Abstract
Bone loss is common in patients with breast cancer. Bone modifying agents (BMAs), such as bisphosphonates and denosumab, have been shown to reverse or stabilize bone loss and may be useful in the primary and metastatic settings. The purpose of this review is to provide clear evidence-based strategies for the management of bone loss and its symptoms in breast cancer. A systematic review of clinical trials and meta-analyses published between 1996 and 2012 was conducted of MEDLINE and EMBASE. Reference lists were hand-searched for additional publications. Recommendations were developed based on the best available evidence. Zoledronate, pamidronate, clodronate, and denosumab are recommended for metastatic breast cancer patients; however, no one agent can be recommended over another. Zoledronate or any oral bisphosphonate and denosumab should be considered in primary breast cancer patients who are postmenopausal on aromatase inhibitor therapy and have a high risk of fracture and/or a low bone mineral density and in premenopausal primary breast cancer patients who become amenorrheic after therapy. No one agent can be recommended over another. BMAs are not currently recommended as adjuvant therapy in primary breast cancer for the purpose of improving survival, although a major Early Breast Cancer Cooperative Trialists’ Group meta-analysis is underway which may impact future practice. Adverse events can be managed with appropriate supportive care.
Highlights
Optimization of bone health is an important aspect of care to consider for patients with a breast cancer diagnosis at any stage
Twenty-nine publications focused on the use of bone modifying agents (BMAs) in the prevention of treatment-related bone loss in patients with primary breast cancer (Table 1); thirteen publications examined the efficacy of BMAs in preventing skeletal related events (SREs) in patients with metastatic breast cancer (Table 2); and fifteen publications looked at the use of BMAs in the adjuvant setting in patients with primary breast cancer (Table 3)
Baseline bone mineral density (BMD) testing and fracture risk assessment is recommended for patients with primary breast cancer for whom therapy with agents that suppress ovarian function is given, including premenopausal women with premature ovarian failure or ovarian suppression with luteinizing hormone releasing hormone analogue (LHRHA) and postmenopausal women on aromatase inhibitors (AIs)
Summary
Optimization of bone health is an important aspect of care to consider for patients with a breast cancer diagnosis at any stage. In patients with primary breast cancer, treatment associated bone loss can occur either with adjuvant endocrine therapy (e.g., aromatase inhibitors), or in patients with a reduction of ovarian function due to surgery or chemotherapy. Bone loss in this setting is due to enhanced bone turnover secondary to estrogen decline [1]. In the primary breast cancer setting, bone loss can present (as is the case with osteopenia or osteoporosis) as bone fractures, bone pain, and/or impaired mobility. There is an impact on overall quality of life for these patients
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