Aromatase Inhibitors & Osteoporosis

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1 Aromatase Inhibitors & Osteoporosis Miss Sarah Horn Consultant Oncoplastic Breast Surgeon April 2018

2 Aims Role of Aromatase Inhibitors (AI) in breast cancer treatment AI s effects on bone health Bone health management Current Guidelines Clinical case as an example.

3 The role of Aromatase Inhibitors Non-Steroidal = Letrozole, Anastrazole Steroidal= Exemestane Commonly known as Endocrine treatment. Used in ER + (Allred 3-8) Postmenopausal Early Breast Cancer Menopause defined as age >60 or amenorrhoea at least 12 months Tamoxifen can be used also (Not standard of care) as alternative 5 years usual treatment but extended adjuvant option in Node + Commonly adjuvant setting but also a neo adjuvant use & primary use in those unfit. Sequential use after chemotherapy most beneficial

4 Side effects AI s Hot flushes- SSRI s paroxetine/fluoxetine helpful (NICE) Fatigue Arthralgia-exercise recommended Muscle pain Atrophic vaginitis-use non hormonal therapies Low mood & depression Difficulty sleeping OSTEOPOROSIS Hypertension & hypercholesterolaemia

5 General recommendations for bone health Weight bearing exercise Stop smoking Moderate caffeine intake Sensible exposure to sunlight Dietician referral for those at risk

6 Bone Density Monitoring & Guidelines The following both at risk groups require this DEXA scan Lumbar and one or both hip measurements OSTEOPOROSIS= BMD >/2.5 STD (t score) below peak bone mass of bone mineral density for young adult women OSTEOPENIA= T score of -1 to 2.5 below the normal score of adult woman

7 a. Presence of major risk factors consider any of the following: Women 65 years, Men 70 years Previous fragility fracture after 50 years Family history of parental hip fracture Smoking history High alcohol intake (>3-4 units per day) Low dietary calcium intake Low BMI (<18) Recurrent falls Sedentary lifestyle over many years Endocrine (e.g. hypogonadism, Cushing syndrome, hyperparathyroidism, hyperthyroidism) Chronic medical conditions: Inflammatory conditions (eg. RA), malabsorption, organ/ bone marrow transplant, chronic kidney disease, chronic liver disease, multiple myeloma Drugs: (e.g. steroids, anti-epileptic, excessive thyroxine, SSRIs)

8 Postmenopausal adjuvant treatment with aromatase inhibitors a. Presence of major risk factors consider any of the following: Women 65 years, Men 70 years Previous fragility fracture after 50 years Family history of parental hip fracture Smoking history High alcohol intake (>3-4 units per day) Low dietary calcium intake Low BMI (<18) Recurrent falls Sedentary lifestyle over many years Endocrine (e.g. hypogonadism, Cushing syndrome, hyperparathyroidism, hyperthyroidism) Chronic medical conditions: Inflammatory conditions (eg. RA), malabsorption, organ/ bone marrow transplant, chronic kidney disease, chronic liver disease, b. Secondary Osteoporosis Markers: FBC / LFT / U&E / egfr / CRP / ESR / Bone Profile / Vitamin D / Thyroid Function Tests / Vitamin B12 / Folate / Random Glucose / Anti-TTG antibodies Treatments c. Alendronic Acid 70mg weekly Risedronate 35mg weekly Denosumab 60mg S/C every 6 months* Zoledronic acid 5mg annually* d. Calcium 1g + Vitamin D 800IU e. Biochemical / bone turnover markers through osteoporosis clinic request only *(requires referral to CHS Osteoporosis Service)

9 . Secondary Osteoporosis Markers: FBC / LFT / U&E / egfr / CRP / ESR / Bone Profile / Vitamin D / Thyroid Function Tests / Vitamin B12 / Folate/Random Glucose / Anti-TTG antibodies Treatments c. Alendronic Acid 70mg weekly Risedronate 35mg weekly Denosumab 60mg S/C every 6 months* Zoledronic acid 5mg annually* Calcium 1g + Vitamin D 800IU Biochemical / bone turnover markers through osteoporosis clinic request only *(requires referral to CHS Osteoporosis Service)

10 Adjuvant treatment associated with ovarian suppression/ failure with or without concomitant aromatase inhibitor use in women who experience premature menopause a. Secondary Osteoporosis Markers: FBC / LFT / U&E / egfr / CRP / ESR / Bone Profile / Vitamin D / Thyroid Function Tests / Vitamin B12 / Folate / Random Glucose / Anti-TTG antibodies Treatments b. Alendronic Acid 70mg weekly Risedronate 35mg weekly Denosumab 60mg S/C every 6 months (requires referral to CHS Osteoporosis Service) Zoledronic acid 5mg annually (requires referral to CHS Osteoporosis Service) c.calcium 1g + Vitamin D 800IU

11 a. Secondary Osteoporosis Markers: FBC / LFT / U&E / egfr / CRP / ESR / Bone Profile / Vitamin D / Thyroid Function Tests / Vitamin B12 / Folate / Random Glucose / Anti-TTG antibodies Treatments b. Alendronic Acid 70mg weekly Risedronate 35mg weekly Denosumab 60mg S/C every 6 months (requires referral to CHS Osteoporosis Service) Zoledronic acid 5mg annually (requires referral to CHS Osteoporosis Service) c. Calcium 1g + Vitamin D 800IU d. Biochemical / bone turnover markers through osteoporosis clinic request only

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14 Case History (1) Post menopausal high risk, ER+ Breast Cancer Started Adj AI, suitable for extended adjuvant for 10 years Baseline DEXA= osteopenia Lifestyle advice Dietary advice Calcium & vit D supplementation ( if clinically deficient as in this case) Continue AI Repeat DEXA at 24 months- unchanged Repeat again at 48 months or Yr 5 decide if to extended Adjuvant AI

15 Case history (2) Positive Decision for extended adjuvant AI Repeated DEXA = OSTEOPOROSIS Discussion re: risks vs benefits continuing AI A) start bisphosphonate + continue AI with DEXA monitoring B) Start bisphosphonate + switch to Tamoxifen for extended adjuvant C) Initiate Bisphosphonate and stop AI with risk benefit discussion Assess for secondary osteoporosis markers All metastatic patients receive bisphosphonates

16 THANK YOU Any Questions?