Ways to support your treatment by keeping bones healthy.
“Metastatic bone disease is most commonly seen with specific cancer types—notably those with metastasis from the breast (70%), prostate (85%), lung (40%) and kidney (40%)—as well as multiple myeloma (MM) (95%).” - Coleman R.E. Clin Cancer Res. 2006; 12: 6243s-6249s
Preventing bone loss is helpful no matter what your age or condition. Fractures to the
hip or spine are particularly concerning especially as they are weight bearing bones. When these bones are healthy, they can withstand significant impact; however, when you have low bone- density, even a minor fall may result in a fracture. Fractures related to decrease in bone density are associated with loss of mobility and social functioning, reduced quality of life, and poor survival.
“The skeleton is a frequent target of metastatic disease. It can be the first and sometimes the only site of advanced disease, contributing greatly to the burden of care in cancer patients.” - Roodman GD. N Engl J Med 2004;350:1655–1664.
Bone loss from cancer therapy is faster and more severe than bone loss from aging; rates
of bone loss are up to 7-fold higher when they occur from cancer therapy. Women with breast cancer receiving an aromatase inhibitor or ovarian suppression should be assessed for fracture risk based on clinical risk factors and bone mineral density. Premenopausal women should also be informed of the potential risk of bone loss before beginning anticancer therapy. Ideally, all women should get their bone density checked by a test called the DEXA scan (dual energy X-ray absorptiometry) which is a type of X ray that measures your bone density. A bone density scan measures the strength of the bone by looking at the amount of calcium it contains in the hip, femoral neck and lower spine. Depending on how low your bone mineral density is, you may be diagnosed with osteopenia or osteoporosis.
Getting a DEXA scan prior to starting cancer treatment and followed by yearly DEXA scans can monitor your risk for fracture.
The fracture risk assessment (FRAX®) calculator is a tool that is used to estimate the
10-year risk of hip and non-hip vertebral fractures. FRAX® uses the age, height, weight, sex and a variety of other risk factors to assess your personal risk. Before starting treatment for cancer, talking about your personal risk factors for osteoporosis is important. Here is a checklist of risk factors that can predispose you to accelerated bone loss. These risk factors include being small and thin, family history of osteoporosis or hip fracture as well as height loss of more than 1-1/2 inches or stooped posture amongst others. Please see this second checklist that you can take to your doctor visit to discuss how to monitor and reduce your risk for fractures, especially if you are on chemotherapy and hormone therapy. If you do get medications for osteoporosis such as bisphosphonates or denosumab, make sure you talk to your physician about the precautions and expected side effects of those medications.
You cannot change some risk factors for osteoporosis but you can take the following steps to keep your bones strong during treatment and in survivorship.
1. Eat a variety of nutrient-rich foods every day including 3-4 servings of fruits and
vegetables each day. Fruits and vegetables provide essential micronutrients as well as
antioxidants associated with higher bone density. Fruits and vegetables also affect the
acid-base balance of the diet which can affect the balance of osteoblast activity versus
osteoclast activity. However it is not the acidity or alkalinity of the food or drinks we put
in our mouth that is the concern here, but what happens to their components after
ingestion and metabolism. Most fruits and vegetables yield an alkaline residue in the
body, which helps prevent bone loss. Studies have also shown that carotenoids such as
beta carotene, lycopene, lutein and zeaxanthin, as found in many fruits and vegetables
can increase bone density, although the mechanism of this is not clear.
2. Take adequate protein every day. Older adults may become protein malnourished due
to inadequate intake of protein and a reduced ability to use available protein because of
age-related changes in metabolism, immunity, as well as hormone imbalances. Dietary
protein is crucial for the maintenance of bone tissue as well as for bone growth. Bone is
35% protein and requires a supply of amino acids to be used for protein turnover.
Protein intake stimulates the release of the hormone IGF-1 which increases muscle mass
and bone growth. While there is some suggestion that excessive increased protein intake
can result in bone loss this has been largely proven to be not clinically significant. Protein
sources can be plant or animal based and have different amino acid profiles. Eating lean,
minimally processed animal protein, white fish, yogurt, cheese, low fat cottage cheese
and various plant based proteins such as lentils, beans, peas, tofu, edamame, tempeh
etc can help maintain optimal bone health.
