Bone Health In Focus: A Report About Breast Cancer's Impact on Bones

The Significance of Bone Health in Patients With Breast Cancer

Today's patient with cancer faces a daunting amount of information. Sorting through it all and deciding what's important can be an immense challenge. And with so many important issues to consider, bone health may not be at the top of a patient's agenda. But breast cancer-related bone diseases- resulting from the consequences of cancer treatment or from metastases to bone- can result in significant pain and disability. Studies have also shown a correlation between cancer-related bone diseases and increased risk of mortality.¹ At the same time, it is an under-recognized issue that may not receive enough attention from patients- and sometimes even from their healthcare providers. 63635-R1-V1 Photo: Getty Images

Conditions of Breast Cancer-Related Bone Diseases

Breast cancer-related bone diseases include two primary conditions: • cancer treatment-induced bone loss (CTIBL): Bone loss due to certain breast cancer treatments, such as aromatase inhibitors (AIs). • bone metastases: Cancer cells can separate from primary tumors and migrate to bone tissue where they settle and grow. These growing cancer cells then weaken and destroy the bone. The damage the tumor causes to the bone can result in a number of serious complications, collectively called skeletal-related events (SREs). Skeletal-related events (SREs) can occur when cancer has spread to the bone (metastasized) and weakened it. SREs include: • pathological fracture • spinal cord compression • need for surgery to bone • radiation to the bone 63635-R1-V1 Photo: Getty Images

Addressing Bone Health in Cancer

Recognizing the importance of addressing bone health in cancer and the need for improved dialogue, a committee of prominent patient advocates and Amgen® formed a multidisciplinary steering committee to address the issue. The committee commissioned a survey in partnership with Harris Interactive to assess the communication between patients with cancer and physicians about bone health in cases involving either non-metastatic or metastatic cancer, and to determine awareness levels and concern about bone health and cancer. Results from the survey are included throughout this report. 63635-R1-V1 Photo: Getty Images

Cancer Treatment-Induced Bone Loss In Patients With Non-Metastatic Breast Cancer

Adjuvant hormonal therapy for women with breast cancer is any treatment given after primary therapy to increase the chance of long-term survival. In breast cancer this includes aromatase inhibitors (AIs), which are designated to reduce estrogen concentrations in the body, but can also accelerate bone loss and increase the risk of fracture. Bone loss due to AIs is also known as cancer treatment-induced bone loss (CTIBL). Since women treated for adjuvant breast cancer with AIs are often over 65 and may have osteoporosis or pre-existing bone loss, AI therapy places them at an even greater risk of bone loss and fracture.² Once a patient has a fracture, there is an increased risk for additional fractures.³ In many cases, bone loss is not even detected until the patient has a fracture.⁴ The American Society of Clinical Oncology (ASCO) recognizes the risk of bone loss due to age and/or treatment in women with breast cancer and recommends regular assessment of bone health in this population.⁵ The rate of CTIBL in women with breast cancer is unknown and depends on several factors, including the cancer therapy administered and the level of ovarian function.⁷ 63635-R1-V1 Photo: Getty Images

The Impact of Breast Cancer Treatment on Bones

In women with breast cancer, AI therapy can lead to accelerated decrease in bone mineral density, thereby increasing the risk of fracture.⁹ Ninety-five percent of the oncologists treating patients with breast cancer surveyed by Harris Interactive consider bone loss a serious issue for their non-metastatic patients on AI therapy.⁸ In a clinical trial, women with early stage breast cancer who received AI therapy had a 21 percent increased risk of fracture, directly resulting from bone loss, compared to women with non-metastatic breast cancer who did not receive AI therapy.¹⁰ In the survey, medical oncologists said the following consequences can result from a fracture: • functional limitations • physical limitations, immobility • surgery • time spent in nursing home or rehab facility • time away from activities of daily living (social events, family, friends, etc.) • detrimental to emotional health and well-being • concern about interrupting treatment for primary cancer to address bone complications 63635-R1-V1 Photo: Getty Images

