Breast Cancer

Bone Health During Treatment

Strong bones are important to your overall health during and after breast cancer treatment. Loss of bone mass and density (osteoporosis) is common as people age, which is why postmenopausal women are at higher risk of developing it. Many other factors can increase your risk of osteoporosis, including gender, ethnicity and lifestyle. Certain cancer treatments can also contribute to the loss of bone density.

Osteoporosis occurs when bone cells that help rebuild bone don’t get replaced at the same rate as the cells that naturally break down bone. Bones may become thin, porous (full of tiny holes) and weak, and this bone loss is linked with a higher risk of fractures (broken bones), pain and disability. The spine, wrists and hips are the most susceptible to fracture as a result of osteoporosis.

Warning signs of bone loss include the following:

  • Joint and back pain
  • Arthritis-like symptoms
  • Slouched posture
  • Shortened stature
  • Broken/fractured bones

Talk to your doctor about the risk for osteoporosis associated with your specific treatment(s). Your health care team can assess your risk, work with you on a treatment plan to address existing bone loss and offer recommendations to help promote your bone health.

Cancer Treatments and Bone Loss

Some chemotherapy drugs can decrease the level of calcium in your body, which can lead to bone loss. Other treatment-related medications, such as corticosteroids, have been found to increase risk of osteoporosis. Hormone therapy is another major factor in bone loss because it lowers the levels of hormones important for optimal bone density. For example, research has shown that a type of hormone therapy known as an aromatase inhibitor, which is used to treat estrogen receptor positive (ER+) or progesterone receptor positive (PR+) breast cancer, can increase the risk of osteoporosis.

Your doctor may want you to have a bone density scan before treatment begins. This test will provide a baseline measurement so that your health care team can monitor changes to your bone density during or after treatment. Osteoporosis is indicated by a bone density lower than the range expected for others similar to you in age, gender and ethnicity.

Most often, bone mass is measured with a bone density scan called a dual-energy X-ray absorptiometry (DEXA) scan. This test calculates bone density by measuring how much radiation the bone absorbs. Testing is noninvasive, painless and takes about 20 to 30 minutes to complete.

Treating Osteoporosis

If your bone density tests show signs of bone loss, your doctor may prescribe a bone-modifying agent. These medications work by slowing the rate of bone loss to help decrease bone damage and promote bone healing. Many bone-modifying agents belong to a class of drugs called bisphosphonates. Use of these drugs can help to reduce pain and bone complications, but they have been linked with a rare but serious side effect called osteonecrosis of the jaw. Experts recommend that you visit your dentist to ensure your teeth and gums are healthy before you start treatment with a bone-modifying agent.

In addition to prescribing medications to treat bone loss, your doctor may suggest physical therapy. Physical therapy can enhance your quality of life by helping to manage pain, decrease your risk of fractures and increase your mobility and safety. Physical therapy usually consists of stretching, balance and stability exercises.

Improving your Bone Health

The best way to prevent bone loss is to take action to keep your bones healthy and strong:

