Seven professional organizations have jointly collaborated to issue a new position statement that provides recommendations on the treatment of aromatase inhibitor (AI)–related bone loss (AIBL) in postmenopausal women receiving treatment for hormone-sensitive breast cancer. The statement also is applicable to other postmenopausal women not being considered for an AI treatment and those receiving ovarian suppression therapies.
A systematic literature review was conducted, and relevant trials and studies are reviewed in the article and assigned a level of evidence. Individual AI agents were assessed based on trial design, size, follow-up, and safety. Several fracture-related risk factors (RF) in patients with early breast cancer were identified.
Overall, the evidence for fracture prevention is strongest for denosumab 60 mg every 6 months. Studies support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality.
In all patients initiating AI treatment, fracture risk should be assessed. Exercise, such as resistance and weight-bearing exercise, and (minimally) calcium 1200 mg daily and vitamin D 800 to 1000 IU daily should be recommended.
Bone-directed therapy should be given to all patients with a T-score <−2.0 or with a T-score of <–1.5 SD with 1 additional RF, or with ≥2 risk factors (without bone mineral density [BMD]) for the duration of AI treatment. Patients with T-score >−1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Adherence should be regularly assessed. Because of the decreased incidence of bone recurrence and breast cancer specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence. The position statement is available here.