Current Treatments

Treatment options for bone loss are still relatively limited. A bone mineral density (BMD) test, which determines the amount of minerals (calcium, phosphorus, magnesium) within certain areas of bone, can predict the risk of fracture and other bone problems. This testing procedure, called bone densitometry (DEXA scan), is painless, non-invasive and involves minimal radiation exposure. Measurements are most commonly made over the lumbar (lower portion of spine) and over the upper part of the hip.¹⁸ 63635-R1-V1 Photo: Getty Images

Bisphosphonates

Although the mechanism of action for bisphosphonates is not completely defined, they are thought to attach to the surface of the bone and inhibit bone loss.¹⁹ Depending on the specific drug and patient need, they are available both orally and intravenously, and can be provided daily, weekly or monthly. Although most physicians (67 percent) are generally satisfied with current treatment options, a substantial percentage are not satisfied. Among oncologists who treat breast cancer, the Harris Interactive Survey indicated that almost one-third (29 percent) were dissatisfied or very dissatisfied with treatment options for CTIBL among patients with breast cancer.⁸ 63635-R1-V1 Photo: Getty Images

Calcium and Vitamin D Supplements and Lifestyle Changes

In addition to drug treatments, the National Osteoporosis Foundation recommends non-pharmacological interventions to reduce fracture risk for the general population. These recommendations include the adequate intake of calcium and vitamin D, regular weight-bearing and muscle-strengthening exercise, strategies for preventing falls and the avoidance of tobacco use and excessive alcohol intake.²⁰ 63635-R1-V1 Photo: Getty Images

Bone Metastases

Bone is a common site for metastases in patients with breast cancer. Sixty five to 75 percent of patients with advanced breast cancer can eventually develop bone metastases throughout the course of their disease.²¹ In this process, cancer cells travel from the primary tumor to bone tissue, where they settle and grow. The growing cancer cells weaken and destroy the bone around the tumor and can result in a number of serious complications called skeletal-related events (SREs), which are associated with increased pain, illness and death.^1,22,23 Bone pain is one of the first signs that cancer has progressed this far,²⁴ and it affects approximately 70 percent of patients whose cancer has spread to the bone.²⁵ Bone pain can dominate the daily lives of patients with metastatic disease and can be characterized as severe.²⁶ It is important for patients to communicate any bone-related symptoms to their doctor as soon as possible so a bone scan can be performed to determine if bone metastases are present. 63635-R1-V1 Photo: Getty Images

Treating Bone Metastases and Skeletal-Related Events in Patients with Breast Cancer

Patients with cancer continue to live longer, which may increase the likelihood that they experience an SRE.⁶ SREs can have negative consequences, as patients with breast cancer without a fracture have been shown to survive longer than those who experienced a fracture.²⁹ Current treatment options are underutilized but offer a positive impact on SREs associated with bone metastases, and improved skeletal health may provide important benefits to patients.²⁷ Since their introduction, IV bisphosphonates have become a mainstay for managing metastatic bone disease from breast cancer, as reflected in the ASCO guidelines.⁵ They have been shown to reduce cancer-related bone complications in specific malignancies by delaying the time to a first SRE and reducing the risk of developing a subsequent bone complication.^30,31,32 Regular monitoring of renal function is recommended when IV bisphosphonates are used for patients with bone metastases due to the potential consequence of renal deterioration.^19,33,34 63635-R1-V1 Photo: Getty Images

Surgical and Radiation Treatment Options for Patients with Advanced Cancer

If a bone is at risk of fracture or has already fractured, surgery to the bone is performed to manage or prevent further complications. For patients with advanced- stage cancer, surgery to the bone is a major operation, and recovery can often be challenging and require hospitalization. When drug treatments are not effective, one option to treating bone pain due to metastases in the spine is the injection of a special kind of cement, a technique called Vertebroplasty, into the bone of the vertebra. Kyphoplasty, another option for cancer that has spread to the spine, repairs fractures and restores the vertebrae to the correct position using a balloon that creates a mold for bone cement.³⁵ Two current trends in radiation therapy for bone pain are hypofractionation, in which oncologists administer fewer larger radiation doses rather than many smaller doses,³⁶ and sterotactic body radiation therapy in which the dose is focused on a specific portion of bone or other tissue, often over several days.^37,38 63635-R1-V1 Photo: Getty Images

