Published Online:March 14, 2014
Life-saving therapies that halt cancer can take a toll on the skeletal system, leaving survivors with bone loss or more serious injuries such as broken wrists, ribs, or hips. Watchful attention, screening, and therapy are needed to prevent these outcomes.
Azeez Farooki, MD, an endocrinologist and specialist in cancer-induced bone loss at Memorial Sloan-Kettering Cancer Center, presented the findings of the National Comprehensive Cancer Network’s (NCCN) Bone Health Task Force on Thursday, March 13, 2014, at the group’s 19th annual conference—Advancing the Standard of Cancer Care—held in Hollywood, Florida.
Avoiding fractures starts with screening, and Dr Farooki said bone mineral density (BMD) assessments for osteoporosis are recommended in all postmenopausal women aged 65 and older, regardless of risk factors, and in all men starting at age 70.
Men and women aged 50 to 70 should receive BMD tests if they have certain risk factors, such as previous fractures, glucocorticoid therapy, parental history of hip fracture, low body weight, excessive alcohol use, and rheumatoid arthritis, or if they are current smokers or have COPD. Other risks are premature menopause, malabsorption, chronic liver disease, hypogonadism and inflammatory bowel disease.
Bone loss with age is normal, Dr Farooki explained, but certain cancer treatments speed up the process more than others. He shared a slide comparing normal bone loss in men at the low end with that of men following various types of cancer treatments. The greatest loss occurred though among women experiencing premature menopause and secondary chemotherapy.
While it is common to associate bone loss with women and menopause, Dr Farooki explained that men are also at risk for bone loss and skeletal injury. He noted that while men experience one-third of hip fractures, they experience higher levels of mortality from hip fractures than women: 37.5% compared with 28.2% in women.
So what to do? Bone health includes strategies in scans and treatment, including preventive treatment. Dr Farooki went through a number of recommendations: In early-stage breast cancer, the use of adjuvant bisphosphonates to reduce recurrence and improve survival is currently considered investigational, though there are some promising data so far in the “low estrogen” state.
In prostate cancer, no bisphosphonate has shown benefit for bone metastases prevention. Denosumab has been shown to delay the onset of bone metastases in castration-resistant prostate cancer, although the clinical significance has yet to be determined.
Dr Farooki said the NCCN does not recommend the use of osteoclast-targeted therapy for prevention of bone metastases in prostate cancer. He also reviewed the use of antiresorptives—which can help with both the prevention of bone loss generally, and aid in treatment of bone metastases and myeloma—in the prevention of fractures and in the easing of bone pain.
Calcium intake goals should be 1200 mg per day, but work with a nutritionist may be needed, because if supplements are used in excess, patients are at risk for developing kidney stones. There are similar recommendations with vitamin D—it is a dietary necessity, but it is food is a better source and there is such a thing as too much vitamin D.
Some caveats: Estrogen is preferred for young women with premature menopause and nonestrogen-dependent cancer. Raloxifene use with an aromatase inhibitor is not advisable. And denosumab is the only drug recommended for men on androgen deprivation therapy that has solid fracture prevention data.
In response to questions, Dr Farooki said he does recommend that patients work with physical therapists to improve bone strength and balance to prevent fractures and falls, which can lead to fractures.