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Skafida E, Andrikopoulou A, Terpos E, Markellos C, Moustafa S, Pectasides D, Dimopoulos MA, Zagouri F, Vassilopoulos D. Impact of CDK4/6 Inhibitors on Aromatase Inhibitor-Associated Musculoskeletal Syndrome (AIMSS) in the Adjuvant Setting. Breast J 2023; 2023:3614296. [PMID: 37293258 PMCID: PMC10247331 DOI: 10.1155/2023/3614296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 09/20/2022] [Accepted: 03/28/2023] [Indexed: 06/10/2023]
Abstract
Background Third-generation aromatase inhibitors (AIs) are the mainstay of treatment in hormone receptor (HR)-positive breast cancer. Even though it is considered to be a well-tolerated therapy, AI-induced musculoskeletal symptoms are common and may be accused for treatment discontinuation. Recently, selective cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors changed the therapeutic setting, and currently, ribociclib, palbociclib, and abemaciclib are all approved in combination with nonsteroidal AIs in patients with ER-positive, HER2-negative advanced or metastatic breast cancer. This systematic review aims to identify the frequency of aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) in the adjuvant setting in patients under AI monotherapy compared to patients under combination therapy with AIs and CDK4/6 inhibitors and demonstrate the underlying mechanism of action. Methods This study was performed in accordance with PRISMA guidelines. The literature search and data extraction from all randomized clinical trials (RCTs) were done by two independent investigators. Eligible articles were identified by a search of MEDLINE and ClinicalTrial.gov database concerning the period 2000/01/01-2021/05/01. Results Arthralgia was reported in 13.2 to 68.7% of patients receiving AIs for early-stage breast cancer, while arthralgia induced by CDK4/6 inhibitors occurred in a much lower rate [20.5-41.2%]. Bone pain (5-28.7% vs. 2.2-17.2%), back pain (2-13.4% vs. 8-11.2%), and arthritis (3.6-33.6% vs. 0.32%) were reported less frequently in patients receiving the combination of CDK4/6 inhibitors with ET. Conclusions CDK4/6 inhibitors might have a protective effect against joint inflammation and arthralgia occurrence. Further studies are warranted to investigate arthralgia incidence in this population.
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Affiliation(s)
- Efthymia Skafida
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | | | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Christos Markellos
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Savvina Moustafa
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Pectasides
- Oncology Section, Second Department of Internal Medicine, Hippokration Hospital, Athens, Greece
| | | | - Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, Athens, Greece
| | - Dimitrios Vassilopoulos
- Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
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Takahashi S. Management of cancer treatment-induced bone loss (CTIBL) in patients with breast cancer or prostate cancer. J Bone Miner Metab 2023; 41:307-316. [PMID: 37036530 DOI: 10.1007/s00774-023-01414-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023]
Abstract
Breast cancer and prostate cancer are sex hormone-dependent cancers, and estrogen or androgen suppression therapy is the standard treatment. Cancer treatment-induced bone loss (CTIBL): bone loss and osteoporosis have become important side effects of these therapies. To summarize the current evidences, (1) Endocrine therapy for breast cancer and prostate cancer is associated with a significant decrease in bone mineral density. (2) Aromatase inhibitors (AI) for breast cancer are associated with a significant increase in fractures, and androgen deprivation therapy (ADT) for prostate cancer is likely to be associated with an increase in fractures. (3) Administration of bisphosphonates and denosumab increases bone mass in patients undergoing endocrine therapy for breast cancer. Administration of bisphosphonates, denosumab, and SERMs increased bone mass in patients undergoing ADT therapy for prostate cancer. (4) Bisphosphonates and denosumab reduce fracture risk in patients on AI for breast cancer, and toremifene and denosumab in patients on ADT for prostate cancer.
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Affiliation(s)
- Shunji Takahashi
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, Japan.
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3
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Filip-Psurska B, Zachary H, Strzykalska A, Wietrzyk J. Vitamin D, Th17 Lymphocytes, and Breast Cancer. Cancers (Basel) 2022; 14:cancers14153649. [PMID: 35954312 PMCID: PMC9367508 DOI: 10.3390/cancers14153649] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary The effect of vitamin D3 on the development of breast cancer (favorable, ineffective, or even unfavorable) depends on many factors, such as age, menopausal status, or obesity. The immunomodulatory effect of vitamin D may be unfavorable in case of breast cancer progression. The effect of vitamin D on Th17 cells may depend on disease type and patients’ age. Our goal was to summarize the data available and to find indications of vitamin D treatment failure or success. Therefore, in this review, we present data describing the effects of vitamin D3 on Th17 cells, mainly in breast cancer. Abstract Vitamin D3, which is well known to maintain calcium homeostasis, plays an important role in various cellular processes. It regulates the proliferation and differentiation of several normal cells, including immune and neoplastic cells, influences the cell cycle, and stimulates cell maturation and apoptosis through a mechanism dependent on the vitamin D receptor. The involvement of vitamin D3 in breast cancer development has been observed in numerous clinical studies. However, not all studies support the protective effect of vitamin D3 against the development of this condition. Furthermore, animal studies have revealed that calcitriol or its analogs may stimulate tumor growth or metastasis in some breast cancer models. It has been postulated that the effect of vitamin D3 on T helper (Th) 17 lymphocytes is one of the mechanisms promoting metastasis in these murine models. Herein we present a literature review on the existing data according to the interplay between vitamin D, Th17 cell and breast cancer. We also discuss the effects of this vitamin on Th17 lymphocytes in various disease entities known to date, due to the scarcity of scientific data on Th17 lymphocytes and breast cancer. The presented data indicate that the effect of vitamin D3 on breast cancer development depends on many factors, such as age, menopausal status, or obesity. According to that, more extensive clinical trials and studies are needed to assess the importance of vitamin D in breast cancer, especially when no correlations seem to be obvious.
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Bassatne A, Bou Khalil A, Chakhtoura M, Arabi A, Van Poznak C, El-Hajj Fuleihan G. Effect of antiresorptive therapy on aromatase inhibitor induced bone loss in postmenopausal women with early-stage breast cancer: A systematic review and meta-analysis of randomized controlled trials. Metabolism 2022; 128:154962. [PMID: 34958816 DOI: 10.1016/j.metabol.2021.154962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/30/2021] [Accepted: 12/14/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Aromatase inhibitors (AIs) are routinely used to treat postmenopausal women with early-stage breast cancer. Although AIs improve breast cancer outcomes, they increase the risk of osteoporosis and fractures. This systematic review and meta-analysis assesses the effect of antiresorptive drugs on AI induced bone loss in postmenopausal women with non-metastatic breast cancer. METHODS We searched four databases until November 4th 2020. We included Randomized controlled trials (RCTs) of antiresorptive drugs in postmenopausal women with breast cancer treated with AI. Two authors screened studies, extracted data and assessed the risk of bias independently and in duplicate. RESULTS We identified 14 RCTs: 7 on zoledronic acid, 6 on oral bisphosphonates and 1 on denosumab. The mean difference in bone mineral density (BMD) was 5% at the lumbar spine and 4% at the total hip, at 12 months, favoring zoledronic acid compared to control. The certainty of the evidence was low for lumbar spine and moderate for total hip BMD. Similarly, the mean difference was 3% at the lumbar spine and 2% at the total hip, favoring oral bisphosphonates with moderate certainty. The mean difference was 6% at the lumbar spine, and 4% at the total hip BMD favoring denosumab compared to placebo. In addition, zoledronic acid resulted in a mean difference in bone turnover marker levels of -35-41%, and the relarive risk for morphometric vertebral fractures was 0.7 [0.3-1.4], compared to control. Denosumab reduced fracture incidence by 50% compared to placebo. CONCLUSION Evidence suggests a protective effect of antiresorptive drugs on BMD and bone turnover markers in postmenopausal women with non-metastatic breast cancer on AI. However, data on fracture risk reduction remains unclear.
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Affiliation(s)
- Aya Bassatne
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abir Bou Khalil
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Asma Arabi
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, Division of Endocrinology and Metabolism, WHO Collaborating Center in Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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de Sire A, Lippi L, Venetis K, Morganti S, Sajjadi E, Curci C, Ammendolia A, Criscitiello C, Fusco N, Invernizzi M. Efficacy of Antiresorptive Drugs on Bone Mineral Density in Post-Menopausal Women With Early Breast Cancer Receiving Adjuvant Aromatase Inhibitors: A Systematic Review of Randomized Controlled Trials. Front Oncol 2022; 11:829875. [PMID: 35127539 PMCID: PMC8814453 DOI: 10.3389/fonc.2021.829875] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 12/26/2022] Open
Abstract
Background Cancer treatment-induced bone loss (CTIBL) is a frequent complication of breast cancer therapies affecting both disability and health-related quality of life (HRQoL). To date, there is still a lack of consensus about the most effective approach that would improve bone health and HRQoL. Therefore, the aim of this systematic review of randomized controlled trials (RCTs) was to summarize the evidence on the effects of antiresorptive drugs on CTIBL in patients with early breast cancer. Methods PubMed, Scopus, and Web of Science databases were systematically searched up to April 30, 2021 to identify RCTs satisfying the following PICO model: P) Participants: postmenopausal women with early breast cancer receiving adjuvant aromatase inhibitors (AI), age >18 years; I) Intervention: antiresorptive drugs (i.e. bisphosphonates and/or denosumab); C) Comparator: any comparator; O) Outcome: bone mineral density (BMD) modifications. Moreover, a quality assessment was performed according to the Jadad scale. Results Out of the initial 2415 records, 21 papers (15 studies) were included in the data synthesis. According to the Jadad scale, 6 studies obtained a score of 5, 1 study obtained a score of 4, 13 studies obtained a score of 3, and 1 study with score 1. Although both bisphosphonates and denosumab showed to increase BMD, only denosumab showed significant advantages on fractures. Conclusions Bone health management in patients with early breast cancer receiving adjuvant AIs remains challenging, and the optimal therapeutic approach is not standardized. Further studies are needed to investigate CTIBL, focusing on both the need for antiresorptive drugs and their duration based on individual patients’ characteristics. Systematic Review Registration https://www.crd.york.ac.uk/prospero, identifier CRD42021267107.
