Breast Cancer Res Treat (2011) 129:107116
DOI 10.1007/s10549-011-1644-6
CLINICAL TRIAL
Vitamin D and aromatase inhibitor-induced musculoskeletal
symptoms (AIMSS): a phase II, double-blind, placebo-controlled,
randomized trial
Antonella L. Rastelli Marie E. Taylor Feng Gao
Reina Armamento-Villareal Shohreh Jamalabadi-Majidi
Nicola Napoli Matthew J. Ellis
Received: 10 March 2011 / Accepted: 14 June 2011 / Published online: 21 June 2011
Springer Science+Business Media, LLC. 2011
Abstract A double-blind placebo-controlled randomized
phase II trial was performed to determine whether High
Dose Vitamin D2 supplementation (HDD) in women
receiving adjuvant anastrozole improves aromatase inhib-
itor-induced musculoskeletal symptoms (AIMSS) and bone
loss. Patients with early breast cancer and AIMSS were
stratified according to their baseline 25-hydroxy vitamin D
(25OHD) level. Stratum A (2029 ng/ml) received either
HDD 50,000 IU capsules weekly for 8 weeks then monthly
for 4 months or placebo. Stratum B (1019 ng/ml)
received either HDD for 16 weeks and then monthly for
2 months, or placebo. AIMSS was assessed by the Brief
Pain Inventory-Short Form (BPI-SF), the Fibromyalgia
Impact Questionnaire (FIQ), and the Health Assessment
Questionnaire-Disability Index (HAQ-DI) at baseline, 2, 4,
and 6 months. Bone Mineral Density (BMD) was measured
at baseline and at 6 months. The primary endpoint of the
study was the change-from-baseline musculoskeletal pain.
The secondary endpoint was the percent change in BMD at
A. L. Rastelli (&)
S. Jamalabadi-Majidi
M. J. Ellis
Department of Medicine, Division of Oncology, Washington
University School of Medicine, 660 S. Euclid Ave, Box 8056,
St. Louis, MO 63110, USA
e-mail: arastell@dom.wustl.edu
M. E. Taylor
Department of Radiation Oncology, Washington University
School of Medicine, St. Louis, MO, USA
F. Gao
Division of Biostatistics, Washington University School of
Medicine, St. Louis, MO, USA
R. Armamento-Villareal
N. Napoli
Department of Medicine, Division of Bone and Mineral
Diseases, Washington University School of Medicine, St. Louis,
MO, USA
6 months. Sixty women were enrolled. Baseline charac-
teristics were comparable between the groups. At
2 months, FIQ pain (P = 0.0045), BPI worst-pain
(P = 0.04), BPI average-pain (P = 0.0067), BPI pain-
severity (P = 0.04), and BPI interference (P = 0.034)
scores were better in the HDD than placebo group. The
positive effect of HDD on AIMSS was stronger across all
time points in Stratum B than Stratum A (FIQ pain,
P = 0.04; BPI average, P = 0.03; BPI severity, P = 0.03;
BPI interference, P = 0.04). BMD at the femoral neck
decreased in the placebo and did not change in the HDD
group (P = 0.06). Weekly HDD improves AIMSS and
may have a positive effect on bone health. Vitamin D
supplementation strategies for breast cancer patients on AI
should be further investigated.
Keywords Breast cancer
Vitamin D
Aromatase-
inhibitors
Anastrozole, arthralgias

