1Sabahat Ahmed, 1Mr. Jonathan Horsnell, 1Miss. Shramana Banerjee
1Royal Surrey County Hospital, NHS Foundation Trust
Background:
Aromatase inhibitors form a key part of adjuvant endocrine treatment for post-menopausal women with hormone receptor positive breast cancer. They are known to reduce the risk of disease recurrence, distant metastases and contralateral breast cancers. However, they are also known to cause an accelerated reduction in bone mineral density and increase fracture risk over time. Current guidelines suggest to identify at-risk patients with a baseline DEXA scan within 3-6 months of commencing treatment. Following results, patients should be treated according to their T-score.
Method(s):
In this audit, 60 breast cancer patients started on aromatase inhibitors in our trust, Royal Surrey County Hospital, were selected, and compliance to these guidelines was assessed.
Result(s): Results showed 66.1% of patients had their baseline DEXA scan within 3-6 months of commencing treatment, 16.95% had a delayed baseline DEXA scan after commencing treatment, which ranged from 6 months to 3 years, and 16.95% did not have a baseline DEXA scan at all.
On assessment of patient compliance and side effects, 10% of patients stopped taking aromatase inhibitors due to side effects – the most common of which was joint pain – or concerns regarding effects on bone health. 12% of patients started on an aromatase inhibitor had presented to the hospital with a fracture since it was commenced.
DEXA scans were performed at a variety of different hospitals, according to the patient’s home address. The trusts that completed the largest number of DEXA scans also showed the highest variation in the time taken to complete the scan from commencement of the aromatase inhibitor.
Of those who had their DEXA scan, over half were found to have osteoporosis. There was a large variation in treatment following receipt of results. Of those found to have osteoporosis, 76.2% received Bisphosphonates as per treatment guidelines, but 23.8% did not receive any medical treatment. Of those found to have osteopenia, 83.3% received Calcium and Vitamin D supplementation as per treatment guidelines, but 16.6% did not receive any medical treatment.
Conclusion(s):
Given these findings, we suggested strategies to improve knowledge and awareness of the guidelines available amongst clinicians, to create a common understanding on the management of bone health in patients on aromatase inhibitors – to do this, we presented these findings at a local trust educational meeting. Re-audit has already shown improvement in the percentage of patients who have had a DEXA scan completed within good time, as per guidelines. Following this, we further suggest standardisation of the location a patient’s DEXA scan is carried out, and standardisation of the team that requests it.