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

Mathis Grossmann, Sabashini K Ramchand, Frances Milat, Amanda Vincent, Elgene Lim, Mark A Kotowicz, Jill Hicks and Helena J Teede
Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50280
Published online: 29 July 2019

Abstract

Introduction: Representatives appointed by relevant Australian medical societies used a systematic approach for adaptation of guidelines (ADAPTE) to formulate clinical consensus recommendations on assessment and management of bone health in women with oestrogen receptor‐positive early breast cancer receiving endocrine therapy. The current evidence suggests that women receiving adjuvant aromatase inhibitors and pre‐menopausal woman treated with tamoxifen have accelerated bone loss and that women receiving adjuvant aromatase inhibitors have increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven anti‐fracture benefit in post‐menopausal women receiving aromatase inhibitors for hormone receptor‐positive breast cancer.

Main recommendations:

  • Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density measurement, with monitoring based on risk factors.
  • Weight‐bearing exercise and vitamin D and calcium sufficiency are recommended routinely.
  • Anti‐resorptive treatment is indicated in women with prevalent or incident clinical or morphometric fragility fractures, and should be considered in women with a T score (or Z score in women aged < 50 years) of < − 2.0 at any site, or if annual bone loss is ≥ 5%, considering baseline bone mineral density and other fracture risk factors.
  • Duration of anti‐resorptive treatment can be individualised based on absolute fracture risk.
  • Relative to their skeletal benefits, risks of adverse events with anti‐resorptive treatments are low.

 

Changes in management as result of the position statement:

  • 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, optimised by non‐pharmacological intervention and, where indicated, anti‐resorptive treatment, in an individualised, multidisciplinary approach.

 

  • Mathis Grossmann1,2
  • Sabashini K Ramchand1,2
  • Frances Milat3,4
  • Amanda Vincent5
  • Elgene Lim6
  • Mark A Kotowicz7,8
  • Jill Hicks9
  • Helena J Teede10

  • 1 University of Melbourne, Melbourne, VIC
  • 2 Austin Health, Melbourne, VIC
  • 3 Monash University, Melbourne, VIC
  • 4 Monash Medical Centre, Melbourne, VIC
  • 5 Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
  • 6 Garvan Institute of Medical Research, Sydney, NSW
  • 7 Deakin University, Geelong, VIC
  • 8 Barwon Health, Geelong, VIC
  • 9 Consumer Representative, Breast Cancer Network Australia, Melbourne, VIC
  • 10 Monash Partners Academic Health Sciences Centre, Monash University, Melbourne, VIC

Correspondence: mathisg@unimelb.edu.au

Acknowledgements: 

We thank the Endocrine Society of Australia Council (chair Warrick Inder); the Australian and New Zealand Bone and Mineral Society (ANZBMS) Council (president Emma Duncan during the writing and reviewing of this statement); the ANZBMS Therapeutics Committee (chair Richard Prince); the ANZBMS Densitometry Committee (chair Nicholas Pocock); Australasian Menopause Society board members, executive director and past presidents Jane Elliott and Anna Fenton; and the Clinical Oncology Society of Australia Council (chair Phyllis Butow) for their support, expert reviews and valuable contributions to this statement.

Competing interests:

Mathis Grossmann has received speaker honoraria and conference support from Besins and Amgen Australia, has been an advisory board member for Otsuka, and has received research support from Bayer, Novartis, Weight Watchers and Eli Lilly. Sabashini Ramchand has received speaker honoraria from Counterpart (breast cancer). Frances Milat has received speaker honoraria and conference support from Novo Nordisk. Amanda Vincent has received speaker honoraria, conference support and research support from Amgen Australia, and has been a Cancer Australia working party member on management of menopause in women with breast cancer (honorary position). Elgene Lim has received speaker honoraria and conference support from Roche, Novartis and Amgen Australia, has been an advisory board member for TEVA, Novartis, Roche, Pfizer Oncology and Bayer, and has received research support from Bayer and Novartis. Mark Kotowicz has received speaker honoraria and conference support from Amgen Australia and Eli Lilly, has been an advisory board member for Amgen Australia and Eli Lilly, and has received research support from Amgen Australia. Helena Teede has received speaker honoraria and conference support from Novo Nordisk, has been an advisory board member for Diabetes Australia Victoria (honorary position), has received research support from Janssen Cilag, and is director of the Epworth Sleep Centre, Melbourne.

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