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Kim C, Na Y, Lee S, Park JY, Chung YJ, Song J, Kim MR. A Recent Review of the Management of Postmenopausal Symptoms in Breast Cancer Survivors. J Menopausal Med 2023; 29:85-91. [PMID: 38230591 PMCID: PMC10796204 DOI: 10.6118/jmm.23016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 12/18/2023] [Accepted: 12/27/2023] [Indexed: 01/18/2024] Open
Abstract
The treatment strategy for postmenopausal symptoms resulting from estrogen deficiency in breast cancer survivors receiving endocrine therapy should differ from that in normal women. Several nonhormonal pharmacological therapies can be used to treat vasomotor symptoms. Cognitive-behavioral therapy can help alleviate psychophysiological symptoms, including depression and sleep disorders. Topical vaginal estrogen and moisturizers may aid in treating genitourinary symptoms. Additionally, chronic conditions must be individually managed. Prevention of osteoporosis should always be included in the management, and physicians should be alert to possible cardiovascular risk and cognitive function changes.
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Affiliation(s)
- Chaewon Kim
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoojin Na
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sanghee Lee
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Yoon Park
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youn-Jee Chung
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeyen Song
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee-Ran Kim
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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2
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Abstract
Individuals with cancer face unique risk factors for osteoporosis and fractures. Clinicians must consider the additive effects of cancer-specific factors, including treatment-induced bone loss, and premorbid fracture risk, utilizing FRAX score and bone mineral densitometry when available. Pharmacologic therapy should be offered as per cancer-specific guidelines, when available, or local general osteoporosis guidelines informed by clinical judgment and patient preferences. Our objective was to review and summarize the epidemiologic burden of osteoporotic fracture risk and fracture risk assessment in adults with cancer, and recommended treatment thresholds for cancer treatment-induced bone loss, with specific focus on breast, prostate, thyroid, gynecological, multiple myeloma, and hematopoietic stem cell transplant. This narrative review was informed by PubMed searches to July 25, 2022, that combined terms for cancer, stem cell transplantation, fracture, bone mineral density (BMD), trabecular bone score, FRAX, Garvan nomogram or fracture risk calculator, QFracture, prediction, and risk factors. The literature informs that cancer can impact bone health in numerous ways, leading to both systemic and localized decreases in BMD. Many cancer treatments can have detrimental effects on bone health. In particular, hormone deprivation therapies for hormone-responsive cancers such as breast cancer and prostate cancer, and hematopoietic stem cell transplant for hematologic malignancies, adversely affect bone turnover, resulting in osteoporosis and fractures. Surgical treatments such as hysterectomy with bilateral salpingo-oophorectomy for gynecological cancers can also lead to deleterious effects on bone health. Radiation therapy is well documented to cause localized bone loss and fractures. Few studies have validated the use of fracture risk prediction tools in the cancer population. Guidelines on cancer-specific treatment thresholds are limited, and major knowledge gaps still exist in fracture risk and fracture risk assessment in patients with cancer. Despite the limitations of current knowledge on fracture risk assessment and treatment thresholds in patients with cancer, clinicians must consider the additive effects of bone damaging factors to which these patients are exposed and their premorbid fracture risk profile. Pharmacologic treatment should be offered as per cancer-specific guidelines when available, or per local general osteoporosis guidelines, in accordance with clinical judgment and patient preferences.
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Affiliation(s)
- Carrie Ye
- University of Alberta, Edmonton, Canada.
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3
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Kline GA, Morin SN, Lix LM, McCloskey EV, Johansson H, Harvey NC, Kanis JA, Leslie WD. General Comorbidity Indicators Contribute to Fracture Risk Independent of FRAX: Registry-Based Cohort Study. J Clin Endocrinol Metab 2023; 108:745-754. [PMID: 36201517 DOI: 10.1210/clinem/dgac582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/28/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT FRAX® estimates 10-year fracture probability from osteoporosis-specific risk factors. Medical comorbidity indicators are associated with fracture risk but whether these are independent from those in FRAX is uncertain. OBJECTIVE We hypothesized Johns Hopkins Aggregated Diagnosis Groups (ADG®) score or recent hospitalization number may be independently associated with increased risk for fractures. METHODS This retrospective cohort study included women and men age ≥ 40 in the Manitoba BMD Registry (1996-2016) with at least 3 years prior health care data and used linked administrative databases to construct ADG scores along with number of hospitalizations for each individual. Incident Major Osteoporotic Fracture and Hip Fracture was ascertained during average follow-up of 9 years; Cox regression analysis determined the association between increasing ADG score or number of hospitalizations and fractures. RESULTS Separately, hospitalizations and ADG score independently increased the hazard ratio for fracture at all levels of comorbidity (hazard range 1.2-1.8, all P < 0.05), irrespective of adjustment for FRAX, BMD, and competing mortality. Taken together, there was still a higher than predicted rate of fracture at all levels of increased comorbidity, independent of FRAX and BMD but attenuated by competing mortality. Using an intervention threshold of major fracture risk >20%, application of the comorbidity hazard ratio multiplier to the patient population FRAX scores would increase the number of treatment candidates from 8.6% to 14.4%. CONCLUSION Both complex and simple measures of medical comorbidity may be used to modify FRAX-based risk estimates to capture the increased fracture risk associated with multiple comorbid conditions in older patients.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine, University of Calgary, Calgary T2N 2T9, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal H3A 1G1, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg R3E 0W2, Canada
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne 3000, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, Southampton SO17 1BJ, UK
- NIHR Southampton Biomedical Research Center, University of Southampton, Southampton SO16 6YD, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Melbourne S5 7AU, UK
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne 3000, Australia
| | - William D Leslie
- Department of Community Health Sciences, University of Manitoba, Winnipeg R3E 0W2, Canada
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4
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Ward MC, Recht A, Vicini F, Al-Hilli Z, Asha W, Chadha M, Abraham A, Thaker N, Khan AJ, Keisch M, Shah C. Cost-Effectiveness Analysis of Ultra-Hypofractionated Whole Breast Radiation Therapy Alone Versus Hormone Therapy Alone or Combined Treatment for Low-Risk ER-Positive Early Stage Breast Cancer in Women Aged 65 Years and Older. Int J Radiat Oncol Biol Phys 2022:S0360-3016(22)03678-1. [PMID: 36586492 DOI: 10.1016/j.ijrobp.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/28/2022] [Accepted: 12/17/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE The optimal management of early-stage, low-risk, hormone-positive breast cancer in older women remains controversial. Recent trials have shown that 5-fraction ultrahypofractionated whole-breast irradiation (U-WBI) has similar outcomes to longer courses, reducing the cost and inconvenience of treatment. We performed a cost-utility analysis to compare U-WBI to hormone therapy alone or their combination. METHODS AND MATERIALS We simulated 3 different treatment approaches for women age 65 years or older with pT1-2N0 ER-positive invasive ductal carcinoma treated with lumpectomy with negative margins using a Markov microsimulation model. The strategies were U-WBI performed with a 3-dimensional conformal technique over 5 fractions without a boost ("radiation therapy [RT] alone"), adjuvant hormone therapy (anastrozole for 5 years) without RT ("aromatase-inhibitor [AI] alone"), or the combination of the 2. The combination strategy was calibrated to match trial results, and the relative effectiveness of the RT alone and AI alone strategies were inferred from previous randomized trials. The primary endpoint was the cost-effectiveness of the 3 strategies over a lifetime horizon as measured by the incremental cost-effectiveness ratio (ICER), with a value of $100,000/quality-adjusted life-year deemed "cost-effective." RESULTS The model results compared with the prespecified target outcomes. On average, RT alone was the least expensive strategy ($14,775), with AI alone slightly more ($14,998), and combination therapy the costliest ($19,802). RT alone dominated AI alone (the incremental cost-effectiveness ratio [ICER] -$5089). Combination therapy, compared with RT alone, was slightly more expensive than our definition of cost-effective (ICER $113,468) but was cost-effective compared with AI alone (ICER $54,451). Probabilistic sensitivity analysis demonstrated RT alone to be cost-effective in 50% of trials, with combination therapy in 36% and AI alone in 14%. CONCLUSIONS U-WBI alone appears the more cost-effective de-escalation strategy for these low-risk patients, compared with AI alone. Combining U-WBI and AI appears more costly but may be preferred by some patients.
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Affiliation(s)
- Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina; Southeast Radiation Oncology Group, Charlotte, North Carolina
| | - Abram Recht
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Frank Vicini
- 21st Century Oncology, Farmington Hills, Michigan
| | - Zahraa Al-Hilli
- Department of Breast Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wafa Asha
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manjeet Chadha
- Ichan School of Medicine at Mt. Sinai, New York, New York
| | - Abel Abraham
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
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Ward MC, Vicini F, Al-Hilli Z, Chadha M, Abraham A, Recht A, Hayman J, Thaker N, Khan AJ, Keisch M, Shah C. Cost-Effectiveness Analysis of No Adjuvant Therapy Versus Partial Breast Irradiation Alone Versus Combined Treatment for Treatment of Low-Risk DCIS: A Microsimulation. JCO Oncol Pract 2021; 17:e1055-e1074. [PMID: 33970684 DOI: 10.1200/op.20.00992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years. MATERIALS AND METHODS Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature. RESULTS No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%. CONCLUSION No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.
