Bone Health After Cancer

Women who have premature (early) menopause or decreased oestrogen production due to cancer therapy (i.e. women taking hormonal therapy, such as aromatase inhibitors or leuprolide, or menopause induced by surgery, chemotherapy, or radiation) are at the higher risk of osteoporosis.

Of note, tamoxifen increases the risk of osteoporosis in premenopausal women, but can actually increase bone density in menopausal women, thereby decreasing the chance of osteoporosis.

Treatment with some chemotherapy medications, radiation to the brain or weight-bearing bones (spine, hips, legs), or allogeneic stem cell or bone marrow transplant.

Long-term use of corticosteroids (dexamethasone and prednisone, greater than 5 mg per day for 2 months or more).

Patients who have had their stomachs surgically removed (gastrectomy).

There are additional risk factors that are not specific to having cancer, including smoking, consuming excessive alcohol, leading an inactive lifestyle, being petite and thin, having a diet low in calcium and vitamin D, and missing menstrual periods. Osteoporosis is more common in women (80% women, 20% men), those with a family history, Caucasians and those of Asian or Latino descent, although all races have some risk. You can learn more about other risk factors by visiting the National Osteoporosis Foundation https://www.nof.org/.

How is osteoporosis detected?

Screening for osteoporosis is done with a bone mineral density (BMD) test. A DEXA scan is the most commonly used test.

The National Osteoporosis Foundation recommends that women should have the test at age 65 and men at age 70 when no risk factors are present.

They recommend screening for younger individuals with risk factors. The test is also used to monitor the bone health of people with osteopenia or osteoporosis.

Experts recommend screening for all patients with cancer who are at increased risk because of their age or the treatments they received.

Cancer survivors should discuss their specific risks and need for screening with their healthcare team. Risk can be evaluated using the FRAX® tool, which was developed by the World Health Organization to evaluate the risk of fracture in people.

What can I do to protect my bone health?

While you may not be able to change your family and health history, there are some steps you can take to protect your bones.

Get 1000-1200 mg of calcium a day ideally in your diet (see more below).

Take 800-1000 IU of vitamin D3 daily.

Do not smoke or drink excessive alcohol (no more than 2 drinks per day).

Watch your caffeine intake- studies have shown large amounts of caffeine increase the risk of fractures (broken bones). Drink milk instead!

Get your weight-bearing exercise and strength/resistance training! This strengthens bones and muscles (learn more below).

Have appropriate bone health screening.

Dietary Tips

Our bodies cannot produce calcium, so we must be sure to get enough in our diet to support healthy bones. You should aim to get 1000-1200 mg of calcium per day. It is best to get calcium in a balanced diet, including 4-8 servings of calcium-rich foods a day.

Dairy foods, such as milk, yogurt, and cheese, are highest in calcium. Sardines and salmon with bones, dark, green vegetables, such as broccoli, kale, and collard greens, contain calcium as well. 

Spinach and rhubarb contain calcium, but also contain large amounts of oxalate and phytate, which prevent the body from absorbing their calcium. However, they do not interfere with the absorption of calcium from other foods.

Other good sources of calcium include almonds, sunflower seeds, apricots, and figs. 

If you cannot take in the recommended amount of calcium in foods, take calcium supplements.

Your body does not absorb calcium supplements well, so spread the dose out by taking 1 tablet multiple times a day. If you take thyroxine  (thyroid hormone), separate it from calcium doses by at least 4 hours.

Vitamin D is often called the "sunshine vitamin" because our skin converts ultraviolet rays from the sun into vitamin D. In general, 10-15 minutes of sun exposure on the hands, arms and face creates the needed amount.

However, it is difficult to measure how much vitamin D you are getting by this method and the amount can vary by season or location. In addition, avoiding the sun and using sunscreen limit how much UV exposure we get.

Very few foods contain vitamin D naturally; these include certain fish (salmon, tuna, mackerel) and fish liver oils, while egg yolks and beef liver contain small amounts.

Many foods are fortified with vitamin D, read the nutrition labels to know how much. Milk is often fortified with vitamin D, but keep in mind that foods made with milk (cheese, ice cream) are not.

Vitamin D is available in two forms, D2 and D3. Supplements typically contain D3. Research has found that both are beneficial for bone health. 

Additionally there are several herbs that increase bone uptake of calcium and help remodel damaged bone. 

Ask us for more information and support you with the right herbs in your formula.