  • Follow all treatments prescribed by your doctor.
  • Make light exercise and non-weight bearing activity part of your daily routine. Walking, dancing, climbing stairs, jogging, yoga, tennis and other racket sports can help stimulate the production of bone-forming cells. Light weightlifting is also beneficial.
  • Get plenty of calcium in your diet with dairy foods, such as milk, yogurt and cheese; dark, leafy greens; broccoli; calcium-fortified orange juice; tofu; and almonds. Ask your doctor if a calcium supplement is recommended.
  • Get enough vitamin D through vitamin D-fortified milk; fatty fish such as salmon, tuna, sardines, herring and swordfish; and vitamin-fortified cereals. Your doctor may also suggest vitamin D supplements.
  • Spend some time in the sun to help your body make vitamin D. Just 5 to 10 minutes two or three days a week is all you need. Always apply sunscreen if you will be in the sun.
  • Reach and maintain a healthy weight. If you are underweight, you are more likely to have bone loss and fractures.
  • If you smoke, try to quit, and keep alcohol consumption minimal. Both can contribute to osteoporosis.
  • Some herbal supplements are marketed to help prevent and/or treat osteoporosis, but research has not proven them to be effective. Be sure to let your doctor know about all supplements and over-the-counter medications before you take them.
  • Falling is the most common cause of fracture for people with osteoporosis. To help prevent falls at home, avoid clutter on floors and stairs, secure or remove throw rugs, use hand rails on stairs, install hand rails in bathrooms and place a nonskid rubber mat in the bathtub/shower. Ensure sufficient lighting inside and outside the house, and use nightlights. Wear well-fitting shoes, ideally with a rubber sole. For shoes with smooth soles, attach self-adhesive non-skid shoe pads.
  • If you feel unsteady on your feet, ask your health care team about exercises you can do at home to improve your balance, or find an exercise class that focuses on improving balance and strength.
  • Consider using a cane or walker if needed, particularly when getting out of bed at night. Be careful walking after taking pain medicine.
  • Don’t hesitate to take a friend’s arm when you’re crossing a street, walking on uneven pavement or feeling unsteady on your feet. It’s OK to ask for a helping hand.

Table 1. Medications to Prevent/Treat Osteoporosis

Drug Indication How given
alendronate sodium (Fosamax) Prevention/treatment Oral
calcitonin (Miacalcin, Fortical) Treatment
Nasal spray
Injection
denosumab (Prolia) Treatment
Injection
estrogen therapy Prevention/treatment
Oral
Skin patch
ibandronate (Boniva) Prevention/treatment Oral
Injection
raloxifene (Evista) Prevention/treatment
Oral
risedronate (Actonel, Atelvia) Prevention/treatment
Oral
teriparatide (Forteo) Treatment Injection
zoledronic acid (Reclast) Prevention/treatment
Injection

Managing Metastatic Bone Disease

Bone is the most common site for breast cancer to metastasize (spread). It can be painful and can also weaken bones, causing them to break easily. Metastasis to the bone most often affects the spine, ribs, pelvis, skull and long bones in the arms and legs.

Drugs have been approved for metastatic breast cancer and evidence of loss of bone density. These treatments help prevent bone fractures and can reduce the need for surgery or radiation therapy to alleviate bone pain. Radiation therapy can also help prevent or treat fractures, especially in weight-bearing bones. Radiation beams target the area of the metastasis, and relief is usually immediate and complete.

Talk to your doctor about which treatments may be best for you, and ask for recommendations on calcium and vitamin D supplements.

Table 2. Lifestyle Habits to Decrease Risk of Osteoporosis

Possible resulting side effects
Activity Specific examples
Include enough calcium and vitamin D in your diet
(The American Society of Clinical Oncology recommends 1,200 mg of calcium and 400-800 U of vitamin D each day for women.)
Calcium:
▪  Dairy products (low-fat milk, yogurt and
   cheese)
▪  Calcium-fortified orange juice
▪  Dark green leafy vegetables (broccoli,
   spinach, collard greens, bok choy)
▪  Tofu
▪  Almonds
▪  Vitamin-fortified cereal
▪  Calcium supplement
Vitamin D:
▪  Vitamin D-fortified milk
▪  Herring, salmon, tuna
▪  Vitamin-fortified cereal
▪  Exposure to sunlight
▪  Multivitamin
Engage in weight-bearing exercise and/or strength training (three to four times per week for maximum benefit)
Walking
Jogging
Tennis (or other racket sports)
Dancing
Lifting weights
Yoga
Minimize the risk of falls
Use hand rails on stairs and in bathroom
Ensure sufficient lighting around the house
Secure or remove throw rugs
Use a cane or walker if necessary
Don’t be afraid to ask for help walking
Wear shoes that fit properly, have a rubber sole and a low heel
Control what you intake
Drink little or no alcohol
Avoid smoking

Table 3. Medications to Manage Metastatic Bone Disease 

Drug How given
denosumab (Xgeva) Injection
pamidronate disodium (Aredia) Injection
zoledronic acid (Zometa) Injection

Additional Resources

 

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