Bone mineral density
Vitamin D deficiency
Introduction
Breast cancer patients receiving any of the three approved
adjuvant aromatase-inhibitors (AI) (anastrozole, letrozole,
or exemestane) frequently experience musculoskeletal
symptoms referred to as aromatase inhibitor-induced
musculoskeletal symptoms (AIMSS) [13]. The clinical
presentation of AIMSS is highly variable, but usually
includes pain/discomfort in the hands, knees, hips, lower
back, shoulders, and feet, often associated with stiffness
[4]. The pain may have a migratory component or be
localized to a particular region. Women usually report that
every bone in the body hurts and that, since starting AIs,
they feel like they have become 100 years old [5]. In
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randomized clinical trials, the incidence of AIMSS has
been reported between 19 and 35% of participants [1, 6, 7],
and some studies have documented that 50% of breast
cancer patients may suffer from these symptoms [8]. The
development of AIMSS interferes with compliance to
therapy [9], and has been reported to be the most common
reason for AI discontinuation [10]. This latter issue is
especially important because women with AIMSS may
have a more favorable prognosis and be more likely to
benefit from AI therapy [11].
It is, therefore, of great clinical importance to under-
stand the pathophysiology of AIMSS and identify treat-
ments in order to improve tolerability and compliance to AI
therapy.
One possible factor underlying AIMSS is the high
prevalence of vitamin D insufficiency or deficiency in
women with breast cancer despite standard supplementa-
tion (e.g. oral Vitamin D2 400 IU/day) [12]. Holick [13]
defined a state of vitamin D insufficiency when serum serum calcium B10.3 mg/dl, and 24 h urine calcium
levels are between 20 and 29 ng/ml, deficiency when excretion B250 mg/g creatinine.
levels are \20 ng/ml, and normalcy when levels are
C30 ng/ml. Clinical observation has suggested that patients
treated with AI who develop musculoskeletal pain, and
have vitamin D deficiency/insufficiency [14], may respond
to high doses of Vitamin D supplementation [15]. Two
observational studies have also reported a potential role of
Vitamin D in reducing the incidence of musculoskeletal
symptoms in women started on AI therapy [16, 17].
The primary goal of our study was to compare the
effectiveness of high doses of Vitamin D2 (HDD) in breast
cancer patients who develop AIMSS after starting anas-
trozole. The study had a randomized, double-blind, pla-
cebo-controlled phase II trial design and was, therefore,
powered to obtain preliminary information that would
justify larger studies.
A secondary goal of the study was to assess the efficacy
of HDD in protecting bone health in breast cancer patients
on AI therapy. It is well known that AIs cause bone loss
and are associated with an increased risk of fragility frac-
tures [1, 2]. Furthermore, vitamin D deficiency/insuffi-
ciency, common in breast cancer patients, is a risk factor
for bone loss through the development of secondary
hyperparathyroidism, a condition characterized by low
Vitamin D, above normal i-PTH and normal calcium levels
[18, 19]. Increased bone turn-over in this condition repre-
sents an appropriate physiologic response to maintain
homeostatic levels of serum calcium, but at the expense of
cortical bone resorption and accelerated bone loss [2022].
Secondary hyperparathyroidism is relatively common in
breast cancer patients with low vitamin D levels. Taylor
et al. reported elevated i-PTH levels in 19% of Caucasian
and 47% of African-American women with breast cancer
[15], while Mann et al. described elevated i-PTH in 14%
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Breast Cancer Res Treat (2011) 129:107116
[23]. These observations underscore the potential impact of
the combined negative effect of AI therapy and vitamin D
deficiency/insufficiency on bone health. For these reasons,
we decided to also study the effect of vitamin D supple-
mentation on bone mass.
Materials and methods
Study population
Subjects were eligible to participate in the study if they had
hormone receptor positive invasive nonmetastatic breast
cancer (Stage I-IIIB), had completed at least 8 weeks of
anastrozole as adjuvant therapy prior to study entry, and
were experiencing new or worsening musculoskeletal pain
unrelated to any history of trauma. Other eligibility criteria
included serum 25OHD level between 10 and 29 ng/ml,
Patients were excluded if they had known metastatic
disease to the bone, kidney stones, primary hyperparathy-
roidism, Pagets disease of the bone, severe arthritis, rheu-
matoid arthritis, severe neuropathy or 25OHD C 30 ng/ml.
Treatment on the trial was stopped if the patient developed
hypercalciuria (C250 mg/g creatinine) or hypercalcemia
(C10.3 mg/dl). Use of nonsteroidal anti-inflammatory
medications and Tylenol was allowed. All subjects provided
written informed consent approved by the Institutional
Review Board at Washington University.
Protocol
Upon entry each patient underwent a history and physical
exam, laboratory assessment (CMP, 25OHD, i-PTH,
phosphorus levels, and 24 h urinary calcium), dual energy
X-ray absorptiometry (DEXA) scan, and three functional
assessment questionnaires. All 25-OH Vitamin D levels
were measured at the Barnes-Jewish Hospital clinical lab-
oratory affiliated with Washington University. The test was
performed with chemiluminescent immunoassay technol-
ogy using the LIASON 25-OH D Assay by Diasorin Inc.
www.diasorin.com. The physical exam and questionnaires
were repeated at 2, 4, and 6 months. At 2 months, serum
calcium levels and 24 h urine calcium collection measured.
At the end of the study, laboratory assessment and DEXA
scan were repeated.
Vitamin D administration
Women were asked to stop any multivitamin and calcium
supplements and start daily supplementation with
1,000 mg of calcium carbonate and 400 IU of Vitamin D3
Breast Cancer Res Treat (2011) 129:107116 109