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Affiliation(s)
- Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Lorenzo Lippi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Konstantinos Venetis
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Stefania Morganti
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Division of Early Drug Development, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Elham Sajjadi
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Claudio Curci
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, ASST Carlo Poma, Mantova, Italy
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Carmen Criscitiello
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Division of Early Drug Development, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Nicola Fusco
- Division of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy.,Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Aromatase and CDK4/6 Inhibitor-Induced Musculoskeletal Symptoms: A Systematic Review. Cancers (Basel) 2021; 13:cancers13030465. [PMID: 33530456 PMCID: PMC7865932 DOI: 10.3390/cancers13030465] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Treatment with aromatase inhibitors (AIs) is fundamental in women with hormone receptor-positive breast cancer in the adjuvant as well as the metastatic setting. Even though it is considered to be a well-tolerated therapy, aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) is the most common adverse event encountered by breast cancer patients. CDK4/6 inhibitors have emerged as a new treatment strategy in metastatic hormone receptor-positive breast cancer. However, the impact of CDK4/6 inhibitors on musculoskeletal symptoms caused by AIs is not well-defined. OBJECTIVES This systematic review aims to identify the frequency of joint symptoms induced by treatment with AIs and CDK4/6 inhibitors in the metastatic setting. SEARCH STRATEGY Eligible articles were identified by a search of existing literature for the period 2005/01/01-2021/01/01; The algorithm consisted of a predefined combination of the following keywords "breast", "cancer", "aromatase inhibitors", "CDK4/6", "phase III". SELECTION CRITERIA This study was performed in accordance with PRISMA guidelines. All randomized controlled Phase III trials (RCTs) evaluating the administration of third-generation aromatase inhibitors (AIs) and CDK4/6 inhibitors in postmenopausal women in the metastatic setting were considered eligible for this review. DATA COLLECTION Overall, 16 randomized control trials (RCTs) were retrieved, of which nine studies explored the administration of AIs in the metastatic setting and seven studies investigated the combination of CDK4/6 inhibitors and AIs. Arthralgia was reported in 1-47% of patients treated with AIs and 5.8-33.3% of patients treated with CDK4/6 inhibitors. Myalgias occurred in 2-23.7% of patients receiving AIs compared with 4.8-11.9% of patients treated with CDK4/6 inhibitors. The incidence of back pain was 7-32.9% vs. 2.9-8.5% in postmenopausal women with metastatic disease treated with AIs and CDK4/6 inhibitors, respectively. Bone pain was reported in 7-32.9% of postmenopausal women treated with AIs and 2.9-8.5% of women treated with CDK4/6 inhibitors. CONCLUSIONS AI treatment-induced musculoskeletal syndrome is an adverse event affecting over one-third (20-47%) of postmenopausal patients treated with AIs that often leads to treatment discontinuation. Data from RCTs provide evidence that the incidence of musculoskeletal symptoms is relatively decreased upon CDK4/6 inhibitor administration. CDK4/6 inhibitors may provide a protective role against AIMSS development.
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Paschou SA, Augoulea A, Lambrinoudaki I. Bone health care in women with breast cancer. Hormones (Athens) 2020; 19:171-178. [PMID: 31853818 DOI: 10.1007/s42000-019-00164-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023]
Abstract
The aim of this article is to analyze and critically appraise the literature regarding optimal bone health care in women with breast cancer and, more specifically, to present (1) the causes of bone loss in breast cancer patients, (2) the appropriate screening for osteoporosis and fracture risk estimation, (3) optimal prevention and therapeutic strategies for osteoporosis and fractures, (4) the role of antiresorptive agents as adjuvant therapy for the prevention of bone metastases and increase of overall survival, and (5) current data on the possible use of menopausal hormone therapy (MHT) in these patients. The objective is to provide a sound pathophysiological background along with evidence-based and practical recommendations for physicians managing such women.
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Affiliation(s)
- Stavroula A Paschou
- Second Department of Obstetrics and Gynaecology, Aretaieio Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Areti Augoulea
- Second Department of Obstetrics and Gynaecology, Aretaieio Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynaecology, Aretaieio Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
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Miyashita H, Satoi S, Kuno T, Cruz C, Malamud S, Kim SM. Bone modifying agents for bone loss in patients with aromatase inhibitor as adjuvant treatment for breast cancer; insights from a network meta-analysis. Breast Cancer Res Treat 2020; 181:279-289. [PMID: 32318956 DOI: 10.1007/s10549-020-05640-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/08/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The data of head-to-head comparisons of the anti-fracture efficacy of bone modifying agents (BMAs) in patients with hormone receptor-positive breast cancer receiving aromatase inhibitor (AI) are not available. Therefore, we conducted a network meta-analysis to compare the efficacy of different BMAs in patients with breast cancer receiving adjuvant AI. METHODS We performed a network meta-analysis to compare the change of bone mineral densities (BMDs) and the risk of fracture in the selected studies using a random effect model. The primary outcomes are the change of BMD of lumbar spine (LS) and total hip (TH) from the baseline (ΔBMD, %) at 1 and 2 years and the risk of fracture. RESULTS We identified and included a total of 16 randomized controlled trials for this analysis. All BMAs included (risedronate, zoledronate, and denosumab) were associated with a significant increase in BMD of LS and TH at 1 and 2 years compared with no upfront treatment group. Among BMAs, zoledronate and denosumab use resulted in significantly higher BMD of LS and TH at 1 and 2 years compared with risedronate. The risk of fracture was significantly lower in the patients who received denosumab or risedronate compared with the patients without upfront treatment (Relative risk (RR) [95% CI] 0.51 [0.38-0.67] and 0.54 [0.35-0.83], respectively). CONCLUSION Among the bisphosphonates, zoledronate increased BMD the most, but risedronate, not zoledronate, use was associated with lower risk of fracture. Denosumab increased BMD not only of LS but also of the cortical-bone-rich hip, and showed a significant reduction of fracture risk.
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Affiliation(s)
- Hirotaka Miyashita
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA. .,Mount Sinai Bone Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Sera Satoi
- Department of Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Christina Cruz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Stephen Malamud
- Mount Sinai Beth Israel Comprehensive Cancer Center, New York, NY, USA
| | - Se-Min Kim
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA. .,Mount Sinai Bone Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Bouvard B, Confavreux CB, Briot K, Bonneterre J, Cormier C, Cortet B, Hannoun-Lévi JM, Hennequin C, Javier RM, Kerbrat P, Lespessailles E, Lesur A, Mayeur D, Paccou J, Trémollières F, Vieillard MH, Debiais F. French recommendations on strategies for preventing and treating osteoporosis induced by adjuvant breast cancer therapies. Joint Bone Spine 2019; 86:542-553. [PMID: 31352137 DOI: 10.1016/j.jbspin.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 01/12/2023]
Abstract
Standard adjuvant therapies for breast cancer such as chemotherapy or aromatase inhibitor and LH-RH agonist hormone therapy are associated with significant survival gains but also induce bone loss by aggravating the estrogen deprivation. The bone loss may be substantial, notably during early treatment, and occurs regardless of the baseline bone mineral density values. The objective of developing these recommendations was to achieve a practical consensus among various scientific societies, based on literature review, about osteoporosis prevention and treatment in these patients. The following scientific societies contributed to the work: Société Française de Rhumatologie (SFR), Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), Groupe Européen d'Etudes des Métastases Osseuses (GEMO), Association Francophone pour les Soins Oncologiques de Support (AFSOS), Société Française de Sénologie et de Pathologie Mammaire (SFSPM), Société Française de Radiothérapie Oncologique (SFRO). Drug prescription and reimbursement modalities in France were taken into account. These recommendations apply to postmenopausal women taking systemic chemotherapy and/or aromatase inhibitor therapy, non-postmenopausal women taking LH-RH agonist therapy, and non-postmenopausal women with persistent amenorrhea 1 year after chemotherapy completion. All women in these three categories should undergo an evaluation of bone health and receive interventions to combat risk factors for bone loss. Patients with a history of severe osteoporotic fracture and/or a T-score value <-2.5 should receive osteoporosis drug therapy. The FRAX® score should be used to guide treatment decisions in patients whose T-score is between -1 and -2.5. General osteoporosis prevention measures should be applied in patients without criteria for osteoporosis drug therapy, who should undergo bone mineral density measurements 18-24 months later if the baseline T-score is<-1 and 3-5 years later if the baseline T-score is>-1. The anti-tumor effect of bisphosphonates and denosumab was not considered when establishing these recommendations.
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Affiliation(s)
| | - Cyrille B Confavreux
- Université de Lyon, Service de rhumatologie, Centre Hospitalier Lyon Sud, Hospices civils de Lyon, 69310 Pierre Bénite, France
| | - Karine Briot
- Service de rhumatologie, Hôpital Cochin 74014 Paris, France
| | - Jacques Bonneterre
- Département de cancérologie sénologique, Centre Oscar Lambret, 59000 Lille, France
| | | | - Bernard Cortet
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | | | - Christophe Hennequin
- Service de cancérologie et radiothérapie, Hôpital Saint Louis, 75010 Paris, France
| | - Rose-Marie Javier
- Service de rhumatologie, CHU de Strasbourg, 67000 Strasbourg, France
| | - Pierre Kerbrat
- Service d'oncologie, Centre Eugène Marquis, 35042 Rennes, France
| | | | - Anne Lesur
- Service d'oncologie, Institut Alexis Vautrin, 54519 Vandoeuvre-Les-Nancy, France
| | - Didier Mayeur
- Centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - Julien Paccou
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | | | - Marie-Hélène Vieillard
- Service de rhumatologie, CHU de Lille, 59037 Lille, France; Département des soins de support, Centre Oscar Lambret, 59000 Lille, France
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Pineda-Moncusí M, Servitja S, Casamayor G, Cos ML, Rial A, Rodriguez-Morera J, Tusquets I, Diez-Perez A, Garcia-Giralt N, Nogués X. Bone health evaluation one year after aromatase inhibitors completion. Bone 2018; 117:54-59. [PMID: 30223134 DOI: 10.1016/j.bone.2018.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/13/2018] [Accepted: 09/13/2018] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Breast cancer patients treated with aromatase inhibitors (AIs) experience increased bone loss during their treatment. However, there is little information about bone mineral density (BMD) after completing AI-treatment. The present study aimed to assess BMD changes one year after AI-therapy completion. METHODS Data were collected from 864 postmenopausal women treated with AI during 5 years (5y-AI group), or during 2-3 years after taking tamoxifen therapy (pTAM-AI group). Participants with osteoporosis were treated with oral bisphosphonates (BP). BMD changes in lumbar spine (LS), femoral neck (FN) and total hip (TH) between baseline, end of treatment, and at one year post-treatment were assessed using repeated-measures ANOVA. RESULTS At the end of AI-treatment, 382 patients had available BMD values and 316 also had post-treatment BMD values. As expected, BMD levels were decreased at AI-completion in non-BP treated patients. After one year, LS BMD increased in both groups (5y-AI: +2.11% [95%CI: 1.55 to 2.68], p < 0.001; pTAM-AI: +1.00% [95%CI: 0.49 to 1.51], p < 0.001) compared with the end of AI-therapy, while values at FN and TH remained stable. On the other hand, BMD values of BP-treated patients were increased or maintained at the end of AI-treatment and also at post-treatment. CONCLUSIONS At one year after AI-completion, FN and TH BMD remained reduced in non-BP treated women, while LS BMD was recovered in the 5y-AI group and partially recovered in the pTAM-AI group. BP treatment increased or maintained BMD values at the end of therapy and at one year post-treatment.
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Affiliation(s)
- Marta Pineda-Moncusí
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain
| | - Sonia Servitja
- Cancer Research Program, IMIM (Hospital del Mar Research Institute), Barcelona, Spain
| | - Guillem Casamayor
- Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Lourdes Cos
- Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Abora Rial
- Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaime Rodriguez-Morera
- Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignasi Tusquets
- Cancer Research Program, IMIM (Hospital del Mar Research Institute), Barcelona, Spain
| | - Adolfo Diez-Perez
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain; Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Garcia-Giralt
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain.
| | - Xavier Nogués
- IMIM (Hospital del Mar Research Institute), Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Barcelona, Spain; Internal Medicine Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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11
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Grossmann M, Ramchand SK, Milat F, Vincent A, Lim E, Kotowicz MA, Hicks J, Teede H. Assessment and management of bone health in women with oestrogen receptor-positive breast cancer receiving endocrine therapy: Position statement of the Endocrine Society of Australia, the Australian and New Zealand Bone & Mineral Society, the Australasian Menopause Society and the Clinical Oncology Society of Australia. Clin Endocrinol (Oxf) 2018; 89:280-296. [PMID: 29741296 DOI: 10.1111/cen.13735] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/01/2018] [Accepted: 05/01/2018] [Indexed: 12/11/2022]
Abstract
To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is ≥5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.
