Skip to main content
SpringerLink
Log in

Management of Osteoporosis in Postmenopausal Breast Cancer Survivors

  • Chapter
  • First Online:
Essentials of Menopause Management

  • 998 Accesses

Abstract

A 55-year-old Caucasian postmenopausal woman with BMI of 22.5 kg/m2 presents to the clinic for follow-up to discuss the results of her recent dual-energy X-ray absorptiometry (DXA) bone mineral density (BMD) scan. She has a personal history of premenopausal early-stage hormone receptor-positive breast cancer at age 47 and a family history of parental hip fracture. Following her initial breast cancer treatment, she received tamoxifen for 5 years (Age 47–52) followed by anastrozole (an aromatase inhibitor) until the current time. The DXA scan reports T-scores of −1.8 at the total hip and −1.6 at the lumbar spine. What would be your preferred management?

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kanis JA, McCloskey EV, Powles T, Paterson AHG, Ashley S, Spector T. A high incidence of vertebral fracture in women with breast cancer. Br J Cancer. 1999;79:1179–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Chen Z, Maricic M, Bassford TL, Pettinger M, Ritenbaugh C, Lopez AM, Barad DH, Gass M, Leboff MS. Fracture risk among breast cancer survivors: results from the Women’s Health Initiative Observational Study. Arch Intern Med. 2005;165:552–8.

    Article  PubMed  Google Scholar 

  3. Powell GJ, Southby J, Danks JA, Stillwell RG, Hayman JA, Henderson MA, et al. Localization of parathyroid hormone-related protein in breast cancer metastases: increased incidence in bone compared with other sites. Cancer Res. 1991;51:3059–61.

    CAS  PubMed  Google Scholar 

  4. Orloff JJ, Wu TL, Stewart AF. Parathyroid hormone-like proteins: biochemical responses and receptor interactions. Endocrinol Rev. 1989;1989(10):476–95.

    Article  Google Scholar 

  5. Kalder M, Hans D, Kyvernitakis I, et al. The effect of exemestane or tamoxifen treatment on bone texture analysis assessed by TBS in comparison with bone mineral density assessed by DXA in women with breast cancer. J Clin Densitom. 2014;17:66–71.

    Article  PubMed  Google Scholar 

  6. Saarto T, Blomqvist C, Valimaki M, Makelo P, Sarna S, Elomaa I. Chemical castration induced by adjuvant cyclophosphamide, methotrexate and fluorouracil chemotherapy causes rapid bone loss that is reduced by clodronate: a randomised study in premenopausal breast cancer patients. J Clin Oncol. 1997;15:1341–7.

    Article  CAS  PubMed  Google Scholar 

  7. Powles TJ, Hickish T, Kanis JA, Tidy A, Ashley S. The effect of tamoxifen on lumbar bone mineral density in pre- and postmenopausal women. J Clin Oncol. 1996;14:78–84.

    Article  CAS  PubMed  Google Scholar 

  8. Chen Z, Arendell L, Aickin M, et al. Hip bone density predicts breast cancer risk independently of Gail score: results from the Women’s Health Initiative. Cancer. 2008;113:907.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Qu X, Zhang X, Qin A, et al. Bone mineral density and risk of breast cancer in postmenopausal women. Breast Cancer Res Treat. 2013;138(1):261–71.

    Article  PubMed  Google Scholar 

  10. Vehmanen L, Elomaa I, Blomqvist C, et al. Tamoxifen treatment after adjuvant chemotherapy has opposite effects on bone mineral density in premenopausal patients depending on menstrual status. J Clin Oncol. 2006;24:675–80.

    Article  CAS  PubMed  Google Scholar 

  11. Reid DM, Doughty J, Eastell R, et al. Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group. Cancer Treat Rev. 2008;34 Suppl 1:S3–18.

    Article  CAS  PubMed  Google Scholar 

  12. Love RR, Mazess RB, Barden HS, et al. Effects of tamoxifen on bone mineral density in postmenopausal women with breast cancer. N Engl J Med. 1992;326:852–6.