tablets provided by the study. Subjects were stratified
according to the baseline 25OHD level. Subjects with
baseline 25OHD levels between 20 and 29 ng/ml were
randomized to receive either vitamin D2, one 50,000 IU
capsule, or a matching placebo orally once a week for a
total of eight consecutive weeks, and then once a month for
the rest of the study (stratum A, vitamin D insufficiency).
Patients with 25OHD levels between 10 and 19 ng/ml
received Vitamin D2 50,000 IU capsule or a matching
placebo orally for 16 consecutive weeks and then once a
month for the rest of the study (stratum B, vitamin D
deficiency). These two groups are similar to the criteria
defined by Holick [13] except that we excluded patients
with levels \10 ng/ml as these patients need immediate
high dose supplementation and are more likely to have
osteomalacia [24, 25].
Vitamin D2 capsules, matching placebo capsules and
calcium with vitamin D supplements were dispensed by the
Investigational Drug Services (IDS) at the Siteman Cancer
Pharmacy. The randomization was also performed by IDS
in balanced blocks of 4 by means of a random number
generator. Both patients and investigators were blinded to
the treatment group assignment. Compliance with the study
medication was monitored with pill counts and pill diaries
throughout the course of the study.
Musculoskeletal pain assessment
Multiple measures of pain were included because there is
no consensus regarding the optimal tools for AIMSS
evaluation. The syndrome may resemble arthritis, but may
also mimic fibromyalgia [2527]. Three widely validated
questionnaires were administered at each visit to each
subject.
(1) The Brief Pain Inventory (BPI) Short Form is a pain
assessment tool used with cancer patients to measure
both pain intensity (sensory dimension) and pain
interference (reactive dimension) in the patients life
[28]. Patients rated their level of pain severity at its

Screened (n =116)

Excluded (n = 56)
Refused to participate (n=18)
25 OH Vitamin D 30 ng/ml (n=28)
Metastatic cancer (n=2)
Elevated serum Calcium (n=2)
Elevated urine Calcium (n=2)
Kidney stones (n=2)
Rheumatoid arthritis (n=1)
Primary hyperparathyroidism (n=1)

Randomly
assigned
(n =60)

Allocated to high dose Vitamin D (N=30) Allocated to Placebo (N=30)

Received intervention (N=28) Received intervention (N=30)

2 never started treatment 1 stopped after 1st week due to diarrhea

4 excluded at 2 months due to high 24 hour
urine Calcium
1 excluded at 2 months due to high serum
Calcium
1 stopped at 2 months due to AIMSS
1 stopped at 4 months due to AIMSS
1excluded at 2 months due to high 24 hour
urine Calcium
1stopped at 4 months due to AIMSS
1 stopped at 4 months due SAE-arterial
thrombosis-not related

Providing Data for Analysis at: Providing Data for Analysis at:
2 months (N=28) 2 months (N=29)
4 months (N=22) 4 months (N=28)
6 months (N=21) 6 months (N=26)