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Affiliation(s)
- Matthew C Ward
- Levine Cancer Institute, Atrium Health, Charlotte, NC.,Southeast Radiation Oncology Group, Charlotte, NC
| | | | - Zahraa Al-Hilli
- Department of Breast Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Abel Abraham
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Abram Recht
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | | | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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6
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Xu JY, O’Connell MA, Notini L, Cheung AS, Zwickl S, Pang KC. Selective Estrogen Receptor Modulators: A Potential Option For Non-Binary Gender-Affirming Hormonal Care? Front Endocrinol (Lausanne) 2021; 12:701364. [PMID: 34226826 PMCID: PMC8253879 DOI: 10.3389/fendo.2021.701364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Gender dysphoria describes the distress associated with having a gender identity that differs from one's birth-assigned sex. To relieve this distress, transgender, and gender diverse (henceforth, trans) individuals commonly undergo medical transition involving hormonal treatments. Current hormonal treatment guidelines cater almost exclusively for those who wish to transition from male to female or vice versa. In contrast, there is a dearth of hormonal options for those trans individuals who identify as non-binary and seek an androgynous appearance that is neither overtly male nor female. Though prolonged puberty suppression with gonadotrophin releasing hormone agonists (GnRHa) could in theory be gender-affirming by preventing the development of unwanted secondary sex characteristics, this treatment option would be limited to pre- or peri-pubertal adolescents and likely have harmful effects. Here, we discuss the theoretical use of Selective Estrogen Receptor Modulators (SERMs) for non-binary people assigned male at birth (AMAB) who are seeking an androgynous appearance through partial feminization without breast growth. Given their unique range of pharmacodynamic effects, SERMs may represent a potential gender-affirming treatment for this population, but there is a lack of knowledge regarding their use and potentially adverse effects in this context.
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Affiliation(s)
- Jane Y. Xu
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
| | - Michele A. O’Connell
- Clinical Sciences and Genetics Themes, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Department of Adolescent Medicine, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Lauren Notini
- Clinical Sciences and Genetics Themes, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Melbourne Law School, University of Melbourne, Parkville, VIC, Australia
| | - Ada S. Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Ken C. Pang
- Clinical Sciences and Genetics Themes, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Department of Adolescent Medicine, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- *Correspondence: Ken C. Pang,
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Adehin A, Kennedy MA, Soyinka JO, Alatise OI, Olasehinde O, Bolaji OO. Breast Cancer and Tamoxifen: A Nigerian Perspective to Effective Personalised Therapy. BREAST CANCER-TARGETS AND THERAPY 2020; 12:123-130. [PMID: 33116814 PMCID: PMC7548221 DOI: 10.2147/bctt.s266314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/08/2020] [Indexed: 12/24/2022]
Abstract
Estrogen-receptor positivity in tumour, often requiring long-term tamoxifen therapy, is thought to characterise between 43% and 65% of breast cancer cases in Nigeria. The patient population is further marked by late-stage diagnosis which significantly heightens the tendency for tumour relapse in the course of tamoxifen therapy. Despite tamoxifen being considered a reliable chemopreventive in high-risk individuals and an effective adjuvant therapy for hormone-sensitive tumours, mortality has remained high among breast cancer patients in the West African region where Nigeria belongs. The Nigerian breast cancer population, like other similar patient-populations in the West African region, provides a mix of intrinsic genome-diversity and perhaps unique tumour biology and evolution. These peculiarities suggest the need for a rational approach to tumour management and a personalised delivery of therapy in Nigeria's dominant estrogen-receptor-positive patient population. Herein, critical indices of tamoxifen-therapy success are discussed in the context of the Nigerian breast cancer population with emphasis on salient aspects of tamoxifen-biotransformation, host- and tumour-genomics, and epigenetics.
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Affiliation(s)
- Ayorinde Adehin
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria.,Institute of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, People's Republic of China
| | - Martin Alexander Kennedy
- Department of Pathology and Biomedical Science; Carney Centre of Pharmacogenomics, University of Otago, Christchurch, New Zealand
| | - Julius Olugbenga Soyinka
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Olusegun Isaac Alatise
- Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Olalekan Olasehinde
- Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Oluseye Oladotun Bolaji
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
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Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older. Breast Cancer Res Treat 2020; 182:355-365. [PMID: 32468336 DOI: 10.1007/s10549-020-05706-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/21/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE We performed a cost-effectiveness analysis of three strategies for the adjuvant treatment of early breast cancer in women age 70 years or older: an aromatase inhibitor (AI-alone) for 5 years, a 5-fraction course of accelerated partial-breast irradiation using intensity-modulated radiation therapy (APBI-alone), or their combination. METHODS We constructed a patient-level Markov microsimulation from the societal perspective. Effectiveness data (local recurrence, distant metastases, survival), and toxicity data were obtained from randomized trials when possible. Costs of side effects were included. Costs were adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALY) were calculated using utilities extracted from the literature. RESULTS The strategy of AI-alone ($12,637) was cheaper than both APBI-alone ($13,799) and combination therapy ($18,012) in the base case. All approaches resulted in similar QALY outcomes (AI-alone 7.775; APBI-alone 7.768; combination 7.807). In the base case, AI-alone was the cost-effective strategy and dominated APBI-alone, while combined therapy was not cost-effective when compared to AI-alone ($171,451/QALY) or APBI-alone ($107,932/QALY). In probabilistic sensitivity analyses, AI-alone was cost-effective at $100,000/QALY in 50% of trials, APBI-alone in 28% and the combination in 22%. Scenario analysis demonstrated that APBI-alone was more effective than AI-alone when AI compliance was lower than 26% at 5 years. CONCLUSIONS Based on a Markov microsimulation analysis, both AI-alone and APBI-alone are appropriate options for patients 70 years or older with early breast cancer with small cost differences noted. A prospective trial comparing the approaches is warranted.
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9
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Leslie WD, Morin SN, Lix LM, Niraula S, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Fracture Risk in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry-Based Cohort Study. Oncologist 2019; 24:1432-1438. [PMID: 31292269 PMCID: PMC6853130 DOI: 10.1634/theoncologist.2019-0149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/12/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Aromatase inhibitors (AIs) used in breast cancer induce loss in bone mineral density (BMD) and are reported to increase fracture risk. MATERIALS AND METHODS Using a population-based BMD registry, we identified women aged at least 40 years initiating AIs for breast cancer with at least 12 months of AI exposure (n = 1,775), women with breast cancer not receiving AIs (n = 1,016), and women from the general population (n = 34,205). Fracture outcomes were assessed to March 31, 2017 (mean, 6.2 years for AI users). RESULTS At baseline, AI users had higher body mass index (BMI), higher BMD, lower osteoporosis prevalence, and fewer prior fractures than women from the general population or women with breast cancer without AI use (all p < .001). After adjusting for all covariates, AI users were not at significantly greater risk for major osteoporotic fractures (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.93-1.42), hip fracture (HR, 0.90; 95% CI, 0.56-1.43), or any fracture (HR, 1.06; 95% CI, 0.88-1.28) compared with the general population. CONCLUSION Higher baseline BMI, BMD, and lower prevalence of prior fracture at baseline may offset the adverse effects of AI exposure. Although confirmatory data from large cohort studies are required, our findings challenge the view that all women with breast cancer initiating AI therapy should be considered at high risk for fractures. IMPLICATIONS FOR PRACTICE In a population-based observational registry that included 1,775 patients initiating long-term aromatase inhibitor therapy, risk for major osteoporotic fracture, hip fracture, or any fracture was similar to the general population. Higher baseline body mass index, bone mineral density, and lower prevalence of prior fracture at baseline may offset the adverse effects of aromatase inhibitor exposure.
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Affiliation(s)
| | | | - Lisa M Lix
- University of Manitoba, Winnipeg, Canada
| | | | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
| | - Nicholas C Harvey
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service (NHS) Foundation Trust, Southampton, United Kingdom
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Health Institute, Catholic University of Australia, Melbourne, Australia
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Radiation Therapy Without Hormone Therapy for Women Age 70 or Above with Low-Risk Early Breast Cancer: A Microsimulation. Int J Radiat Oncol Biol Phys 2019; 105:296-306. [DOI: 10.1016/j.ijrobp.2019.06.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/04/2019] [Accepted: 06/08/2019] [Indexed: 12/17/2022]
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11
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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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12
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Zheng N, Hsieh E, Cai H, Shi L, Gu K, Zheng Y, Bao PP, Shu XO. Soy Food Consumption, Exercise, and Body Mass Index and Osteoporotic Fracture Risk Among Breast Cancer Survivors: The Shanghai Breast Cancer Survival Study. JNCI Cancer Spectr 2019; 3:pkz017. [PMID: 31157323 PMCID: PMC6527440 DOI: 10.1093/jncics/pkz017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 01/31/2019] [Accepted: 03/18/2019] [Indexed: 11/25/2022] Open
Abstract
Background Breast cancer survivors have a high incidence of osteoporosis-related fractures; the associated factors are understudied. We investigated incidence of bone fracture and its associations with soy food consumption, exercise, and body mass index among breast cancer survivors. Methods This prospective study included 4139 stage 0–III breast cancer patients and 1987 pre-/perimenopausal and 2152 postmenopausal patients. Fractures were assessed at 18 months and at 3, 5, and 10 years after cancer diagnosis. Osteoporotic fractures were defined as fractures caused by falls from standing height and at sites associated with osteoporosis. Exercise and soy isoflavone intake were assessed at 6 and 18 months postdiagnosis. Weight and height were measured at baseline. Lifetable and Cox regression analyses were employed. All statistical tests were two sided. Results The 10-year incidence for osteoporotic fractures was 2.9% and 4.4% for pre-/perimenopausal and postmenopausal patients, respectively. High soy isoflavone intake was associated with reduced risk among pre-/perimenopausal patients (hazard ratio [HR] = 0.22, 95% confidence interval [CI] = 0.09 to 0.53, for soy isoflavone mg/d ≥56.06 vs <31.31; Ptrend < .001) but not among postmenopausal patients (Pinteraction < .01). Overweight (vs normal weight) was a risk factor for pre-/perimenopausal patients (HR = 1.81, 95% CI = 1.04 to 3.14) but not for postmenopausal patients (HR = 0.67, 95% CI = 0.43 to 1.03; Pinteraction = .01). Exercise was inversely associated with osteoporotic fractures in postmenopausal patients (HR = 0.56, 95% CI = 0.33 to 0.97, for metabolic equivalents hours ≥12.6 vs <4.5) following a dose-response pattern (Ptrend = .035), an association not modified by menopausal status. Conclusions Our findings, especially the novel association of soy food intake with osteoporotic fractures in breast cancer survivors, if confirmed, can help guide future strategies for fracture risk reduction in this vulnerable population.