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Affiliation(s)
- Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Vic., Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Heidelberg, Vic., Australia
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Vic., Australia
| | - Frances Milat
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Hudson Institute of Medical Research, Clayton, Vic., Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Vic., Australia
| | - Amanda Vincent
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventative Medicine, Monash University, Clayton, Vic., Australia
| | - Elgene Lim
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
- St Vincent's Hospital, University of New South Wales Sydney, Darlinghurst, NSW, Australia
| | - Mark A Kotowicz
- Deakin University, Geelong, Vic., Australia
- Department of Endocrinology and Diabetes, University Hospital, Geelong, Vic., Australia
- Department of Medicine, Melbourne Medical School - Western Campus, The University of Melbourne, St Albans, Vic., Australia
| | - Jill Hicks
- Breast Cancer Network Australia, Camberwell, Vic., Australia
| | - Helena Teede
- Department of Endocrinology, Monash Health, Clayton, Vic., Australia
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventative Medicine, Monash University, Clayton, Vic., Australia
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12
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Evidence for the prevention of bone loss in elderly and old early non-metastatic breast cancer patients treated with aromatase inhibitors. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Monda V, Lupoli GA, Messina G, Peluso R, Panico A, Villano I, Salerno M, Sessa F, Marciello F, Moscatelli F, Valenzano A, Molino L, Lupoli R, Fonderico F, Tortora A, Pisano A, Ruberto M, Gabriella M, Cavaliere G, Trinchese G, Mollica MP, Cipolloni L, Cibelli G, Monda M, Lupoli G, Messina A. Improvement of Bone Physiology and Life Quality Due to Association of Risedronate and Anastrozole. Front Pharmacol 2017; 8:632. [PMID: 28955236 PMCID: PMC5601069 DOI: 10.3389/fphar.2017.00632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/28/2017] [Indexed: 12/16/2022] Open
Abstract
The endocrine therapy is the new frontiers of many breast cancers hormone sensitive. Hormone therapy for treating women with hormone receptor-positive cancer suppresses breast cancer growth either by reducing estrogen synthesis or by interfering with the action of estrogen within tumor cells. In this prospective randomized observational study we investigate the effect of adjuvant anastrozole in monotherapy or associated with risedronate on bone physiology and quality of life in postmenopausal, hormone-sensitive early breast cancer women at mild to moderate risk of fragility fractures. Methods : 84 women were randomly assigned to receive anastrozole alone (group A) or anastrozole plus oral risedronate (group A+R). At baseline and after 24 months lumbar spine (LS) and femoral neck (FN) BMD were evaluated with dual-energy x-ray absorptiometry and health-related quality of life (HRQoL) was examined using the short-form healthy survey. Results : After 24 months, the group A+R has showed a significant increase in T-score for LS (p < 0.05) and for FN (p < 0.05) whereas women of group A had a statistically significant rate of bone loss both in LS T-score (p < 0.05) and in FN (p < 0.05). A significant change in T-score BMD was seen for group A+R compared with group A at the LS (p = 0.04) and at FN (p = 0.04). Finally, group A+R showed an overall significant improvement of health profile (SF-36) in group A (p = 0.03). Conclusion : Postmenopausal breast cancer women with osteopenia during treatment with anastrozole have considerable risk of developing osteoporosis during the first 2 years; preventive measures such as healthy lifestyle and daily supplements of calcium and vitamin D alone seem to be insufficient in holding their bones healthy. Our findings suggest the usefulness of addition of risedronate in order to prevent aromatase inhibitors-related bone loss, not only in case of high-risk of fractures, but also for women at mild-moderate risk. This determines a significant improvement in bone health and a positive impact on HRQoL.
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Affiliation(s)
- Vincenzo Monda
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Gelsy A Lupoli
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
| | - Giovanni Messina
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Rosario Peluso
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy.,Rheumatology Research Unit, University of Naples Federico IINaples, Italy
| | - Annalisa Panico
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Ines Villano
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
| | - Monica Salerno
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Francesco Sessa
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Francesca Marciello
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Fiorenzo Moscatelli
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Anna Valenzano
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Leonardo Molino
- Rheumatology Research Unit, University of Naples Federico IINaples, Italy
| | - Roberta Lupoli
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Francesco Fonderico
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Anna Tortora
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Agata Pisano
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy.,Department of Oncohematology, Santa Maria delle Grazie HospitalPozzuoli, Italy
| | - Maria Ruberto
- Department of Medical-Surgical and Dental Specialties, University of Campania "L.Vanvitelli"Naples, Italy
| | - Marsala Gabriella
- Struttura Complessa di Farmacia, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di FoggiaFoggia, Italy
| | - Gina Cavaliere
- Department of Biology, University of Naples Federico IINaples, Italy
| | | | - Maria P Mollica
- Department of Biology, University of Naples Federico IINaples, Italy
| | | | - Giuseppe Cibelli
- Department of Clinical and Experimental Medicine, University of FoggiaFoggia, Italy
| | - Marcellino Monda
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
| | - Giovanni Lupoli
- Section of Human Physiology and Unit of Dietetic and Sport Medicine, Department of Experimental Medicine, University of Campania "L. Vanvitelli"Naples, Italy
| | - Antonietta Messina
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
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14
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Kommalapati A, Tella SH, Esquivel MA, Correa R. Evaluation and management of skeletal disease in cancer care. Crit Rev Oncol Hematol 2017; 120:217-226. [PMID: 29032892 DOI: 10.1016/j.critrevonc.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/15/2017] [Accepted: 09/07/2017] [Indexed: 01/04/2023] Open
Abstract
Recently, there have been considerable advancements in cancer therapies thereby prolonging the life of cancer survivors. However, these recent advancements present new challenges in the management of bone disease in cancer survivors. Bone acts as a fertile soil for cancer seeding and bone health is often compromised because of increased inflammatory cytokines in cancer, direct cancer metastasis and toxic effects of anti-cancer therapies. This effect is more pronounced in elderly population who already have compromised bone mineral density leading to increased skeletal related events and bone pain. Timely diagnosis and effective interventions are essential for reducing bone-related morbidity in cancer survivors. Also, a complex interdependence exists between cancer related bone disease and tumor growth, creating a vicious circle of extensive bone destruction and cancer progression. Hence, maintenance of bone health and integrity plays a pivotal role in comprehensive cancer care. The bone-targeted treatments have been shown to preserve bone health, and modify the course of the underlying cancer. Management of long-term bone health requires a broad knowledge base that endocrinologists, oncologists and other care team members should be aware of. The manuscript highlights the skeletal effects of cancer, adjuvant therapies used for hormone-responsive cancers, chemotherapy induced bone loss and steps for accurate diagnosis and management of bone disease in cancer survivors by bridging the gaps in the comprehensive cancer care.
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Affiliation(s)
- Anuhya Kommalapati
- Department of Internal Medicine, Washington Hospital Center, Washington DC, USA
| | | | - Mary Angelynne Esquivel
- Endocrinology, Diabetes and Metabolism, Warren Alpert Medical School of Brown University, Rhode Island, USA
| | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, Warren Alpert Medical School of Brown University, Rhode Island, USA
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15
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Safaei-Nodehi R, Esmaili J, Sharifian R, Movaseghi S, Parkhideh S. Does adjuvant chemotherapy change bone mineral density and related serum biomarkers in women with breast cancer? CASPIAN JOURNAL OF INTERNAL MEDICINE 2017; 8:91-98. [PMID: 28702147 PMCID: PMC5494042 DOI: 10.22088/cjim.8.2.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: The primary objective of this study was to assess BMD change in Iranian females with breast cancer. Methods: A sample of 73 female breast cancer patients treated with adjuvant chemotherapy either alone or followed by radiotherapy between March 2013 and February 2016 were considered for this study. Bone mineral density (BMD) change was evaluated by measuring z-score of lumbar spine, femoral neck (right and left side) as well as biochemical measurements. With respect to WHO categorization for the treatment of osteoporosis, patients were categorized as normal BMD, osteopenic and all analysis was done separately. Results: In women with normal BMD, lumbar spine and femoral neck (right side) z-score decreased significantly by 15.7 and 39%, respectively (p<0.05). In osteoporosis group, there was no BMD change in any of the lumbar or femoral neck z-scores. However, in osteopenic patients, femoral neck BMD decreased significantly by 40.9% after 8 months (p=0.003). The level of all measured biomedical markers such as Ca, Alb, P and vitamin OHD decreased significantly in a follow-up visit in both osteoporosis and normal BMD. Conclusion: Our results revealed that adjuvant chemotherapy led to unfavorable effects on lumbar spine and femoral neck means z-score during 8 months. Also, unfavorable changes in biochemical markers appeared in all groups.
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Affiliation(s)
- Reza Safaei-Nodehi
- Hematology- Oncology and BMT center, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Esmaili
- Department of Nuclear Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramazanali Sharifian
- Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shafieh Movaseghi
- Taleghani Bone Marrow Transplantation Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayeh Parkhideh
- Hematology- Oncology and BMT center, Tehran University of Medical Sciences, Tehran, Iran
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16
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Limon-Miro AT, Lopez-Teros V, Astiazaran-Garcia H. Dietary Guidelines for Breast Cancer Patients: A Critical Review. Adv Nutr 2017; 8:613-623. [PMID: 28710147 PMCID: PMC5502868 DOI: 10.3945/an.116.014423] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Current dietary guidelines for breast cancer patients (BCPs) fail to address adequate dietary intakes of macro- and micronutrients that may improve patients' nutritional status. This review includes information from the PubMed and Biomed Central databases over the last 15 y concerning dietary guidelines for BCPs and the potential impact of a personalized, nutrient-specific diet on patients' nutritional status during and after antineoplastic treatment. Results indicated that BCPs should receive a nutritional assessment immediately after diagnosis. In addition, they should be encouraged to pursue and maintain a healthy body weight [body mass index (BMI; in kg/m2) 20-24.9], preserving their lean mass and avoiding an increase in fat mass. Therefore, after nutritional status diagnosis, a conservative energy restriction of 500-1000 kcal/d could be considered in the dietary intervention when appropriate. Based on the reviewed information, we propose a personalized nutrition intervention for BCPs during and after antineoplastic treatment. Specifications in the nutritional therapy should be based on the patients' nutritional status, dietary habits, schedule, activities, and cultural preferences. BCPs' daily energy intake should be distributed as follows: <30% fat/d (mainly monounsaturated and polyunsaturated fatty acids), ∼55% carbohydrates (primarily whole foods such as oats, brown rice, and fruits), and 1.2-1.5 g protein ⋅ kg-1 ⋅ d-1 to avoid sarcopenic obesity. Findings suggest that 5-9 servings/d of fruits (∼150 g/serving) and vegetables (∼75 g/serving) should be encouraged. Garlic and cruciferous vegetables must also be part of the nutrition therapy. Adequate dietary intakes of food-based macro- and micronutrients rich in β-carotene and vitamins A, E, and C can both prevent deterioration in BCPs' nutritional status and improve their overall health and prognosis.
