1. BONE HEALTH AFTER BREAST CANCER Studies and Recommendations April 30, 2012

2. Bone Health Overview Dynamic state of bone resorption (breaking down bone) and formation When the rate of resorption is greater than formation, bone loss occurs

3. Measuring Bone Health Bone Mineral Density (BMD) is generally the measure of bone health BMD looks at the amount of mineral matter per square centimeter of bone DEXA scanner is used to measure BMD

4. World Health Organization Online Tool The WHO developed an online tool that evaluates risk for fracture Web address: http://www.shef.ac.uk/F RAX/tool.jsp?country=9

5. Bone Effects of Adjuvant Therapies Bone loss comes with age and onset of menopause, but accelerated by cancer treatments Chemotherapy can cause early onset of menopause, which increases the risk of fracture Hormone therapies have different effects: Tamoxifen can help protect against bone loss In bone cells, it mimics the effects of estrogen, which helps with bone formation Aromatase inhibitors speed up bone loss Absence of estrogen causes more resorption of the bone “What Breast Cancer Survivors Need to Know About Osteoporosis.” 2011. http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_ cancer.asp Tamoxifen Use and Osteoporotic Fracture Risk: A Population-Based Analysis. Journal of Clinical Oncology. http://jco.ascopubs.org/content/26/32/5227.full.pdf+html

6. Guidelines on screening Bone Mineral Density monitoring recommended for women who: Are older than 65 Have had breast cancer and have high risk factors (such as family history of fractures) Are receiving aromatase inhibitor Have had therapy-induced ovarian failure NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

7. Improving Bone Health Nutritional Supplements Exercise Strength-training If necessary, other pharmacological therapies

8. What is recommended for supplements? Total daily calcium intake of at least 1000 mg per day for individuals under 50 years of age without major osteoporosis risk factors, and at least 1200 mg per day for those older than 50 years Calcium is critical for bone mineralization 800 to 1,000 international units (IU) of vitamin D per day for adults aged 50 and older Vitamin D is important for absorption of calcium through the stomach and intestines NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

9. Exercise and Strength-training Both shown to improve bone health A recent study in Germany showed that an aerobics and strength-training exercise intervention for women over the age of 65 significantly improved bone health (BMD and fall risk) Compared this group with a similar group receiving a wellness intervention Exercise Effects on Bone Mineral Density, Falls, Coronary Risk Factors, and Health Care Costs in Older Women. Arch Intern Med. 2010;170(2):179-185. http://archinte.ama-assn.org/cgi/content/full/170/2/179http://archinte.ama-assn.org/cgi/content/full/170/2/179

10. Strength-training A recent study of progressive, moderate-intensity resistance with impact training showed it to slow bone density loss among post-menopausal breast cancer survivors Examples of these exercises: using dumbbells, lunges, modified push- ups Strength-training also shown to reduce the risk of lymphedema for women who have had breast surgery Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Breast Cancer Res Treat (2011) 127:447–456. http://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdfhttp://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdf Weight Lifting in Women with Breast-Cancer–Related Lymphedema. The New England Journal of Medicine. (2009) 361;7. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118

11. Medications to Prevent Bone Loss If lifestyle and exercise do not improve bone health, other treatments may be used Some osteoporosis medications also used to make the bone an inhospitable environment for cancer (prevent cancer from entering the bone) E.g. Zometa, denosumab NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html

12. Sources WHO FRAX Online Tool http://www.shef.ac.uk/FRAX/tool.jsp?country=9 http://www.shef.ac.uk/FRAX/tool.jsp?country=9 “What Breast Cancer Survivors Need to Know About Osteoporosis.” 2011. National Institutes of Health Osteoporosis and Related Bone Diseases http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_cancer.asp http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_cancer.asp Tamoxifen Use and Osteoporotic Fracture Risk: A Population-Based Analysis. Andrew L. Cooke, Colleen Metge, Lisa Lix, Heather J. Prior, and William D. Leslie. Journal of Clinical Oncology. 26:5227-5232. http://jco.ascopubs.org/content/26/32/5227.full.pdf+html http://jco.ascopubs.org/content/26/32/5227.full.pdf+html NCCN Task Force Report: Bone Health in Cancer Care. 2009;7:S-1-S-32 J Natl Compr Canc Netw http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html http://www.jnccn.org/content/7/Suppl_3/S-1.full.pdf+html Exercise Effects on Bone Mineral Density, Falls, Coronary Risk Factors, and Health Care Costs in Older Women. Wolfgang Kemmler, PhD; Simon von Stengel, PhD; Klaus Engelke, PhD; Lothar Häberle, PhD; Willi A. Kalender, PhD, MD Archives of Internal Medicine. 2010;170(2):179-185. http://archinte.ama- assn.org/cgi/content/full/170/2/179 Wolfgang Kemmler, PhD; Simon von Stengel, PhD; Klaus Engelke, PhD; Lothar Häberle, PhD; Willi A. Kalender, PhD, MD http://archinte.ama- assn.org/cgi/content/full/170/2/179 Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial. Kerri M. Winters-Stone, Jessica Dobek, Lillian Nail, Jill A. Bennett, Michael C. Leo, Arpana Naik, Anna Schwartz. Breast Cancer Research and Treatment (2011) 127:447–456. http://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdf http://www.springerlink.com/content/548814073xqg4mj0/fulltext.pdf Weight Lifting in Women with Breast-Cancer–Related Lymphedema. Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed.,Catherine T. Williams-Smith, B.S., and Quincy P. Greene The New England Journal of Medicine. (2009) 361;7. http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118http://www.nejm.org/doi/pdf/10.1056/NEJMoa0810118