Clearly there are limitations to

Clearly there are limitations to the current study. These include the single centre, retrospective nature of the study as well as its relatively small sample size compared with the randomised data. However, the duration of follow up is considerably longer than these trials (Table 1). In conclusion, despite our increased understanding of the biology of metastatic bone disease [31,32] bone remains the most common site of breast cancer recurrence. Despite extensive use of BTAs the incidence of SREs remains high as does the use of opioid analgesics and hospitalizations secondary to bone metastases. Thus despite significant advances in the care of these patients there is a need for more effective treatment options and more individualized approach for these patients.
Conflict of interest statement Mark Clemons received honoraria for talks from Amgen and Novartis and funding for meetings from Amgen and Novartis. The other authors declare that 6 his tag there are no conflicts of interest.
Introduction The cancer survival rates in Australia from 1998 to 2004 indicates that the majority of women diagnosed with breast cancer will survive over the long term with 88.0% alive at five years and 79.4% at ten years [1]. Extended survival exposes the majority of patients to the late effects of breast cancer therapies. Osteoporosis and the increased risk of associated skeletal related events are recognised as undesirable outcomes of various adjuvant therapies for early breast cancer [2]. Surveillance strategies for breast cancer need to incorporate monitoring for recurrence of disease as well as strategies to prevent and manage the bone related complications of adjuvant therapies. Aromatase inhibitors in early breast cancer have demonstrated greater efficacy compared to tamoxifen in postmenopausal women with improved disease free survival, time to recurrence and time to distant recurrence [3]. The suppression of oestrogen levels with AIs results in accelerated bone mineral loss and increased fracture risk. AIBL almost doubles the rate of loss seen in healthy postmenopausal women [4]. Results from the ATAC sub-study demonstrated that progressive AIBL occurs throughout the duration of AI treatment. This is greater in the lumbar spine in the first two years of therapy commencement and the decline appears to be less marked in years two to five of treatment but does not slow down in the hip [5]. In 2005, Osteoporosis Australia proposed an algorithm [6] to manage AIBL (Fig. 1). The algorithm assesses changes in bone mineral density (BMD) and N-telopeptide (NTx, a bone resorption marker) to determine timing of bisphosphonate therapy commencement. The Bisphosphonate and Anastrozole Trial – Bone Maintenance Algorithm Assessment (BATMAN) was designed to test the utility of this algorithm in postmenopausal women with hormone-receptor positive early breast cancer receiving adjuvant anastrozole, and the efficacy of intervention with alendronate, given in an osteoporosis schedule. Most studies in this area have excluded patients with osteoporosis due to the concern of worsening BMD. This study specifically addresses the issues of women with osteopaenia and osteoporosis in this setting.
Patients and method Eligible participants were postmenopausal women with Stage I–IIIa hormone receptor positive breast cancer assessed as suitable for treatment with an aromatase inhibitor, specifically anastrozole. Postmenopausal status was defined as age >55 years with cessation of menstruation; <55 years of age and no menses for 12 months;> 50 but <55 and amenorrhoeic (spontaneous, hysterectomy) and with postmenopausal gonadotrophin or oestradiol levels (luteinising hormone >14IU/L, follicle stimulating hormone levels >40IU/L, oestradiol <110pmol/L or according to the reference range for the laboratory involved); or bilateral oophorectomy. Following the observation of resumption of menses and reversal of menopause in a number of patients all of whom were under 50 years of age, we amended the entry criterion to exclude women under 50 years. Hormone replacement therapy must have been discontinued at least 2 weeks prior to registration. Other eligibility requirements were WHO performance status ≤2, with adequate renal and liver function.