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Several guidelines have been reported for bone-directed treatment in women with early breast cancer for averting fractures, particularly during aromatase inhibitor (AI) therapy. A systematic literature review identified both several fracture-related risk factors as well as recent advances in the management of aromatase inhibitor-associated bone loss (AIBL). Although the FRAX algorithm includes fracture risk factors in addition to bone mineral density (BMD), it does not seem to adequately address the effects of AIBL. Several antiresorptive agents can prevent and treat AIBL. However, concerns regarding compliance and long-term safety remain. Overall, the evidence for fracture prevention is strongest for denosumab 60 mg s.c. every 6 months. Additionally, recent studies as well as an individual patient data meta-analysis of all available randomized trial data support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women, with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality that needs to be taken into account when advising on management of AIBL.

A Joint Position Statement of the International Osteoporosis Foundation, the Cancer and Bone Society, the European Calcified Tissue Society, the International Expert Group for AIBL, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, the International Society for Geriatric Oncology and the International Menopause Society recently provided a treatment algorithm [1]. In all patients initiating AI treatment, fracture risk should be assessed and recommendation with regard to exercise and calcium/vitamin D supplementation given. Bone-directed therapy should be given to all patients with a T-score <−2.0 or with a T-score of < –1.5 SD with one additional risk factor, or with two or more risk factors (without BMD) for the duration of AI treatment. Patients with a T-score > −1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Compliance should be regularly assessed as well as BMD on treatment after 12–24 months. Furthermore, because of the decreased incidence of bone recurrence and breast cancer-specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.


  • Rod Baber
    Clinical Professor of Obstetrics and Gynaecology, The University of Sydney, Australia


  1. Hadji P, Aapro MS, Body JJ, et al. Management of AIBL in postmenopausal women with hormone sensitive breast cancer. Joint Position Statement of IOF, CABS, ECTS, IEG, ESCEO, IMS and SIOG. J Bone Oncol 2017;7:1-12
  2. Ryden L, Heibert Arnlind M, Vitols S, Hoistad M, Ahlgren J. Aromatase inhibitors alone or sequentially combined with tamoxifen in postmenopausal early breast cancer compared with tamoxifen or placebo. Breast 2016;26:106-14
  3. Colzani E, Clements M, Johansson AL, et al. Risk of hospitalization and death due to bone fracture after breast cancer; a registry based cohort. Br J Cancer 2016;115:1400-7
  4. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet 2016;386:1353-61
  5. Hadji P, Coleman RE, Wilson C, et al. Adjuvant bisphosphonates in early breast cancer: consensus guidance for clinical practice from a European Panel. Ann Oncol 2016;27:379-90
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