Also Read : Improve Your Diet to Decrease Cancer Risk
3. Maintain your calcium intake at the correct level. Your bones contain 99.5% of the
total calcium in your body. Premenopausal women should consume at least 1000 mg of
calcium, while postmenopausal women should consume 1200 mg (total diet plus
supplement). You should not consume more than 2000 mg of calcium per day (total diet
plus supplement) due to the risk of side effects. It is best to get calcium from the foods
you eat. Foods rich in calcium such as dairy foods (milk, yogurt, cheese), dark green,
leafy vegetables (bok choy, broccoli collard greens, kale, and turnip greens), fish
(sardines, salmon), almonds, tofu or calcium-fortified foods. If you don't eat dairy there
are several other sources to get your daily dose of calcium. The bioavailability of calcium
is an important consideration to keep in mind. The absorption of calcium from dairy
products and fortified foods is about 30%. In the case of plants, certain compounds in
plants like oxalic acid, phytic acid can decrease calcium absorption by forming
indigestible salts with calcium, decreasing its absorption. As a result, absorption of
calcium is only 5% for spinach, whereas it is much higher, at 27%, for milk. Depending
on the type of diet you follow, you should be mindful of your dietary sources of calcium
and make sure you eat a balanced meal.
4. Get your regular dose of Vitamin D. Vitamin D is not a vitamin, rather it functions as
a hormone that is essential for bone health. Vitamin D decreases bone loss and lowers
the risk of fracture, especially in older men and women. Along with calcium, vitamin D
also helps to prevent and treat osteoporosis. To absorb calcium efficiently, an adequate
amount of vitamin D must be present. The skin, liver and kidneys work together to
synthesize the active form of vitamin D. Exposure to the UV rays from the sun converts
a molecule made from cholesterol in your skin to vitamin D. Vitamin D in its active
form acts on the intestine, kidneys, and bones to maintain normal levels of blood calcium
and phosphorus. The primary effect of vitamin D is increased calcium absorption in the
small intestine but also maintenance of serum calcium and phosphate concentrations, as
well as by its action on bone growth and remodeling. If you are unable to get about 20
minutes of exposure to the morning sun because of where you live, a Vitamin D
supplement prescribed by your physician based on your blood levels may be necessary.
The current recommendation is that postmenopausal women consume at least 800
international units (20 micrograms) of vitamin D per day. Lower levels of vitamin D are
not as effective, while high doses can be toxic, especially if taken for long periods of
time. Although the optimal intake has not been clearly established in premenopausal
women, 600 international units (15 micrograms) of vitamin D daily is generally
suggested. There are only a few good natural food sources of vitamin D, including fatty
fish such as mackerel, salmon, sardines, and tuna. Small amounts of vitamin D are added
to all milk and some types of soy milk, rice milk, almond milk, yogurt, cheese, juice, and
5. Don’t forget magnesium. It helps your body regulate the levels of calcium and Vitamin
D and is found in green vegetables, nuts, seeds, avocados, legumes and whole grains. The
current recommendation for adults 19-51+ years is 310-320 mg for women. A good rule
of thumb is to eat a daily diet that includes some magnesium-rich foods and take a
supplement if directed by a physician to correct a deficiency if blood levels are low.
6. Be physically active. Your bones get stronger and denser when you make them work.
Weight-bearing exercise especially can help preserve your bone health. Some examples
are running, tennis or pickleball, and weight training. When you do weight-bearing
exercise, you put stress on the bones. That triggers the bone cells to build more bones,
which can lead to increased bone strength. This process is called osteogenic loading.
Walking, climbing stairs, and dancing are also exercises that strengthen your bones by
moving your body against gravity when you are upright. Tai Chi and yoga are examples
of physical activity that improve posture and balance to help decrease your risk for falls
and fractures. Avoid exercises that increase your risk of falls. Extension exercises are
better at protecting your spine from vertebral fractures than flexion exercises where your
back is curved forward.
7. Don't smoke or vape.
8. Limit your alcohol intake. Before drinking alcohol, it is important to speak to your
health care provider about possible interactions with your medication or your medical
condition. Too much alcohol can be bad for your bones and your overall health.
Excessive alcohol interferes with the balance of calcium as well as interferes with the
production of vitamin D.
9. Take precaution against falls. Preventing falls, especially if you already have low bone
density is important. Most broken bones occur as a result of a fall that can be prevented.
Some actions to prevent falls at home include using nightlights, removing or securing
scatter rugs, using handrails on stairs, using grab bars in the shower and bathroom, using
a seat riser on the toilet, and getting rid of clutter. Be careful of little pets that can get
underfoot and trip you. Clean up spills immediately and don't use floor polish which can
cause you to slip. If you are on medication that causes drowsiness, you should be extra