Improving Compliance with Baseline Bone Health Assessment in Postmenopausal Women with Hormone Receptor-Positive Breast Cancer Receiving Adjuvant Letrozole: A Clinical Audit

Abstract

Background
Aromatase inhibitors (AIs) represent the standard adjuvant endocrine therapy for postmenopausal women with hormone receptor-positive breast cancer. Although highly effective in reducing recurrence risk and improving disease outcomes, AI therapy is associated with accelerated bone loss and increased risk of osteopenia, osteoporosis, and fragility fractures. International guidelines therefore recommend baseline assessment of bone mineral density using dual-energy X-ray absorptiometry (DEXA) before or shortly after initiation of AI treatment.

Objective
To evaluate compliance with baseline skeletal health assessment recommendations in postmenopausal women with hormone receptor-positive breast cancer receiving adjuvant letrozole and to assess the impact of an educational intervention on clinical practice.

Methods
A retrospective clinical audit was conducted at Baran Radiotherapy and Oncology Centre, affiliated with Lorestan University of Medical Sciences, Khorramabad, Iran. Medical records of postmenopausal women who initiated adjuvant letrozole therapy between March 2021 and March 2023 were reviewed. The audit standard required completion of a baseline DEXA scan within three months of treatment initiation. Following the initial audit, educational sessions targeting oncology physicians were implemented. A re-audit was conducted six months after implementation of the educational intervention using the same methodology.

Results

A total of 150 eligible patients were included in the initial audit cycle (mean age 60.8 ± 6.4 years). A baseline DEXA scan within 3 months of treatment initiation was documented in 48 patients (32.0%), with a median interval of 47 days from letrozole initiation to DEXA scanning. Following the educational intervention, a re-audit conducted six months later included 70 eligible patients (mean age 61.1 ± 5.9 years). Compliance increased to 63 patients (90.0%), with a median interval of 43 days from letrozole initiation to DEXA scanning.

Conclusion
Compliance with baseline DEXA scan recommendations was initially suboptimal. An educational intervention combined with audit feedback was associated with a marked improvement in adherence to the guideline-recommended baseline DEXA scan. Regular audit cycles may represent an effective strategy for sustaining high-quality skeletal health assessment in breast cancer survivorship care.