Postmenopausal Breast Cancer, Aromatase Inhibitors, and Bone Health: What the Surgeon Should Know

Abstract

Breast cancer, as the most common malignancy in women, remains a major public health issue despite countless advances across decades. Endocrine therapy is the cornerstone of treatment of the hormone-sensitive subtype of breast cancer. The use of aromatase inhibitors (AIs) in the postmenopausal women has extended the survival beyond that of Tamoxifen, but harbors a subset of side effects, most notably accelerated bone loss. This, however, does not occur in all women undergoing treatment. It is vital to identify susceptible patients early, to limit such events, employ early treatment thereof, or alter drug therapy. International trials on AIs, predominantly performed in North American and European females, provide little information on what to expect in women in developing countries. Here, surgeons often prescribe and manage endocrine therapy. The prescribing surgeon should be aware of the adverse effect of the endocrine therapy and be able to attend to side effects. This review highlights clinical and biochemical factors associated with decrease in bone mineral density in an, as yet, unidentified subgroup of postmenopausal women. In the era of personalized medical care, appropriate management of bone health by surgeons based on these factors becomes increasingly important.

Novel insights into the complex architecture of osteoporosis molecular genetics

“…Aromatase inhibitors therapy rigorously suppresses estrogen biosynthesis leading to an almost whole depletion of estrogen, which accelerates bone loss and increases the risk of osteoporotic fractures . Although aromatase inhibitors therapy improves survival in breast cancer patients, they harbor a subclass of adverse events, including accelerated bone loss and the risk of bone fracture, which is due to the depletion of estrogens…”

Local estrogen axis in the human bone microenvironment regulates estrogen receptor-positive breast cancer cells

“…Aromatase inhibitors constitute the preferred therapeutic agent for the treatment of postmenopausal ER+ breast cancer patients, in the adjuvant setting to prevent recurrence of early-stage breast cancer, and as first-line and later agents to treat metastatic breast cancer [ 53 ]. Although these agents provide an invaluable armamentarium for fighting breast cancer progression, their efficacy is reduced by the challenges of side effects (most notably bone loss and skeletal fractures) [ 54 ] and endocrine resistance. In general, up to a third of all ER+ breast cancer patients exhibit intrinsic or acquired resistance to endocrine therapies [ 53 ].…”

Patients with Early-Stage and Estrogen Receptor-Negative Breast Cancers: Young Age Does Link to Poor Outcomes

“…Breast cancer is the most common cancer in women worldwide [1] [2]. In European and American countries, the majority of breast cancer patients are postmenopausal women [3]. Breast cancers are relatively rare in young adults, representing a small fraction of cases.…”