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Affiliation(s)
- Neil Zheng
- Yale College, Yale University, New Haven, CT
| | - Evelyn Hsieh
- Section of Rheumatology, Yale School of Medicine, Yale University, New Haven, CT
| | - Hui Cai
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Liang Shi
- Shanghai Municipal Center for Disease Prevention and Control, Shanghai, China
| | - Kai Gu
- Shanghai Municipal Center for Disease Prevention and Control, Shanghai, China
| | - Ying Zheng
- Shanghai Municipal Center for Disease Prevention and Control, Shanghai, China.,Shanghai Cancer Hospital, Fudan University, Shanghai, China
| | - Ping-Ping Bao
- Shanghai Municipal Center for Disease Prevention and Control, Shanghai, China
| | - Xiao-Ou Shu
- Division of Epidemiology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
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13
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Hamood R, Hamood H, Merhasin I, Keinan-Boker L. Hormone therapy and osteoporosis in breast cancer survivors: assessment of risk and adherence to screening recommendations. Osteoporos Int 2019; 30:187-200. [PMID: 30413856 DOI: 10.1007/s00198-018-4758-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
UNLABELLED The long-term impact of hormone therapy for breast cancer on risk of osteoporosis and the extent to which bone screening recommendations are implemented in daily practice remain unknown. We found that the aromatase inhibitor-induced risk of osteoporosis did not continue in the off-treatment follow-up. Adherence to screening recommendations was suboptimal. INTRODUCTION A case-cohort study was undertaken to better understand the impact of hormone therapy on breast cancer patients' risk of osteoporosis, and to estimate the extent to which current bone mineral density screening recommendations are implemented in real-life daily practice. METHODS This study is based on 1692 female breast cancer survivors recruited from "Leumit" healthcare fund, who were diagnosed with primary nonmetastatic invasive breast cancer between 2002 and 2012. A 20% random subcohort was sampled at baseline, and all osteoporosis cases were identified. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were estimated by weighted Cox proportional hazards models. RESULTS Of 1692 breast cancer survivors, 312 developed osteoporosis during a median follow-up of 5 years. The crude cumulative incidence of osteoporosis accounting for death as a competing risk was 25.7% (95% CI, 21.9-29.5%). In multivariable analyses, osteoporosis was positively associated with the aromatase inhibitor (AI) sequential treatment after tamoxifen (HR, 3.14; 95% CI, 1.44-6.88; P = .004) but was more pronounced with AI use as upfront monotherapy (HR, 5.53; 95% CI, 1.46-20.88; P = .012). This effect did not continue in the off-treatment follow-up. In subgroup analysis by menopausal status, tamoxifen did not seem to confer a protective effect on bone health in postmenopausal patients. Adherence to screening recommendations in AI-treated postmenopausal women was suboptimal, particularly at baseline and after 48 months of continuous AI use. CONCLUSIONS The natural, age-related reduction in bone density is exacerbated by breast cancer active AI treatment. Future research should focus on investigating screening adherence-related barriers/facilitators and effective strategies to bring practice in line with agreed standards.
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Affiliation(s)
- R Hamood
- School of Public Health, University of Haifa, Haifa, Israel
| | - H Hamood
- School of Public Health, University of Haifa, Haifa, Israel.
- Leumit Health Services, Haharoshet 13, Karmiel, Israel.
| | | | - L Keinan-Boker
- School of Public Health, University of Haifa, Haifa, Israel
- Ministry of Health, Israel Center for Disease Control, Ramat Gan, Israel
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14
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Hung SC, Liao KF, Hung HC, Lin CL, Lee PC, Hung SJ, Lai SW. Tamoxifen use correlates with increased risk of hip fractures in older women with breast cancer: A case-control study in Taiwan. Geriatr Gerontol Int 2018; 19:56-60. [PMID: 30511361 DOI: 10.1111/ggi.13568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 09/18/2018] [Accepted: 10/08/2018] [Indexed: 12/18/2022]
Abstract
AIM This study aimed to evaluate the association between tamoxifen use and hip fractures in older women with breast cancer in Taiwan. METHODS We carried out a retrospective nationwide case-control study using the database of the Taiwan National Health Insurance Program. A total of 762 female patients with breast cancer aged ≥65 years newly diagnosed with hip fractures from 2000 to 2011 were identified for inclusion in the study. Additionally, 7620 female patients with breast cancer aged ≥65 years without hip fractures were randomly selected as controls. Patients were defined as having used tamoxifen if they had an existing prescription for tamoxifen before the index date. Patients were defined as having never used tamoxifen if they had never been given a prescription for tamoxifen before the index date. We used an unconditional logistic regression model to calculate the odds ratio and 95% confidence interval for the association between tamoxifen use and risk of hip fractures. RESULTS After adjustment for confounding variables, compared with patients who did not use tamoxifen, the adjusted odds ratio of hip fracture was 2.29 for those who had used tamoxifen (95% confidence interval 1.92, 2.72). Furthermore, adjusted odds ratios were 2.74 (95% confidence interval 2.19, 3.42) among patients with a cumulative duration of tamoxifen use of >3 years. CONCLUSION Tamoxifen use is associated with increased risk of hip fractures among older women with breast cancer in Taiwan. Geriatr Gerontol Int 2019; 19: 56-60.
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Affiliation(s)
- Shih-Chang Hung
- Department of Emergency Medicine, Nantou Hospital, Nantou, Taiwan
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, Taichung Tzu Chi General Hospital, Taichung, Taiwan
| | - Hung-Chang Hung
- Department of Internal Medicine, Nantou Hospital, Nantou, Taiwan.,Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - Cheng-Li Lin
- College of Medicine, China Medical University, Taichung, Taiwan.,Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Po-Chang Lee
- Department of Surgery, Nantou Hospital, Nantou, Taiwan
| | - Shih-Jung Hung
- Department of Pharmacy, Erlin Christian Hospital, Changhua, Taiwan
| | - Shih-Wei Lai
- College of Medicine, China Medical University, Taichung, Taiwan.,Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
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15
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Kyvernitakis I, Kostev K, Hadji P. The tamoxifen paradox-influence of adjuvant tamoxifen on fracture risk in pre- and postmenopausal women with breast cancer. Osteoporos Int 2018; 29:2557-2564. [PMID: 30032359 DOI: 10.1007/s00198-018-4642-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/11/2018] [Indexed: 11/26/2022]
Abstract
UNLABELLED Our data demonstrate that tamoxifen does not reduce fracture risk. Close surveillance is necessary to prevent bone loss in premenopausal women with breast cancer upon treatment initiation. INTRODUCTION Endocrine treatment of breast cancer may interfere with bone turnover and influence fracture risk. METHODS Out of a cohort of almost 5 million patients in total, we identified 5520 women between 18 and 90 years of age with breast cancer receiving tamoxifen, matched them with 5520 healthy controls using the Disease Analyzer Database, and investigated the fracture risk. RESULTS We found a cumulative incidence of fractures of 6.3% in patients aged between 18 and 50 years (n = 3634) treated with tamoxifen versus a cumulative incidence of 3.6% in the control group (p < 0.001). As such, the risk of fracture was 75% higher for patients receiving tamoxifen than that for healthy controls (HR 1.75; 95% CI 1.25-2.48). With regard to patients aged between 55 and 90 years (n = 7406), the cumulative incidence of fractures in patients treated with tamoxifen was 10.1% compared to 9.3% in the control group (p = 0.740), i.e., there was no significant difference between the two groups (HR 0.97; 95% CI 0.81-1.16). CONCLUSIONS Compared to healthy controls, premenopausal women with breast cancer treated with tamoxifen showed an increased risk of fracture, while postmenopausal women on tamoxifen did not show any risk reduction.
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Affiliation(s)
- I Kyvernitakis
- Department of Obstetrics and Gynecology, Buergerhospital and Clementine Kinderhospital Frankfurt, Nibelungenallee 37-41, 60318, Frankfurt, Germany.
- Dr. Senckenberg Foundation and Goethe-University of Frankfurt, Frankfurt, Germany.
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany.
| | - K Kostev
- Epidemiology, IQVIA, Frankfurt, Germany
| | - P Hadji
- Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
- Department of Bone Oncology, Gyn. Endocrinology and Reproductive Medicine, Nordwest Hospital, Frankfurt, Germany
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16
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Zhou LP, Wong KY, Yeung HT, Dong XL, Xiao HH, Gong AGW, Tsim KWK, Wong MS. Bone Protective Effects of Danggui Buxue Tang Alone and in Combination With Tamoxifen or Raloxifene in vivo and in vitro. Front Pharmacol 2018; 9:779. [PMID: 30150931 PMCID: PMC6099153 DOI: 10.3389/fphar.2018.00779] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022] Open
Abstract
Danggui Buxue Tang (DBT), a traditional Chinese Medicine decoction containing Astragali Radix (AR) and Angelicae Sinensis Radix (ASR), is commonly prescribed for women in China as a remedy for menopausal symptoms. Previous study indicated that DBT stimulated cell growth and differentiation of human osteosarcoma MG-63 cells and exhibited estrogenic properties via estrogen receptors (ERs). The present study aimed to study the bone protective effects of DBT and its potential interactions with selective estrogen receptor modulators (SERMs, tamoxifen and raloxifene) in both in vivo and in vitro models as they act via similar ERs. Six-month-old Sprague-Dawley rats were randomly assigned to the following treatments for 12 weeks: (1) sham-operated control group with vehicle (sham), (2) ovariectomized group with vehicle (OVX), (3) OVX with 17β-estradiol (E2, 2.0 mg/kg day), (4) OVX with tamoxifen (Tamo, 1.0 mg/kg day), (5) OVX with raloxifene (Ralo, 3.0 mg/kg day), (6) OVX with DBT (DBT, 3.0 g/kg day), (7) OVX with DBT+Tamoxifen (DBT+Tamo), and (8) OVX with DBT+Raloxifene (DBT+Ralo). Effects of DBT and potential interactions between DBT and SERMs were also evaluated in MG-63 cells. DBT, tamoxifen, raloxifene, and their combinations significantly increased bone mineral density (BMD) and improved trabecular bone properties, including bone surface (BS), trabecular bone number (Tb.N), and trabecular bone separation (Tb.Sp), as well as restored changes in bone turnover biomarkers and mRNA expression of genes involved in bone metabolism in OVX rats. Furthermore, DBT, SERMs, and their combinations significantly increased serum estradiol and suppressed follicle stimulating hormone and luteinizing hormone in OVX rats, suggesting the possible involvement of the hypothalamus–pituitary–gonadal axis in mediating their bone protective effects. However, SERMs, but not DBT, significantly increased uterus index in OVX rats. DBT significantly induced ALP activity and estrogen response element-dependent transcription in MG-63 cells. Our study demonstrated that DBT alone and in combinations with SERMs could exert bone protective effects in vitro and in vivo.