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Affiliation(s)
- Ana Teresa Limon-Miro
- Department of Nutrition, Research Center for Food and Development, Hermosillo, Sonora, Mexico; and
| | - Veronica Lopez-Teros
- Department of Chemical and Biological Sciences, University of Sonora, Hermosillo, Sonora, Mexico
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17
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Trémollieres FA, Ceausu I, Depypere H, Lambrinoudaki I, Mueck A, Pérez-López FR, van der Schouw YT, Senturk LM, Simoncini T, Stevenson JC, Stute P, Rees M. Osteoporosis management in patients with breast cancer: EMAS position statement. Maturitas 2017; 95:65-71. [DOI: 10.1016/j.maturitas.2016.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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18
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Abushwereb HS, Elhabash M, Elhamshari S, Eshaefi H. A retrospective study on screening and management of osteoporosis in breast cancer women treated with aromatase inhibitors in Libya. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2016; 13:186-189. [PMID: 28228779 PMCID: PMC5318169 DOI: 10.11138/ccmbm/2016.13.3.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Negative health effects of aromatase inhibitors (AI) treatments on bones such as osteoporosis are evidenced. This impact of the aromatase inhibitors on bone. This study aimed to improve the medical assistance given to patients under AI treatment to minimize secondary osteoporosis. Fifty Libyan postmenopausal women treated with AI to fight breast cancer were selected from attendants Tripoli Medical Center (TMC), Oncology Department during year 2014. A closed questionnaire was requested from each women including data about age, age at AI therapy, and types of AI, age at bone densitometry measurement, onset and symptoms of osteoporosis, treatment of osteoporosis and measurement of vitamin D and calcium supplement given. The study revealed a poor consideration given to apply the recommendation in cases suffering osteoporosis events. Our results suggest an active implementation of the guidelines concerning the high corporation levels that should be done between oncologist, specialist in osteoporosis, and patients to offer reliable diagnostic and post-therapy follow up.
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Affiliation(s)
- Hanan Saaddedin Abushwereb
- Pharmacology and Clinical Pharmacy Department, University of Tripoli, Faculty of Pharmacy, Tripoli, Libya
| | - M. Elhabash
- Oncology Department, Tripoli Medical Center, Tripoli, Libya
| | - S. Elhamshari
- Pharmacology and Clinical Pharmacy Department, University of Tripoli, Faculty of Pharmacy, Tripoli, Libya
| | - H. Eshaefi
- Pharmacology and Clinical Pharmacy Department, University of Tripoli, Faculty of Pharmacy, Tripoli, Libya
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19
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Vescini F, Attanasio R, Balestrieri A, Bandeira F, Bonadonna S, Camozzi V, Cassibba S, Cesareo R, Chiodini I, Francucci CM, Gianotti L, Grimaldi F, Guglielmi R, Madeo B, Marcocci C, Palermo A, Scillitani A, Vignali E, Rochira V, Zini M. Italian association of clinical endocrinologists (AME) position statement: drug therapy of osteoporosis. J Endocrinol Invest 2016; 39:807-34. [PMID: 26969462 PMCID: PMC4964748 DOI: 10.1007/s40618-016-0434-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/22/2016] [Indexed: 12/17/2022]
Abstract
Treatment of osteoporosis is aimed to prevent fragility fractures and to stabilize or increase bone mineral density. Several drugs with different efficacy and safety profiles are available. The long-term therapeutic strategy should be planned, and the initial treatment should be selected according to the individual site-specific fracture risk and the need to give the maximal protection when the fracture risk is highest (i.e. in the late life). The present consensus focused on the strategies for the treatment of postmenopausal osteoporosis taking into consideration all the drugs available for this purpose. A short revision of the literature about treatment of secondary osteoporosis due both to androgen deprivation therapy for prostate cancer and to aromatase inhibitors for breast cancer was also performed. Also premenopausal females and males with osteoporosis are frequently seen in endocrine settings. Finally particular attention was paid to the tailoring of treatment as well as to its duration.
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Affiliation(s)
- F. Vescini
- Endocrinology and Metabolic Disease Unit, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, P.le S.M. della Misericordia, 15, 33100 Udine, Italy
| | - R. Attanasio
- Endocrinology Service, Galeazzi Institute IRCCS, Milan, Italy
| | - A. Balestrieri
- Unit of Endocrinology and Diabetology, Department of Internal Medicine, M. Bufalini Hospital, Cesena, Italy
| | - F. Bandeira
- Division of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhães Hospital, University of Pernambuco Medical School, Recife, Brazil
| | | | - V. Camozzi
- Unit of Endocrinology, Department of Medicine, University of Padova, Padua, Italy
| | - S. Cassibba
- Endocrinology and Diabetology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - R. Cesareo
- Endocrinology, S. Maria Goretti Hospital, Latina, Italy
| | - I. Chiodini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - C. Maria Francucci
- Post Acute and Long Term Care Department, I.N.R.C.A., Ancona, Italy
- San Pier Damiano Hospital, Villa Maria Group Care and Research, Faenza, Ravenna Italy
| | - L. Gianotti
- Endocrinology and Metabolic Diseases, S. Croce e Carle Hospital, Cuneo, Italy
| | - F. Grimaldi
- Endocrinology and Metabolic Disease Unit, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, P.le S.M. della Misericordia, 15, 33100 Udine, Italy
| | - R. Guglielmi
- Endocrinology Unit, Regina Apostolorum Hospital, Albano Laziale, Rome Italy
| | - B. Madeo
- Integrated Department of Medicine, Endocrinology and Metabolism, Geriatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - C. Marcocci
- Endocrine Unit 2, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - A. Palermo
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy
| | - A. Scillitani
- Endocrinology, Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - E. Vignali
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - V. Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - M. Zini
- Endocrinology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy
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20
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Abdel-Rahman O. Denosumab versus zoledronic acid to prevent aromatase inhibitors-associated fractures in postmenopausal early breast cancer; a mixed treatment meta-analysis. Expert Rev Anticancer Ther 2016; 16:885-91. [DOI: 10.1080/14737140.2016.1192466] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Rodríguez-Sanz M, Prieto-Alhambra D, Servitja S, Garcia-Giralt N, Garrigos L, Rodriguez-Morera J, Albanell J, Martínez-García M, González I, Diez-Perez A, Tusquets I, Nogués X. AI-related BMD variation in actual practice conditions: A prospective cohort study. Endocr Relat Cancer 2016; 23:303-12. [PMID: 26911377 DOI: 10.1530/erc-16-0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/24/2016] [Indexed: 01/23/2023]
Abstract
The aim of the study was to evaluate the progression of bone mineral density (BMD) during 3 years of aromatase inhibitors (AI) therapy in actual practice conditions. This prospective, clinical cohort study of Barcelona-Aromatase induced Bone Loss in Early breast cancer (B-ABLE) assessed BMD changes during 3 years of AI treatment in women with breast cancer. Patients with osteoporosis (T score < -2.5 or T score ≤ -2.0) and a major risk factor and/or prevalent fragility fractures were treated with oral bisphosphonates (BPs). Of 685 women recruited, 179 (26.1%) received BP treatment. By the third year of AI therapy, this group exhibited increased BMD in the lumbar spine (LS; 2.59%) and femoral neck (FN; 2.50%), although the increase was significant only within the first year (LS: 1.99% and FN: 2.04%). Despite BP therapy, however, approximately 15% of these patients lost more than 3% of their baseline bone mass. At 3 years, patients without BP experienced BMD decreases in the LS (-3.10%) and FN (-2.79%). In this group, BMD changes occurred during the first (LS: -1.33% and FN: -1.25%), second (LS: -1.19% and FN: -0.82%), and third (LS: -0.57% and FN: -0.65%) years of AI treatment. Increased BMD (>3%) was observed in just 7.6% and 10.8% of these patients at the LS and FN, respectively. Our data confirm a clinically relevant bone loss associated with AI therapy amongst nonusers of preventative BPs. We further report on the importance of BMD monitoring as well as calcium and 25-hydroxy vitamin D supplementation in these patients.
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Affiliation(s)
- María Rodríguez-Sanz
- IMIM (Hospital del Mar Research Institute)Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Barcelona, Spain
| | - Daniel Prieto-Alhambra
- IMIM (Hospital del Mar Research Institute)Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Barcelona, Spain IDIAP Jordi Gol Primary Care Research InstituteUniversitat Autònoma de Barcelona, Barcelona, Spain Nuffield Department of OrthopaedicsRheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK MRC Lifecourse Epidemiology UnitUniversity of Southampton, Southampton, UK
| | - Sonia Servitja
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Natalia Garcia-Giralt
- IMIM (Hospital del Mar Research Institute)Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Barcelona, Spain
| | - Laia Garrigos
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Jaime Rodriguez-Morera
- Internal Medicine DepartmentHospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Albanell
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Maria Martínez-García
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Iria González
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Adolfo Diez-Perez
- IMIM (Hospital del Mar Research Institute)Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Barcelona, Spain Internal Medicine DepartmentHospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignasi Tusquets
- Cancer Research ProgramIMIM (Hospital del Mar Research Institute), Medical Oncology Department, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain
| | - Xavier Nogués
- IMIM (Hospital del Mar Research Institute)Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), Barcelona, Spain Internal Medicine DepartmentHospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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Benefit/risk for adjuvant breast cancer therapy with tamoxifen or aromatase inhibitor use by age, and race/ethnicity. Breast Cancer Res Treat 2015; 154:609-16. [DOI: 10.1007/s10549-015-3647-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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Abstract
Breast cancer is one of the most common malignancies of women. The majority of breast cancers express estrogen and/or progesterone receptors, permitting anticancer targeting strategies to reduce estrogen signaling in the cancer cells and thereby lowering the risk of breast cancer recurrence. The development of the selective estrogen receptor modulator (SERM) tamoxifen marked a significant milestone in breast cancer care that transcended older estrogen ablative strategies such as oophorectomy and ovarian irradiation. An unintended benefit of tamoxifen in postmenopausal women was bone density preservation. The third generation of aromatase inhibitors (AIs) have demonstrated superior efficacy to tamoxifen in improving disease-free survival in postmenopausal women. However, the AIs significantly increase bone resorption, reduce bone mineral density, and increase the risk of fracture above that of tamoxifen. As a consequence of this, clinical oncologists have assumed a larger role in the screening and treatment of the skeletal complications of breast cancer therapies. The key features of managing bone health in women with early stage breast cancer receiving adjuvant endocrine therapy are reviewed here.
