Osteoporosis management in patients with breast cancer: EMAS position statement.
Aromatase inhibitors (AIs) are the first-line recommended standard of care for postmenopausal estrogen receptor-positive breast cancer. Because they cause a profound suppression of estrogen levels, concerns regarding their potential to increase the risk of fracture were rapidly raised. There is currently a general consensus that a careful baseline evaluation is needed of the risk of fracture in postmenopausal women about to start treatment with AIs but also in all premenopausal women with early disease. Bisphosphonates have been shown in several phase III trials to prevent the bone loss induced by cancer treatment, although no fracture data are available. Even though they do not have regulatory approval for this indication, their use must be discussed with women at high risk of fracture. Accordingly, several guidelines recommend considering treatment in women with a T-score ≤-2 or those with two or more clinical risk factors. Moreover, recent data suggest that bisphosphonates, especially intravenous zoledronic acid, may have an anticancer effect, in that they reduce bone recurrence as well as extra-skeletal metastasis and breast cancer mortality in postmenopausal women. The anti-RANK ligand antibody denosumab is also emerging as a new adjuvant therapeutic option to prevent AI-induced bone loss. It has been shown to extend the time to first fracture in postmenopausal women treated with AIs. Several issues still need to be addressed regarding the use of these different agents in an adjuvant setting. The purpose of this position statement is to review the literature on antifracture therapy and to discuss the current guidelines for the management of osteoporosis in women with early breast cancer.
Menopause and Metabolic Bone Disease Unit, Hôpital Paule de Viguier, CHU Toulouse, Toulouse, France. Electronic address: tremollieres.fr@chu-toulouse.fr.
Florence A
FA
Trémollieres
Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, and Department of Obstetrics and Gynecology, 'Dr. I. Cantacuzino' Hospital, Bucharest, Romania.
Iuliana
I
Ceausu
Breast Clinic and Menopause Clinic, University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
Herman
H
Depypere
Second Department of Obstetrics and Gynecology, National and Kapodestrian University of Athens, Greece.
Irene
I
Lambrinoudaki
University Women's Hospital of Tuebingen, Calwer Street 7, 72076 Tuebingen, Germany.
Alfred
A
Mueck
Department of Obstetrics and Gynecology, Zaragoza University Faculty of Medicine, Lozano-Blesa University Hospital, Zaragoza 50009, Spain.
Faustino R
FR
Pérez-López
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Yvonne T
YT
van der Schouw
Istanbul University Cerrahpasa School of Medicine. Dept. of Obstetrics and Gynecology, Division of Reproductive Endocrinology, IVF Unit, Istanbul, Turkey.
Levent M
LM
Senturk
Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56100, Pisa, Italy.
Tommaso
T
Simoncini
National Heart and Lung Institute, Imperial College London, Royal Brompton Campus Hospital, London SW3 6NP, UK.
John C
JC
Stevenson
Department of Obstetrics and Gynecology, University Women's Hospital, Bern, Switzerland.
Petra
P
Stute
Women's Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK.
Margaret
M
Rees
D047072:Aromatase Inhibitors / Q000627:therapeutic use; D015519:Bone Density / Q000187:drug effects; D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000150:complications* / Q000188:drug therapy; D004164:Diphosphonates / Q000627:therapeutic use*; D005260:Female; D050723:Fractures, Bone / Q000517:prevention & control; D006801:Humans; D007093:Imidazoles / Q000627:therapeutic use*; D009364:Neoplasm Recurrence, Local / Q000139:chemically induced; D010024:Osteoporosis / Q000150:complications* / Q000188:drug therapy*; D017697:Premenopause; D000077211:Zoledronic Acid
D047072:Aromatase Inhibitors; D050071:Bone Density Conservation Agents; D004164:Diphosphonates; D007093:Imidazoles; D000077211:Zoledronic Acid
Adjuvant therapy; Aromatase inhibitors; Bisphosphonates; Breast cancer; Denosumab; Fractures; Osteoporosis; Screening