Joint Position Statement on Management of Aromatase Inhibitor–Associated Bone Loss in Postmenopausal Women With Hormone-Sensitive Breast Cancer

A new position statement, jointly published by seven international and European organizations, identifies fracture-related risk factors in patients treated with aromatase inhibitors and outlines key management strategies to help prevent bone loss and related fractures. It was published by Hadji et al in the Journal of Bone Oncology.

The statement is authored by experts from the International Osteoporosis Foundation; Cancer and Bone Society; International Expert Group for Aromatase Inhibitor–Associated Bone Loss; European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases; European Calcified Tissue Society; International Menopause Society; and the International Society for Geriatric Oncology.

Women receiving adjuvant aromatase inhibitor therapy for breast cancer experience a 2- to 4-fold increase in bone loss compared to the normal rate of bone loss with menopause, and as a result, they are at heightened risk of fracture.

René Rizzoli, MD, PhD, Chairman of the International Osteoporosis Foundation Bone and Cancer Working Group, stated, “While clinical trials have shown an approximately 10% increase in absolute fracture risk for women on [aromatase inhibitor] therapy, other real-world studies indicate that the fracture risk may be significantly higher. Additionally, breast cancer patients hospitalized for a bone fracture showed a higher risk of death compared to breast cancer patients without a bone fracture. These are compelling reasons to ensure that all women on [aromatase inhibitor] therapy for breast cancer receive early assessment and treatment.”

Statements

Among its conclusions, the position states:

  • In all patients initiating aromatase inhibitor treatment, fracture risk should be assessed and recommendations given in regard to exercise and calcium/vitamin D supplementation.
  • Bone-directed therapy should be recommended for the duration of aromatase inhibitor treatment to all patients with a T score less than –2.0 standard deviations (SD), or with a T score less than –1.5 SD with 1 additional risk factor, or with 2 or more risk factors (without bone mineral density).
  • Patients with a T score greater than –1.5 SD and no risk factors should be managed based on bone mineral density loss during the first year and based on local guidelines for postmenopausal osteoporosis.
  • Based on current evidence, 6-monthly denosumab (Xgeva) or yearly zoledronic acid for the duration of aromatase inhibitor therapy is recommend for the prevention of aromatase inhibitor–associated bone loss in postmenopausal women receiving adjuvant aromatase inhibitor therapy, with zoledronic acid recommended when effects on disease recurrence are the priority and denosumab recommended when fracture risk is the dominant concern.
  • Because of the decreased incidence of bone recurrence and breast cancer–specific mortality associated with bisphosphonate use, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.
  • Compliance should be regularly assessed as well as bone mineral density after 12 to 24 months on treatment.

Peyman Hadji, MD, PhD, first author of the paper and board member of the Cancer and Bone Society, added, “As fragility fractures often result in prolonged disability and loss of independence, it is important that women who are being treated for hormone-sensitive breast cancer are managed to prevent bone loss and related fractures. As well, given that recent research has revealed the potential anticancer benefits of antiresorptive agents in early breast cancer, these agents can also play a role in preventing disease recurrence.”

The authors note that in addition to the established risk factors used in the position statement’s bone health algorithm, other potential fracture risk factors in women with breast cancer include chemotherapy, radiotherapy, low weight, and family history of hip fractures. Further studies examining the role of these factors are encouraged, and annual assessment of breast cancer patients with these potential risk factors may be prudent.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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