    Article  CAS  PubMed  Google Scholar 

  13. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Lewiecki EM. Osteoporotic fracture risk assessment. UpToDate. Last updated: Dec 17, 2015. Available at http://www.uptodate.com/contents/osteoporotic-fracture-risk-assessment?source=machineLearning&search=risk+factors+for+fracture&selectedTitle=1%7E150&sectionRank=1&anchor=H2#H18. Accessed 9 Mar 2016.

  15. Body JJ, Bergmann P, Boonen S, et al. Management of cancer treatment-induced bone loss in early breast and prostatic cancer – a consensus paper of the Belgian Bone Club. Osteoporos Int. 2007;18:1439–50.

    Article  CAS  PubMed  Google Scholar 

  16. Datta M, Schwartz GG. Calcium and vitamin D supplementation and loss of bone mineral density in women undergoing breast cancer therapy. Crit Rev Oncol Hematol. 2013;88(3):613–24.

    Article  PubMed  Google Scholar 

  17. Lips P, Bouillon R, van Schoor NM, et al. Reducing fracture risk with calcium and vitamin D. Clin Endocrinol (Oxf). 2010;73(3):277–85.

    Article  CAS  Google Scholar 

  18. Imtiaz S, Siddiqui N, Raza SA, Loya A, Muhammad A. Vitamin D deficiency in newly diagnosed breast cancer patients. Indian J Endocrinol Metab. 2012;16(3):409–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Friedman CF, DeMichele A, Su HI, Feng R, Kapoor S, Desai K, et al. Vitamin D deficiency in postmenopausal breast cancer survivors. J Women’s Health (Larchmt). 2012;21(4):456–62.

    Article  Google Scholar 

  20. Neuhouser ML, Sorensen B, Hollis BW, et al. Vitamin D insufficiency in a multiethnic cohort of breast cancer survivors. Am J Clin Nutr. 2008;88(1):133–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Adami S, Giannini S, Bianchi G, et al. Vitamin D status and response to treatment in post-menopausal osteoporosis. Osteoporos Int. 2009;20:239–44.

    Article  CAS  PubMed  Google Scholar 

  22. Bischoff-Ferrari HA, Shao A, Dawson-Hughes B, Hathcock J, Giovannucci E, Willett WC. Benefit-risk assessment of vitamin D supplementation. Osteoporos Int. 2010;21:1121–32.

    Article  CAS  PubMed  Google Scholar 

  23. Jiang X, Gruner M, Trémollieres F, et al. Diagnostic accuracy of FRAX in predicting the 10-year risk of osteoporotic fractures: a systematic review and meta-analysis. The North American Menopause Society (NAMS) 26th Annual Meeting (P-61). Las Vegas: Nevada; 2015.

    Google Scholar 

  24. Hadji P. Aromatase inhibitor-associated bone loss in breast cancer patients is distinct from postmenopausal osteoporosis. Crit Rev Oncol Hematol. 2009;69:73–82.

    Article  PubMed  Google Scholar 

  25. Forbes JF, Cuzick J, Buzdar A, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100 month analysis of the ATAC trial. Lancet Oncol. 2008;9:45–53.

    Article  PubMed  Google Scholar 

  26. Rabaglio M, Sun Z, Price KN, et al. Bone fractures among postmenopausal patients with endocrine-responsive early breast cancer treated with 5 years of letrozole or tamoxifen in the BIG 1-98 trial. Ann Oncol. 2009;20:1489–98.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Howell A, Cuzick J, Baum M, et al. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years’ adjuvant treatment for breast cancer. Lancet. 2005;365:60–2.

    Article  CAS  PubMed  Google Scholar 

  28. Hadji P, Body JJ, Aapro MS, et al. Practical guidance for the management of aromatase inhibitor-associated bone loss. Ann Oncol. 2008;19:1407–16.

    Article  CAS  PubMed  Google Scholar 

  29. Aapro M, Abrahamsson PA, Body JJ, et al. Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel. Ann Oncol. 2008;19:420–32.

