How should osteoarthritis (OA) be managed in a patient with a history of cancer, particularly those who have undergone treatments such as chemotherapy or radiation therapy?

Managing Osteoarthritis in Patients with a History of Cancer

Manage osteoarthritis in cancer survivors using the same evidence-based approach as the general population, starting with exercise and weight management, followed by topical or oral NSAIDs, while being mindful of treatment-related comorbidities such as osteoporosis, cardiovascular disease, and renal dysfunction that may influence medication selection. 1

Initial Assessment and Risk Stratification

Before finalizing any OA treatment plan, assess for cancer treatment-related complications that may impact therapy selection 1:

• Cardiovascular disease from chemotherapy (anthracyclines) or radiation therapy, which increases risk with NSAIDs 1
• Chronic kidney disease from cisplatin or other nephrotoxic agents, limiting NSAID use 1
• Osteoporosis from hormonal therapies, chemotherapy, or radiation, requiring bone density screening and fall prevention 1
• Peripheral neuropathy from chemotherapy (taxanes, platinum agents), affecting balance and exercise safety 1
• Gastrointestinal complications from prior treatments, increasing bleeding risk with NSAIDs 1

First-Line Non-Pharmacological Management

Exercise is the cornerstone of OA management and is safe during and after cancer treatment, with proven benefits for bone health, muscle strength, and quality of life. 1

Exercise Prescription

• Initiate structured exercise programs with quadriceps strengthening, aerobic activity, and balance training regardless of cancer history 1, 2
• For patients with peripheral neuropathy or osteoporosis, careful attention to balance is essential to reduce fall risk; consider supervision by a caregiver or exercise professional during sessions 1
• For those with bone metastases (though your question specifies history of cancer, not active disease), low-intensity activities like stretching and slow walks are appropriate 1
• Tai Chi is strongly recommended as it addresses strength, balance, fall prevention, and has holistic benefits 2

Weight Management

• Weight loss of ≥5% is strongly recommended for overweight patients with knee OA, with enhanced benefits when combined with exercise 2
• Cancer survivors should receive nutrition counseling to achieve healthy weight, particularly if they gained weight during treatment or are obese 1

Additional Non-Pharmacological Interventions

• Self-management programs and patient education are strongly recommended to improve coping strategies 2
• Assistive devices such as a cane in the contralateral hand for knee OA or knee sleeves for joint stability 3, 2

Pharmacological Management Algorithm

Step 1: Topical and Minimal Systemic Exposure Agents

Begin with treatments having the least systemic exposure, particularly important in cancer survivors with treatment-related organ damage. 1

• Acetaminophen (paracetamol) up to 4g daily for mild-to-moderate pain with minimal systemic effects 1, 2, 4
• Topical NSAIDs are preferred over oral NSAIDs in older patients or those with cardiovascular, gastrointestinal, or renal comorbidities from cancer treatment 1, 5

Step 2: Oral NSAIDs (If Step 1 Inadequate)

• Oral NSAIDs (diclofenac, naproxen) are more effective for moderate-to-severe pain but require careful risk assessment 3, 6, 5
• COX-2 selective inhibitors have better gastrointestinal safety profiles but still carry cardiovascular risks 6
• Critical caveat: Many cancer survivors have increased cardiovascular risk from anthracyclines or chest radiation, and renal impairment from platinum-based chemotherapy—these are relative contraindications to NSAIDs 1

Step 3: Intra-articular Therapies

• Intra-articular corticosteroid injections provide short-term relief during disease flares 3, 4
• Hyaluronic acid injections should be considered if oral medications provide inadequate relief 4

Agents NOT Recommended

• Glucosamine does not appear better than placebo for pain, with uncertain effects on structural progression 5
• Fish oil has not been found to reduce structural progression of knee arthritis 5

Special Considerations for Cancer Survivors

Bone Health Integration

• Cancer survivors on hormonal therapies (GnRH agonists, aromatase inhibitors) or with history of high-dose chemotherapy are at high risk for osteoporosis 1
• Screen with DXA and calculate 10-year fracture risk; if hip fracture risk >3% or major osteoporotic fracture risk >20%, initiate bisphosphonates or denosumab 1
• Dental screening before starting bone-modifying agents to reduce MRONJ risk 1
• Exercise programs for OA simultaneously benefit bone health in this population 1

Supplement Caution

• Do not recommend high-dose antioxidant supplements (vitamins C, E) during active cancer treatment, as they may interfere with chemotherapy or radiation efficacy 1
• After treatment completion, supplements should not exceed 100% of daily value unless correcting a specific deficiency 1

Coordination of Care

• Bone health and OA management may transition from oncology to primary care; clear communication and a treatment summary should identify the responsible provider 1

Surgical Considerations

• Arthroscopic procedures should be avoided as they show no benefit over sham procedures or optimized medical therapy 5
• Total joint arthroplasty is appropriate for advanced tricompartmental disease after conservative measures fail 3
• Preoperative optimization includes glycemic control if diabetic and nicotine cessation 3

Common Pitfalls to Avoid

• Do not delay exercise due to cancer history; it is safe and beneficial during and after treatment 1
• Do not prescribe oral NSAIDs without assessing cardiovascular, renal, and gastrointestinal risk from prior cancer treatments 1
• Do not ignore osteoporosis screening in cancer survivors, as fracture risk may be substantially elevated from treatments 1
• Do not use radiation therapy for OA management in cancer survivors without specialized consultation, as this is an emerging and controversial approach 7