Patient Story: Dikla*

Dikla, 40, from Los Angeles, was first diagnosed in 2002 with stage 3 breast cancer. Two years later, it changed to stage 4 when bone metastases were clearly evident. PET/CT scans showed a sub-centimeter speck on her T7 vertebrae (thoracic spine). But a year after chemotherapy and radiation, Dikla developed excruciating back pain. In 2004, another PET/CT scan and biopsy found a growing tumor on her spine (where the “speck” was first found), which caused a fracture and threatened her spinal cord. Soon after radiation treatments began, the tumor was removed surgically. While she still has metastases – small but stable lesions in her lungs diagnosed in 2007 – none are present in her bones. Dikla sees an oncologist and an integrative oncologist** simultaneously at UCLA. Bone metastases were not discussed when Dikla was first diagnosed, but she found out about bone health issues through support groups. Dikla said the focus was on the breast cancer rather than bone problems. As a self-described patient activist – she works out, takes vitamin supplements and participates in support groups at UCLA and online – Dikla says she would have liked a patient advocate to guide her at the very beginning. _{*Patient testimonials were collected separately from the Harris Interactive Survey and are not affiliated with Harris Interactive.
**UCLA has a Center for Integrative Oncology.} 63635-R1-V1 Photo: Getty Images

Patient Story: Lauralee*

Lauralee, who is 56 and lives in Sandusky, Ohio, has stage 4 breast cancer, first diagnosed in 2002. She has had significant bone metastases in her vertebrae, discovered by a bone biopsy and magnetic resonance imaging (MRI). Lauralee saw a local oncologist who recommended an NIH (National Institutes of Health) protocol, which was endorsed by a second opinion. As a result, she was treated with an aromatase inhibitor. Her physician prescribed an IV bisphosphonate to strengthen the bone and to help diminish the metastases. After three and half years, her physician recommended that Lauralee stop the infusions because her bones had improved, though she had to resume bone loss treatment in late 2009, because a DEXA scan indicated the presence of osteopenia. Lauralee is very involved in Breast Cancer Network of Strength and has consulted with over 100 women with similar conditions. She regularly discusses her condition and the plan of action with her oncologist, usually armed with questions and the latest scientific articles. She believes information and hope are strong medicines. _{*Patient testimonials were collected separately from the Harris Interactive Survey and are not affiliated with Harris Interactive.} 63635-R1-V1 Photo: Getty Images

Be Your Own Advocate

Role of Effective Communication As with any medical issue, the quality, accuracy and timeliness of communications between physicians and patients are critical to successful outcomes. Nurses are also play an important role in communication. Information is Available Knowledge is power, especially for patients with breast cancer. So, as the ultimate consumers of healthcare, patients can make the best decisions about their treatment by becoming educated. Information is available to help patients understand their diagnosis and treatment options. The Support of Family and Friends- A Network of Support Having the support and help of friends and loved ones is also very important. Bringing someone along to medical appointments not only provides emotional support, but also gives the patient a critical back-up: someone who can listen carefully to directions, think of questions to ask and remember details the patient may have forgotten. Keep Records To improve and maintain effective communications, patients should prepare a list of specific questions beforehand and write down responses from their healthcare providers, to prevent important concerns from being forgotten during medical appointments.³⁹ Taking notes or recording visits can help too. Some patients find it beneficial to keep track of details in a journal or notebook. Speak Up In any conversation with a doctor, patients should be assertive. If they don't understand a doctor, they should ask questions. Sources: 1 Yong M, Jensen A, Jacobsen J, Nørgaard M, Fryzek J, Sørensen H. The incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in Denmark (1999–2007). Cancer Res 2009;69(24 Suppl). Abstract and poster. 2 Brufsky AM. Cancer treatment-induced bone loss: pathophysiology and clinical perspectives. Oncologist. 2008;13:187-195. 3 Klotzbuecher CM, Ross PD, Landsman PM, Abbott TA, Berger M. 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