NcXHF

BONE HEALTH AND ENDOCRINE THERAPY IN BREAST OR PROSTATE CANCER
TABLE 2. Overview of Two Prominent Bone Health Screening and Treatment Guidelines 5
USPSTF
NOF
Advises universal counseling
on risks, nutrition, exercise,
and behaviors
Vitamin D Screening Vitamin D and Calcium Intake
Evidence is insufficient to Evidence is insufficient to assess
assess the benefit/ the benefit/harm in
harm in Asymptomatic premenopausal women
adults
and in men
Evidence is insufficient to assess
the benefit/harm of daily
supplements with 400 IU of
vitamin D and 1,000 mg of
calcium in noninstitutionalized
postmenopausal women
Not specifically addressed Women under the age of 50
1,000 mg of calcium from all
sources daily
Women age 50 and older
1,200 mg calcium daily
Men age 70 and younger
1,000 mg calcium daily
Men age 71 and older
1,200 mg calcium daily
Adults under the age of 50
400–800 IU vitamin D
Adults age 50 and older
800–1,000 IU vitamin D
Osteoporosis BMD
Screening
Recommends screening in
women age 65 and
older and in younger
women with significant
fracture risk
Evidence is insufficient to
assess the benefit/
harm in men; men most
likely to benefit from
screening have a 10-yr risk
for osteoporotic fracture
greater than a 65-year-old
white woman without
risk factors
Postmenopausal women and
men over the age of 50
with an adult age fracture
Postmenopausal woman and
men above age 50–69 based
on risk factor profile
Women age 65 and older
Men age 70 and older
BMD Threshold for
Pharmacologic Intervention
Not specifically addressed;
drug therapy may be considered
in the primary (no previous
osteoporotic fracture) or
in the secondary (prior
osteoporotic fracture) setting
Clinical or asymptomatic hip
or vertebral fracture
T score -2.5 in femoral neck,
total hip or lumbar spine by DXA
Postmenopausal women and
men age 50 and older with
low bone mass (-1.0 to -2.5)
and a high-risk FRAX score (*)
Monitoring
Evidence is lacking
on intervals of
repeat screening
BMD 1–2 years after
initiating therapy
& every 2 years
thereafter
Abbreviations: USPSTF, U.S. Preventive Services Task Force; NOF, National Osteoporosis Foundation; BMD, bone mineral density.
*FRAX: Fracture Risk Algorithm; High-risk scores: 10-year hip fracture probability 3% or 10-year major osteoporosis-related fracture probability 20% based on the USA adapted World
Health Organization fracture risk model.
static breast cancer and prostate cancer, respectively. Great
advances have been made in understanding the molecular
mechanisms of the sex hormones and hormonal influences
on cancer and bone. Refınements in targeted endocrine therapy
and cancer care have moved endocrine therapy into the
(neo-)adjuvant setting. The goals of (neo-)adjuvant endocrine
therapy are to improve disease-free and overall survival.
With the use of endocrine systemic therapy to eradicate
occult residual tumor cells, the skeleton is also exposed to
endocrine intervention. The resulting deprivation of estrogen
and androgen accelerate bone loss and increases the risk
for fracture. Managing these risks are important aspects of
cancer survivorship care. The effects of antiestrogen and antiandrogen
cancer therapies on bone have been a subject of
study for more than 20 years. 15,16 Much has been published
on the effects of cancer therapy on BMD and the increased
risk of fracture. Components of that literature will be reviewed
here, but this is not an exhaustive review.
Breast Cancer Endocrine Therapies
Approximately 75% of breast cancers express the estrogen
receptor or progesterone receptor and are considered hormone
receptor positive (HR). 17 Use of antiestrogen adjuvant
therapies reduces the risk of breast cancer recurrence by
approximately 30% to 50%. 18 Current guidelines recommending
the use of targeted antiestrogen therapy for earlystage
HR breast cancer include those published by the
American Society of Clinical Oncology (ASCO). 19 The
ASCO guideline supports the use of adjuvant tamoxifen in
premenopausal and perimenopausal women with HR
breast cancer. For women with HR early breast cancer who
are postmenopausal, the use of an aromatase inhibitor (AI) is
favored either as the sole adjuvant endocrine therapy or in
sequence with tamoxifen. The menopausal status of the patient,
the drug used, and the duration of treatment all affect
how adjuvant breast cancer endocrine therapy will affect
bone and may influence treatment decisions.
Tamoxifen is a selective estrogen receptor modulator
(SERM) with both agonist and antagonist effects. In postmenopausal
women, tamoxifen acts as a partial estrogen agonist
on bone, stabilizing or even increasing bone mass. In a
randomized placebo-controlled study 20 mg tamoxifen administered
daily increased the lumbar spine BMD by 0.61%
per year, whereas treatment with the placebo was associated
with a 1% decrease in BMD per year (p 0.001). 14 With longer
follow-up of these patients the sample size dwindled; at 5
years there was a trend for the tamoxifen-treated group to
have a higher BMD, but the difference was not signifıcant
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