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Postmenopausal Breast Cancer, Aromatase Inhibitors, and Bone Health: What the Surgeon Should Know

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Abstract

Breast cancer, as the most common malignancy in women, remains a major public health issue despite countless advances across decades. Endocrine therapy is the cornerstone of treatment of the hormone-sensitive subtype of breast cancer. The use of aromatase inhibitors (AIs) in the postmenopausal women has extended the survival beyond that of Tamoxifen, but harbors a subset of side effects, most notably accelerated bone loss. This, however, does not occur in all women undergoing treatment. It is vital to identify susceptible patients early, to limit such events, employ early treatment thereof, or alter drug therapy. International trials on AIs, predominantly performed in North American and European females, provide little information on what to expect in women in developing countries. Here, surgeons often prescribe and manage endocrine therapy. The prescribing surgeon should be aware of the adverse effect of the endocrine therapy and be able to attend to side effects. This review highlights clinical and biochemical factors associated with decrease in bone mineral density in an, as yet, unidentified subgroup of postmenopausal women. In the era of personalized medical care, appropriate management of bone health by surgeons based on these factors becomes increasingly important.

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Abbreviations

AIs:

Aromatase inhibitors

ATAC:

Arimidex, Tamoxifen, alone or in combination

AEs:

Adverse effects

BMD:

Bone mineral density

BMI:

Body mass index

BS-ALP:

Bone-specific alkaline phosphatase

BIG 1-98:

Breast International Group 1-98

CYP 19:

Cytochrome P450 enzyme

CR:

Clinical response

CTX:

C terminal telopeptide

DNA:

Deoxyribonucleic acid

DXA:

Dual-energy X-ray absorptiometry

ER:

Estrogen receptor

FRAX:

Fracture Risk Assessment Tools

HER 2:

Human epidermal growth factor 2

IOF:

International Osteoporosis Foundation

IES:

Intergroup Exemestane Study

LVA:

Lateral vertebral assessment

NCIC CTG:

National Cancer Institute of Canada Clinical Trials Group

NTX:

Cross-linked N-telopeptides of bone type I collagen

NOF:

National Osteoporosis Foundation

NHANES:

National Health and Nutrition Examination Survey

PTH:

Parathyroid hormone

PR:

Progesterone receptor

RANKL:

Receptor activator of NF-κB ligand

SNPs:

Single nucleotide polymorphisms

SDs:

Standard deviations

25(OH) vitamin D:

25 hydroxy vitamin D

WHO:

World Health Organisation

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Acknowledgments

Research reported in this publication was supported by the Strategic Health Innovation Partnerships (SHIP) Unit of the South African Medical Research Council (MRC) with funds received from the South African Department of Science and Technology (Research Grant No. S003665). MJ Kotze is a director and shareholder of Gknowmix (Pty) Ltd. that has developed a database tool for research translation under the auspices of the MRC.

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Authors and Affiliations

  1. Department Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, PO Box 19063, Tygerberg, 7505, South Africa

    K. J. Baatjes & J. P. Apffelstaedt

  2. Division of Endocrinology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa

    M. Conradie

  3. Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa

    M. J. Kotze

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  1. K. J. Baatjes
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Correspondence to K. J. Baatjes.

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Baatjes, K.J., Apffelstaedt, J.P., Kotze, M.J. et al. Postmenopausal Breast Cancer, Aromatase Inhibitors, and Bone Health: What the Surgeon Should Know. World J Surg 40, 2149–2156 (2016). https://doi.org/10.1007/s00268-016-3555-5

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