Older Women in the United States Not Receiving Recommended Bone Density Testing before Starting Cancer Treatment, Study Finds
A Medical College of Wisconsin study published in the July issue of JNCCN found that older women are not receiving recommended bone density assessment prior to adjuvant therapy with aromatase inhibitors, possibly making them more vulnerable to bone fracture and comorbidity as a result of injury.
FORT WASHINGTON, PA — Aromatase inhibitors (AIs)—drugs that stop the production of estrogen in women—are standard adjuvant therapy for post-menopausal women with hormone-receptor positive breast cancer. AIs are an effective treatment for this population, but have the major side effect of bone density loss, which can lead to increased fractures and long-term injury. To ensure patient safety, the National Comprehensive Cancer Network® (NCCN®) recommends that patients undergo bone mineral density (BMD) testing before starting treatment with AIs, and that women at increased risk for osteoporosis consider antiresorptive therapy, such as bisphosphonates, which slow or stop bone density loss.
Researchers at Medical College of Wisconsin, led by John Alan Charlson, MD, Associate Professor of Medicine, Division of Hematology and Oncology, studied women ages 67 and older to assess when and if they were undergoing the recommended bone density testing. According to the findings, as women aged—increasing their odds of osteoporosis and bone fracture—they were less likely to receive NCCN-recommended baseline testing. The study, Bone Mineral Density Testing Disparities among Breast Cancer Patients Prescribed Aromatase Inhibitors (AIs), is featured in the July issue of JNCCN – Journal of the National Comprehensive Cancer Network.
“This study highlights sub-optimal U.S. compliance with guideline recommendations for baseline BMD testing when starting AI therapy,” said Dr. Charlson. “Older women, at higher risk for fractures in general, are least likely to get testing, and the slight increase in empiric treatment in no way closes the gap.”
Looking at Medicare Part A, B, and D claims from 2006 through 2012, Dr. Charlson and fellow investigators found that approximately two-thirds of patients received recommended baseline BMD testing. Lower rates of baseline testing correlated to several factors, including race and income, but the most substantial correlation, the investigators found, was older age—86 years and older. In the study population, baseline BMD test rates fell progressively from 73 percent in women ages 67-70 to 51 percent in women over the age of 85.
“The oldest patients are most likely to be vulnerable to bone density loss, so BMD testing results may be especially important in this age group for analysis of risks and benefits of treatment, as well as to determine whom should be treated with bone-modifying agents,” said Dr. Charlson.
Older women are at higher risk of osteoporosis and bone fracture. Hip fracture rates, according to the study, are seven times higher in women ages 70 and older than in other populations and higher comorbidity is also linked to these fractures. Although the oldest women in the study were least likely to receive BMD assessment, they did receive slightly higher rates of bisphosphonates as empiric therapy.
“While a larger number of older patients did receive bisphosphonates, this does not explain the disparities in bone density findings, or even substantially change our finding that attending to BMD was higher in lower risk younger women,” said Dr. Charlson.
“These findings may be even more important in light of recent data from additional studies suggesting bone fracture rates may be even higher than previously recognized for women using adjuvant aromatase inhibitors,” said Steven J. Isakoff, MD, PhD, Massachusetts General Hospital Cancer Center, Member of the NCCN Guidelines Panel for Breast Cancer. “In addition, many women may now be using aromatase inhibitors beyond five years, which may further increase the risk of fractures. This study highlights that, as a breast cancer community, we need to do a better job screening for bone health because with proper screening and treatment, many of these fractures can be prevented, particularly in the older patients at highest risk for fractures but who have the lowest rates of bone health screening.”
Complimentary access to this research is available until September 30, 2016 at JNCCN.org.
About JNCCN – Journal of the National Comprehensive Cancer Network
More than 23,000 oncologists and other cancer care professionals across the United States read JNCCN–Journal of the National Comprehensive Cancer Network. This peer-reviewed, indexed medical journal provides the latest information about best clinical practices, health services research, and translational medicine. JNCCN features updates on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), review articles elaborating on guidelines recommendations, health services research, and case reports highlighting molecular insights in patient care. JNCCN is published by Harborside Press. Visit JNCCN.org. For a FREE subscription to JNCCN, visit http://www.nccn.org/jnccn/subscribe.asp
About the National Comprehensive Cancer Network
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 of the world’s leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.
The NCCN Member Institutions are: Fred & Pamela Buffett Cancer Center, Omaha, NE; Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Mayo Clinic Cancer Center, Phoenix/Scottsdale, AZ, Jacksonville, FL, and Rochester, MN; Memorial Sloan Kettering Cancer Center, New York, NY; Moffitt Cancer Center, Tampa, FL; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UC San Diego Moores Cancer Center, La Jolla, CA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Colorado Cancer Center, Aurora, CO; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Wisconsin Carbone Cancer Center, Madison, WI; Vanderbilt-Ingram Cancer Center, Nashville, TN; and Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT.
About the Medical College of Wisconsin
The Medical College of Wisconsin is the state’s only private medical school and health sciences graduate school. Founded in 1893, it is dedicated to leadership and excellence in education, patient care, research and community engagement. More than 1,200 students are enrolled in MCW’s medical school and graduate school programs in Milwaukee, 56 medical students are enrolled at MCW-Green Bay and 26 students are enrolled at MCW-Central Wisconsin. A regional medical education campus is scheduled to open in Central Wisconsin in 2016. MCW’s School of Pharmacy will open in 2017 or 2018 with an initial class size of 60 students. A major national research center, MCW is the largest research institution in the Milwaukee metro area and second largest in Wisconsin. In FY 2014-15, faculty received approximately $158 million in external support for research, teaching, training and related purposes, of which approximately $139 million is for research. This total includes highly competitive research and training awards from the National Institutes of Health (NIH). Annually, MCW faculty direct or collaborate on more than 3,200 research studies, including clinical trials. Additionally, more than 1,500 physicians provide care in virtually every specialty of medicine for more than 525,000 patients annually.
 Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer V2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed July 11, 2016. To view the most recent and complete version of the guideline, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.
Katie Kiley Brown, NCCN