Fig. 1 Diagram of patient participation and drop out throughout the study period

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highest and lowest in the preceding 24 h, on the
average, and right now. Patients rated their level of
pain interference in seven contexts: (a) work,
(b) activity, (c) mood, (d) enjoyment, (e) sleep,
(f) walking, and (g) relationships. A consensus panel
recommended that the two domains measured by the
BPIpain intensity (severity) and the impact of pain
on functioning (interference)be included as out-
comes in chronic pain clinical trials [29].
(2) The Fibromyalgia Impact Questionnaire (FIQ)
assesses physical function (instrumental activities of
daily living), general well being, and muscle and joint
status [30, 31].
(3) The Health Assessment Questionnaire-Disability
Index (HAQ-DI) assesses the extent of the patients
functional ability [32].
Bone density assessment
Bone Mineral Density (BMD) of the lumbar spine, total
femur, and femoral neck were measured on all subjects at the
beginning of the trial and at 6 months by DEXA using Ho-
logic QDR 4500 (Hologic Inc., Waltham MA, USA). In the
Bone Health Program at Washington University, where all
the bone density tests were performed, the coefficient of
variability for this technique is 1.09% for the lumbar spine
and 1.2% for the total femur. All the DEXA scans were
interpreted by a specialist in bone densitometry who was
blinded to the study (RAV).
Statistical analysis
Data analysis was performed following the intent-to-treat
principle. The primary outcome measures included the FIQ
pain score, BPI pain severity and interference scores, and the
HAQ-DI total score at 2 months after correction for baseline
scores. Scores were also analyzed at 4 and 6 months. The
secondary outcome measure was the change in bone density
between baseline and 6 months post-HDD treatment at the
lumbar spine, total femur, and femoral neck. Distributions of
the demographic characteristics were summarized with
descriptive statistics and compared using Students t-test or
Fishers exact test as appropriate. For each outcome, the
post-randomization measures between the two arms were
compared using an analysis of covariance (CO-ANOVA)
that included six terms: the baseline score, an indicator for
treatment, an indicator for timing of measurement, an indi-
cator for strata, as well as the interaction of treatment versus
timing, or treatment versus strata. Given the relatively small
sample size, the three-way interaction of treatment, timing,
and strata was not considered in the model. Post-hoc
multiple comparisons were also performed to assess the
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Breast Cancer Res Treat (2011) 129:107116
between-group difference at each time point and for each
stratum. All the analyses were implemented by the gener-
alizing estimating equations (GEEs) method in the standard
statistical package SAS and a P value less than 0.05 was used
to indicate a significant effect.
Changes in BMD were expressed as percent change at
6 months from baseline, and the difference between the
groups was calculated using analysis of variance adjusted
for covariates (age, BMI). One subject on bisphosphonate
therapy was excluded from the bone density analysis.
Power calculation
Based on a 2-sample t-test, the designed sample size
(N = 30/arm) allows to detect, with 80% power at a
1-sided 0.05 significance level, a minimum between-group
difference of 0.65*SD, where SD represents the standard
deviation of the pooled data. A P value of \0.05 uncor-
rected for multiple endpoints is appropriate since the study
was planned as a randomized phase II trial.
Results
Baseline characteristics
Sixty subjects were randomly assigned to Vitamin D or
Placebo between January 2006 and February 2009 (Fig. 1).
Baseline subject characteristics were similar between groups
(Table 1). The retention rates at 2, 4, and 6 months of the
study were, respectively, 95, 83, and 78% of the subjects.
Effects of vitamin D on musculoskeletal pain
Pain decreased significantly at 2 months in the Vitamin D
group compared to placebo. Significant differences were
found on several measures of pain intensity including FIQ
pain (3.3 vs. 4.6, P = 0.0045), BPI worst pain (3.6 vs. 5.1,
P = 0.04), BPI average pain (2.7 vs. 3.7, P = 0.0067), and
BPI pain severity (2.7 vs. 3.5, P = 0.04), as well as on a
measure of interference on subjects life activities (BPI
interference, 1.8 vs. 2.5, P = 0.034). The effect on pain
was not observed at 4 and 6 months when the majority of
subjects were switched from weekly to monthly vitamin D
supplementation (Table 2).
The improvement in pain severity and interference with
daily activities was significant when averaging across all
time points (2, 4, 6 months) for the patients with baseline
vitamin D deficiency (1019 ng/ml, Stratum B), but not in
the patients with baseline insufficiency (2029 ng/ml,
Stratum A) (Fig. 2, Table 3).
No significant effect was found on the HAQ-DI ques-
tionnaire in the overall or Strata analysis.
Breast Cancer Res Treat (2011) 129:107116 111