    Article  CAS  PubMed  Google Scholar 

  30. Hillner B, Ingle J, Chlebowski RT, et al. American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer. J Clin Oncol. 2003;21:4042–57.

    Article  CAS  PubMed  Google Scholar 

  31. Rochlitz C, Senn HJ, Betticher D, et al. Der einsatz von bisphosphonaten bei der behandlung solider tumoren: empfehlungen einer Schweizer expertengruppe [The use of bisphosphonates in treating solid tumors: recommendations of a Swiss expert group]. Schweiz Med Forum. 2010;10:562–4.

    Google Scholar 

  32. National Osteoporosis Foundation-Osteoporosis Clinical Updates. Update on bisphosphonates FDA-approved for prevention and treatment of osteoporosis. June 2008. http://webcache.googleusercontent.com/search?q=cache:boKT5r3ujpIJ:nof.org/files/nof/public/content/file/729/upload/293.pdf+&cd=4&hl=en&ct=clnk&gl=us. Accessed 8 Mar 2016.

  33. Rosen HN. The use of bisphosphonates in postmenopausal women with osteoporosis. UpToDate. Last updated: Dec 10, 2015. Available at http://www.uptodate.com/contents/the-use-of-bisphosphonates-in-postmenopausal-women-with-osteoporosis#H4002798. Accessed 9 Mar 2016.

  34. Saarto T, Vehmanen L, Blomqvist C, Elomaa I. Ten-year follow-up of 3 years of oral adjuvant clodronate therapy shows significant prevention of osteoporosis in early-stage breast cancer. J Clin Oncol. 2008;26:4289–95.

    Article  CAS  PubMed  Google Scholar 

  35. Lester JE, Dodwell D, Purohit OP, et al. Prevention of anastrozole-induced bone loss with monthly oral ibandronate during adjuvant aromatase inhibitor therapy for breast cancer. Clin Cancer Res. 2008;14:6336–42.

    Article  CAS  PubMed  Google Scholar 

  36. Van Poznak C, Hannon RA, Mackey JR, et al. Prevention of aromatase inhibitor-induced bone loss using risedronate: the SABRE trial. J Clin Oncol. 2010;28:967–75.

    Article  PubMed  Google Scholar 

  37. Brufsky AM, Harker WG, Beck JT, et al. Final 5-year results of Z-FAST trial: adjuvant zoledronic acid maintain bone mass in postmenopausal breast cancer patients receiving letrozole. Cancer. 2012;118:1192–201.

    Article  CAS  PubMed  Google Scholar 

  38. Coleman R, de Boer R, Eidtmann H, et al. Zoledronic acid (zoledronate) for postmenopausal women with early breast cancer receiving adjuvant letrozole (ZO-FAST study): final 60-month results. Ann Oncol. 2013;24:398–405.

    Article  CAS  PubMed  Google Scholar 

  39. Llombart A, Frassoldati A, Paija O, et al. Immediate administration of zoledronic acid reduces aromatase inhibitor-associated bone loss in postmenopausal women with early breast cancer: 12-month analysis of the E-ZO-FAST trial. Clin Breast Cancer. 2012;12(1):40–8.

    Article  CAS  PubMed  Google Scholar 

  40. Gnant M, Mlineritsch B, Luschin-Ebengreuth G, et al. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 5-year follow-up of the ABCSG-12 bone-mineral density substudy. Lancet Oncol. 2008;9:840–9.

    Article  CAS  PubMed  Google Scholar 

  41. Gnant M, Mlineritsch B, Stoeger H, et al. Zoledronic acid combined with adjuvant endocrine therapy of tamoxifen versus anastrozol plus ovarian function suppression in premenopausal early breast cancer: final analysis of the Austrian Breast and Colorectal Cancer Study Group Trial 12. Ann Oncol. 2015;26(2):313–20.

    Article  CAS  PubMed  Google Scholar 

  42. Llombarto A, Frassoldati A, Paija O, et al. Effect of zoledronic acid on aromatase inhibitor-associated bone loss in postmenopausal women with early breast cancer receiving adjuvant letrozole: E-ZO-FAST 36-month follow up. Presented at American Society of Clinical Oncology 2009 Breast Cancer Symposium; Oct 8-10, 2009, San Francisco, Abstract 213.

