Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline

Abstract

PURPOSE The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer. METHODS ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature. RESULTS The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline. RECOMMENDATIONS Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.

Osteoporosis: A Long-Term and Late-Effect of Breast Cancer Treatments

“…Women need to identify a health care provider who will take responsibility for bone health depending on local expertise and experience (e.g., the primary care provider, the oncologist, the obstetric and gynecologist, the endocrinologist, or rheumatologist). Despite guidelines [ 31 ], and algorithms [ 57 ], compliance with recommendations is often lacking [ 124 ]. Lifestyle interventions that promote bone health (i.e., smoking cessation, reducing alcohol consumption, and increasing physical activity) promote overall health and are the first-line approach to bone loss.…”

“…Figure 2 illustrates the magnitude of bone loss with breast treatments in the lumbar spine annually. Healthy postmenopausal bone loss is about 1–2 percentage (%) change per year [ 31 ]. Tamoxifen has differential effects on bone depending on menopausal status.…”

“…Modifications to FRAX ® when assessing AI-induced bone loss include checking “secondary osteoporosis” [ 31 ]. This practice is called into question by a Canadian-based registry cohort study.…”

“…The significant difference is that some breast cancer treatments cause bone loss [ 70 ] that, for some women, increases the risks of osteoporosis. Various policy-making organizations have guidelines for preventing or treating osteoporosis in cancer survivors [ 31 , 71 ] or AI-induced bone loss [ 72 ]. All guidelines begin with risk factor assessment ( Table 1 ), making lifestyle changes that promote bone health and overall health (i.e., smoking cessation, reducing alcohol consumption, increasing physical activity), and taking adequate amounts of daily calcium and vitamin D3.…”

The Interaction of Lean Body Mass With Fat Body Mass Is Associated With Vertebral Fracture Prevalence in Women With Early Breast Cancer Undergoing Aromatase Inhibitor Therapy

“…( 4 ) Inasmuch, identification of the body composition phenotype associated with a higher risk of fracture may help in the management of the bone outcomes of BC patients treated with AIs. In fact, at odds with recommendations of international guidelines, ( 31 ) the use of BMD and the FRAX score (from the Fracture Risk Assessment Tool), which identifies low BMI as a risk factor of fractures, could only detect a minority of women with BC at higher risk of fracture. We suggest instead that the proactive identification of the unfavorable body composition phenotype (with high‐FBM and low‐LBM) may significantly add to an effective bone health management of women undergoing AI therapy.…”