➤ 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.
Screening
➤ 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)
Assessment