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Affiliation(s)
- Li-Ping Zhou
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Ka-Ying Wong
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Hoi-Ting Yeung
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Xiao-Li Dong
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Hui-Hui Xiao
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Amy G-W Gong
- Division of Life Science and Center for Chinese Medicine R&D, Hong Kong University of Science and Technology, Kowloon, Hong Kong
| | - Karl W-K Tsim
- Division of Life Science and Center for Chinese Medicine R&D, Hong Kong University of Science and Technology, Kowloon, Hong Kong
| | - Man-Sau Wong
- Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Kowloon, Hong Kong.,State Key Laboratory of Chinese Medicine and Molecular Pharmacology (Incubation), The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
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17
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Awasthi H, Mani D, Singh D, Gupta A. The underlying pathophysiology and therapeutic approaches for osteoporosis. Med Res Rev 2018; 38:2024-2057. [DOI: 10.1002/med.21504] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/28/2018] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Harshika Awasthi
- Herbal Medicinal Products Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow India
| | - Dayanandan Mani
- Herbal Medicinal Products Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow India
| | - Divya Singh
- Division of Endocrinology; CSIR-Central Drug Research Institute; Lucknow India
| | - Atul Gupta
- Medicinal Chemistry Department; CSIR-Central Institute of Medicinal and Aromatic Plants; Lucknow India
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18
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Kristensen B, Ejlertsen B, Jensen MB, Mouridsen HT. The occurrence of fractures after adjuvant treatment of breast cancer: a DBCG register study. Acta Oncol 2018; 57:141-145. [PMID: 29168668 DOI: 10.1080/0284186x.2017.1403043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Adjuvant treatment in breast cancer patients especially with aromatase inhibitors (AIs) has adverse effects on bone metabolism resulting in an increased occurrence of fractures. In order to demonstrate this occurrence, long-term follow-up studies are necessary. From several national registries in Denmark, it is possible to link data from different sources and analyze this issue. METHODS A study cohort of 68,842 breast cancer patients prospectively diagnosed and registered in the Danish Breast Cancer Cooperative Group's database during the period 1995-2012 formed the basis of the analysis. These data were matched with data on all types of fractures from the Danish National Patient Register and vital data from the Danish Civil Registration System. RESULTS After data cleaning 66,502 patients were available for analysis and 16,360 of these had incurred 20,341 fractures with 13,182 patients having just one fracture. These fractures were distributed over 214 specific fracture sites. An extended multivariable Cox regression model revealed significant association between the occurrence of fractures and age, menopause, Charlson comorbidity index (CCI) and endocrine therapy such that late menopause and tamoxifen treatment were associated with a lower occurrence and AI treatment, age and CCI were associated with a higher occurrence of fractures. CONCLUSION Before advising adjuvant therapy with AIs fragile patients with chronic diseases should receive special attention in order to reduce the incidence of fractures in this vulnerable group of patients.
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Affiliation(s)
- Bent Kristensen
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group (DBCG) Secretariat and Statistical Office, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maj-Britt Jensen
- Danish Breast Cancer Cooperative Group (DBCG) Secretariat and Statistical Office, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henning T. Mouridsen
- Danish Breast Cancer Cooperative Group (DBCG) Secretariat and Statistical Office, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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19
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Jung S, Kim MG, Lee JI. Lumbar Scoliosis in Patients With Breast Cancer: Prevalence and Relationship With Breast Cancer Treatment, Age, Bone Mineral Density, and Body Mass Index. Ann Rehabil Med 2017; 41:868-874. [PMID: 29201827 PMCID: PMC5698675 DOI: 10.5535/arm.2017.41.5.868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/23/2017] [Indexed: 01/28/2023] Open
Abstract
Objective To identify the prevalence of lumbar scoliosis in breast cancer patients and to investigate the potential risk factors of lumbar scoliosis. Methods A retrospective chart review was performed in breast cancer patients aged more than 40 years who underwent dual energy X-ray absorptiometry (DEXA) scanning between January 2014 and December 2014. We divided the patients into control and experimental groups in order to investigate the influence of breast cancer treatment. The curvature of the lumbar spine was measured by using the Cobb method on a DEXA scan. Scoliosis was defined by the presence of a curvature 10° or larger. The variables, including age, bone mineral density (BMD), body mass index (BMI), and breast cancer treatments, were also obtained from the medical chart. Prevalence of lumbar scoliosis was evaluated, and it was compared between the two groups. The relationships between lumbar scoliosis and these variables were also investigated. Results Lumbar scoliosis was present in 16 out of our 652 breast cancer patients. There was no difference in the prevalence of lumbar scoliosis between the control group (7/316) and the experimental group (9/336) (p=0.70). According to the logistic regression analysis, lumbar scoliosis had no significant association with operation, chemotherapy, hormone therapy, BMI, and BMD (p>0.05). However, age showed a significant relationship with prevalence of lumbar scoliosis (p<0.001; odds ratio, 1.11; 95% confidence interval, 1.054–1.170). Conclusion Prevalence of lumbar scoliosis in patients with breast cancer was 2.45%. Lumbar scoliosis had no association with breast cancer treatments, BMD, and BMI. Age was the only factor related to the prevalence of lumbar scoliosis.
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Affiliation(s)
- Sangeun Jung
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Gang Kim
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong In Lee
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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20
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Sattari M, Cauley JA, Garvan C, Johnson KC, LaMonte MJ, Li W, Limacher M, Manini T, Sarto GE, Sullivan SD, Wactawski-Wende J, Beyth RJ. Osteoporosis in the Women's Health Initiative: Another Treatment Gap? Am J Med 2017; 130:937-948. [PMID: 28366425 DOI: 10.1016/j.amjmed.2017.02.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/23/2017] [Accepted: 02/27/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Osteoporotic fractures are associated with high morbidity, mortality, and cost. METHODS We performed a post hoc analysis of the Women's Health Initiative (WHI) clinical trials data to assess osteoporosis treatment and identify participant characteristics associated with utilization of osteoporosis medication(s) after new diagnoses of osteoporosis or fracture. Information from visits prior to and immediately subsequent to the first fracture event or osteoporosis diagnosis were evaluated for medication use. A full logistic regression model was used to identify factors predictive of osteoporosis medication use after a fracture or a diagnosis of osteoporosis. RESULTS The median length of follow-up from enrollment to the last WHI clinic visit for the study cohort was 13.9 years. Among the 13,990 women who reported new diagnoses of osteoporosis or fracture between enrollment and their final WHI visit, and also had medication data available, 21.6% reported taking an osteoporosis medication other than estrogen. Higher daily calcium intake, diagnosis of osteoporosis alone or both osteoporosis and fracture (compared with diagnosis of fracture alone), Asian or Pacific Islander race/ethnicity (compared with White/Caucasian), higher income, and hormone therapy use (past or present) were associated with significantly higher likelihood of osteoporosis pharmacotherapy. Women with Black/African American race/ethnicity (compared with White/Caucasian), body mass index ≥30 (compared with body mass index of 18.5-24.9), current tobacco use (compared with past use or lifetime nonusers), and history of arthritis were less likely to use osteoporosis treatment. CONCLUSION Despite well-established treatment guidelines in postmenopausal women with osteoporosis or history of fractures, pharmacotherapy use was suboptimal in this study. Initiation of osteoporosis treatment after fragility fracture may represent an opportunity to improve later outcomes in these high-risk women. Specific attention needs to be paid to increasing treatment among women with fragility fractures, obesity, current tobacco use, history of arthritis, or of Black race/ethnicity.
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Affiliation(s)
| | - Jane A Cauley
- University of Pittsburgh Graduate School of Public Health, Pa
| | | | | | | | - Wenjun Li
- University of Massachusetts Medical School, Worcester
| | | | - Todd Manini
- University of Florida College of Medicine, Gainesville
| | - Gloria E Sarto
- School of Medicine and Public Health, University of Wisconsin-Madison
| | | | | | - Rebecca J Beyth
- University of Florida College of Medicine, Gainesville; North Florida/South Georgia Geriatric Research, Education, and Clinical Center, Gainesville, Fla
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21
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Martinez KA, Fagerlin A, Witteman HO, Holmberg C, Hawley ST. What Matters to Women When Making Decisions About Breast Cancer Chemoprevention? PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2017; 9:149-59. [PMID: 26115846 DOI: 10.1007/s40271-015-0134-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Despite the effectiveness of chemoprevention (tamoxifen and raloxifene) in preventing breast cancer among women at high risk for the disease, uptake is low. The objective of this study was to determine the tradeoff preferences for various attributes associated with chemoprevention among women not currently taking the drugs. METHODS We used rating-based conjoint analysis to evaluate the relative importance of a number of attributes associated with chemoprevention, including risk of side effects, drug effectiveness, time needed to take the drugs, and availability of a blood test to see if the drugs were working in an Internet sample of women. We generated mean importance values and part-worth utilities for all attribute levels associated with taking chemoprevention. We then used multivariable linear regression to examine attribute importance scores controlling for participant age, race, Hispanic ethnicity, educational level, and a family history of breast cancer. RESULTS Overall interest in taking chemoprevention was low among the 1094 women included in the analytic sample, even for the scenario in which participants would receive the greatest benefit and fewest risks associated with taking the drugs. Time needed to take the pill for it to work and 5-year risk of breast cancer were the most important attributes driving tradeoff preferences between the chemoprevention scenarios. CONCLUSIONS Interest in taking chemoprevention among this sample of women at average risk was low. Addressing women's concerns about the time needed to take chemoprevention for it to work may help clinicians improve uptake of the drugs among those likely to benefit.
