Treatment
Non-pharmacological Intervention
➤ Recommendation 3.1. Clinicians should encourage patients to consume
a diet with adequate calcium and vitamin D. If intake of calcium (1000–
1200 mg/day) and vitamin D (at least 800–1000 IU/day) is not being
consumed, then supplements to reach those levels are recommended.
(Moderate Recommendation; EB-B-I)
➤ Recommendation 3.2. Clinicians should actively encourage patients to
engage in a combination of exercise types including balance training,
flexibility or stretching exercises, endurance exercise and resistance and/
or progressive strengthening exercises to reduce risk of fractures caused
by falls. Whenever possible, exercise should be tailored according to the
needs and abilities of the individual patient. Patients with an impairment
hindering their gait or balance should be offered medical rehabilitation.
(Moderate Recommendation; EB-B-L)
➤ Recommendation 3.3. Clinicians should actively encourage patients
to stop smoking and to limit alcohol consumption, as smoking and
alcohol consumption are risk factors for osteoporosis. (Moderate
Recommendation; EB-B-L)
Pharmacological Intervention
➤ Recommendation 3.4. For patients with non-metastatic cancer with
osteoporosis (T-scores -2.5 or less in the femoral neck, total hip, or
lumbar spine) or at increased risk of osteoporotic fractures based on
clinical assessment or risk assessment tools (10-year probability of ≥20%
for major osteoporotic fractures or ≥3% for hip fractures based on the US-
adapted FRAX tool), bone-modifying agents such as oral bisphosphonates,
intravenous (IV) bisphosphonates or subcutaneous (SQ) denosumab at
the osteoporosis-indicated dosage may be offered to reduce the risk
of fracture. Hormonal therapies for osteoporosis management (e.g.,
estrogens) are generally avoided in patients with hormonal-responsive
cancers. For patients without hormonally-responsive cancers, estrogens
may be offered along with other BMAs when clinically appropriate. (Strong
Recommendation; EB-B-H)
Qualifying statement. The current evidence suggests oral bisphosphonates, IV bisphosphonates
and SQ denosumab are each efficacious options. The choice of which bone-modifying agent
to offer should be based on several important considerations including patient preference,
potential adverse effects, quality of life considerations, adherence, safety for that population,
cost and availability.