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Affiliation(s)
- Gregory A Clines
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA,
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24
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Greenspan SL, Vujevich KT, Brufsky A, Lembersky BC, van Londen GJ, Jankowitz RC, Puhalla SL, Rastogi P, Perera S. Prevention of bone loss with risedronate in breast cancer survivors: a randomized, controlled clinical trial. Osteoporos Int 2015; 26:1857-64. [PMID: 25792492 PMCID: PMC4766869 DOI: 10.1007/s00198-015-3100-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In postmenopausal women with low bone mass and hormone-receptor-positive breast cancer on an aromatase inhibitor, risedronate maintained skeletal health assessed by bone density and turnover markers. Women with the greatest decreases in bone turnover markers at 12 months had the greatest increases in bone density at 24 months. INTRODUCTION Aromatase inhibitors (AIs), adjuvant endocrine therapy for postmenopausal women with hormone-receptor-positive breast cancer, are associated with bone loss and fractures. Our objectives were to determine if (1) oral bisphosphonate therapy can prevent bone loss in women on an AI and (2) early changes in bone turnover markers (BTM) can predict later changes in bone mineral density (BMD). METHODS We conducted a 2-year double-blind, placebo-controlled, randomized trial in 109 postmenopausal women with low bone mass on an AI (anastrozole, letrozole, or exemestane) for hormone-receptor-positive breast cancer. Participants were randomized to once weekly risedronate 35 mg or placebo, and all received calcium plus vitamin D. The main outcome measures included BMD, BTM [carboxy-terminal collagen crosslinks (CTX) and N-terminal propeptide of type 1 procollagen (P1NP)], and safety. RESULTS Eighty-seven percent completed 24 months. BMD increased more in the active treatment group compared to placebo with an adjusted difference at 24 months of 3.9 ± 0.7 percentage points at the spine and 3.2 ± 0.5 percentage points at the hip (both p < 0.05). The adjusted difference between the active treatment and placebo groups were 0.09 ± 0.04 nmol/LBCE for CTX and 23.3 ± 4.8 μg/mL for P1NP (both p < 0.05). Women with greater 12-month decreases in CTX and P1NP in the active treatment group had a greater 24-month increase in spinal BMD (p < 0.05). The oral therapy was safe and well tolerated. CONCLUSION In postmenopausal women with low bone mass and breast cancer on an AI, the oral bisphosphonate risedronate maintained skeletal health.
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Affiliation(s)
- S L Greenspan
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA.
| | - K T Vujevich
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - A Brufsky
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - B C Lembersky
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - G J van Londen
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - R C Jankowitz
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - S L Puhalla
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - P Rastogi
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - S Perera
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
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Garg A, Leitzel K, Ali S, Lipton A. Antiresorptive therapy in the management of cancer treatment-induced bone loss. Curr Osteoporos Rep 2015; 13:73-7. [PMID: 25575469 DOI: 10.1007/s11914-014-0252-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cancer treatment-induced bone loss treatment has an important role to prevent bone loss-related events like fracture, significant morbidity, mortality, disfigurement and loss of self-esteem, and health-care expenditure. Numerous factors, including treatment regimens and bone metastasis, increase the risk of osteoporosis or local bone destruction in most breast and prostate cancer patients. Cytotoxic chemotherapies, radiation, and hormonal therapies can lead to premature menopause and decrease bone mineral density. Over 60 % of breast cancer patients within 1 year of beginning postoperative adjuvant chemotherapy experience ovarian failure. Also, ovarian ablation and aromatase inhibitors used to treat breast cancer and orchiectomy and androgen deprivation therapy (ADT; to treat prostate cancer) cause substantial bone loss. In this article, we will focus mainly on antiresorptive therapy in the management of cancer treatment-induced bone loss (CTIBL). An understanding of CTIBL is critical for determining how to assess the risk and identify which patients may benefit from preventive therapy.
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Affiliation(s)
- Ashwani Garg
- Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA,
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26
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Bouvard B, Soulié P, Hoppé E, Georgin-Mege M, Royer M, Mesgouez-Nebout N, Lassalle C, Cellier P, Jadaud E, Abadie-Lacourtoisie S, Tuchais C, Vinchon-Petit S, Audran M, Chappard D, Legrand E. Fracture incidence after 3 years of aromatase inhibitor therapy. Ann Oncol 2014; 25:843-847. [PMID: 24608193 DOI: 10.1093/annonc/mdu008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to describe the fracture incidence and bone mineral density (BMD) evolution in a large cohort of post-menopausal women with breast cancer after 3 years of aromatase inhibitor (AI) therapy. PATIENTS AND METHODS A prospective, longitudinal study in real-life setting. Each woman had an extensive medical assessment, a biological evaluation, a BMD measurement, and systematic spinal X-rays at baseline and after 3 years of AI therapy. Women with osteoporosis at baseline (T-score < -2.5 and/or non-traumatic fracture history) were treated by oral weekly bisphosphonates. RESULTS Among 497 women (mean age 63.8 ± 9.6 years) included in this study, 389 had a bone evaluation both at baseline and after 3 years of AI therapy: 267 women (mean age 61.2 ± 8.6) with no osteoporosis at baseline and 122 women (mean age 67.2 ± 9.1) with osteoporosis at baseline justifying a weekly oral bisphosphonate treatment. Women without bisphosphonates had a significant decrease in spine BMD (-3.5%, P < 0.01), neck BMD (-2.0%, P < 0.01), and total hip BMD (-2.1%, P < 0.01) over the 3 years but only 15 of them (5.6%) presented an incident vertebral or non-vertebral fracture. In osteoporotic women treated with bisphosphonates, spine and hip BMD were maintained at 3 years but 12 of them (9.8%) had an incident fracture. These fractured women were significantly older (74.1 ± 9.8 versus 66.5 ± 8.8) but also presented BMD loss during treatment suggesting poor adherence to bisphosphonate treatment. CONCLUSION This real-life study confirmed that AIs induced moderate bone loss and low fracture incidence in post-menopausal women without initial osteoporosis. In women with baseline osteoporosis and AI therapy, oral bisphosphonates maintain BMD but were associated with a persistent fracture risk, particularly in older women.
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Affiliation(s)
- B Bouvard
- Department of Rheumatology; Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers.
| | - P Soulié
- Paul Papin Cancer Institute, ICO, Angers, France
| | - E Hoppé
- Department of Rheumatology; Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers
| | | | - M Royer
- Department of Rheumatology; Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers
| | | | | | - P Cellier
- Paul Papin Cancer Institute, ICO, Angers, France
| | - E Jadaud
- Paul Papin Cancer Institute, ICO, Angers, France
| | | | - C Tuchais
- Paul Papin Cancer Institute, ICO, Angers, France
| | | | - M Audran
- Department of Rheumatology; Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers
| | - D Chappard
- Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers
| | - E Legrand
- Department of Rheumatology; Research Group on Bone Remodeling and BioMaterials, UPRES EA 4658, University Hospital, Angers
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27
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The efficacy of bisphosphonates in preventing aromatase inhibitor induced bone loss for postmenopausal women with early breast cancer: a systematic review and meta-analysis. JOURNAL OF ONCOLOGY 2014; 2014:625060. [PMID: 24795759 PMCID: PMC3984802 DOI: 10.1155/2014/625060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/20/2013] [Accepted: 11/20/2013] [Indexed: 11/17/2022]
Abstract
Objectives. We aim to determine the efficacy of bisphosphonates in preventing aromatase inhibitor induced bone loss (AIBL) in postmenopausal women with early breast cancer. The secondary objective was to determine the safety of bisphosphonates. Materials and Methods. We searched electronic databases in a time period of 1995 January to 2013 June. Random effects meta-analytical models were used; between study heterogeneity and publication bias was assessed. Results. A total of six eligible studies reported the BMD T score of LS at 12 months and from that 3 trials of Zoledronic acid compared the change in BMD in immediate ZOL versus delayed ZOL done with subgroups like patients with normal BMD at baseline (OR = 5.402, 95% CI = 1.329-21.959, P value = 0.018) and osteopenic BMD at baseline (OR = 4.008, 95% CI = 2.249-7.143, P value = 0.0002). Both had a significant decrease in BMD that favoured the delayed ZOL; 3 trials of risedronate and ibandronate also had a significant decrease in BMD in AIs alone group. Immediate ZOL versus delayed ZOL also showed increased risk of getting an ADR in immediate group. Conclusion. Third generation bisphosphonates has an effect on BMD of patients who are on treatment of AIs in breast cancer. Furthermore, the patients treated with immediate ZOL had a significantly high risk of musculoskeletal ADR's than patients with delayed ZOL.
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Goss PE, Hershman DL, Cheung AM, Ingle JN, Khosla S, Stearns V, Chalchal H, Rowland K, Muss HB, Linden HM, Scher J, Pritchard KI, Elliott CR, Badovinac-Crnjevic T, St Louis J, Chapman JAW, Shepherd LE. Effects of adjuvant exemestane versus anastrozole on bone mineral density for women with early breast cancer (MA.27B): a companion analysis of a randomised controlled trial. Lancet Oncol 2014; 15:474-82. [PMID: 24636210 DOI: 10.1016/s1470-2045(14)70035-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of breast cancer with aromatase inhibitors is associated with damage to bones. NCIC CTG MA.27 was an open-label, phase 3, randomised controlled trial in which women with breast cancer were assigned to one of two adjuvant oral aromatase inhibitors-exemestane or anastrozole. We postulated that exemestane-a mildly androgenic steroid-might have a less detrimental effect on bone than non-steroidal anastrozole. In this companion study to MA.27, we compared changes in bone mineral density (BMD) in the lumbar spine and total hip between patients treated with exemestane and patients treated with anastrozole. METHODS In MA.27, postmenopausal women with early stage hormone (oestrogen) receptor-positive invasive breast cancer were randomly assigned to exemestane 25 mg versus anastrozole 1 mg, daily. MA.27B recruited two groups of women from MA.27: those with BMD T-scores of -2·0 or more (up to 2 SDs below sex-matched, young adult mean) and those with at least one T-score (hip or spine) less than -2·0. Both groups received vitamin D and calcium; those with baseline T-scores of less than -2·0 also received bisphosphonates. The primary endpoints were percent change of BMD at 2 years in lumbar spine and total hip for both groups. We analysed patients according to which aromatase inhibitor and T-score groups they were allocated to but BMD assessments ceased if patients deviated from protocol. This study is registered with ClinicalTrials.gov, NCT00354302. FINDINGS Between April 24, 2006, and May 30, 2008, 300 patients with baseline T-scores of -2·0 or more were accrued (147 allocated exemestane, 153 anastrozole); and 197 patients with baseline T-scores of less than -2·0 (101 exemestane, 96 anastrozole). For patients with T-scores greater than -2·0 at baseline, mean change of bone mineral density in the spine at 2 years did not differ significantly between patients taking exemestane and patients taking anastrozole (-0·92%, 95% CI -2·35 to 0·50 vs -2·39%, 95% CI -3·77 to -1·01; p=0·08). Respective mean loss in the hip was -1·93% (95% CI -2·93 to -0·93) versus -2·71% (95% CI -4·32 to -1·11; p=0·10). Likewise for those who started with T-scores of less than -2·0, mean change of spine bone mineral density at 2 years did not differ significantly between the exemestane and anastrozole treatment groups (2·11%, 95% CI -0·84 to 5·06 vs 3·72%, 95% CI 1·54 to 5·89; p=0·26), nor did hip bone mineral density (2·09%, 95% CI -1·45 to 5·63 vs 0·0%, 95% CI -3·67 to 3·66; p=0·28). Patients with baseline T-score of -2·0 or more taking exemestane had two fragility fractures and two other fractures, those taking anastrozole had three fragility fractures and five other fractures. For patients who had baseline T-scores of less than -2·0 taking exemestane, one had a fragility fracture and four had other fractures, whereas those taking anastrozole had five fragility fractures and one other fracture. INTERPRETATION Our results demonstrate that adjuvant treatment with aromatase inhibitors can be considered for breast cancer patients who have T-scores less than -2·0. FUNDING Canadian Cancer Society Research Institute, Pfizer, Canadian Institutes of Health Research.
