|The role of aromatase inhibitors (AIs) in breast cancer has expanded since their introduction in
the mid-1990s. They are superior to tamoxifen in the treatment of postmenopausal women with
oestrogen dependant tumours in the metastatic, neoadjuvant, and adjuvant settings and are
currently been explored as chemopreventive agents. When compared to tamoxifen they are
known to reduce bone mineral density (BMD), increase fracture rate, increase joint symptoms,
and may also increase the risk of cardiovascular disease. The International Breast Cancer
Intervention Study-II (IBIS-II) is the only breast cancer prevention randomised trial studying
the role of anastrozole versus placebo in preventing breast cancer in postmenopausal women
with a high risk of breast cancer.
This thesis focus on four main areas: (a) Analysis of data from the bone sub-study of the IBISII
study, exploring the effects of anastrozole on bone mineral density at 12 and 36-months, and
the ability of bisphosphonates treatment to reduce bone loss in women with low mineral density
(BMD) at baseline. (b) Analysis of data from the prevention stratum of the IBIS-II study,
exploring the effect of anastrozole on cholesterol fractions. (c) Analysis of the data from the
Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial, exploring different risk factors
for fractures in women with breast cancer who received either anastrozole or tamoxifen for five
years (d) Analysis of data from the prevention stratum of the IBIS-II study, exploring if baseline
25(OH) vitamin D levels predicted arthralgia within one year of study.
Women with normal BMD at baseline had a significant BMD loss at lumbar spine and total hip
for both anastrozole and placebo. However, the BMD loss at lumbar spine was significantly
greater with anastrozole. Osteopenic women, who received anastrozole plus risedronate, after
12-months of treatment gained significant bone density at lumbar spine compared to women
receiving anastrozole without risedronate, but not at total hip. At 36 months, there was no
significant gain in bone density either at lumbar spine or total hip. In osteoporotic women,
risedronate abrogated the detrimental effect of anastrozole, after 12 months of treatment,
significantly at lumbar spine, but not at total hip. After 36 months of treatment, risedronate still
abrogated the effect of anastrozole at lumbar spine, but not significantly. These 12 and 36-
months data suggest that bone loss associated with anastrozole may be manageable with DXA
monitoring and bisphosphonate use.
Use of anastrozole did not lead to any significant changes in total cholesterol and high-density
lipoprotein cholesterol levels when compared with placebo, except that anastrozole marginally
decreased TC levels. These data support the lack of cardiovascular toxicity with anastrozole
seen in the adjuvant trials.
Using a model containing the following risk factors; age, weight/height/BMI, geographical
regions, smoking, use of statins and other medication at baseline, previous chemotherapy,
previous radiotherapy and trial therapy, only treatment, age and geographical regions were
found to be significantly associated with fracture risk.
No significant effect of baseline vitamin D levels were seen on the risk of musculoskeletal
symptoms in healthy postmenopausal women at a high risk of breast cancer. The serum 25 (OH)
vitamin D levels significantly increased in the anastrozole group from baseline to 12 months,
when compared with placebo.