Adult Cancer Survivors Need Osteoporosis Screening and Treatment: Guidelines
NEW YORK (Reuters Health) - Survivors of adult cancers with nonmetastatic disease should undergo osteoporosis screening and, where indicated, treatment, according to a new American Society of Clinical Oncology (ASCO) clinical-practice guideline.
Rates of bone loss with cancer therapy can be more than seven-fold higher than those associated with normal aging, the guideline authors say.
The complete guideline appears in the Journal of Clinical Oncology, online September 18.
Dr. Charles L. Shapiro of Mount Sinai Hospital, in New York City, and a multidisciplinary expert panel reviewed the literature to provide guidance to clinicians on management of osteoporosis in survivors of adult-onset, nonmetastatic cancer. The guideline does not address patients with metastatic disease.
The guideline considered three clinical questions: Which patients with nonmetastatic cancer face an increased risk for developing osteoporotic fractures? How should such patients be screened? And which patients should be treated, and what interventions are effective in reducing the risk of osteoporotic fractures?
Numerous factors can place these patients at increased risk for osteoporotic fractures, including advanced age, current cigarette smoking, excessive alcohol consumption, fracture history, postmenopausal status, and so on. Chemotherapy with aromatase inhibitors, antiandrogens and chemotherapy-induced ovarian failure can further increase that risk.
Patients with any of these risk factors should be offered bone-mineral density (BMD) testing with central/axial dual-energy x-ray absorptiometry (DXA), according to the guideline.
Regardless of risk, patients should be encouraged to pursue nonpharmacologic preventive interventions, such as adequate calcium and vitamin D consumption, active participation in a variety of exercises, smoking cessation and moderation of alcohol consumption.
Patients found to have osteoporosis or an increased risk of osteoporotic fractures based on risk-assessment tools should be treated with bone-modifying agents, such as oral or intravenous bisphosphonates or subcutaneous denosumab to reduce their risk of fracture. Hormonal therapies (e.g., estrogens) should generally be avoided in patients with hormone-responsive cancers.
The choice of pharmacologic treatment should be based on patient preference, potential adverse effects, quality-of-life considerations, adherence, safety, cost and availability, the guideline says.
Dr. Maria Papaleontiou of the University of Michigan, in Ann Arbor, who recently reviewed the risk of osteoporosis and fractures in patients with thyroid cancer, told Reuters Health by email, "Physicians should be aware that osteoporosis is a significant public health issue in cancer survivorship care, especially in the setting of an aging population. Clinicians should assess fracture risk using established tools and recommend treatment when indicated based on bone mineral density scan results."
"Physicians should be aware that osteoporosis is a significant public health issue in cancer survivorship care, especially in the setting of an aging population."
"This (paper) is the first step towards shedding light and increasing awareness on the issue of osteoporosis in nonmetastatic cancer patients," said Dr. Papaleontiou, who was not involved in the study. "This article can be used to identify gaps in knowledge in this subject in order to inform future research aiming to guide personalized care of these patients."
Dr. Shapiro and Dr. Neuner did not respond to a request for comments.
J Clin Oncol 2019.