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Affiliation(s)
- Paul E Goss
- Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | - Vered Stearns
- Johns Hopkins Oncology Centre, School of Medicine, Baltimore, MD, USA
| | | | | | - Hyman B Muss
- University of North Carolina/Lineberger Comp Cancer Center, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | - Lois E Shepherd
- NCIC Clinical Trials Group, Queen's University, Kingston, ON, Canada
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29
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Abstract
PURPOSE OF REVIEW Over the past few years, a number of studies have examined the relationship between breast cancer and osteoporosis, the effect of breast cancer treatment on bone health, and the effect of osteoporosis therapies on aromatase inhibitor-induced bone loss and breast cancer recurrence. New guidelines have been released on the prevention of osteoporotic fractures in women with breast cancer who are on aromatase inhibitors for adjuvant therapy. RECENT FINDINGS Despite common factors linking high bone mineral density and increased risk of breast cancer, women with breast cancer are not protected from osteoporosis or osteoporotic fractures. Recent data suggest that aromatase inhibitors have a detrimental effect on bone mineral density and can increase the risk of fractures. Bisphosphonate therapy not only preserves aromatase inhibitor-induced bone loss, but may also improve disease-free survival and decrease risk of death in select women with breast cancer (i.e., postmenopausal women). SUMMARY Osteoporosis and breast cancer are common in women, especially in postmenopausal women. Current guidelines suggest that we need to pay special attention to those on aromatase inhibitors to prevent adverse bone outcomes.
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Affiliation(s)
- Angela M Cheung
- aWomen's Health Program bOsteoporosis Program cDepartment of Medicine dDepartment of Family and Community Medicine, University Health Network, University of Toronto, Ontario, Canada
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30
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Abstract
Breast cancer and osteoporosis are common diagnoses in women. Breast cancer survival has improved due to earlier detection and improved treatments. As most breast cancers are estrogen receptor positive, treatment is often aimed at altering the hormonal environment. Both pre and postmenopausal women undergoing these therapies are at risk for bone loss. The patient's health care team ought to have an awareness of the potential for breast cancer treatments to accelerate bone loss. Women with early stage breast cancer are treated with curative intent and, therefore, maintaining bone health is important and is part of the survivorship care to ensure an optimal quality of life.
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Affiliation(s)
- Palak Choksi
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Health System, 24 Frank Lloyd Wright Drive, Lobby C, Ann Arbor, MI, 48106, USA,
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Abstract
Cancer is a major risk factor for bone loss and fractures. This is due both to direct effects of cancer cells on the skeleton and to deleterious effects of cancer-specific therapies on bone cells. Marked improvements in survival for many cancers mean that strategies to limit bone loss and reduce fracture risk must be incorporated into the care plans for nearly all patients with cancer. The vast majority of effort thus far has focused on bone loss in patients with breast and prostate cancers, with comparatively few studies in other malignancies. Antiresorptive therapies have proven nearly universally effective for limiting bone loss in cancer patients, although few studies have been powered sufficiently to include fractures as primary endpoints, and patients are frequently neither identified nor treated according to published guidelines. Nonpharmacologic approaches to limit falls, particularly in elderly patients, are also likely important adjunctive measures for most cancer patients.
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Affiliation(s)
- Matthew T Drake
- Division of Endocrinology, Department of Medicine, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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Datta M, Schwartz GG. Calcium and vitamin D supplementation and loss of bone mineral density in women undergoing breast cancer therapy. Crit Rev Oncol Hematol 2013; 88:613-24. [PMID: 23932583 DOI: 10.1016/j.critrevonc.2013.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/20/2013] [Accepted: 07/09/2013] [Indexed: 02/07/2023] Open
Abstract
An unintended consequence of breast cancer therapies is an increased risk of osteoporosis due to accelerated bone loss. We conducted a systematic review of calcium and/or vitamin D (Ca±D) supplementation trials for maintaining bone mineral density (BMD) in women with breast cancer using the "before-after" data from the Ca±D supplemented comparison group of trials evaluating the effect of drugs such as bisphosphonates on BMD. Whether Ca±D supplements increase BMD in women undergoing breast cancer therapy has never been tested against an unsupplemented control group. However, results from 16 trials indicate that the Ca±D doses tested (500-1500mg calcium; 200-1000IU vitamin D) were inadequate to prevent BMD loss in these women. Cardiovascular disease is the main cause of mortality in women with breast cancer. Because calcium supplements may increase cardiovascular disease risk, future trials should evaluate the safety and efficacy of Ca±D supplementation in women undergoing breast cancer therapy.
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Affiliation(s)
- Mridul Datta
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Role of bisphosphonates in postmenopausal women with breast cancer. Cancer Treat Rev 2013; 40:476-84. [PMID: 23906846 DOI: 10.1016/j.ctrv.2013.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/02/2013] [Accepted: 07/08/2013] [Indexed: 11/21/2022]
Abstract
Data suggest that bisphosphonates protect bone health and may have anticancer activity in postmenopausal women during adjuvant breast cancer therapy. However, key questions remain surrounding the role of adjuvant bisphosphonates in breast cancer, including patient populations deriving benefit, timing/scheduling of therapy, and specific clinical benefits. PubMed, Embase, and San Antonio Breast Cancer Symposium databases provide study results that address these issues in postmenopausal women. Review of these data would aid physicians in providing optimal management of breast cancer in postmenopausal women. For example, recent data reinforce use of intravenous bisphosphonates concurrently with adjuvant endocrine therapy to ameliorate bone loss in recently postmenopausal or osteopenic postmenopausal women with early breast cancer. In contrast, clinical data for oral bisphosphonates have not provided support for using anti-osteoporosis doses in this setting, and the optimal dose is unclear. Additionally, current clinical data show improvements in disease outcomes with bisphosphonates in many studies, although not in all patient subsets. Strong support for the potential adjuvant anticancer benefits from bisphosphonates has been demonstrated in women with established menopause (i.e., very low circulating estrogen levels). Initiating bisphosphonates early and concomitantly with adjuvant therapy generally provided the greatest benefits. However, questions remain such as schedule of treatment and relative potency among the intravenous bisphosphonates and elucidation of the role of oral bisphosphonates, as well as ongoing studies that might provide clarification. This review addresses these controversies in the context of translational research, which may provide the rationale for ongoing studies and evolving treatment paradigms in this area.
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Sperati F, Vici P, Maugeri-Saccà M, Stranges S, Santesso N, Mariani L, Giordano A, Sergi D, Pizzuti L, Di Lauro L, Montella M, Crispo A, Mottolese M, Barba M. Vitamin D supplementation and breast cancer prevention: a systematic review and meta-analysis of randomized clinical trials. PLoS One 2013; 8:e69269. [PMID: 23894438 PMCID: PMC3718745 DOI: 10.1371/journal.pone.0069269] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/06/2013] [Indexed: 12/14/2022] Open
Abstract
In recent years, the scientific evidence linking vitamin D status or supplementation to breast cancer has grown notably. To investigate the role of vitamin D supplementation on breast cancer incidence, we conducted a systematic review and meta-analysis of randomized controlled trials comparing vitamin D with placebo or no treatment. We used OVID to search MEDLINE (R), EMBASE and CENTRAL until April 2012. We screened the reference lists of included studies and used the “Related Article” feature in PubMed to identify additional articles. No language restrictions were applied. Two reviewers independently extracted data on methodological quality, participants, intervention, comparison and outcomes. Risk Ratios and 95% Confident Intervals for breast cancer were pooled using a random-effects model. Heterogeneity was assessed using the I2 test. In sensitivity analysis, we assessed the impact of vitamin D dosage and mode of administration on treatment effects. Only two randomized controlled trials fulfilled the pre-set inclusion criteria. The pooled analysis included 5372 postmenopausal women. Overall, Risk Ratios and 95% Confident Intervals were 1.11 and 0.74–1.68. We found no evidence of heterogeneity. Neither vitamin D dosage nor mode of administration significantly affected breast cancer risk. However, treatment efficacy was somewhat greater when vitamin D was administered at the highest dosage and in combination with calcium (Risk Ratio 0.58, 95% Confident Interval 0.23–1.47 and Risk Ratio 0.93, 95% Confident Interval 0.54–1.60, respectively). In conclusions, vitamin D use seems not to be associated with a reduced risk of breast cancer development in postmenopausal women. However, the available evidence is still limited and inadequate to draw firm conclusions. Study protocol code: FARM8L2B5L.
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Affiliation(s)
- Francesca Sperati
- Bostatistics/Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
| | - Patrizia Vici
- Division of Medical Oncology B, Regina Elena National Cancer Institute, Rome, Italy
| | - Marcello Maugeri-Saccà
- Division of Medical Oncology B/Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
| | - Saverio Stranges
- Health Sciences, Warwick Medical School, Coventry, United Kingdom
| | - Nancy Santesso
- Department of Clinical Epidemiology and Biostatistics, McMaster University Health Sciences Centre, Ontario, Canada
| | - Luciano Mariani
- Division of Gynecologic Oncology, Regina Elena National Cancer Institute, Rome, Italy
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine and Center of Biotechnology, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Domenico Sergi
- Division of Medical Oncology B, Regina Elena National Cancer Institute, Rome, Italy
| | - Laura Pizzuti
- Division of Medical Oncology B, Regina Elena National Cancer Institute, Rome, Italy
| | - Luigi Di Lauro
- Division of Medical Oncology B, Regina Elena National Cancer Institute, Rome, Italy
| | - Maurizio Montella
- Epidemiology Unit, National Cancer Institute G. Pascale Foundation, Naples, Italy
| | - Anna Crispo
- Epidemiology Unit, National Cancer Institute G. Pascale Foundation, Naples, Italy
| | - Marcella Mottolese
- Department of Pathology, Regina Elena National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Division of Medical Oncology B/Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
- * E-mail:
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Khan AJ, Parikh RR, Neboori HJ, Goyal S, Haffty BG, Moran MS. The relative benefits of tamoxifen in older women with T1 early-stage breast cancer treated with breast-conserving surgery and radiation therapy. Breast J 2013; 19:490-5. [PMID: 23800027 DOI: 10.1111/tbj.12150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Small, hormone receptor-positive breast carcinomas in older women are associated with low local recurrence rates. The relative benefits of adjuvant hormonal therapy remain unclear in elderly women with small, node-negative breast cancer after breast-conserving surgery and adjuvant radiation therapy. From our institutional data base, 224 patients ≥65 years of age with T1N0M0 breast cancer treated with BCS+RT were identified. Of these, 102 patients (45.5%) received tamoxifen (TAM) and 122 patients (54.5%) did not (no-TAM). The median follow-up time was 62.6 months. The 10-year local relapse-free survival (LRFS) was 98% in both the TAM and no-TAM cohorts (p = 0.58); the 10-year DMFS was 83% TAM vs. 89% no-TAM (p = 0.91). There was no difference in 10-year contralateral breast relapse or overall survival (OS) between the two cohorts. In univariate and multivariate analysis, use of TAM was not associated with LRFS, distant metastases-free survival (DMFS), OS, or a reduction in contralateral breast cancers when compared with the no-TAM cohort. In this large cohort of T1N0 elderly breast cancer patients treated with CS+RT, the use of TAM did not appear to decrease ipsilateral breast relapse, contralateral breast relapse, distant metastasis, or OS.
