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National Collaborating Centre for Cancer (UK). Early and Locally Advanced Breast Cancer: Diagnosis and Treatment [Internet]. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2009 Feb. (NICE Clinical Guidelines, No. 80.)

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Early and Locally Advanced Breast Cancer: Diagnosis and Treatment [Internet].

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Appendix 2Algorithms taken from ‘Guidance for the management of breast cancer treatment-induced bone loss: A consensus position statement from a UK expert group (2008)’1

Algorithm 1: Women who experience premature menopause

The development of a treatment-induced menopause or planned ovarian suppression treatment before the age of 45 years are indications for evaluation of BMD by DXA.

BMD assessments should be done at the lumbar spine and at one or both total hip sites. There is no requirement to obtain a DXA before starting treatment, but a baseline assessment should be obtained within 3 months of commencing ovarian suppression therapy or oophorectomy and within 12 months of developing postchemotherapy amenorrhoea.

Monitoring and treatment thereafter depends on the baseline BMD and the type of any concomitant endocrine treatment. Owing to the very rapid bone loss observed with the use of ovarian suppression therapy plus an aromatase inhibitor, a different threshold for follow-up, monitoring and intervention is recommended.

Any patient with a documented vertebral fragility fracture or previous low trauma hip fracture should receive prophylactic bisphosphonate treatment irrespective of baseline BMD.

For patients who are not receiving a concomitant aromatase inhibitor, three groups of patients are defined based on baseline BMD

  • [filled square] High-Risk Group: Patients with a baseline T-score of <−2 at the lumbar spine or either hip site or whose BMD falls below this threshold should receive bisphosphonate therapy at osteoporosis doses in addition to lifestyle advice, calcium and vitamin D supplementation.
    • The choice of bisphosphonate should be based on local protocols and funding arrangements. Weekly oralalendronate 70 mg or risedronate 35 mg, monthly oral ibandronate 150 mg, 3-monthly intravenous ibandronate 3 mg, or 6-monthly intravenous zoledronic acid 4 mg are all considered appropriate.
    • Bisphosphonates are contraindicated in patients with a low glomerular filtration rate (<30 ml/min/1.73m2) or hypocalcaemia. Such patients who require bone sparing therapy should be referred to the local bone service. Oral bisphosphonates must be used with caution in patients with oesophageal disease, although intravenous bisphosphonates will usually be appropriate in such patients.
    • Follow-up of patients requiring bisphosphonate treatment should include a repeat DXA after 24 months and/or measurement of a bone resorption marker, if desired, as an aid to judging compliance and response. If there is bone loss associated with bisphosphonate therapy, first check that the compliance with instructions is correct, then re-evaluate for secondary osteoporosis. Poor compliance and secondary osteoporosis explain most cases of poor response. However, some patients may be true non-responders and a switch of therapy, for example to an intravenous bisphosphonate, or a referral to the local bone service should be considered in these patients.
  • [filled square] Medium-Risk Group: For those patients with a T-score between −1 and −2, lifestyle advice plus calcium (1 g/day) and vitamin D (400–800 IU) supplementation are recommended unless dietary intake of calcium exceeds 1 g/day and serum 25-hydroxyvitamin D is known to be >20 μg/L.
    • A follow-up DXA scan should be performed at 24 month intervals to exclude a clinically significant reduction in BMD (T-score of <−2 or >−4% per annum decline in BMD at either the spine or hip [the forearm is not suitable for repeat assessments within such time-frames]).
    • Patients who exceed these limits should commence bone protection therapy as described in the high-risk group.
  • [filled square] Low-Risk Group: For those patients with normal BMD (T-score of >−1), the risk of developing osteoporosis over a 5-year treatment and follow-up period is very low. Advice on lifestyle (diet, weight-bearing exercise, reduced alcohol consumption and cessation of smoking) is sufficient and no specific intervention or follow-up assessment of BMD is required.

For patients receiving a concomitant aromatase inhibitor, only two groups are defined

  • [filled square] High-Risk Group: Those patients with a T-score of <−1 should receive bone protection therapy with a bisphosphonate as described above.
  • [filled square] Medium-Risk Group: Those patients with a T-score of >−1 should be monitored as indicated for all medium-risk groups.
Flowchart Icon

Algorithm 1. Adjuvant treatment associated with ovarian suppression/failure with or without concomitant aromatase inhibitor use in women who experience premature menopause (PDF, 101K)

Algorithm 2: Postmenopausal women

The use of an aromatase inhibitor (steroidal or non-steroidal) is an indication for evaluation of BMD by DXA.

