What are the National Comprehensive Cancer Network (NCCN) guidelines for optimizing bone health in patients with cancer?

NCCN Optimization of Bone Health in Cancer Patients

All cancer patients receiving therapies that lower sex steroids should undergo baseline DEXA scanning with periodic follow-up, combined with calcium and vitamin D supplementation, lifestyle modifications, and pharmacologic therapy when clinically indicated. 1

Risk Assessment and Screening

High-Risk Populations Requiring Baseline DEXA

• Women with breast cancer receiving aromatase inhibitors (any age if postmenopausal), those with chemotherapy-induced ovarian failure, or high-risk factors (family history of fractures, body weight <70 kg, prior non-traumatic fracture) 1
• Men with prostate cancer on androgen-deprivation therapy, following National Osteoporosis Foundation guidelines (all men ≥70 years; younger men with risk factors) 1
• All patients receiving glucocorticoid therapy for hematologic malignancies or as supportive agents 1

Fracture Risk Stratification

Use the WHO FRAX calculator combined with BMD measurements to estimate 10-year fracture probability, as this provides superior risk assessment compared to BMD alone 1. The FRAX algorithm integrates:

• BMD T-scores from DEXA
• Clinical risk factors (age, prior fracture, parental hip fracture history, smoking, alcohol use, glucocorticoid use) 1

Diagnostic Criteria

WHO T-Score Classification via DEXA

• Normal: T-score ≥ -1.0 1
• Osteopenia: T-score -1.0 to -2.5 1
• Osteoporosis: T-score ≤ -2.5 1

Important caveat: Serial BMD monitoring must be performed on the same DEXA equipment using identical reference standards, as results vary significantly between machines, calibration methods, and anatomic sites 1. Osteoarthritis or aortic calcification can falsely elevate BMD readings 1.

Universal Interventions for All Cancer Patients

Lifestyle Modifications

• Smoking cessation and limiting alcohol intake to reduce fracture risk 1
• Weight-bearing exercise programs to maintain bone density 1
• Fall prevention strategies particularly in elderly patients 1

Calcium and Vitamin D Supplementation

All cancer patients at risk for bone loss should receive adequate calcium and vitamin D repletion 1. Vitamin D deficiency must be corrected before initiating bisphosphonate therapy 1.

Pharmacologic Therapy Indications

Initiate drug therapy for osteoporosis when:

• T-score ≤ -2.5 at hip or spine 1
• T-score -1.0 to -2.5 with high FRAX-calculated fracture probability 1
• Prior fragility fracture regardless of BMD 1

Bisphosphonates remain the primary pharmacologic option, with emerging data suggesting they may reduce recurrence risk in early-stage breast cancer beyond bone density effects 1.

Monitoring Strategy

DEXA Scan Intervals

Repeat DEXA scanning at 1-2 year intervals in patients on bone-depleting cancer therapies 1. Consider 1-year intervals when major risk factor changes occur or after initiating bone-protective interventions 1.

Additional Monitoring

Obtain lateral thoracic and lumbar spine x-rays if: 1

• Historical height loss >4 cm (1.6 inches)
• Prospective height loss >2 cm (0.8 inches)
• Acute back pain complaints
• Vertebral height loss >20% warrants referral to bone health specialist 1

Management of Bone Metastases

Multidisciplinary Approach Required

Patients with documented bone metastases need coordinated care including: 1

• Systemic anticancer therapy
• Osteoclast-targeted therapy (bisphosphonates or denosumab)
• Pain control strategies
• Serial imaging studies
• Surgical stabilization for impending fractures (before fracture occurs) 1
• Radiation therapy when indicated 1

Critical pitfall: The key to surgical management is identifying impending fractures and referring for prophylactic stabilization before actual fracture occurs, as outcomes are significantly better with preventive intervention 1.

Skeletal-Related Event Prevention

Without bisphosphonate treatment, skeletal-related events occur in 60% of breast cancer patients, 50% of prostate cancer patients, and 40% of multiple myeloma patients with bone metastases within 24 months 1. This underscores the importance of early osteoclast-targeted therapy initiation.

Algorithm Implementation

Follow this systematic approach: 1

1. Identify all patients receiving sex steroid-lowering therapies or glucocorticoids
2. Obtain baseline DEXA scan of hip and spine
3. Calculate FRAX score incorporating BMD and clinical risk factors
4. Initiate calcium/vitamin D supplementation universally
5. Start pharmacologic therapy based on T-scores and FRAX results
6. Monitor with repeat DEXA at 1-2 year intervals
7. Screen for vertebral compression fractures with height measurements and spine x-rays when indicated