    Google Scholar 

  43. Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA. 2002;288:1889–97.

    Article  PubMed  Google Scholar 

  44. Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res. 2005;20:1185–94.

    Article  PubMed  Google Scholar 

  45. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Siris ES, Brenneman SK, Miller PD, et al. Predictive value of low BMD for 1-year fracture outcomes is similar for postmenopausal women ages 50-64 and 65 and older: results from the National Osteoporosis Risk Assessment (NORA). J Bone Miner Res. 2004;19:1215–20.

    Article  PubMed  Google Scholar 

  47. Wagner-Johnston ND, Sloan JA, Liu H, et al. 5-year follow-up of a randomized controlled trial of immediate versus delayed zoledronic acid for the prevention of bone loss in postmenopausal women with breast cancer starting letrozole after tamoxifen: N03CC (Alliance) trial. Cancer. 2015;121(15):2537–43.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Coleman R, Body JJ, Hadji P, et al on behalf of the ESMO guidelines working group. Bone health in cancer patients: ESMO clinical practice guidelines. Ann Oncol. 2014; 25(Suppl 3): iii124–37.

    Google Scholar 

  49. Hadji P, Aapro MS, Body JJ, et al. Management of aromatase inhibitor-associated bone loss in postmenopausal women with breast cancer: practical guidance for prevention and treatment. Ann Oncol. 2011;22(12):2546–55.

    Article  CAS  PubMed  Google Scholar 

  50. Gnant M, Pfeiler G, Dubsky PC, et al. Adjuvant denosumab in breast cancer (ABCSG-18): a multicenter, randomized, double-blind, placebo-controlled trial. Lancet. 2015;386(9992):433–43.

    Article  CAS  PubMed  Google Scholar 

  51. Coleman R, Cameron D, Dodwell D, et al. Adjuvant zoledronic acid in patients with early breast cancer: final efficacy analysis of the AZURE (BIG 01/04) randomised open-label phase 3 trial. Lancet Oncol. 2014;15(9):997–1006.

    Article  CAS  PubMed  Google Scholar 

  52. Coleman R, Powles T, Paterson A, et al. Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet. 2015;386(10001):1353–61.

    Article  Google Scholar 

  53. Black DM, Bauer DC, Schwartz AV, et al. Continuing bisphosphonate treatment for osteoporosis — for whom and for how long? N Engl J Med. 2012;366:2051–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Jiang X, Schnatz PF. Denosumab: an antifracture therapy for postmenopausal women with osteoporosis. Menopause. 2013;20(2):117–9.

    CAS  PubMed  Google Scholar 

  55. Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361:756–65.

    Article  CAS  PubMed  Google Scholar 

  56. Highlights of Prescribing Information. Available at http://pi.amgen.com/united_states/prolia/prolia_pi.pdf. Accessed 9 Mar 2015.

  57. Papapoulos S, Lippuner K, Roux C, et al. The effect of 8 or 5 years of denosumab treatment in postmenopausal women with osteoporosis: results from the FREEDOM Extension study. Osteoporos Int. 2015;26(12):2773–83.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  58. Busko M. Decade of data on denosumab for osteoporosis reassuring. Medscape Medical News. October 15, 2015. Available at http://www.medscape.com/viewarticle/852709. Accessed 14 Mar 2016.

  59. National Cancer Institute – FDA Approval for Denosumab. July 2013. Available at http://www.cancer.gov/about-cancer/treatment/drugs/fda-denosumab. Accessed 9 Mar 2016.

  60. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999; 282(7):637–45. (Erratum in: JAMA 1999;282(22):2124).

    Google Scholar 

  61. Seeman E, Crans GG, Diez-Perez A, et al. Anti-vertebral fracture efficacy of raloxifene: a meta-analysis. Osteoporos Int. 2006;17(2):313–6.

    Article  PubMed  Google Scholar 

  62. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999;282(7):637–45.

