Aromatase Inhibitors & Osteoporosis Miss Sarah Horn Consultant Oncoplastic Breast Surgeon April 2018
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.
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
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
General recommendations for bone health Weight bearing exercise Stop smoking Moderate caffeine intake Sensible exposure to sunlight Dietician referral for those at risk
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
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)
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)
. 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)
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
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
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
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
THANK YOU Any Questions?