- Patients with non-metastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks associated with their cancer therapy.
- Clinicians are advised to assess fracture risk using established tools.
- For those with substantial risk of osteoporotic fracture the clinician should obtain a bone mineral density.
- 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.
- Recommendation 1.1. It is recommended that patients with non-metastatic cancer who meet any of the following criteria should be considered at increased risk for developing osteoporotic fractures (Moderate Recommendation; EB-B-I):
- advanced age
- current cigarette smoking
- excessive alcohol consumption
- history of prior non-traumatic fractures in adulthood
- impaired mobility
- increased risks for falls
- long-term exposure to glucocorticoids
- low body weight
- parental history of hip fracture
- postmenopausal status
Qualifying Statement. Cutoffs used to define advanced age, excessive alcohol consumption, long-term glucocorticoid exposure and low body weight vary across studies and populations. The specifics around these continuous predictors and the thresholds most often associated with increased risk are described further within the supporting text.
- Recommendation 1.2. Clinicians should be aware that the patient’s anticancer therapy (e.g., aromatase inhibitors [AIs], androgen deprivation therapy [ADT], gonadotropin releasing hormones [GnRH] agonists, or chemotherapy-induced ovarian failure [CIOF]) may result in short- or long-term increased risk of osteoporotic fracture and should take anticancer therapy into account as potentially adding to baseline risk. (Moderate Recommendation; EB-B-I)
- Recommendation 1.3. Clinicians may use a risk assessment tool (e.g., FRAX [www. sheffield.ac.uk/FRAX]) to quantify the risk estimates for osteoporotic fracture in adult patients with non-metastatic cancer. To date, existing risk assessment tools have not been validated in patients with cancer, and clinical judgment is necessary in interpreting results from these tools. (Moderate Recommendation; EB-B-I)
Qualifying statement. Note that several medical conditions known to cause bone loss are included in risk assessment tools such as FRAX. Clinicians who are attempting to quantify risk of osteoporosis or osteoporotic fracture should also consider additional evaluation or referral if there is a history or clinical suspicion of rarer high-risk conditions such as endocrine or metabolic causes of secondary osteoporosis (e.g., hypercortisolism, hyperparathyroidism, acromegaly), disorders of collagen metabolism, and high-risk medications (or multiple moderate-risk medications) as described in the text.
- Recommendation 2.1. Patients with non-metastatic cancer with one or more risk factors for osteoporotic fracture as per Recommendation 1, should be offered bone mineral density (BMD) testing with central/axial dual-energy x-ray absorptiometry (DXA). In settings where DXA is not available or technically feasible, other BMD testing (for example, quantitative ultrasound or calcaneal DXA) should be offered. (Moderate Recommendation; EB-B-I)
- Recommendation 2.2. Patients with non-metastatic cancer who are prescribed a drug that causes bone loss, or whose baseline or subsequent BMD is near the threshold of treatment by using FRAX should be offered BMD testing every 2 years or more frequently if deemed medically necessary, based on the results of BMD testing and expected bone loss. Testing should generally not be conducted more than annually. (EP-B/H-Ins)