Table 1 Baseline demographics Table 2 Efficacy measures over the course of the study for the
vitamin D and Placebo groups
Characteristic Vitamin D Placebo P value
Mean SD Mean SD Questionnaire Vitamin D Placebo P value
Mean SD Mean SD
Age (years) 60 8.8 63 7.8 0.168
BMI (kg/m )2
30.9 6.3 33.1 8.4 0.262 FIQ pain baseline 5.1 2.4 5.8 2.2
Race 0.707 FIQ pain 2 months 3.3 2.2 4.6 2.0 0.0045
Caucasian 25 (83%) 27 (90%) FIQ pain 4 months 3.6 2.2 4.0 2.1 ns
African-American 5 (17%) 3 (10%) FIQ pain 6 months 4.0 2.4 3.5 2.2 ns
Age at menopause (years) 46.8 6.5 47 7.5 0.927 BPI worst pain baseline 5.2 2.4 6.1 1.9
Length of menopause (years) 13.7 11 16.8 12.9 0.391 BPI worst pain 2 months 3.6 2.1 5.1 2.1 0.041
Previous HRT use 16 (53%) 16 (63%) 0.99 BPI worst pain 4 months 3.4 2.7 4.5 2.6 ns
(# subjects) BPI worst pain 6 months 3.8 2.9 3.6 2.3 ns
Length of HRT use (years) 8.7 9 12.1 10.7 0.493 BPI average pain baseline 4.2 2.3 4.6 1.8
Previous tamoxifen use 2 (6.7%) 4 (13.3%) 0.67 BPI average pain 2 months 2.7 2.1 3.7 1.8 0.0067
(# subjects) BPI average pain 4 months 2.8 2.4 3.4 2.0 ns
Length of tamoxifen use 2.5 0.7 2.8 2.5 BPI average pain 6 months 2.6 2.3 2.8 1.8 ns
(years)
BPI pain severity baseline 3.9 2.0 4.4 1.7
Previous chemotherapy 16 (53%) 19 (63%) 0.601
BPI pain severity 2 months 2.7 1.9 3.5 1.5 0.04
(# subjects)
BPI pain severity 4 months 2.6 2.3 3.2 1.8 ns
Months on anastrozole 15.2 13.1 21 15.4 0.095
BPI pain severity 6 months 2.6 2.3 2.7 1.8 ns
25-OH Vitamin D level 23 4.64 22 4.7 0.402
(ng/ml) BPI interference baseline 2.7 2.0 3.0 2.3
PTH levels (pg/ml) 47.5 20 46.8 18.1 0.912 BPI interference 2 months 1.8 1.7 2.5 1.7 0.034
BPI interference 4 months 1.5 1.5 1.9 1.8 ns
BPI interference 6 months 1.5 1.8 1.8 1.6 ns
Ninety-six percent of the patients were compliant with HAQ disability index (DI) 0.7 0.6 1.0 0.6
the assigned study medication based on diaries and pill baseline
counts. Sixty-five percent of patients reported taking pain HAQ-DI 2 months 0.5 0.5 0.7 0.6 ns
medication (nonsteroidals and acetaminophen) at enroll- HAQ-DI 4 months 0.4 0.5 0.7 0.6 ns
ment and were equally distributed in the two groups. HAQ-DI 6 months 0.4 0.4 1.1 2.4 ns
Fourteen percent of patients (4/29) in the placebo groups FIQ Fibromyalgia impact questionnaire, BPI brief pain inventory,
versus 7% (2/28) in the vitamin D group reported discon- HAQ health assessment questionnaire-disability index. The P values
tinuation of pain medication at 2 months. in this table refer to post-hoc tests after a significant analysis of
co-variance of treatment over time was found
Effects of vitamin D on BMD
P = 0.5) was found between changes in vitamin D levels
There were no differences in the BMD values (lumbar and changes in pain scores from baseline to 6 months.
spine, total femur, and femoral neck) at baseline between At baseline, 10% of the subjects had secondary hyper-
the groups (Table 4). Subjects on placebo showed a decline parathyroidism because of low 25OHD levels; at the end of
in BMD of the femoral neck at 6 months (mean percent the study 8.5% still displayed elevated i-PTH. At 2 months,
change = -1.4 0.68) while subjects on vitamin D sup- four subjects in the HDD group and one in the placebo
plementation maintained BMD (0.35 0.72, P = 0.06) developed asymptomatic hypercalciuria, and were removed
(Fig. 3). No significant changes were observed at the from the study as per protocol.
lumbar spine and total femur (Table 4).

