turnover markers, serum tartrate-resistant acid phosphatase isoform 5b, and bone alkaline phosphatase were determined at baseline and 6, 12, 18, 24, and 36 months. RESULTS At 36 months, the bone mineral density of the lumbar spine, right femoral neck, and left femoral neck were found to increase by 8.8% (95% confidence interval CI 7.6-10.1), 4.3% (95% CI 3.0-5.5), and 3.1% (95% CI 2.1-4.1), respectively. No non-traumatic clinical fractures occurred in patients receiving AI and denosumab. CONCLUSION Twice-yearly administration of denosumab to the breast cancer patients treated with adjuvant AI, regardless of the skeletal site, resulted in consistent increases in BMD without severe adverse events at 36 months.
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Affiliation(s)
- Yoshimi Ouchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | - Koichi Sakaguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Midori Morita
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | | | | | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisako Ono
- Drug Discovery Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Taguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Vasconcelos de Matos L, Fernandes L, Neves MT, Alves F, Baleiras M, Ferreira A, Giesteira Cotovio P, Dias Domingues T, Malheiro M, Plácido A, Miranda MH, Martins A. From Theory to Practice: Bone Health in Women with Early Breast Cancer Treated with Aromatase Inhibitors. Curr Oncol 2021; 28:1067-1076. [PMID: 33652975 PMCID: PMC8025750 DOI: 10.3390/curroncol28020104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 11/20/2022] Open
Abstract
Aromatase inhibitors (AI) are extensively used as adjuvant endocrine therapy in post-menopausal women with hormone receptor-positive early breast cancer (HR+ EBC), but their impact on bone health is not negligible. This work aimed to assess bone loss, fracture incidence, and risk factors associated with these events, as well as the prognostic influence of fractures. We have conducted a retrospective cohort study of women with HR+ EBC under adjuvant therapy with AI, during a 3-year period. Four-hundred-and-fifty-one eligible women were reviewed (median age 68 years). Median time under AI was 40 months. A fracture event occurred in 8.4%, mostly in the radium and femoral neck and in older women (mean 74 vs. 68 years, p = 0.006). Age (OR 1.01, 95% CI 1.01-1.07, p = 0.024) and time under AI (OR 1.02, 95% CI 1.00-1.04, p = 0.037) were independent predictors of fracture, with a fair discrimination (AUC 0.71). Analysis of disease-free survival according to fracture event varied between groups, disfavoring the fracture cohort (at 73 months, survival 78.6%, 95% CI, 47.6-92.4 vs. 95.6%, 95% CI, 91.2-97.8, p = 0.027). The multivariate model confirmed the prognostic impact of fracture occurrence (adjusted HR of 3.17, 95% CI 1.10-9.11; p = 0.032). Bone health is often forgotten, despite its great impact in survivorship. Our results validate the pathophysiologic link between EBC and bone metabolism, which translates into EBC recurrence. Further research in this area may help refine these findings. Moreover, early identification of women at higher risk for fractures is warranted.
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Affiliation(s)
- Leonor Vasconcelos de Matos
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Leonor Fernandes
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Maria Teresa Neves
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Fátima Alves
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Mafalda Baleiras
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - André Ferreira
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Pedro Giesteira Cotovio
- CEAUL, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal; (P.G.C.); (T.D.D.)
| | - Tiago Dias Domingues
- CEAUL, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal; (P.G.C.); (T.D.D.)
| | - Mariana Malheiro
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
- Department of Medical Oncology, Hospital Cuf Tejo, 1350-353 Lisbon, Portugal
| | - Ana Plácido
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Maria Helena Miranda
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
| | - Ana Martins
- Department of Medical Oncology, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, 1449-005 Lisbon, Portugal; (L.F.); (M.T.N.); (F.A.); (M.B.); (A.F.); (M.M.); (A.P.); (M.H.M.); (A.M.)
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Hadji P, Aapro MS, Body JJ, Gnant M, Brandi ML, Reginster JY, Zillikens MC, Glüer CC, de Villiers T, Baber R, Roodman GD, Cooper C, Langdahl B, Palacios S, Kanis J, Al-Daghri N, Nogues X, Eriksen EF, Kurth A, Rizzoli R, Coleman RE. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol 2017; 7:1-12. [PMID: 28413771 PMCID: PMC5384888 DOI: 10.1016/j.jbo.2017.03.001] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Several guidelines have been reported for bone-directed treatment in women with early breast cancer (EBC) for averting fractures, particularly during aromatase inhibitor (AI) therapy. Recently, a number of studies on additional fracture related risk factors, new treatment options as well as real world studies demonstrating a much higher fracture rate than suggested by randomized clinical controlled trials (RCTs). Therefore, this updated algorithm was developed to better assess fracture risk and direct treatment as a position statement of several interdisciplinary cancer and bone societies involved in the management of AI-associated bone loss (AIBL). PATIENTS AND METHODS A systematic literature review identified recent advances in the management of AIBL. Results with individual agents were assessed based on trial design, size, follow-up, and safety. RESULTS Several fracture related risk factors in patients with EBC were identified. Although, the FRAX algorithm includes fracture risk factors (RF) in addition to BMD, it does not seem to adequately address the effects of AIBL. Several antiresorptive agents can prevent and treat AIBL. However, concerns regarding compliance and long-term safety remain. Overall, the evidence for fracture prevention is strongest for denosumab 60 mg s.c. every 6 months. Additionally, recent studies as well as an individual patient data meta-analysis of all available randomized trial data support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality that needs to be taken into account when advising on management of AIBL. CONCLUSIONS In all patients initiating AI treatment, fracture risk should be assessed and recommendation with regard to exercise and calcium/vitamin D supplementation given. Bone-directed therapy should be given to all patients with a T-score<-2.0 or with a T-score of <-1.5 SD with one additional RF, or with ≥2 risk factors (without BMD) for the duration of AI treatment. Patients with T-score>-1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Compliance should be regularly assessed as well as BMD on treatment after 12 - 24 months. Furthermore, because of the decreased incidence of bone recurrence and breast cancer specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - John Kanis
- Catholic University of Australia, Melbourne, Australia and University of Sheffield, UK
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