BONE HEALTH AFTER BREAST CANCERStudies and Recommendations

April 30, 2012

Bone Health Overview• Dynamic state of bone resorption (breaking down bone) and formation

• When the rate of resorption is greater than formation, bone loss occurs

Measuring Bone Health • Bone Mineral Density (BMD) is generally the measure of

bone health• BMD looks at the amount of mineral matter per square

centimeter of bone• DEXA scanner is used to measure BMD

World Health Organization Online Tool • The WHO developed

an online tool that evaluates risk for fracture

• Web address:http://www.shef.ac.uk/FRAX/tool.jsp?country=9

Bone Effects of Adjuvant Therapies• Bone loss comes with age and onset of menopause, but

accelerated by cancer treatments • Chemotherapy can cause early onset of menopause, which

increases the risk of fracture • Hormone therapies have different effects:

• Tamoxifen can help protect against bone loss• In bone cells, it mimics the effects of estrogen, which helps with bone

formation• Aromatase inhibitors speed up bone loss

• Absence of estrogen causes more resorption of the bone

“What Breast Cancer Survivors Need to Know About Osteoporosis.” 2011. http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_cancer.aspTamoxifen Use and Osteoporotic Fracture Risk: A Population-Based Analysis. Journal of Clinical Oncology. http://jco.ascopubs.org/content/26/32/5227.full.pdf+html

Guidelines on screening• Bone Mineral Density monitoring recommended for

women who:• Are older than 65• Have had breast cancer and have high risk factors (such as family

history of fractures)• Are receiving aromatase inhibitor• Have had therapy-induced ovarian failure

NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

Improving Bone Health• Nutritional Supplements • Exercise• Strength-training• If necessary, other pharmacological therapies

What is recommended for supplements?

• Total daily calcium intake of at least 1000 mg per day for individuals under 50 years of age without major osteoporosis risk factors, and at least 1200 mg per day for those older than 50 years • Calcium is critical for bone mineralization

• 800 to 1,000 international units (IU) of vitamin D per day for adults aged 50 and older • Vitamin D is important for absorption of calcium through the

stomach and intestines

NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

Exercise and Strength-training• Both shown to improve bone health • A recent study in Germany showed that an aerobics and

strength-training exercise intervention for women over the age of 65 significantly improved bone health (BMD and fall risk)• Compared this group with a similar group receiving a wellness intervention

• Exercise Effects on Bone Mineral Density, Falls, Coronary Risk Factors, and Health Care Costs in Older Women. Arch Intern Med. 2010;170(2):179-185. http://archinte.ama-assn.org/cgi/content/full/170/2/179

Strength-training• A recent study of progressive, moderate-intensity resistance

with impact training showed it to slow bone density loss among post-menopausal breast cancer survivors• Examples of these exercises: using dumbbells, lunges, modified

push-ups

• Strength-training also shown to reduce the risk of lymphedema for women who have had breast surgery

Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Breast Cancer Res Treat (2011) 127:447–456. http://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdf

Weight Lifting in Women with Breast-Cancer–Related Lymphedema. The New England Journal of Medicine. (2009) 361;7. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118.

Medications to Prevent Bone Loss• If lifestyle and exercise do not improve bone health, other

treatments may be used• Some osteoporosis medications also used to make the

bone an inhospitable environment for cancer (prevent cancer from entering the bone)

• E.g. Zometa, denosumab

NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

Sources• WHO FRAX Online Tool http://www.shef.ac.uk/FRAX/tool.jsp?country=9

• “What Breast Cancer Survivors Need to Know About Osteoporosis.” 2011. National Institutes of Health Osteoporosis and Related Bone Diseases http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_cancer.asp

• Tamoxifen Use and Osteoporotic Fracture Risk: A Population-Based Analysis. Andrew L. Cooke, Colleen Metge, Lisa Lix, Heather J. Prior, and William D. Leslie. Journal of Clinical Oncology. 26:5227-5232. http://jco.ascopubs.org/content/26/32/5227.full.pdf+html

• NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

• Exercise Effects on Bone Mineral Density, Falls, Coronary Risk Factors, and Health Care Costs in Older Women. Wolfgang Kemmler, PhD; Simon von Stengel, PhD; Klaus Engelke, PhD; Lothar Häberle, PhD; Willi A. Kalender, PhD, MD Archives of Internal Medicine. 2010;170(2):179-185. http://archinte.ama-assn.org/cgi/content/full/170/2/179

• Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Kerri M. Winters-Stone, Jessica Dobek, Lillian Nail, Jill A. Bennett, Michael C. Leo, Arpana Naik, Anna Schwartz. Breast Cancer Research and Treatment (2011) 127:447–456. http://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdf

• Weight Lifting in Women with Breast-Cancer–Related Lymphedema. Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed.,Catherine T. Williams-Smith, B.S., and Quincy P. Greene The New England Journal of Medicine. (2009) 361;7. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118