BMD assessments should be done at the lumbar spine and at one or both total hip sites. There is no requirement to obtain a DXA before starting treatment, but a baseline assessment should be obtained within 3 months of commencing an aromatase inhibitor.

Monitoring and treatment thereafter depends on the baseline BMD, age, and presence of any major risk factors for osteoporotic fracture. These are defined as:

  • previous fragility fracture above the age of 50 years;
  • parental history of fracture;
  • a body mass index (BMI) of <22;
  • alcohol consumption of 4 or more units per day;
  • diseases known to increase fracture risk such as premature menopause, rheumatoid arthritis;
  • ankylosing spondylitis, immobility, and Crohn’s disease; and
  • prior oral corticosteroid use for more than 6 months.

For women over the age of 75 years with one or more major risk factors, bone protection therapy with a bisphosphonate is recommended irrespective of baseline BMD.

For women aged under 75 years or without major risk factors, three groups of patients are defined based on baseline BMD

  • [filled square] High-Risk Group: Patients with a baseline T-score of <−2 at the lumbar spine or either hip site or whose BMD falls below this threshold should receive bisphosphonate therapy at osteoporosis doses in addition to lifestyle advice, calcium and vitamin D supplementation.
    • The choice of bisphosphonate should be based on local protocols and funding arrangements. Weekly oral alendronate 70 mg or risedronate 35 mg, monthly oral ibandronate 150 mg, 3-monthly intravenous ibandronate 3 mg, or 6-monthly intravenous zoledronic acid 4 mg are all considered appropriate.
    • Bisphosphonates are contraindicated in patients with a low glomerular filtration rate (<30 ml/min/1.73m2) or hypocalcaemia. Such patients who require bone sparing therapy should be referred to the local bone service. Oral bisphosphonates must be used with caution in patients with oesophageal disease, although intravenous bisphosphonates will usually be appropriate in such patients.
    • Follow-up of patients requiring bisphosphonate treatment should include a repeat DXA after 24 months and/or measurement of a bone resorption marker, if desired, as an aid to Judging compliance and response. If there is bone loss associated with bisphosphonate therapy, first check that the compliance with instructions is correct, then re-evaluate for secondary osteoporosis. Poor compliance and secondary osteoporosis explain most cases of poor response. However, some patients may be true non-responders and a switch of therapy, for example to an intravenous bisphosphonate, or a referral to the local bone service should be considered in these patients.
  • [filled square] Medium-Risk Group: For those patients with a T-score between −1 and −2, lifestyle advice plus calcium (1 g/day) and vitamin D (400–800 IU) supplementation are recommended unless dietary intake of calcium exceeds 1 g/day and serum 25-hydroxyvitamin D is known to be>2 μg/L.
    • A follow-up DXA scan should be performed at 24 month intervals to exclude a clinically significant reduction in BMD (T-score of <−2 or >4% per annum decline in BMD at either the spine or hip [the forearm is not suitable for repeat assessments within such timeframes]).
    • Patients who exceed these limits should commence bone protection therapy as described in the high-risk group.
  • [filled square]Low-Risk Group: For those patients with normal BMD (T-score >−1), the risk of developing osteoporosis over a 5-year treatment period is very low. Advice on lifestyle (diet, weight-bearing exercise, reduced alcohol consumption and cessation of smoking) is sufficient and no specific intervention or follow-up assessment of BMD is required.
Flowchart Icon

Algorithm 2. Postmenopausal adjuvant treatment with aromatase inhibitors (PDF, 103K)

Reprinted from: Cancer Treatment Reviews. Volume 34, Supplement 1. David M. Reid, Julie Doughty, Richard Eastell, Steven D. Heys, Anthony Howell, Eugene V. McCloskey, Trevor Powles, Peter Selby, Robert E. Coleman. Guidance for the management of breast cancer treatment-induced bone-loss: A consensus position statement from a UK Expert Group. Pages S3–S18, Copyright 2008 with permission from Elsevier.

Footnotes

1

Reprinted from: Cancer Treatment Reviews. Volume 34, Supplement 1. David M. Reid, Julie Doughty, Richard Eastell, Steven D. Heys, Anthony Howell, Eugene V. McCloskey, Trevor Powles, Peter Selby, Robert E. Coleman. Guidance for the management of breast cancer treatment-induced bone-loss: A consensus position statement from a UK Expert Group. Pages S3–S18, Copyright 2008 with permission from Elsevier.

Copyright © 2009, National Collaborating Centre for Cancer.

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The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK11642
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