Algorithms and recommendations
The American Society of Clinical Oncology (ASCO) has suggested an algorithm for the management of treatment- induced bone loss.84 In patients with a history of breast cancer, postmenopausal women receiving aromatase
inhibitors are considered as “high-risk” and recommended to undergo annual DXA assessment of the spine and hip, and receive calcium and vitamin D supplements. Those with BMD above the T-score threshold for a diagnosis of osteoporosis (T-score of >–2.5) are reassured and monitored on an annual basis, while those with a T-score of ≤2.5 are recommended to receive a bisphosphonate in addition to calcium and vitamin D supplementation and continue with annual DXA scans.
We have modified this algorithm to reflect the more recent findings summarised previously and the importance of risk factors other than BMD in selection of patients for intervention. Elderly (>75 years of age) women with one or more risk factors for osteoporotic fracture should receive bone protection with a bisphosphonate irrespective of BMD. Additionally, to reflect the speed of cancer treatment-induced bone loss, we suggest a more cautious BMD level for intervention. In postmenopausal women we recommend intervention when the T-score falls below –2 or if the rate of bone loss in women with pre-existing osteopaenia exceeds 4% per year. Similar recommendations apply to women with a premature menopause, with the exception of those receiving ovarian suppression plus an aromatase inhibitor in whom the recommended T-score threshold for intervention is –1, due to the very rapid losses of bone which occurs in this group of women averaging 16% over 3 years.
Where bisphosphonate therapy has been recommended, local protocols and funding arrangements should be taken into consideration when choosing the most appropriate product to use. 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. The dose of zoledronic acid used in postmenopausal osteoporosis is 5 mg annually given by the intravenous route. However the studies referenced in this document where zoledronic acid has been used to prevent breast cancer treatment-induced bone loss have used 4 mg biannually. The 4 mg dose every 6 months has thus been included in the algorithm, but individual clinicians may wish to use 5 mg annually.
The American Society of Clinical Oncology (ASCO) has suggested an algorithm for the management of treatment- induced bone loss.84 In patients with a history of breast cancer, postmenopausal women receiving aromatase
inhibitors are considered as “high-risk” and recommended to undergo annual DXA assessment of the spine and hip, and receive calcium and vitamin D supplements. Those with BMD above the T-score threshold for a diagnosis of osteoporosis (T-score of >–2.5) are reassured and monitored on an annual basis, while those with a T-score of ≤2.5 are recommended to receive a bisphosphonate in addition to calcium and vitamin D supplementation and continue with annual DXA scans.
We have modified this algorithm to reflect the more recent findings summarised previously and the importance of risk factors other than BMD in selection of patients for intervention. Elderly (>75 years of age) women with one or more risk factors for osteoporotic fracture should receive bone protection with a bisphosphonate irrespective of BMD. Additionally, to reflect the speed of cancer treatment-induced bone loss, we suggest a more cautious BMD level for intervention. In postmenopausal women we recommend intervention when the T-score falls below –2 or if the rate of bone loss in women with pre-existing osteopaenia exceeds 4% per year. Similar recommendations apply to women with a premature menopause, with the exception of those receiving ovarian suppression plus an aromatase inhibitor in whom the recommended T-score threshold for intervention is –1, due to the very rapid losses of bone which occurs in this group of women averaging 16% over 3 years.
Where bisphosphonate therapy has been recommended, local protocols and funding arrangements should be taken into consideration when choosing the most appropriate product to use. 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. The dose of zoledronic acid used in postmenopausal osteoporosis is 5 mg annually given by the intravenous route. However the studies referenced in this document where zoledronic acid has been used to prevent breast cancer treatment-induced bone loss have used 4 mg biannually. The 4 mg dose every 6 months has thus been included in the algorithm, but individual clinicians may wish to use 5 mg annually.
Posted in: Oncology and Cancer Articles
0 comments:
Post a Comment