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Affiliation(s)
- Kathryn A Martinez
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.
| | - Angela Fagerlin
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.,Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Holly O Witteman
- Department of Family and Emergency Medicine and Office of Education and Continuing Professional Development, Laval University, Quebec City, QC, Canada.,Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Centre, Quebec City, QC, Canada
| | | | - Sarah T Hawley
- Ann Arbor VA Center for Clinical Management Research, Building 16, 4th Floor, 2800 Plymouth Road, Ann Arbor, MI, 48105, USA.,Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
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22
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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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23
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Colzani E, Clements M, Johansson ALV, Liljegren A, He W, Brand J, Adolfsson J, Fornander T, Hall P, Czene K. Risk of hospitalisation and death due to bone fractures after breast cancer: a registry-based cohort study. Br J Cancer 2016; 115:1400-1407. [PMID: 27701383 PMCID: PMC5129831 DOI: 10.1038/bjc.2016.314] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 08/18/2016] [Accepted: 09/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bone fractures may have an impact on prognosis of breast cancer. The long-term risks of bone fracture in breast cancer patients have not been thoroughly studied. METHODS Poisson regression was used to investigate the incidence of hospitalisation due to bone fracture comparing women with and without breast cancer based on Swedish National registers. Cox regression was used to investigate the risk of being hospitalised with bone fracture, and subsequent risk of death, in a regional cohort of breast cancer patients. RESULTS For breast cancer patients, the 5-year risk of bone fracture hospitalisation was 4.8% and the 30-day risk of death following a bone fracture hospitalisation was 2.0%. Compared with the general population, breast cancer patients had incidence rate ratios of 1.25 (95% CI: 1.23-1.28) and 1.18 (95% CI: 1.14-1.22) for hospitalisation due to any bone fracture and hip fracture, respectively. These ratios remained significantly increased for 10 years. Comorbidities (Charlson Comorbidity Index ⩾1) were associated with the risk of being hospitalised with bone fracture. Women taking aromatase inhibitors were at an increased risk as compared with women taking tamoxifen (HR=1.48; 95% CI: 0.98-2.22). Breast cancer patients hospitalised for a bone fracture showed a higher risk of death (HR=1.83; 95% CI: 1.50-2.22) compared with those without bone fracture. CONCLUSIONS Women with a previous breast cancer diagnosis are at an increased risk of hospitalisation due to a bone fracture, particularly if they have other comorbidities.
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Affiliation(s)
- Edoardo Colzani
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
- Department of Health Sciences, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Monza 20126, Italy
| | - Mark Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Annelie Liljegren
- Department of Oncology and Pathology, Karolinska University Hospital, Karolinska Institutet, P.O. Box 260, Stockholm SE-171 76, Sweden
| | - Wei He
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Judith Brand
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm SE-171 77, Sweden
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm SE-102 33, Sweden
| | - Tommy Fornander
- Department of Oncology and Pathology, Karolinska University Hospital, Karolinska Institutet, P.O. Box 260, Stockholm SE-171 76, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
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Neuhaus V, Abdullayev N, Hellmich M, Krämer S, Maintz D, Krug B, Borggrefe J. Association of Quality and Quantity of Bone Metastases and Computed Tomography Volumetric Bone Mineral Density With Prevalence of Vertebral Fractures in Breast Cancer Patients. Clin Breast Cancer 2016; 16:402-409. [DOI: 10.1016/j.clbc.2016.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/22/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
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He W, Sofie Lindström L, Hall P, Czene K. Cause-specific mortality in women with breast cancer in situ. Int J Cancer 2016; 140:2414-2421. [PMID: 27594272 DOI: 10.1002/ijc.30413] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/20/2016] [Accepted: 08/24/2016] [Indexed: 11/09/2022]
Abstract
The long-term mortality remains unknown in women diagnosed with breast cancer in situ (BCIS). Here, we assessed the cause-specific mortality in BCIS patients. This population-based cohort study included 12,243 women diagnosed with BCIS in Sweden between 1980 and 2011. Patients were followed until death, emigration, or 31 December 2013, whichever came first. The 30-year cumulative incidence of breast cancer-specific mortality was 6.3%, which is considerably lower than 49.7% observed for other-cause mortality. Women diagnosed with BCIS were more likely to die from breast cancer (standardized mortality ratio [SMR], 3.85; 95% CI, 3.47-4.27) but less likely to die from cardiovascular disease (SMR, 0.88; 95% CI, 0.82-0.95) than women in the general population. Specifically, the SMRs for breast cancer-specific mortality decreased over time from 5.19 (95% CI, 3.95-6.81) among BCIS diagnosed during 1980-1989 to 3.03 (95% CI, 2.35-3.91) among those diagnosed during 2000-2011. Furthermore, higher risk of death from other causes was seen among those with older age at BCIS diagnosis, lower levels of education, nulliparity, higher Charlson Comorbidity Index, and being hospitalized before BCIS diagnosis; whereas, lower risk of death from breast cancer was seen among BCIS diagnosed in the later time period and those with younger age at first birth. We conclude that most women diagnosed with BCIS die from causes other than breast cancer, which highlights the need for actions not only to reduce nonbreast cancer mortality but also to identify patient where extensive curative BCIS treatment is not adding to survival.
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Affiliation(s)
- Wei He
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Current Knowledge, Drug-Based Therapeutic Options and Future Directions in Managing Osteoporosis. Clin Rev Bone Miner Metab 2016. [DOI: 10.1007/s12018-016-9207-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Edwards BJ, Gradishar WJ, Smith ME, Pacheco JA, Holbrook J, McKoy JM, Nardone B, Tica S, Godinez-Puig V, Rademaker AW, Helenowski IB, Bunta AD, Stern PH, Rosen ST, West DP, Guise TA. Elevated incidence of fractures in women with invasive breast cancer. Osteoporos Int 2016; 27:499-507. [PMID: 26294292 DOI: 10.1007/s00198-015-3246-3] [Citation(s) in RCA: 12] [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: 04/08/2015] [Accepted: 07/08/2015] [Indexed: 01/13/2023]
Abstract
UNLABELLED This study evaluates the incidence of bone fractures in women with BC.We found that women with invasive breast cancer are at an increased risk for bone fractures, with fractures most commonly occurring at lower extremity and vertebral sites. The risk is further increased in women undergoing cancer therapy. INTRODUCTION Bone loss and fractures in breast cancer have generally been attributed to aromatase inhibitor use. This study assessed the incidence of fractures after invasive breast cancer diagnosis and evaluated bone density and FRAX risk calculation at time of fracture occurrence. METHODS Retrospective cohort study of women with invasive breast cancer [June 2003-December 2011] who participated in an academic hospital based genetic biobank. Demographic and clinical characteristics were abstracted from the electronic medical record (EMR). RESULTS A total of 422 women with invasive breast cancer were assessed; 79 (28 %) sustained fractures during the observation period; fractures occurred at multiple skeletal sites in 27 cases (116 fractures). The incidence of fractures was 40 per 1000 person-years. Women who sustained fractures were mostly white and had a family history of osteoporosis (36.9 %, p = 0.03) or history of a prior fracture (6/79, p = 0.004). Fractures occurred 4.0 years (range 0-12 years) after cancer diagnosis. Fracture cases had femoral neck bone mineral density (BMD) of 0.72 + 0.12 g/cm(2), T-score of -1.2, that is, within the low bone mass range. Fractures most commonly occurred in lower extremities, vertebral, and wrist sites. Hip fractures accounted for 11 % of fractures, occurring at a median age of 61 years. CONCLUSIONS Fractures occur shortly after commencing cancer therapy. Rapid bone loss associated with cancer therapy may precipitate fractures. Fractures occur at relatively higher BMD in BC. Occurrence of fractures in invasive breast cancer raises the possibility of cancer-induced impairment in bone quality.
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Affiliation(s)
- B J Edwards
- Department of General Internal Medicine, University of Texas, MD Anderson Cancer Center, 1515 Holcombe, unit 1465, Houston, TX, 77030, USA.
| | - W J Gradishar
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - M E Smith
- NUgene Project, Center for Genetic Medicine, Northwestern University, Chicago, IL, USA
| | - J A Pacheco
- NUgene Project, Center for Genetic Medicine, Northwestern University, Chicago, IL, USA
| | - J Holbrook
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J M McKoy
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - B Nardone
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S Tica
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - V Godinez-Puig
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A W Rademaker
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - I B Helenowski
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A D Bunta
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P H Stern
- Department of Molecular Pharmacology and Biological Chemistry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S T Rosen
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D P West
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - T A Guise
- Department of Medicine, Division of Endocrinology, Indiana University, Indianapolis, IN, USA
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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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Dimitrakopoulos FID, Kottorou A, Antonacopoulou AG, Makatsoris T, Kalofonos HP. Early-Stage Breast Cancer in the Elderly: Confronting an Old Clinical Problem. J Breast Cancer 2015; 18:207-17. [PMID: 26472970 PMCID: PMC4600684 DOI: 10.4048/jbc.2015.18.3.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/20/2015] [Indexed: 01/06/2023] Open
Abstract
Breast cancer generally develops in older women and its incidence is continuing to increase with increasing age of the population. The pathology and biology of breast cancer seem to be different in the elderly, often resulting in the undertreatment of elderly patients and thus in higher rates of recurrence and mortal-ity. The aim of this review is to describe the differences in the biology and treatment of early breast cancer in the elderly as well as the use of geriatric assessment methods that aid decision-making. Provided there are no contraindications, the cornerstone of treatment should be surgery, as the safety and efficacy of surgical resection in elderly women have been well documented. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant setting. The role of chemotherapy is limited to patients who test negative for hormone receptors and demonstrate an aggressive tumor profile. Although the prognosis of breast cancer patients has generally improved during the last few decades, there is still a demand for evidence-based optimization of therapeutic interventions in older patients.