Effects on 25OHD, i-PTH, and 24 h urine calcium Discussion

There were no toxicities or significant adverse events in the
Vitamin D group. At the end of the study, mean serum
25OHD was higher in the Vitamin D group (P = 0.03) and
a greater proportion of subjects normalized serum 25OHD
(HDD 43 vs. 11.5% of placebo subjects, P = 0.02)
(Table 5). However, no linear relationship (r = 0.15,
This is the first reported randomized double-blind placebo-
controlled trial to examine the effect of high dose Vitamin
D supplementation on AIMSS induced by anastrozole in
breast cancer patients with low vitamin D levels. Our
results suggest a beneficial effect on musculoskeletal pain
and its consequences regarding daily activity after weekly

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Vitamin D3 16,000 IU every 2 weeks for 3 months and

Fig. 2 Mean scores for FIQ, BPI severity, and BPI interference in the
Vitamin D and Placebo groups as function of Strata averaged over all
time points. * P \ 0.05. FIQ fibromyalgia impact questionnaire, BPI
brief pain inventory
supplementation with 50,000 IU of Vitamin D2 for
8 weeks (Table 2).
Our findings are consistent with two previous observa-
tional studies. Khan et al. reported that breast cancer
patients started on adjuvant letrozole therapy experienced
less disability from musculoskeletal symptoms when they
received 50,000 units of Vitamin D3 supplementation
weekly for 12 weeks and achieved a 25OHD level of
[66 ng/mg [16]. Prieto-Alhambra et al. found that breast
cancer patients on AI had attenuated joint pain intensity on
their 25OHD level reached a concentration of C40 ng/ml
[17]. Our randomized phase II trial shows the beneficial
effect of HDD on AIMSS even when present for more than
1 year.
The positive effect of vitamin D supplementation was
not maintained at 4 and 6 months once subjects were
switched to 50,000 IU monthly. The apparent decline in
efficacy may reflect the relatively short half-life and weak
potency of Vitamin D2 [3335]. The possibility of under-
dosing was also raised by the finding that the study subjects
with baseline vitamin D deficiency treated for 16 weeks
(cumulative dose 800,000 IU plus 50,000 monthly for
2 months) showed an overall improvement over the entire
course of the study, whereas subjects with insufficiency
treated for only 8 weeks (cumulative dose 400,000 IU plus
50,000 IU/monthly for 4 months) did not. While this sec-
ondary analysis was exploratory, it does suggest that
weekly high dose vitamin D2 for all patients could be
considered in a definitive study. As an alternative high dose
vitamin D3 could be considered as a more effective
approach to raising 25OHD concentrations [36].
Another important issue is whether patients should be
dosed to achieve a normal 25OHD serum level rather than
receive a fixed dose. Our study showed that 43% of the
patients achieved normal 25OHD serum levels (C30 ng/ml)
versus 11.5% in the placebo group. However, we did not
find a significant correlation between changes in vitamin D
levels and changes in pain scores from baseline to
6 months. In previous investigations, levels of vitamin D
associated with lesser incidence of AIMSS ranged between
40 and 66 ng/ml [16, 17], while in our study the mean
post-treatment value achieved was 30 8.8 ng/ml. It is,
therefore, possible that we did not reach high enough serum
levels of vitamin D to maximize its therapeutic effect, and
that were the levels higher a more significant correlation
with pain scores might have been found.

