The actual cause of AI-related joint symptoms is not well understood. Correction of low vitamin D may improve musculoskeletal symptoms in women with breast cancer ( Khan et al., 2017 Singer et al., 2014). The prevalence of AI-associated arthralgias ranges between 20% and 70% in studies ( Niravath, 2013 Younus & Kligman, 2010). Literature surrounding positive outcomes associated with pharmacist-driven oral chemotherapy programs continues to grow ( Quinones et al., 2016). They reinforce treatment goals, address compliance, medication interactions, possible adverse effects, and ensure safe and effective use of medications. Clinical pharmacists spend more time than ever in direct patient contact. Meeting with oncology providers, including advanced practitioners (nurse practitioners, physician assistants, and clinical pharmacists) on a regular basis promotes patient adherence, addresses patient concerns, educates patients on new research reports, and supports healthy behaviors. Adherence rates of 55% to 88% have been reported in year 1 and a drop to 62% to 79% in year 3 ( Atkins & Fallowfield, 2006 Partridge et al., 2008). Patient education is imperative for medication adherence and the improvement of long-term survival. The patient teaching sheet, “Precautions for Patients Taking Aromatase Inhibitors” (see Appendix A), serves as a reference for patients and providers on which medications and supplements to avoid while taking AIs. Patient education reduces complications and improves AIs effectiveness, resulting in improved long-term survival. There are safety and efficacy issues when taking AIs. The effectiveness of AIs is well documented, but they are not without concerns. As the population of breast cancer survivors continues to grow, attention to supporting patients is paramount to providers’ practice. Additionally, the ExCel and IBIS-II trials reported that exemestane and anastrozole (respectively), significantly reduce invasive breast cancer in postmenopausal women who are at moderately increased risk for a new breast cancer ( Cuzick et al., 2014). Women with metastatic breast cancer continue to experience improved progression-free survival with nonsteroidal AIs (anastrozole or letrozole) alone or in combination with various drugs such as CDK4/6 or mTOR inhibitors as reported in the MONALESSA, PALOMA, and MONARCH trials ( Cristofanilli et al., 2016 Johnston et al., 2019 Slamon et al., 2018). Premenopausal women under the age of 35 also have a reduction in recurrence with the use of AIs and ovarian ablation as reflected in the subset analysis of the Suppression of Ovarian Function Trial (SOFT) and the Tamoxifen and Exemestane Trial (TEXT Francis et al., 2018). In the extended adjuvant setting (therapy for 5–10 years), the MA.17 study showed that in the group that continued letrozole, there was a statistically significant reduction in recurrence, particularly in the node-positive population ( Burstein et al., 2018 Goss et al., 2016). Early studies such as “Arimidex, Tamoxifen, Alone or in Combination (ATAC)”, “A Comparison of Letrozole and Tamoxifen in Postmenopausal Women With Early Breast Cancer (BIG 1-98)”, and “Adjuvant Tamoxifen and Exemestane in Early Breast Cancer (TEAM)” have shown a reduction in the recurrence of breast cancer in the postmenopausal population ( Breast International Group 1-98 Collaborative Group, 2005 Derks et al., 2017 Howell et al., 2005). The following review of research has demonstrated significantly prolonged disease-free survival, time to recurrence, and reduced distant metastases and contralateral breast cancers by 40% with the use of AIs. Aromatase inhibitors are also effective in the preventative setting. Aromatase inhibitor research has demonstrated improved survival in postmenopausal women, postmenopausal women with metastasis, and premenopausal women under the age of 35 with ovarian ablation. However, the drug’s efficacy was limited by the rate of breast cancer recurrence. Tamoxifen, a selective estrogen receptor modulator (SERM) with antiestrogenic activity in the breast tissue, was the previous standard of care for both pre- and postmenopausal, estrogen receptor–positive breast cancer patients. A significant amount of research has gone into determining whether there are benefits for breast cancer patients who receive AIs compared with the previous standard of care, tamoxifen.
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