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Affiliation(s)
| | - Anastasia Kottorou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Anna G Antonacopoulou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Thomas Makatsoris
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Haralabos P Kalofonos
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
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Tzeng HE, Muo CH, Chen HT, Hwang WL, Hsu HC, Tsai CH. Tamoxifen use reduces the risk of osteoporotic fractures in women with breast cancer in Asia: a nationwide population-based cohort study. BMC Musculoskelet Disord 2015; 16:123. [PMID: 25989902 PMCID: PMC4438570 DOI: 10.1186/s12891-015-0580-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/12/2015] [Indexed: 11/19/2022] Open
Abstract
Purpose Bone mineral density changes with tamoxifen treatment have been reported in pre- and post-menopausal women with breast cancer. However, there remains controversy as to whether tamoxifen significantly reduces fracture rates in different age groups. Breast cancer occurs at 10-20 years younger in Asian women compared with Western women. Therefore we conducted this population-based case-control study to determine whether or not tamoxifen use is associated with osteoporotic fractures. Patients and methods We selected 75488 women with breast cancer with no prior history of fractures from the Longitudinal Health Insurance Database for Catastrophic Illness Patients in 2000-2011. They were followed from the date of the diagnosis of breast cancer to the date a hip, vertebral or wrist fracture occurred. Because the use of tamoxifen was a time-dependent variable, we used a Cox proportional hazard model with time-dependent exposure covariates to estimate the risk of a fracture. Results There were 50257 and 25231 women with breast cancer who did and did not receive tamoxifen treatment, respectively. The tamoxifen users had lower risks for overall fractures with hazard ratios (HRs) of 0.52 and 0.59 in the crude and adjusted models (95 % CI = 0.45-0.61 and 0.51-0.69), respectively. They also had lower risks for hip (HR = 0.55, 95 % CI = 0.45-0.67) and vertebral (HR = 0.64, 95 % CI = 0.50-0.82) fractures in the adjusted model. The risk of fractures decreased with an increasing dosage of tamoxifen. Regardless of the age group, the tamoxifen users had a lower risk of fractures than the non-users. Conclusion In this Asian population-based case-control study, tamoxifen use was associated with a reduction in osteoporotic fractures, especially in hip fractures.
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Affiliation(s)
- Huey-En Tzeng
- Graduate Institute of Clinical Medicine, China Medical University, #91 Hsueh-Shih Road, Taichung, 404, Taiwan. .,Division of Hematology/Oncology, Taichung Veterans General Hospital, Taichung, Taiwan. .,School of Medicine, China Medical University, Taichung, Taiwan.
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.
| | - Hsien-Te Chen
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan. .,School of Chinese Medicine, China Medical University, Taichung, Taiwan.
| | - Wen-Li Hwang
- Division of Hematology/Oncology, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Horng-Chang Hsu
- School of Medicine, China Medical University, Taichung, Taiwan. .,Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan.
| | - Chun-Hao Tsai
- Graduate Institute of Clinical Medicine, China Medical University, #91 Hsueh-Shih Road, Taichung, 404, Taiwan. .,School of Medicine, China Medical University, Taichung, Taiwan. .,Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan.
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O'Sullivan S, Grey A. Adverse skeletal effects of drugs - beyond Glucocorticoids. Clin Endocrinol (Oxf) 2015; 82:12-22. [PMID: 25039381 DOI: 10.1111/cen.12549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 06/28/2014] [Accepted: 07/07/2014] [Indexed: 12/13/2022]
Abstract
Osteoporotic fractures are an important public health problem with significant individual and societal costs. In addition to the major risk factors for osteoporotic fracture, low bone mineral density (BMD), age, low body weight and history of fracture or falls, some drugs are now considered to be important secondary risk factor for bone loss and fracture, particularly amongst predisposed individuals. Currently available data are often generated from small observational clinical studies, making risk assessment and development of management guidelines difficult. In many cases, the exposed population has a low baseline risk for fracture and additional assessment and treatment may not be necessary. In this review, we focus on drugs other than glucocorticoids identified as potentially causing adverse skeletal effects, summarizing the existing evidence from preclinical and clinical studies, and suggest recommendations for patient management.
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Trémollieres FA. Screening for osteoporosis after breast cancer: for whom, why and when. Maturitas 2014; 79:343-8. [PMID: 25308162 DOI: 10.1016/j.maturitas.2014.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 07/31/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
Osteoporosis and breast cancer are common diseases in postmenopausal women. Bone and the breast are both estrogenic dependent tissues and different surrogate markers for osteoporosis are opposite of those for the risk of breast cancer. In particular, numerous studies have reported a positive relationship between high bone mineral density (BMD) and a greater risk of breast cancer. On the other hand, most treatments in early breast cancer women including ovarian suppression treatments (chemotherapy, surgery or GnRH agonists) and aromatase inhibitor (AI) therapy induce a profound and rapid suppression of estrogen levels thereby increasing the rate of bone loss. Nevertheless, their impact on the risk of fracture is still questionable, especially in postmenopausal women with no osteoporosis at baseline. The purpose of this minireview is to examine the relationship between breast cancer and the risk of fracture and to discuss a screening strategy for osteoporosis after breast cancer.
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Affiliation(s)
- Florence A Trémollieres
- Menopause and Metabolic Bone Disease Unit Hôpital Paule de Viguier CHU Toulouse 330 avenue de Grande-Bretagne TSA 70034 31059 Toulouse cedex France.
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Pawloski PA, Geiger AM, Haque R, Kamineni A, Fouayzi H, Ogarek J, Petersen HV, Bosco JLF, Thwin SS, Silliman RA, Field TS. Fracture risk in older, long-term survivors of early-stage breast cancer. J Am Geriatr Soc 2013; 61:888-895. [PMID: 23647433 DOI: 10.1111/jgs.12269] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To examine the effect of breast cancer and its treatment on fracture risk in older breast cancer survivors. DESIGN A 10-year prospective cohort study beginning 5 years after a diagnosis of breast cancer for survivors and match date for comparison women. SETTING Six integrated healthcare systems. PARTICIPANTS Women aged 65 and older (1,286 survivors, 1,286 comparison women, mean age 77.7 in both groups, white, non-Hispanic: survivors, 81.6%; comparison women, 85.2%) who were alive and recurrence free 5 years after a diagnosis of early-stage breast cancer and matched on age, study site, and enrollment year to a comparison cohort without breast cancer. MEASUREMENTS Cox proportional hazards models were used to estimate the association between fracture risk and survivor-comparison status, adjusting for drugs and risk factors associated with bone health. A subanalysis was used to evaluate the association between tamoxifen exposure and fracture risk. RESULTS No difference was observed in fracture rates between groups (hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 0.9-1.3). The protective effect of tamoxifen was not statistically significant (HR = 0.9, 95% CI = 0.6-1.2). CONCLUSION Long-term survivors of early-stage breast cancer diagnosed at age 65 and older are not at greater risk of osteoporotic fractures than age-matched women without breast cancer. There appears to be no long-term protection from fractures with tamoxifen use.
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Affiliation(s)
- Pamala A Pawloski
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota 55425, USA.
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Galea GL, Meakin LB, Sugiyama T, Zebda N, Sunters A, Taipaleenmaki H, Stein GS, van Wijnen AJ, Lanyon LE, Price JS. Estrogen receptor α mediates proliferation of osteoblastic cells stimulated by estrogen and mechanical strain, but their acute down-regulation of the Wnt antagonist Sost is mediated by estrogen receptor β. J Biol Chem 2013; 288:9035-48. [PMID: 23362266 PMCID: PMC3610976 DOI: 10.1074/jbc.m112.405456] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mechanical strain and estrogens both stimulate osteoblast proliferation through estrogen receptor (ER)-mediated effects, and both down-regulate the Wnt antagonist Sost/sclerostin. Here, we investigate the differential effects of ERα and -β in these processes in mouse long bone-derived osteoblastic cells and human Saos-2 cells. Recruitment to the cell cycle following strain or 17β-estradiol occurs within 30 min, as determined by Ki-67 staining, and is prevented by the ERα antagonist 1,3-bis(4-hydroxyphenyl)-4-methyl-5-[4-(2-piperidinylethoxy)phenol]-1H-pyrazole dihydrochloride. ERβ inhibition with 4-[2-phenyl-5,7-bis(trifluoromethyl)pyrazolo[1,5-β]pyrimidin-3-yl] phenol (PTHPP) increases basal proliferation similarly to strain or estradiol. Both strain and estradiol down-regulate Sost expression, as does in vitro inhibition or in vivo deletion of ERα. The ERβ agonists 2,3-bis(4-hydroxyphenyl)-propionitrile and ERB041 also down-regulated Sost expression in vitro, whereas the ERα agonist 4,4′,4″-[4-propyl-(1H)-pyrazol-1,3,5-triyl]tris-phenol or the ERβ antagonist PTHPP has no effect. Tamoxifen, a nongenomic ERβ agonist, down-regulates Sost expression in vitro and in bones in vivo. Inhibition of both ERs with fulvestrant or selective antagonism of ERβ, but not ERα, prevents Sost down-regulation by strain or estradiol. Sost down-regulation by strain or ERβ activation is prevented by MEK/ERK blockade. Exogenous sclerostin has no effect on estradiol-induced proliferation but prevents that following strain. Thus, in osteoblastic cells the acute proliferative effects of both estradiol and strain are ERα-mediated. Basal Sost down-regulation follows decreased activity of ERα and increased activity of ERβ. Sost down-regulation by strain or increased estrogens is mediated by ERβ, not ERα. ER-targeting therapy may facilitate structurally appropriate bone formation by enhancing the distinct ligand-independent, strain-related contributions to proliferation of both ERα and ERβ.