    Article  CAS  PubMed  Google Scholar 

  63. Ensrud KE, Stock JL, Barrett-Connor E, et al. Effects of raloxifene on fracture risk in postmenopausal women: the Raloxifene Use for the Heart Trial. J Bone Miner Res. 2008;23(1):112–20.

    Article  CAS  PubMed  Google Scholar 

  64. Lin T, Yan SG, Cai XZ, et al. Alendronate versus raloxifene for postmenopausal women: a meta-analysis of seven head-to-head randomized controlled trials. Int J Endocrinol. 2014;2014:796510.

    PubMed  PubMed Central  Google Scholar 

  65. Vogel VG, Costantino JP, Wickerham DL, et al. Effects of tamoxifen vs. raloxifene on the risk of developing invasive breast cancer and other disease outcomes: the NSABP Study of Tamoxifen and Raloxifene (STAR) P-2 trial. JAMA. 2006;295(23):2727–41.

    Article  CAS  PubMed  Google Scholar 

  66. Barrett-Connor E, Mosca L, Collins P. RaloxifeneUse for The Heart (RUTH) Trial Investigators, et al. Effects of raloxifene on cardiovascular events and breast cancer in postmenopausal women. N Engl J Med. 2006;355(2):125–37.

    Article  CAS  PubMed  Google Scholar 

  67. Stefanick ML. Risk-benefit profiles of raloxifene for women. N Engl J Med. 2006;355:190–2.

    Article  CAS  PubMed  Google Scholar 

  68. Gralow JR, Biermann JS, Farooki A, et al. NCCN task force report: bone health in cancer care. JNCCN. 2013;11 Suppl 3:S1–50.

    PubMed  Google Scholar 

  69. Wardell SE, Nelson ER, Chao CA, et al. Bazedoxifene exhibits antiestrogenic activity in animal models of tamoxifen-resistant breast cancer: implications for treatment of advanced disease. Clin Cancer Res. 2013;19(9):2420–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  70. FDA approves Duavee to treat hot flashes and prevent osteoporosis. October 2013. Available at http://www.fda.gov/Drugs/NewsEvents/ucm370679.htm. Accessed 9 Mar 2016.

Download references

Author information

Authors and Affiliations

  1. The Reading Hospital, Department of ObGyn, Reading, PA, USA

    Xuezhi Jiang MD, PhD, FACOG, NCMP & Peter F. Schnatz DO, FACOG, FACP, NCMP

  2. Sidney Kimmel Medical College of Thomas Jefferson University, Departments of ObGyn, Philadelphia, PA, USA

    Peter F. Schnatz DO, FACOG, FACP, NCMP

  3. Internal Medicine, Reading, PA, USA

    Xuezhi Jiang MD, PhD, FACOG, NCMP & Peter F. Schnatz DO, FACOG, FACP, NCMP

  4. Internal Medicine, Philadelphia, PA, USA

    Peter F. Schnatz DO, FACOG, FACP, NCMP

  5. East Bay Physicians Medical Group, 2500 Milvia Street, Berkeley, CA, 94704, USA

    Risa Kagan MD, FACOG, CCD, NCMP

  6. University of California, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA, USA

    Risa Kagan MD, FACOG, CCD, NCMP

Authors
  1. Xuezhi Jiang MD, PhD, FACOG, NCMP
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter F. Schnatz DO, FACOG, FACP, NCMP
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Risa Kagan MD, FACOG, CCD, NCMP
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Risa Kagan MD, FACOG, CCD, NCMP .

Editor information

Editors and Affiliations

  1. Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Reproductive Endocrinology and Infertility Yale School of Medicine, New Haven, Connecticut, USA

    Lubna Pal

  2. Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts, USA

    Raja A. Sayegh

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Jiang, X., Schnatz, P.F., Kagan, R. (2017). Management of Osteoporosis in Postmenopausal Breast Cancer Survivors. In: Pal, L., Sayegh, R. (eds) Essentials of Menopause Management. Springer, Cham. https://doi.org/10.1007/978-3-319-42451-4_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-42451-4_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-42449-1

  • Online ISBN: 978-3-319-42451-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation