Treatment
Figure 1. Algorithm for Maintaining Bone Health in Individuals
with Non-metastatic Cancers
• Clinician should be aware that patients with non-metastatic cancer may
have baseline risks for osteoporosis as well as the added risks of treatment
related bone loss due to hypogonadism from endocrine therapy (i.e.,
oophorectomy, GnRH agonists, chemotherapy-induced ovarian failure,
aromatase inhibitors, anti-androgens) chemotherapy or other cancer
therapy-associated medications (i.e., glucocoriticoids).
• All patients should be counseled on intake of calcium and vitamin D, weight
bearing exercises, minimizing the risk of falls and bone-healthy lifestyle and
behaviors such as tobacco cessation and limiting alcohol consumption.)
• Osteoporosis fracture risk assessment may include use of FRAX
(www. sheffield.ac.uk/FRAX) or other tool.
When one or more risk factors for osteoporotic fracture are present, and
there is consideration for use of a bone modifying agent, then evaluate bone
mineral density to further quantify fracture risk. The preferred assessment
uses Dual X-ray Absorptiometry (DXA) of total spine, hip, and femoral neck.
All patients should be counseled on intake of calcium and vitamin D, weight
bearing exercises, minimizing the risk of falls and bone-healthy lifestyle and
behaviors such as tobacco cessation and limiting alcohol consumption.)
DEFERRAL OF BONE-MODIFYING
AGENT
If the bone density result does not
demonstrate osteoporosis (or if
there is not significant osteopenia
with additional risk factors) and if
FRAX calculation does not exceed
ten-year risk of hip fracture at 3%
or greater, or ten-year risk of non-
hip fracture at 20% and/or bone
mineral density is not sufficiently
low to trigger use of a bone
modifying agent then repeat DXA
in 2 years or in 1 year if medically
indicated.
INITIATION OF BONE-MODIFYING
AGENT
Thresholds to initiate a bone
modifying agent include:
• If FRAX (ten-year risk of hip fracture
at 3% or greater, or ten-year risk of
non-hip fracture at 20%)
• The BMD (DXA) demonstrates
osteoporosis or significant
osteopenia with additional risk
factors
• The clinical scenario indicates
significant risk for osteoporotic
fracture (such as history of prior
osteoporotic fracture that has
not been treated), then initiate
a bone modifying agent. The
bisphosphonates (oral or IV) or
denosumab are the preferred
agents dosed for osteopenia or
osteoporosis as clinically indicated.
Repeat DXA every 2 years, or
as clinically indicated
a
a
Bone mineral density should not be
conducted more than annually.
Management
Screening
At
Risk