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Affiliation(s)
- Gabriel L Galea
- School of Veterinary Sciences, University of Bristol, Bristol BS40 5DU, United Kingdom.
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Abstract
Selective estrogen receptor modulators (SERMs), which exhibit estrogen receptor agonist or antagonist activity based on the target tissue, have evolved through multiple generations for the prevention and/or treatment of postmenopausal osteoporosis. An ideal SERM would protect bone without stimulating the breast or endometrium. Raloxifene, lasofoxifene, and bazedoxifene have demonstrated unique preclinical profiles. Raloxifene, lasofoxifene, and bazedoxifene have shown significant reduction in the risk of vertebral fracture and improvement in bone mineral density versus placebo in postmenopausal women with osteoporosis. Raloxifene has been shown to reduce the risk of non-vertebral fractures in women with severe prevalent fractures at baseline. Lasofoxifene 0.5 mg, but not lasofoxifene 0.25 mg, has shown reduction in the incidence of non-vertebral fractures. Bazedoxifene 20 mg has been associated with a significant reduction in the risk of non-vertebral fracture versus placebo and raloxifene 60 mg in women at higher baseline fracture risk. Neither raloxifene, lasofoxifene, nor bazedoxifene has shown an increase in the incidence of endometrial hyperplasia or carcinoma. All SERMs have been associated with increased venous thromboembolic events and hot flushes. SERMs are effective alternatives for women who cannot tolerate or are unwilling to take bisphosphonates and may be appropriate for women at higher risk of fracture, particularly younger women who expect to remain on therapy for many years and are concerned about the long-term safety of bisphosphonates.
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Affiliation(s)
- P Hadji
- Department of Endocrinology, Reproductive Medicine, and Osteoporosis, Philipps-University of Marburg, Marburg, Germany
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Lix LM, Azimaee M, Osman BA, Caetano P, Morin S, Metge C, Goltzman D, Kreiger N, Prior J, Leslie WD. Osteoporosis-related fracture case definitions for population-based administrative data. BMC Public Health 2012; 12:301. [PMID: 22537071 PMCID: PMC3356235 DOI: 10.1186/1471-2458-12-301] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 04/26/2012] [Indexed: 12/28/2022] Open
Abstract
Background Population-based administrative data have been used to study osteoporosis-related fracture risk factors and outcomes, but there has been limited research about the validity of these data for ascertaining fracture cases. The objectives of this study were to: (a) compare fracture incidence estimates from administrative data with estimates from population-based clinically-validated data, and (b) test for differences in incidence estimates from multiple administrative data case definitions. Methods Thirty-five case definitions for incident fractures of the hip, wrist, humerus, and clinical vertebrae were constructed using diagnosis codes in hospital data and diagnosis and service codes in physician billing data from Manitoba, Canada. Clinically-validated fractures were identified from the Canadian Multicentre Osteoporosis Study (CaMos). Generalized linear models were used to test for differences in incidence estimates. Results For hip fracture, sex-specific differences were observed in the magnitude of under- and over-ascertainment of administrative data case definitions when compared with CaMos data. The length of the fracture-free period to ascertain incident cases had a variable effect on over-ascertainment across fracture sites, as did the use of imaging, fixation, or repair service codes. Case definitions based on hospital data resulted in under-ascertainment of incident clinical vertebral fractures. There were no significant differences in trend estimates for wrist, humerus, and clinical vertebral case definitions. Conclusions The validity of administrative data for estimating fracture incidence depends on the site and features of the case definition.
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Affiliation(s)
- Lisa M Lix
- School of Public Health, University of Saskatchewan, Saskatoon, Canada.
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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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38
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Melton LJ, Hartmann LC, Achenbach SJ, Atkinson EJ, Therneau TM, Khosla S. Fracture risk in women with breast cancer: a population-based study. J Bone Miner Res 2012; 27:1196-205. [PMID: 22258822 PMCID: PMC3361522 DOI: 10.1002/jbmr.1556] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A positive association has been reported between greater bone density and higher breast cancer risk, suggesting that these women could be at reduced risk of fracture. To estimate fracture risk among unselected community women with breast cancer and to systematically assess associations with various risk factors including breast cancer treatments, we conducted a population-based historical cohort study of 608 Olmsted County, MN, USA, women with invasive breast cancer first diagnosed in 1990 to 1999 (mean age 61.6 ± 14.8 years), who were followed for 5776 person-years. Altogether, 568 fractures were observed in 270 women (98 per 1000 person-years). Overall fracture risk was elevated 1.8-fold, but the absolute increase in risk was only 9%, and 56% of the women did not experience a fracture during follow-up. Excluding pathologic fractures (15%) and those found incidentally (24%), to allow for ascertainment bias, the standardized incidence ratio was 1.2 (95% confidence interval [CI] 0.99 to 1.3) for total fracture risk and 0.9 (95% CI 0.7 to 1.2) for osteoporotic fracture risk alone. Various breast cancer treatments were associated with an increased risk of fracture, but those associations were strongest for pathologic fractures, which were relatively more common among the women who were premenopausal when their breast cancer was diagnosed. Moreover, underlying clinical characteristics prompting different treatments may have been partially responsible for the associated fracture outcomes (indication bias). These data thus demonstrate that breast cancer patients in general are not at greatly increased risk of fracture but neither are they protected from fractures despite any determinants that breast cancer and high bone density may have in common.
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Affiliation(s)
- L Joseph Melton
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA.
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39
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Lix LM, Quail J, Teare G, Acan B. Performance of comorbidity measures for predicting outcomes in population-based osteoporosis cohorts. Osteoporos Int 2011; 22:2633-43. [PMID: 21305268 DOI: 10.1007/s00198-010-1516-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 11/30/2010] [Indexed: 12/22/2022]
Abstract
UNLABELLED The performance of five comorbidity measures, including the Charlson and Elixhauser indices, was investigated for predicting mortality, hospitalization, and fracture outcomes in two osteoporosis cohorts defined from administrative databases. The optimal comorbidity measure depended on the outcome of interest, although overall the Elixhauser index performed well. INTRODUCTION Studies that use administrative data to investigate population-based health outcomes often adopt risk-adjustment models that include comorbidities, conditions that coexist with the index disease. There has been limited research about the measurement of comorbidity in osteoporotic populations. The study purpose was to compare the performance of comorbidity measures for predicting mortality, fracture, and health service utilization outcomes in two cohorts with diagnosed or treated osteoporosis. METHODS Administrative data were from the province of Saskatchewan, Canada. Osteoporosis cohorts were identified from diagnoses in hospital and physician data and prescriptions for osteo-protective medications using case definitions with high sensitivity or high specificity. Five diagnosis- and medication-based comorbidity measures and five 1-year outcomes, including mortality, hospitalization (two measures), osteoporotic-related fracture, and hip fracture, were defined. Performance of the comorbidity measures was assessed using the c-statistic (discrimination) and Brier score (prediction error) for multiple logistic regression models. RESULTS In the specific cohort (n = 9,849) for the mortality outcome, the Elixhauser index resulted in the largest improvement (8.96%) in the c-statistic and lowest Brier score compared to a model that contained demographic and socioeconomic variables, followed by the Charlson index (6.06%). For hospitalization, the number of different diagnoses resulted in the largest improvement (14.01%) in the c-statistic. The Elixhauser index resulted in significant improvements in the c-statistic for osteoporosis-related and hip fractures. Similar results were observed for the sensitive cohort (n = 28,068). CONCLUSIONS Recommendations about the optimal comorbidity measure will vary with the outcome under investigation. Overall, the Elixhauser index performed well.
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Affiliation(s)
- L M Lix
- School of Public Health, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK, Canada.
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40
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Servitja S, Nogués X, Prieto-Alhambra D, Martínez-García M, Garrigós L, Peña MJ, de Ramon M, Díez-Pérez A, Albanell J, Tusquets I. Bone health in a prospective cohort of postmenopausal women receiving aromatase inhibitors for early breast cancer. Breast 2011; 21:95-101. [PMID: 21924904 DOI: 10.1016/j.breast.2011.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 08/30/2011] [Accepted: 09/01/2011] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Baseline bone health in postmenopausal women is poorly characterized in prospective series of early breast cancer (EBC) patients candidates to aromatase inhibitor (AI) therapy. Our objective is to comprehensively evaluate bone health in a prospective clinical cohort of patients recruited prior to adjuvant AI therapy, with the aim of establishing potential AI impact on bone loss and fractures. METHODS From January 2006 to April 2010, we consecutively included 343 women with EBC who were about to start adjuvant AI therapy. Participants were assessed at baseline (before AI initiation) and at 3 months, with annual assessments thereafter. Bone mineral density (BMD), spine X-ray, bone metabolism (vitamin D [25(OH)D], bone turnover markers [BTM]), arthralgia and quality of life are measured. RESULTS Mean age was 61.9 years; 197 (57.4%) had been previously treated with tamoxifen; 145 (42.3%) were taking exemestane, 187 (54.5%) letrozole, and 11 (3.2%) anastrozole. Analysis of baseline data shows only 59 women (17.7%) had normal BMD; 200 (60.1%) had osteopenia and 74 (22.2%) had osteoporosis; 39 women (11.4%) had a prevalent fracture, 293 (89.1%) had 25(OH)D insufficiency (<30 ng/ml), and 61 (18.5%) severe deficiency (<10 ng/ml). Low 25(OH)D concentrations were associated with lower BMD and 233 (67.9%) participants had some degree of arthralgia. CONCLUSIONS Low bone mass, prevalent fractures and vitamin D insufficiency were highly prevalent among candidates to adjuvant AI for EBC. Therefore, it is crucial to assess BMD, prevalent fractures and 25(OH)D concentrations before starting AI therapy and during follow-up.
