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Bone density screenings ‘suboptimal’ among older breast cancer survivors
Most older breast cancer survivors prescribed anti-estrogen therapy do not undergo the recommended bone density screening to monitor the effects of treatments on osteoporosis risk, according to a database analysis published in Bone.
“As more women survive breast cancer, there is a need to optimize long-term follow-up to prevent [breast cancer] recurrence and manage delayed cancer treatment-related toxicity,” David Henault, MD, of the department of surgery at the University of Montreal, and colleagues wrote in the study background. “The majority of patients have estrogen-receptor positive disease and will therefore require adjuvant anti-estrogen therapy. Both tamoxifen and aromatase inhibitors are effective estrogen-reducing therapies; however, [aromatase inhibitors] are prioritized in postmenopausal women because of greater efficacy and more tolerable side-effect profile.”
In a retrospective cohort study, Henault and colleagues analyzed provincial universal health insurance agency data from 16,480 women aged at least 65 years with a new diagnosis of local or regional breast cancer diagnosed between 1998 and 2012 (mean age, 74 years). The researchers assessed baseline bone density screenings conducted during the 12 months before and after initiation of anti-estrogen therapy, consistent with National Comprehensive Cancer Network (NCCN) guidelines, which advise bone density screenings every 24 months.
Primary outcome was bone density screening within the 24-month period surrounding anti-estrogen therapy initiation.
Researchers used a generalized estimating equations regression model to evaluate the association between predictor variables and baseline bone density, accounting for physician-level clustering by the most prevalent anti-estrogen therapy prescriber for each patient.
Within the cohort, 7,407 (44.9%) patients were exposed to aromatase inhibitors, with 5,944 (36.1%) undergoing a bone density screening.
In multivariate analysis, researchers observed decreasing odds for undergoing a bone density screening among older patients. The OR was 0.79 for women aged 70 to 79 years (95% CI, 0.72-0.86) and 0.41 for women aged at least 80 years (95% CI, 0.37-0.47). Women who required partial or full income supplementation had lower odds of undergoing a bone density screening vs. those who did not need income supplementation (full income supplementation OR = 0.62; 95% CI, 0.52-0.72; partial income supplementation OR = 0.74; 95% CI, 0.69-0.81).
Researchers found that lower odds of undergoing a bone density screening were associated with failure to receive an expected radiotherapy consultation (OR = 0.69; 95% CI, 0.57-0.83), chemotherapy (OR = 0.82; 95% CI, 0.71-0.94) and nonadherence to anti-estrogen therapy (OR = 0.76; 95% CI, 0.68-0.84). Additionally, women who were exposed to bisphosphonate therapy for less than 6 months or not at all had low odds of undergoing a bone density screening (short-term exposure OR = 0.76; 95% CI, 0.65-0.89; no exposure OR = 0.24; 95% CI, 0.21-0.28).
Women who received their breast cancer diagnosis after 2003 were more likely to undergo a bone density screening vs. women diagnosed before 2003 (OR = 5.41; 95% CI, 4.86-6.02). However, researchers observed several other factors associated with lower odds for undergoing a bone density screening, including the lack of a comprehensive health examination prior to initiating anti-estrogen therapy (OR = 0.78; 95% CI, 0.72-0.86), exclusive use of tamoxifen or a switch to tamoxifen in anti-estrogen therapy vs. using an aromatase inhibitor exclusively (exclusive tamoxifen/switch to tamoxifen OR = 0.27; 95% CI, 0.24-0.31) and vs. exclusive aromatase inhibitor use (OR = 0.5; 95% CI, 0.45-0.56). Women were also less likely to undergo a bone density screening when the most frequent prescriber of anti-estrogen therapy was a general practitioner vs. a medical oncologist (OR = 0.81; 95% CI, 0.69-0.94).
“Despite an increase in rates since 2003, [bone density] screening remains suboptimal, especially for women at higher risk of osteoporosis,” the researchers wrote. “Coordination of health care and service-delivery monitoring can potentially optimize long-term management of treatment-related toxicity in older [breast cancer] survivors.”
– by Jennifer Byrne
Disclosures: The authors report no relevant financial disclosures.
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Henault D et al. Bone. 2018;doi:10.1016/j.bone.2018.06.005.