University of Melbourne, Melbourne, VIC.
Austin Health, Melbourne, VIC.
Med J Aust. 2019 Sep;211(5):224-229. doi: 10.5694/mja2.50280. Epub 2019 Jul 18.
Representatives appointed by relevant Australian medical societies used a systematic approach for adaptation of guidelines (ADAPTE) to formulate clinical consensus recommendations on assessment and management of bone health in women with oestrogen receptor-positive early breast cancer receiving endocrine therapy. The current evidence suggests that women receiving adjuvant aromatase inhibitors and pre-menopausal woman treated with tamoxifen have accelerated bone loss and that women receiving adjuvant aromatase inhibitors have increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven anti-fracture benefit in post-menopausal women receiving aromatase inhibitors for hormone receptor-positive breast cancer.
Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density measurement, with monitoring based on risk factors. Weight-bearing exercise and vitamin D and calcium sufficiency are recommended routinely. Anti-resorptive treatment is indicated in women with prevalent or incident clinical or morphometric fragility fractures, and should be considered in women with a T score (or Z score in women aged < 50 years) of < - 2.0 at any site, or if annual bone loss is ≥ 5%, considering baseline bone mineral density and other fracture risk factors. Duration of anti-resorptive treatment can be individualised based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with anti-resorptive treatments are low.
Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimised by non-pharmacological intervention and, where indicated, anti-resorptive treatment, in an individualised, multidisciplinary approach.
相关澳大利亚医学协会指定的代表采用系统方法进行适应性调整（ADAPTE），以制定关于接受内分泌治疗的雌激素受体阳性早期乳腺癌女性骨骼健康评估和管理的临床共识建议。目前的证据表明，接受辅助芳香酶抑制剂治疗的绝经前妇女和接受他莫昔芬治疗的绝经前妇女骨丢失加速，而接受辅助芳香酶抑制剂治疗的妇女骨折风险增加。双膦酸盐和地舒单抗均可预防骨丢失；此外，地舒单抗已被证明可预防接受芳香酶抑制剂治疗的激素受体阳性乳腺癌的绝经后妇女骨折。
考虑内分泌治疗的女性需要进行骨折风险评估，包括临床危险因素、生化和骨密度测量，并根据危险因素进行监测。建议常规进行负重运动以及维生素 D 和钙的充足摄入。对于有现患或新发临床或形态计量学脆性骨折的女性，建议进行抗吸收治疗，对于任何部位 T 评分（或<50 岁女性的 Z 评分）< -2.0 的女性，或如果每年骨丢失≥5%，考虑基线骨密度和其他骨折危险因素，应考虑抗吸收治疗。抗吸收治疗的持续时间可以根据绝对骨折风险进行个体化。与骨骼益处相比，抗吸收治疗的不良事件风险较低。
在选择和内分泌治疗持续时间的决策过程中应考虑骨骼健康。在接受内分泌治疗之前和期间，应定期评估骨骼健康，通过非药物干预进行优化，并在有指征时采用个体化、多学科的方法进行抗吸收治疗。