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Affiliation(s)
- Sònia Servitja
- Medical Oncology Department, Breast Cancer Unit, Parc de Salut Mar-Barcelona, Molecular Therapeutics and Biomarkers in Breast Cancer, Cancer Research Program, Autonomous University of Barcelona, Spain.
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Abstract
As people with cancer survive longer, and as the US population ages, skeletal effects of cancer treatment are becoming more pronounced. This is particularly true for breast and prostate cancer survivors because of the high average age of patients with these malignancies, the propensity of older adults in general toward the development of osteoporosis, and the wide use of therapeutic agents in these cancers that negatively impact bone health. Various therapies used in the treatment and prevention of cancer may cause decreases in bone mineral density and an increased risk of debilitating fracture, even in the absence of bone metastases. Aging is both a baseline risk factor in the development of osteoporosis and bony fracture, as well as a predictor of poor outcome after fracture. A variety of mechanisms may be responsible for the development of bone loss in patients with breast or prostate cancer. Cytotoxic chemotherapy may directly exert long-term toxic effects on bone. Chemotherapy and endocrine therapy can induce hypogonadism, leading to an increased rate of bone loss. The risk of skeletal events in older adults due to cancer therapy should be appreciated by all oncologists, geriatricians, and internists. The following review may serve as a guide to the skeletal side effects of cancer therapy in older adults with breast or prostate cancer, how to screen for treatment-related bone loss, and how to best prevent and/or treat skeletal events.
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Affiliation(s)
- Ari VanderWalde
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA.
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42
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The gynecologic effects of lasofoxifene, an estrogen agonist/antagonist, in postmenopausal women. Menopause 2011; 18:6-7. [PMID: 21173718 DOI: 10.1097/gme.0b013e318203a46b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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43
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Abdel-Razeq H. Caring for the breast cancer survivor. Am J Med 2011; 124:e11; author reply e13. [PMID: 21295181 DOI: 10.1016/j.amjmed.2010.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/12/2010] [Indexed: 10/18/2022]
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Yu KD, Huang AJ, Shao ZM. Tailoring adjuvant endocrine therapy for postmenopausal breast cancer: a CYP2D6 multiple-genotype-based modeling analysis and validation. PLoS One 2010; 5:e15649. [PMID: 21187922 PMCID: PMC3004945 DOI: 10.1371/journal.pone.0015649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 11/18/2010] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Previous studies have suggested that postmenopausal women with breast cancer who present with wild-type CYP2D6 may actually have similar or superior recurrence-free survival outcomes when given tamoxifen in place of aromatase inhibitors (AIs). The present study established a CYP2D6 multiple-genotype-based model to determine the optimal endocrine therapy for patients harboring wild-type CYP2D6. METHODS We created a Markov model to determine whether tamoxifen or AIs maximized 5-year disease-free survival (DFS) for extensive metabolizer (EM) patients using annual hazard ratio (HR) data from the BIG 1-98 trial. We then replicated the model by evaluating 9-year event-free survival (EFS) using HR data from the ATAC trial. In addition, we employed two-way sensitivity analyses to explore the impact of HR of decreased-metabolizer (DM) and its frequency on survival by studying a range of estimates. RESULTS The 5-year DFS of tamoxifen-treated EM patients was 83.3%, which is similar to that of genotypically unselected patients who received an AI (83.7%). In the validation study, we further demonstrated that the 9-year EFS of tamoxifen-treated EM patients was 81.4%, which is higher than that of genotypically unselected patients receiving tamoxifen (78.4%) and similar to that of patients receiving an AI (83.2%). Two-way sensitivity analyses demonstrated the robustness of the results. CONCLUSIONS Our modeling analyses indicate that, among EM patients, the DFS/EFS outcome of patients receiving tamoxifen is similar to that of patients receiving an AI. Further prospective clinical trials are needed to evaluate the value of the CYP2D6 genotype in the selection of endocrine therapy.
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Affiliation(s)
- Ke-Da Yu
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
| | - A-Ji Huang
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
| | - Zhi-Ming Shao
- Department of Oncology, Shanghai Medical College, Cancer Institute and Cancer Center, Institutes of Biomedical Science, Fudan University, Shanghai, People's Republic of China
- * E-mail:
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Chalasani P, Downey L, Stopeck AT. Caring for the breast cancer survivor: a guide for primary care physicians. Am J Med 2010; 123:489-95. [PMID: 20569749 DOI: 10.1016/j.amjmed.2009.09.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 09/08/2009] [Accepted: 09/27/2009] [Indexed: 10/19/2022]
Abstract
Breast cancer accounts for more than 25% of cancers in women. Because of improved screening and treatment modalities, mortality has decreased significantly. Currently, over 2.5 million breast cancer survivors live in the US and receive care from a primary care provider. Providers need to be aware of common and serious complications of breast cancer treatment. In this review we discuss complications of local and systemic treatment for breast cancer, including lymphedema, osteoporosis, cardiovascular disease, and vasomotor symptoms. Current strategies for screening, monitoring, and treating these complications also are outlined.
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Affiliation(s)
- Pavani Chalasani
- Arizona Cancer Center, University of Arizona, Tucson, AZ 85724-5024, USA.
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46
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Nogues X, Servitja S, Peña MJ, Prieto-Alhambra D, Nadal R, Mellibovsky L, Albanell J, Diez-Perez A, Tusquets I. Vitamin D deficiency and bone mineral density in postmenopausal women receiving aromatase inhibitors for early breast cancer. Maturitas 2010; 66:291-7. [PMID: 20399042 DOI: 10.1016/j.maturitas.2010.03.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 03/15/2010] [Accepted: 03/16/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Aromatase inhibitors (AI) treatment leads to an increased risk of bone loss and fractures. In a group of women with early breast cancer (EBC) and baseline Vitamin D deficiency (<30 ng/ml) who are treated with AI, we aim to describe: serum levels of Vitamin D, bone mineral density (BMD), calcium intake, and the increase of serum 25(OH)D accomplished in 3 months of treatment with Vitamin D supplements. STUDY DESIGN Prospective, non-randomized clinical trial. METHODS In 232 consecutively included women with EBC in treatment with AI, we assessed baseline calcium intake, serum levels of 25(OH)D, BMD and, spine X-ray. All received Calcium and Vitamin D supplements, and those with vitamin deficiency received 16,000 IU Vitamin D every 2 weeks. Serum levels of 25(OH)D were newly assessed after treatment. All the baseline evaluation was performed before starting AI treatment. RESULTS Mean age at baseline (+/-SD) was 63.2+/-8.8 years. In 150 (64.9%) cases, the women had been treated previously with tamoxifen; 101 (43.7%) started exemestane, 119 (51.5%) letrozole, and 11 (4.8%) anastrozole. The AI were initiated within 6 weeks after surgery or after the last cycle of chemotherapy. At baseline, 88.1% had 25(OH)D levels <30 ng/ml, 21.2% had severe deficiency (<10 ng/ml), and 25% of the participants had osteoporosis. Mean daily calcium intake was low (841+/-338). We found a significant association between 25(OH)D levels and BMD at baseline, which remained significant in femoral neck BMD after multivariate adjustment. Plasma 25(OH)D levels improved significantly at 3 months follow-up in those treated with high dose Vitamin D supplements: mean increase 32.55 ng/ml (95%CI 28.06-37.03). CONCLUSIONS Our study suggests a high prevalence of commonly unrecognized Vitamin D deficiency in women with EBC treated with AI, a known osteopenic agent. Our results support the need for a routine assessment of 25(OH)D levels and, when necessary, supplementation in these patients.
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Affiliation(s)
- Xavier Nogues
- Internal Medicine Department, URFOA-IMIM, RETICEF, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain.
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Blaha P, Exner R, Borgo AD, Bigenzahn S, Panhofer P, Riedl O, Schoppmann S, Bachleitner-Hofmann T, Sporn E, Pluschnig U, Fitzal F, Steger G, Jakesz R, Dubsky P, Gnant M. Is Endocrine Therapy Really Pleasant? Considerations about the Long-Term Use of Antihormonal Therapy and Its Benefit/Side Effect Ratio. ACTA ACUST UNITED AC 2009; 4:155-161. [PMID: 21160541 DOI: 10.1159/000227829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Endocrine therapy has become a key part in the adjuvant treatment of hormone responsive breast cancer. The positive effect on relapse risk reduction is well defined, but therapy is not free from bothersome side effects for which estrogen deprivation accounts to a great extent. Since endocrine therapy is usually prescribed for 5 years or longer to optimally display its protective effect, and because physical strain is missing, good tolerability and safety properties are important, particularly in low-risk patients. While tamoxifen has been the standard adjuvant endocrine treatment with well documented efficiency, it is increasingly replaced by third generation aromatase inhibitors due to their better effectiveness and tolerability. Because tamoxifen holds a risk for life-threatening adverse events such as endometrial cancer, pulmonary embolism, and stroke, its recommended duration of therapy is limited to 5 years, also because extension beyond that time did not produce a measurable advantage. While some side effects are present both with tamoxifen and aromatase inhibitors, differences in side effect profiles are well established. Although side effects of aromatase inhibitor-related therapy usually are mild and common to symptoms of menopause, misconception of the symptoms and their mechanism of action, as well as lack of knowledge about how to handle them, can easily lead to dangerous discontinuation of therapy.
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Affiliation(s)
- Peter Blaha
- Department of Surgery, Medical University of Vienna, Austria
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