A group of experts from seven professional societies have published a joint position statement in the Journal of Bone Oncology on the management of aromatase inhibitor–associated bone loss (AIBL) as a guide for osteoporosis specialists and oncologists. This position statement acts as an update on recommendations on AIBL from 2017, especially to highlight and address the heightened risk of fracture among women undergoing endocrine therapy for estrogen-responsive breast cancer.
“The significant negative impact that aromatase inhibitors and other breast cancer therapies can have on bone health in postmenopausal women reinforces the need for clear strategies to routinely assess and appropriately treat this patient group alongside their primary disease management. This updated position statement reflects the latest combined thinking on fracture and risk assessment in postmenopausal women with breast cancer who are receiving adjuvant aromatase inhibitor therapy and summarizes the most suitable treatment modalities and an ideal treatment algorithm for the management of AIBL,” stated lead author Peyman Hadji, MD, of Frankfurt Centre for Bone Health and Endocrinology, and Philipps University of Marburg, Marburg, Germany.
Putting Together the Updated Statement
Although aromatase inhibitors are a backbone of many treatments for patients with hormone-responsive breast cancers, they also accelerate bone resorption, leading to an increased risk for osteoporosis and fractures.
Several interdisciplinary societies published an initial joint position statement on AIBL in 2017 to address the issue of bone loss from standard hormonal therapy in women with breast cancer.
Representatives from the International Osteoporosis Foundation (IOF); Cancer and Bone Society (CABS); European Calcified Tissue Society (ECTS); International Expert Group for AIBL (IEG); European Society for Clinical and Economics Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO); International Menopause Society (IMS); and the International Society for Geriatric Oncology (SIOG) combined new evidence with the prior recommendations to create the updated joint position statement. They conducted a systematic literature review to identify relevant studies and reviews for the updated statement to provide strategies for the assessment and treatment of AIBL alongside cancer treatment.
Key Takeaways From the Joint Statement
The updated joint statement clarifies that the risk for fractures in women with breast cancer receiving adjuvant aromatase inhibition only increases with the extended duration approach of 5 to 10 years that is currently commonly used. Extended aromatase inhibition use was associated with a significantly higher risk of fractures (odds ratio [OR] = 1.34; P < .001). A meta-analysis showed a relative risk of 1.59 for low-energy fractures from extended aromatase inhibition treatment (P = .002) and a relative risk of 1.53 for osteoporosis (P = .005).
The statement includes more details on risk stratification and factors for fracture assessment as well as appropriate antiresorptive treatment options for the prevention of AIBL. Additionally, the statement includes several evidence-based AIBL treatment algorithms.
The group also showed that bisphosphonate treatment can lead to direct and indirect antitumor benefits in addition to its effect on bone health. Bisphosphonate treatment was associated with a reduced rate of skeletal metastases and improved recurrence-free and overall survival outcomes in postmenopausal women with breast cancer experiencing AIBL.
“Every woman undergoing aromatase inhibitor therapy deserves to understand her heightened fracture risk and its consequences. This updated guidance unites the latest expertise in fracture prevention and treatment, and calls on osteoporosis specialists and oncologists to integrate it into everyday practice,” added Nicholas Harvey, MD, President of the IOF, Professor of Rheumatology and Clinical Epidemiology at the University of Southampton, and Director of the University's MRC Lifecourse Epidemiology Centre, Southampton, United Kingdom. “By working together, physicians and patients can promote a personalized, evidence-based strategy that safeguards bone health while optimizing cancer care.”
Disclosure: For full disclosures of the study authors, visit sciencedirect.com.
