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Understanding Aromatase inhibitors and bone health in breast cancer care

In the realm of medical science, the development and progression of certain conditions can sometimes be influenced by various treatments. Secondary osteoporosis, distinct from primary osteoporosis, arises due to specific clinical scenarios or treatments, leading to modifications in bone strength. This includes potential changes in bone mass and bone microarchitecture deterioration. These alterations can increase the vulnerability of bones.

Among the medical scenarios that can trigger these effects are hormone-sensitive cancers, such as breast cancer. These are characterized by malignant cancer cells that proliferate and propagate under the influence of hormones.

Thanks to significant strides in oncology over the past years, survival rates have vastly improved. With this progress, it has become essential to understand and monitor possible implications of certain anticancer treatments. A prominent example is the use of aromatase inhibitors, which are effective, first line treatments for patients with hormone-receptor-positive breast cancer, and can minimize the risk of cancer recurrence1.

Aromatase inhibitors function by targeting the estrogen receptor and reducing the conversion of androgens to estrogen. Though generally well-tolerated, they may have some effects on bone health, primarily due to increased bone turnover.

A recent meta-analysis2 led by an international expert working group, summarized the findings from prospective studies examining the skeletal effects of aromatase inhibitors in women with breast cancer3-6. Reductions in trabecular bone score (TBS), a validated index of bone microarchitecture of up to 4.6% over 3 years, were reported and were unrelated to change in bone mineral density (BMD)4. In another study of 321 non-osteoporotic postmenopausal women with breast cancer, aromatase inhibitor therapy corresponded with reductions in both BMD and TBS6. The loss of TBS was more pronounced during the first year of treatment with a slowing thereafter, whereas the annual loss of BMD continued for up to 4 years.

Consequently, for patients undergoing aromatase inhibitor treatment for breast cancer, the management of bone health is important. Baseline and follow-up DXA evaluations of bone health parameters, including TBS, can enable the timely identification of patients at risk of secondary osteoporosis and fractures. This proactive approach facilitates the implementation of effective preventive and therapeutic measures7.

It is encouraging to note that for those who might experience bone loss, there are a number of effective anti-osteoporosis treatments. A recent study demonstrated the efficacy of denosumab therapy, which improved TBS and decreased vertebral fracture incidence in women undergoing breast cancer treatment with aromatase inhibitors8

Note: Always consult a healthcare professional

  1. Ratre, P., Mishra, K., Dubey, A., Vyas, A., Jain, A. and Thareja, S (2020) Aromatase inhibitors for the treatment of breast cancer: A journey from the scratch. Anti-Cancer Agents in Medicinal Chemistry 20(17), 1994-2004.
  2. Shevroja, et al., 2023. Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporos Int (2023)
  3. Pedrazzoni M, Casola A, Verzicco I, Abbate B, Vescovini R, Sansoni P (2014) Longitudinal changes of trabecular bone score after estrogen deprivation: efect of menopause and aromatase inhibition. J Endocrinol Invest 37:871–874
  4. Mariotti V, Page DB, Davydov O, Hans D, Hudis CA, Patil S, Kunte S, Girotra M, Farooki A, Fornier MN (2017) Assessing fracture risk in early stage breast cancer patients treated with aromatase-inhibitors: an enhanced screening approach incorporating trabecular bone score. Journal of bone oncology 7:32–37
  5. Hong AR, Kim JH, Lee KH, Kim TY, Im SA, Kim TY, Moon HG, Han WS, Noh DY, Kim SW, Shin CS (2017) Long-term effect of aromatase inhibitors on bone microarchitecture and macroarchitecture in non-osteoporotic postmenopausal women with breast cancer. Osteoporos Int 28:1413–1422
  6. Catalano A, Gaudio A, Agostino RM, Morabito N, Bellone F, Lasco A (2019) Trabecular bone score and quantitative ultrasound measurements in the assessment of bone health in breast cancer survivors assuming aromatase inhibitors. J Endocrinol Invest 42:1337–1343
  7. Handforth C, D’Oronzo S, Coleman R, Brown J. (2018) Cancer Treatment and Bone Health. Calcif Tissue Int 102(2):251-264. doi: 10.1007/s00223-017-0369-x. Epub 2018 Jan 20. PMID: 29353450; PMCID: PMC5805796.
  8. Antonini, S., Pedersini, R., Birtolo, M.F., Baruch, N.L., Carrone, F., Jaafar, S., Ciafardini, A., Cosentini, D., Laganà, M., Torrisi, R. and Farina, D. (2023) Denosumab improves trabecular bone score in relationship with decrease in fracture risk of women exposed to aromatase inhibitors. Journal of Endocrinological Investigation 1-10

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