Table 3 Efficacy measures for Strata A (25OHD between 20 and 29 ng/ml) and B (25OHD between 10 and 19 ng/ml) across time points
Questionnaire Stratum B Stratum A
Vitamin D Placebo P value Vitamin D Placebo P value
Mean SD Mean SD Mean SD Mean SD

FIQ pain across all time points 3.8 2.4 4.8 2.3 0.04 4.2 2.4 4.4 2.3 ns
BPI worst pain across all time points 3.9 2.4 4.7 2.5 ns 4.2 2.7 4.9 2.3 ns
BPI average pain across all time points 3.0 2.1 3.7 1.7 0.03 3.2 2.5 3.6 2.0 ns
BPI pain severity across all time points 2.9 1.9 3.7 1.7 0.03 3.1 2.2 3.4 1.8 ns
BPI interference across all time points 1.5 1.3 2.9 2.2 0.04 2.2 2.0 2.1 1.7 ns
HAQ-DI across all time points 0.4 0.3 1.0 0.7 ns 0.5 0.5 0.8 1.4 ns
FIQ Fibromyalgia impact questionnaire, BPI brief pain inventory, HAQ health assessment questionnaire-disability index. The P values in this
table refer to post-hoc tests after a significant analysis of co-variance of treatment by strata was found. Scores are averaged across 2, 4, 6 months
time points

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Table 4 Absolute BMD and percent change from baseline in patients randomly assigned to high dose Vitamin D or placebo at 6 months
BMD (g/cm2) % Change in BMD
Baseline 6 months
Placebo Vitamin D P value Placebo Vitamin D P value Placebo Vitamin D P value
Mean SEM Mean SEM Mean SEM Mean SEM Mean SEM Mean SEM

Spine 1.018 0.02 1.018 0.02 0.99 1.029 0.03 1.030 0.03 0.97 -0.36 0.75 0.12 0.82 0.67
Femoral neck 0.753 0.02 0.761 0.02 0.75 0.752 0.02 0.766 0.02 0.67 -1.39 0.66 0.45 0.72 0.06
Total Femur 0.949 0.02 0.925 0.02 0.44 0.962 0.03 0.928 0.03 0.40 ?0.04 0.63 -0.005 0.69 0.96
BMD Bone mineral density

Changes in the femoral neck BMD after 6 months of therapy collagen matrix. In this setting, pain could be caused by the
1.5 hydration and expansion of the sub-periosteal tissue with
secondary pressure on sensory pain fibers [27, 40]. This
Femoral neck BMD changes (%)

1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
Fig. 3 Percent change in bone mineral density at the femoral neck
6 months from baseline in patients treated with high dose vitamin D
or placebo
The pathogenesis of AIMSS and why it may respond to
vitamin D is unclear. One hypothesis is that estrogen
deficiency causes a reduction in the activity of 1-alpha-
hydroxylase, the enzyme that catalyzes the hydroxylation
of calcidiol (25(OH)D) to calcitriol (1-25(OH)2D) [37].
Moreover, AI therapy may increase the requirements of
vitamin D through competition with hepatic CYP3A4 [38,
39]. Decreased vitamin D may also lead to secondary
hyperparathyroidism and the deposition of unmineralized
p=0.06
sequence of events has been implicated in the pathogenesis
of osteomalacia and so could be a factor in AIMSS.
While some of our patients could have had some degree
of subclinical osteomalacia, we were careful to avoid
patients with very low levels of vitamin D (i.e.\10 ng/ml),
who would be more likely to have overt osteomalacia [24],
and none of our patients had elevated alkaline phosphatase,
Placebo a biochemical indicator that is consistently elevated in
Vit. D osteomalacia [24, 25]. Thus, the results cannot be dis-
missed as simply the effect of treatment for osteomalacia
and we contend that the optimal level of Vitamin D sup-
plementation for patients experiencing the extreme estro-
gen deprivation associated with aromatase inhibition
remains an open question.
Irrespective of the precise mechanism, our results sug-
gest that high dose vitamin D supplementation for women
with AIMSS and low vitamin D levels is effective, whether
the patient has osteomalacia or not. Importantly, since
AIMSS is one of the reasons resulting in discontinuation of
AI [9, 10] and women with AIMSS may have a better
prognosis [11], increased compliance with AI may provide
a significant clinical benefit from this approach.
The secondary endpoint of this study examined the
effect of vitamin D supplementation on bone loss at