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Affiliation(s)
- Atif J Khan
- Department of Radiation Oncology, The Cancer Institute of New Jersey, UMDNJ/Robert Wood Johnson Medical School, New Brunswick, New Jersey
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[Treatment effect of breast cancer and prostate cancer on bone]. Med Clin (Barc) 2013; 140:164-8. [PMID: 22841464 DOI: 10.1016/j.medcli.2012.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/17/2012] [Accepted: 05/31/2012] [Indexed: 11/23/2022]
Abstract
Aromatase inhibitors are used in the treatment of breast cancer and androgen deprivation therapy is used in prostate cancer. Both of them induce bone loss and increase fracture incidence. Early detection is important for patients with increased risk of osteoporotic fractures. In this article we review the available treatments and their indication to prevent the onset of osteoporosis and osteoporotic fractures in this patient group.
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Abstract
Bisphosphonates, as potent inhibitors of osteoclast-mediated bone resorption, significantly reduce the risk of skeletal complications in metastatic bone disease and also prevent cancer treatment-induced bone loss (CTIBL). However, more recently, there has been increasing data indicating that bisphosphonates exhibit anti-tumour activity, possibly via both indirect and direct effects, and can potentially modify the metastatic disease process providing more than just supportive care. The evidence from previous studies of an anti-tumour effect of bisphosphonates was inconclusive, with conflicting evidence from adjuvant oral clodronate trials. However, more recent trials using zoledronic acid have shown benefits in terms of disease-free and overall survival outcomes in certain subgroups, most evidently in older premenopausal women with hormone-sensitive disease treated with ovarian suppression, and in women in established menopause at trial entry. In the adjuvant setting, the use of bisphosphonates has also been focused on the prevention and treatment of CTIBL and recent guidelines have defined treatment strategies for CTIBL. The role of bisphosphonates in CTIBL in early breast cancer is well defined. There have been mixed results from large adjuvant metastasis-prevention studies of bisphosphonates, but there are strong signals from large subgroups analyses of randomised phase III trials suggesting significant anti-tumour beneficial effects in specific patient populations.
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Affiliation(s)
- M C Winter
- Weston Park Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Rizzoli R, Body JJ, DeCensi A, Reginster JY, Piscitelli P, Brandi ML. Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper. Osteoporos Int 2012; 23:2567-76. [PMID: 22270857 DOI: 10.1007/s00198-011-1870-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/05/2011] [Indexed: 10/14/2022]
Abstract
UNLABELLED 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%.
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Affiliation(s)
- R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Khan AJ, Haffty BG. Issues in the Curative Therapy of Breast Cancer in Elderly Women. Semin Radiat Oncol 2012; 22:295-303. [DOI: 10.1016/j.semradonc.2012.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Taxel P, Choksi P, Van Poznak C. The management of osteoporosis in breast cancer survivors. Maturitas 2012; 73:275-9. [PMID: 23017944 DOI: 10.1016/j.maturitas.2012.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/12/2012] [Indexed: 01/24/2023]
Abstract
Breast cancer is a common diagnosis and the majority of women treated will be cured. Women with early stage breast cancer may be at increased risk for osteoporosis due to anticancer therapies. Chemotherapy induced amenorrhea and the use of anti-estrogens can promote bone loss; thus, the management of bone health in women with breast cancer is an important component of survivorship care. Osteoporosis is considered a "silent" disease as there are often no discrete warning signs, until a fracture occurs; therefore, clinicians must be cognizant of the underlying risk for osteoporosis and co-morbid conditions and/or medications that accelerate risk of fracture. Breast cancer therapies that effect bone, screening for bone loss and interventions to mitigate the treatment toxicities are reviewed.
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Abstract
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.
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Affiliation(s)
- Paul D Miller
- Colorado Center for Bone Research, 3190 South Wadsworth Boulevard, Lakewood, CO 80227, USA.
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Lipton A, Smith MR, Ellis GK, Goessl C. Treatment-induced bone loss and fractures in cancer patients undergoing hormone ablation therapy: efficacy and safety of denosumab. Clin Med Insights Oncol 2012; 6:287-303. [PMID: 22933844 PMCID: PMC3427033 DOI: 10.4137/cmo.s8511] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hormone ablation therapy (HALT) for breast or prostate cancer accelerates the development of osteoporosis in both men and women by causing estrogen deficiency, which increases the risk for fracture by promoting bone resorption mediated by osteoclasts. Denosumab, a fully human monoclonal antibody that inhibits osteoclast formation and function, increases bone mass in patients undergoing hormone ablation therapy. In the HALT study of 1,468 men with prostate cancer on androgen-deprivation therapy, denosumab significantly reduced the risk of new vertebral fractures, increased bone mineral density (BMD), and reduced markers of bone turnover. In a study of 252 women with breast cancer undergoing adjuvant aromatase inhibitor (AI) therapy, denosumab increased BMD at 12 and 24 months, overall and in all patient subgroups. The overall rates of adverse events were similar to placebo. Clinicians should consider fracture risk assessment and therapies such as denosumab to increase bone mass in patients on hormone ablation therapy who are at high risk for fracture.
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Affiliation(s)
- Allan Lipton
- College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
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Sergi G, Pintore G, Falci C, Veronese N, Berton L, Perissinotto E, Basso U, Brunello A, Monfardini S, Manzato E, Coin A. Preventive effect of risedronate on bone loss and frailty fractures in elderly women treated with anastrozole for early breast cancer. J Bone Miner Metab 2012; 30:461-7. [PMID: 22160398 DOI: 10.1007/s00774-011-0341-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 11/23/2011] [Indexed: 11/26/2022]
Abstract
The aim of this study was to assess the effect of adjuvant anastrozole, alone or associated with risedronate, on BMD and bone fracture risk in women more than 70 years old with hormone receptor-positive early breast cancer (EBC). In a group of 51 elderly women (aged 76.4 ± 5.0 years) considered for adjuvant aromatase inhibitors for EBC, 24 patients with T-scores ≥ -2 and no prevalent fractures received anastrozole 1 mg/day (group A), and 27 patients with T-scores < -2, or with T-scores ≥ -2 and prevalent fractures (group B), received anastrozole (1 mg/day) plus risedronate (35 mg/week). Both groups received supplementation with 1 g calcium carbonate and 800 IU vitamin D per day. Differences in BMD and frailty fractures were evaluated after 1 and 2 years. In group A, significant decreases in BMD were observed in the lumbar spine (Δ BMD, -0.030 ± 0.04 g/cm², P < 0.05), femoral neck (Δ BMD, -0.029 ± 0.05 g/cm², P < 0.05), and trochanter (Δ BMD, -0.026 ± 0.03 g/cm², P < 0.01) after 2 years. The greatest percent reduction in height (Hpr) emerged in the thoracic spine (3.6 ± 2.4%, P < 0.01), although only one incident vertebral fracture was observed. In group B, BMD increased in the lumbar spine (Δ BMD, 0.038 ± 0.04, P < 0.001), although no significant changes were seen in the hip regions. The decline in Hpr was negligible (about 1%). No incident fractures were observed at follow-up. In conclusion, anastrozole treatment for EBC in elderly women seems to have only mild negative effects on the femoral bone. Risedronate makes the use of anastrozole safer, even for osteopenic or osteoporotic elderly patients.
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Affiliation(s)
- Giuseppe Sergi
- Department of Medical and Surgical Sciences, University of Padova, Padua, Italy.
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Age effect on bone mineral density changes in breast cancer patients receiving anastrozole: results from the ARBI prospective clinical trial. J Cancer Res Clin Oncol 2012; 138:1569-77. [PMID: 22552718 PMCID: PMC3418493 DOI: 10.1007/s00432-012-1233-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/10/2012] [Indexed: 11/09/2022]
Abstract
Purpose We investigated whether age at anastrozole (A) initiation influences the effect of treatment on bone mineral density (BMD). We conducted a post hoc analysis of the dataset of Arimidex Bone Mass Index Oral Bisphosphonates prospective trial, studying the effect of risedronate (R) on BMD of postmenopausal, early breast cancer patients receiving A. Methods Patients were stratified into those with normal BMD or mild osteopenia (T > −2) receiving A-only and patients with mild or severe osteopenia (T ≤ −2) or osteoporosis (T < −2.5) receiving A and per os R (A + R). Depending on age on treatment initiation, patients were grouped into two age cohorts, above and below 65 years. BMD change in lumbar spine (LS) and hip (HP) was evaluated at 12 months. An analysis of patients with normal BMD at baseline was additionally performed. Results Among patients receiving A-only, women ≤65 years were more likely to have a decrease in LS-BMD than older (p = 0.034). HP-BMD decrease at 12 months was not related to age (p = 0.182). In patients with mild or severe osteopenia or osteoporosis, treated with A + R, no age effect was observed for LS or HP (p = 0.099 and p = 0.939, respectively). Among patients with normal BMD at baseline, the age effect on LS-BMD change was more profound (p = 0.026). Conclusions Our study suggests that younger postmenopausal women with normal BMD or mild osteopenia receiving A-only face an increased risk of bone loss in LS. Among patients with mild or severe osteopenia or osteoporosis treated with A + R, 12 months LS or HP BMD variations were configured regardless of age group.
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Ito K, Blinder VS, Elkin EB. Cost Effectiveness of Fracture Prevention in Postmenopausal Women Who Receive Aromatase Inhibitors for Early Breast Cancer. J Clin Oncol 2012; 30:1468-75. [DOI: 10.1200/jco.2011.38.7001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Aromatase inhibitors (AIs) increase the risk of osteoporosis and related fractures in postmenopausal women who receive adjuvant AIs for hormone receptor (HR) –positive early breast cancer (EBC). We compared the cost effectiveness of alternative screening and treatment strategies for fracture prevention. Methods We developed a Markov state transition model to simulate clinical practice and outcomes in a hypothetical cohort of women age 60 years with HR-positive EBC starting a 5-year course of AI therapy after primary surgery for breast cancer. Outcomes were quality-adjusted life-years (QALYs), lifetime cost, and incremental cost-effectiveness ratio (ICER). We compared the following strategies: no intervention; one-time bone mineral density (BMD) screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; annual BMD screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; and universal bisphosphonate therapy. Results ICERs for annual BMD screening followed by oral bisphosphonates for those with osteoporosis, annual BMD screening followed by oral bisphosphonates for those with osteopenia, and universal treatment with oral bisphosphonates were $87,300, $129,300, and $283,600 per QALY gained, respectively. One-time BMD screening followed by oral bisphosphonates for those with osteoporosis or osteopenia was dominated. Our results were sensitive to age at the initiation of AI therapy, type of bisphosphonates, post-treatment residual effect of bisphosphonates, and a potential adjuvant benefit of intravenous bisphosphonates. Conclusion In postmenopausal women receiving adjuvant AIs for HR-positive EBC, a policy of baseline and annual BMD screening followed by selective treatment with oral bisphosphonates for those diagnosed with osteoporosis is a cost-effective use of societal resources.
