Assessment and management of bone health in women with oestrogen receptor‐positive breast cancer receiving endocrine therapy: Position statement of the Endocrine Society of Australia, the Australian and New Zealand Bone & Mineral Society, the Australasian Menopause Society and the Clinical Oncology Society of Australia

Abstract

To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is ≥5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.

Assessment and management of bone health in women with oestrogen receptor‐positive breast cancer receiving endocrine therapy: position statement summary

“…The draft statement was submitted to the society councils who provided feedback. The working group responded to feedback, the final version was approved and, following peer review, was published in Clinical Endocrinology (Oxford) …”

“…Anti‐resorptive therapies are generally well tolerated, especially if dosing regimens used in osteoporosis studies are prescribed. However, discussion regarding potential side effects (reviewed in the full position statement) is necessary, with particular caveats for women who desire future pregnancy . Briefly, oral bisphosphonates can cause gastrointestinal toxicity and should be avoided in patients with active upper gastrointestinal disease.…”

“…We summarise recommendations on the assessment and management of bone health in such women. The full position statement is available at https://onlinelibrary.wiley.com/doi/epdf/10.1111/cen.13735 …”

Straddling medical specialties: should we have more comprehensive advanced training?

“…women with hormone-responsive breast cancer are aggressively rendered oestrogen deficient, whilst bone health, fertility and general well-being may be given less attention. 2 2 Glycaemic control: High dose steroids are commonly prescribed by non-endocrinologist physicians who under-appreciate the complexities of steroid-induced diabetes or steroid withdrawal. Cross-referral to endocrinologists can be delayed and expensive and may involve disconnected colleagues who have no control over the dose of steroid prescribed.…”

“…Ironically, oncologists blithely prescribe far bigger doses of the same agents for bony metastases, more focused on the threats of spinal cord compression, uncontrolled tumoural hypercalcaemia or even impending death. Young women with hormone‐responsive breast cancer are aggressively rendered oestrogen deficient, whilst bone health, fertility and general well‐being may be given less attention Glycaemic control: High dose steroids are commonly prescribed by non‐endocrinologist physicians who under‐appreciate the complexities of steroid‐induced diabetes or steroid withdrawal.…”