• Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group.

      Reid, David M; Doughty, Julie; Eastell, Richard; Heys, Steven D; Howell, Anthony; McCloskey, Eugene V; Powles, Trevor J; Selby, Peter; Coleman, Robert E; Department of Rheumatology, University of Aberdeen, United Kingdom. d.m.reid@abdn.ac.uk (2008)
      In postmenopausal women, the use of aromatase inhibitors increases bone turnover and induces bone loss at sites rich in trabecular bone at an average rate of 1-3% per year leading to an increase in fracture incidence compared to that seen during tamoxifen use. The bone loss is much more marked in young women with treatment-induced ovarian suppression followed by aromatase inhibitor therapy (average 7-8% per annum). Pre-treatment with tamoxifen for 2-5 years may reduce the clinical significance of the adverse bone effects associated with aromatase inhibitors, particularly if this leads to a shortening in the duration of exposure to an aromatase inhibitor. However, skeletal status should still be assessed at the commencement of aromatase inhibitor therapy. The rate of bone loss in women who experience a premature menopause before the age of 45 or are receiving ovarian suppression therapy is accelerated by the concomitant use of aromatase inhibitors. These patients are considered to be at high risk of clinically important bone loss and should have a baseline dual energy X-ray absorptiometry (DXA) assessment of bone mineral density (BMD). Randomised clinical trials in postmenopausal women indicate that bisphosphonates prevent the bone loss and accelerated bone turnover associated with aromatase inhibitor therapy and are a promising strategy for the prevention and treatment of osteoporosis in this setting. Treatment initiation recommendations are based on a combination of risk factors for osteoporotic fracture and BMD levels. Bisphosphonates, along with a healthy lifestyle and adequate intake of calcium and vitamin D are the treatments of choice to prevent bone loss. Due to the rate of bone loss associated with breast cancer treatments, and uncertainties about the interaction between aromatase inhibitor use and BMD for fracture risk, the threshold for intervention has been set at a higher level than that generally recommended for postmenopausal osteoporosis. Management recommendations have been summarised in two algorithms, one for women experiencing a premature menopause and the other for postmenopausal women requiring adjuvant aromatase inhibitor therapy.
    • Impact of skeletal complications on patients' quality of life, mobility, and functional independence.

      Costa, Luis; Badia, Xavier; Chow, Edward; Lipton, Allan; Wardley, Andrew M; Instituto de Medicina Molecular-Lisboa, Servico de Oncologia, Hospital de Santa Maria, Av Professor Egaz Moniz, Lisbon, 1649-039, Portugal. luiscosta.p@netcabo.pt (2008-08)
      INTRODUCTION: Skeletal-related events (SREs) from malignant bone disease cause considerable morbidity and can dramatically reduce patients' quality of life. DISCUSSION: Pathologic fractures often require surgical intervention and palliative radiotherapy. Thus, patients suffer impaired mobility, loss of functional independence, and diminished health-related quality of life (HRQOL). Bisphosphonates can delay the onset and reduce the incidence of SREs and have become the standard of care for the treatment of malignant bone disease; however, minimal information on the effects of bisphosphonate treatment on HRQOL is available. Targeted HRQOL assessments for patients with malignant bone disease are currently under development and are discussed herein.
    • Preventive therapy for breast cancer: a consensus statement.

      Cuzick, J; DeCensi, A; Arun, B; Brown, P; Castiglione, M; Dunn, B; Forbes, J; Glaus, A; Howell, Anthony; Von Minckwitz, G; et al. (2011-05)
      In March, 2010, a group of breast cancer experts met to develop a consensus statement on breast cancer prevention, with a focus on medical and therapeutic interventions. We present the conclusions in this Review. First we agreed that the term chemoprevention is inappropriate and suggested that the term preventive therapy better represents this feature of management. Two selective oestrogen-receptor modulators--tamoxifen and raloxifene--are so far the only medical options approved by the US Food and Drug Administration for preventive therapy. Of these tamoxifen has greater efficacy and can be used in premenopausal women, but raloxifene has fewer side-effects. Two newer drugs in this class, lasofoxifene and arzoxifene, also show efficacy and possibly a better overall risk-benefit profile, but need further assessment. Aromatase inhibitors might be more efficacious, and results of prevention trials are eagerly awaited. Newer agents, notably bisphosphonates and metformin, have shown promise in observational studies and need to be assessed in randomised prevention trials. Other agents, such as aspirin, other non-steroidal anti-inflammatory drugs, COX-2 inhibitors, retinoids, rexinoids, and dietary components have limited effects or are in the early phases of investigation. New contralateral tumours in women with breast cancer might be generally useful as a model for prevention, as has been seen for tamoxifen. If valid such a model would facilitate the design of simpler, cheaper, and better-focused trials for assessing new agents.