Table 5 Laboratory values

Laboratory Baseline Follow-up
Placebo Vitamin D Placebo Vitamin D P value*

25OHD (ng/ml) mean SD 22.0 4.7 23.0 4.6 25.5 4.2 29.7 8.8 0.03*
# Patients with 25OHD C 30 ng/ml (%) 0/30 (0) 0/30 (0) 3/26 (11.5) 9/21 (42.9) 0.02**
i-PTH (pg/ml) mean SD 46.8 18.1 47.5 20.0 42.5 12.4 48.9 22.7 ns
# Patients i-PTH C 72 pg/ml (%) 2/30 (6.7) 4/30 (13.3) 0/26 (0) 4/20 (20.0) 0.03**
24 h urine calcium (mg/cr) mean SD 134.6 56.6 183.6 53.0 159.0 55.6 203.7 77.8 ns
# Patients (%) with urine calcium C250 mg/cr (%) 0/30 (0) 0/30 (3.3) 1/29 (3.5) 4/28 (14.3) ns
25OHD and i-PTH were re-measured at 6 months and at the end of the study, while 24 h urine calcium excretion was re-measured at 2 months.
*After adjusting for baseline values; **Comparing the follow-up data only

123
114
6 months. At the femoral neck, subjects on vitamin D
maintained bone mass (0.45% 0.72), whereas subjects in
the placebo group lost bone mass (-1.39% 0.66). This
difference approached significance, while no differences
were observed at the lumbar spine and total femur.
BMD changes in the control group at 6 months were
smaller than those found in other trials at 1236 months
[41, 42]; however, our patients had already been on anas-
trozole for 1521 months prior to enrollment. It is possible
that greater bone loss might have been detected if patients
had been enrolled at the time of AI initiation, since anas-
trozole induces higher bone loss in the first 2 years after
starting therapy with rates of bone loss slowing down
afterward [43].
Regarding the site with the most pronounced bone loss,
there seems to be variability across studies. While some
documented greater changes at the spine than hip (SABRE,
Z-FAST [41, 42]), others (ARBI, ARIBON [44, 45])
showed more bone loss at the total hip than spine. Lonning
et al. [46] reported significant bone loss at the femoral neck
after 2 years of exemestane versus placebo.
The favorable effect of vitamin D on BMD at the femoral
neck potentially reflects increased mineralization of bone
matrix from improved calcium absorption. An additional
potential effect could be via the regulation of i-PTH levels.
Secondary hyperparathyroidism because of Vitamin D
deficiency/insufficiency is a known risk factor for cortical
bone loss and fractures of the femoral neck [47]. In our study,
10% of subjects had elevated i-PTH at baseline, and 8.5%
still showed elevated i-PTH at 6 months suggesting that the
doses of vitamin D supplementation were insufficient to
reverse hyperparathyroidism.
A final issue to consider is the relatively high drop-
out rate due to hypercalciuria. At 2 months, five patients
(four in the Vitamin D and one in the placebo group)
(Table 5) developed abnormally high 24-h urinary cal-
cium excretion. The loss of subjects influenced dispro-
portionately the vitamin D group hence potentially
affecting statistical sensitivity at 4 and 6 months. The
relative high rate of hypercalciuria (14%) in the vitamin
D group underscores the importance of periodic moni-
toring of urine calcium in patients on high dose vitamin
D for AIMSS.
In conclusion, this study demonstrated that weekly high
doses of vitamin D2 are effective at reducing AIMSS when
given after initiation of AI therapy. Optimal approaches for
Vitamin D supplementation in this population should be
further investigated.
Acknowledgments We would like to thank Maurizio Corbetta, MD,
Adriana Dusso, PhD, Nicholas Davidson, MD and Roberto Civitelli,
MD, for reading previous versions of the manuscript and provide
helpful comments. The study was supported by Astra-Zeneca.
123
Breast Cancer Res Treat (2011) 129:107116
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