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Affiliation(s)
- Kouta Ito
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Victoria S. Blinder
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Elena B. Elkin
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
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Bosco D. Osteoporosis and aromatase inhibitors: experience and future prospects. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2012; 9:89-91. [PMID: 23087717 PMCID: PMC3476523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The aim of this study is to improve the assistance given to patients under treatment with aromatase inhibitors in order to prevent secondary osteoporosis through the planning of an awareness programme for the oncologist and offering a facilitated treatment path. MATERIALS AND METHODS Thirty-nine postmenopausal women treated with aromatase inhibitors for breast cancer were selected. For each subject, the age at the beginning of the therapy, the type of aromatase inhibitors and the age at the performance of the bone densitometry was registered. In addition, the use of osteoporosis medication and supplementation of calcium and vitamin D were evaluated. Participants were required to answer a questionnaire consisting of closed questions relating to booking procedures of the bone densitometry and about their own knowledge of osteoporosis related to the use of aromatase inhibitors. CONCLUSIONS Although there is evidence of negative impact of the aromatase inhibitors on bone, our data still show a poor application of the recommendations in order to prevent osteoporosis related to the administration of these drugs. Our suggestion is a more active implementation of the guidelines, also by means of a greater collaboration between the oncologist and the specialist in osteoporosis, and the offer of a diagnostic and therapeutic pathway.
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Affiliation(s)
- Daniela Bosco
- Address for correspondence: Daniela Bosco, MD, UOSD of Endocrinology, AO San Giovanni Addolorata, Via Amba Aradam, 9, 00185 Rome, Italy, Phone/Fax: +39 06 77055753, E-mail:
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Recommendations for antiresorptive therapy in postmenopausal patients with breast cancer: Marburg AIBL Guideline Evaluation Study (MAGES). Breast Cancer Res Treat 2012; 133:1089-96. [PMID: 22453753 DOI: 10.1007/s10549-012-2023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 03/07/2012] [Indexed: 12/21/2022]
Abstract
Postmenopausal women with hormone-receptor-positive breast cancer usually receive aromatase inhibitor (AI) therapy at some point in their disease management. Accelerated bone loss during AI therapy poses a problem, especially in postmenopausal women who may already have age-related osteopenia or several fracture-related risk factors. Guidelines and algorithms have been developed to identify women at risk for fractures from low bone mineral density and to provide recommendations for antiresorptive treatment. However, the factors used to calculate fracture risk and the thresholds for antiresorptive treatment vary among the current guidelines and algorithms, potentially leading to inconsistent recommendations for or against antiresorptive treatment. The present study analyzed antiresorptive treatment decisions in a population of postmenopausal women with hormone-receptor-positive breast cancer receiving AI therapy using five different guidelines/algorithms (World Health Organization Fracture Risk Assessment tool [FRAX], expert consensus, German Dachverband Osteologie, American Society of Clinical Oncology, and World Health Organization). The consistency of a recommendation for antiresorptive treatment among the five methods was low (4 %). The consistency of a recommendation against antiresorptive treatment among the five methods was higher (57 %), but left approximately 40 % of patients with an inconsistent recommendation. The consequences of overtreatment (unnecessary exposure to adverse events) and undertreatment (increased risk of fractures and possibly decreased disease-free survival) make it imperative that the existing guidelines and algorithms be improved. Moreover, evidence-based outcomes from antiresorptive treatment decisions are required to validate guidelines and algorithms.
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Prieto-Alhambra D, Servitja S, Javaid MK, Garrigós L, Arden NK, Cooper C, Albanell J, Tusquets I, Diez-Perez A, Nogues X. Vitamin D threshold to prevent aromatase inhibitor-related bone loss: the B-ABLE prospective cohort study. Breast Cancer Res Treat 2012; 133:1159-67. [PMID: 22434523 DOI: 10.1007/s10549-012-2013-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 02/28/2012] [Indexed: 12/31/2022]
Abstract
Aromatase inhibitor (AI)-related bone loss is associated with increased fracture rates. Vitamin D might play a role in minimising this effect. We hypothesised that 25-hydroxy-vitamin D concentrations [25(OH)D] after 3 months supplementation might relate to bone loss after 1 year on AI therapy. We conducted a prospective cohort study from January 2006 to December 2011 of a consecutive sample of women initiating AI for early breast cancer who were ineligible for bisphosphonate therapy and stayed on treatment for 1 year (N = 232). Serum 25(OH)D was measured at baseline and 3 months, and lumbar spine (LS) bone mineral density at baseline and 1 year. Subjects were supplemented with daily calcium (1 g) and vitamin D(3) (800 IU) and additional oral 16,000 IU every 2 weeks if baseline 25(OH)D was <30 ng/ml. Linear regression models were fitted to adjust for potential confounders. After 1 year on AI therapy, 232 participants experienced a significant 1.68 % [95 % CI 1.15-2.20 %] bone loss at LS (0.017 g/cm(2) [0.012-0.024], P < 0.0001). Higher 25(OH)D at 3 months protected against LS bone loss (-0.5 % per 10 ng/ml [95 % CI -0.7 to -0.3 %], adjusted P = 0.0001), and those who reached levels ≥40 ng/ml had reduced bone loss by 1.70 % [95 % CI 0.4-3.0 %; adjusted P = 0.005] compared to those with low 25(OH)D levels (<30 ng/ml). We conclude that improved vitamin D status using supplementation is associated with attenuation of AI-associated bone loss. For this population, the current Institute of Medicine target recommendation of 20 ng/ml might be too low to ensure good bone health.
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Affiliation(s)
- Daniel Prieto-Alhambra
- URFOA-IMIM, Parc de Salut Mar, Parc de Recerca Biomèdica de Barcelona, C/Dr Aiguader, 88, 2nd Floor, 08003 Barcelona, Spain.
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Abstract
BACKGROUND Bone is the most common site of metastatic disease associated with breast cancer (BC). Bisphosphonates inhibit osteoclast-mediated bone resorption, and novel targeted therapies such as denosumab, inhibit key pathways in the vicious cycle of bone metastases. OBJECTIVES To assess the effect of bisphosphonates on skeletal-related events (SREs), bone pain, quality of life (QoL), recurrence and survival in women with breast cancer with bone metastases (BCBM), advanced breast cancer (ABC) without clinical evidence of bone metastases and early breast cancer (EBC).To assess the effect of denosumab on SREs, bone pain and (QoL) in women with (BCBM). SEARCH METHODS We searched the Specialised Register maintained by the Cochrane Breast Cancer Group (CBCGSR), MEDLINE, EMBASE and the WHO International Cancer Trials Registry Platform (WHO ICTRP) on 30 April 2011. We conducted additional handsearching of journals and proceedings of key meetings. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing: (a) bisphosphonates and control, or different bisphosphonates in women with BCBM; (b) denosumab and bisphosphonates in women with BCBM; (c) bisphosphonates and control in women with ABC; (d) bisphosphonates and control in women with EBC; and (e) early versus delayed bisphosphonate treatment in women with EBC. DATA COLLECTION AND ANALYSIS Two review authors (MW and NP) independently assessed the trials and extracted the data. We collected toxicity information from the trials. MAIN RESULTS We included thirty-four RCTs. In nine studies (2806 patients with BCBM), comparing bisphosphonates with placebo or no bisphosphonates, bisphosphonates reduced the SRE risk by 15% (risk ratio (RR) 0.85; 95% confidence interval (CI) 0.77 to 0.94; P = 0.001). This benefit was most certain with intravenous (i.v.) zoledronic acid (4 mg) (RR 0.59; 95% CI 0.42 to 0.82); i.v. pamidronate (90 mg) (RR 0.77; 95% CI 0.69 to 0.87); and i.v. ibandronate (RR 0.80; 95% CI 0.67 to 0.96). A direct comparison of i.v. zoledronic acid and i.v. pamidronate confirmed at least equivalent efficacy in a single large study. In three studies (3405 patients with BCBM), compared with bisphosphonates, subcutaneous (s.c.) denosumab was more effective in reducing the risk of SREs (RR 0.78; 95% CI 0.72 to 0.85; P < 0.00001).Bisphosphonates reduced the SRE rate in 12 studies (median reduction 28%, range 14% to 48%), with statistically significant reductions reported in 10 studies. Women with BCBM treated with bisphosphonates showed significant delays in the median time to SREs. Compared with placebo or no bisphosphonates, treatment with bisphosphonates significantly improved bone pain in six out of eleven studies. Improvements in global QoL with bisphosphonates compared to placebo were reported in two out of five studies (both ibandronate studies). Treatment with bisphosphonates did not appear to affect survival in women with BCBM. Compared to i.v. zoledronic acid, denosumab also significantly reduced the SRE rate, delayed the time to SREs and prolonged the time in developing pain for patients with no or mild pain at baseline; but there was no difference in survival between patients treated with denosumab and zoledronic acid.Bisphosphonates in women with ABC without clinically evident bone metastases did not reduce the incidence of bone metastases, or improve survival in three studies (320 patients).In seven studies (7847 patients with EBC), currently there is no evidence supporting bisphosphonates in reducing the incidence of bone metastases compared to no bisphosphonates (RR 0.94; 95% CI 0.82 to 1.07; P = 0.36). In three studies (2190 patients with EBC), early bisphosphonate treatment also did not significantly reduce the incidence of bone metastases compared to delayed bisphosphonate treatment (RR 0.73; 95% CI 0.40 to 1.33; P = 0.31). Currently, there is insufficient evidence to make a conclusion about the role of adjuvant bisphosphonates in reducing visceral metastases, locoregional recurrence and total recurrence, or improving survival. There was strong heterogeneity in EBC studies examining the outcomes of total recurrence and survival.Reported toxicity was generally mild. Renal toxicity and osteonecrosis of the jaw (ONJ) have been identified as potential problems with bisphosphonate use. ONJ was reported at similar rates for patients on denosumab compared to zoledronic acid. This highlighted a need for maintaining good oral care, prior to and during treatment, for patients who received long-term bone agents. AUTHORS' CONCLUSIONS In women with clinically evident BCBM, bisphosphonates (oral and i.v.) and denosumab (s.c.) reduced the risk of developing SREs, as well as delaying the time to SREs. Some bisphosphonates may also reduce bone pain and may improve QoL. The optimal timing and duration of treatment for patients with BCBM remains uncertain. There is currently insufficient evidence to support the routine use of bisphosphonates as adjuvant treatment for patients with EBC. However, a number of large clinical trials investigating bisphosphonates in EBC have completed accrual and are awaiting results.
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Affiliation(s)
- Matthew H F Wong
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, Australia
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Colón-Emeric C, O'Connell MB, Haney E. Osteoporosis piece of multi-morbidity puzzle in geriatric care. ACTA ACUST UNITED AC 2011; 78:515-26. [PMID: 21748741 DOI: 10.1002/msj.20269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Osteoporosis frequently coexists with other chronic diseases and syndromes of aging, and therefore multimorbidity interactions can potentially complicate its evaluation and treatment. This article reviews osteoporosis comorbidity interactions with select common diseases of aging including cardiovascular, neurologic, and geriatric syndromes, and select commonly used medications by older adults. Using depression as a case example, we describe the complex relationship between osteoporosis, mood, and antidepressant medications, and the implications of these interactions for patients and clinicians.
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Affiliation(s)
- Cathleen Colón-Emeric
- Duke University Medical Center and the Durham VA Geriatric Research, Education, and Clinical Center, Durham, NC, USA.
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