REDUCED BONE MINERAL DENSITY

Evidence-based recommendation for surveillance of reduced bone mineral density (BMD) a (IGHG b )

This page is part of the PanCare follow-up recommendations for surveillance of late effects. Click here, for more information on these recommendations.

On this page you can find:

Click here, to read this recommendation in PLAIN language.

Who is at risk for reduced BMD? b

CAYA cancer survivors treated with or with a history of

  • Cranial or craniospinal radiotherapy
  • TBI

What surveillance modality should be used and at what frequency should it be performed?

  • A history with specific attention to risk factors c and symptoms (back pain, fractures) of reduced bone mineral density at least every 5 years, starting at entry into long-term follow-up
  • A DXA scan d once at entry into long-term follow-up (between two to five years following completion of therapy), to be repeated at 25 years of age when peak bone mass should be achieved, and thereafter as clinically indicated

What other advice should be given?

  • Be aware of other potential risk factors for low and very low bone mineral density for survivors, including corticosteroids as anti-cancer treatment, e hypogonadism, growth hormone deficiency, low BMI or underweight, male sex, white race, lack of physical activity, f smoking
  • Due to insufficient evidence, no recommendation can be formulated for or against BMD surveillance for survivors with these potential risk factors for reduced BMD
  • Counsel about lifestyle habits that are important to maintain or improve bone health: adequate calcium and vitamin D intake, abstinence from smoking and alcohol, and adequate physical activity according to guidelines for the general population

What should be done if abnormalities are identified?

In CAYA cancer survivors with a BMD Z-score ≤-2:

  • Refer to (or consult) a medical bone health specialist g for further (endocrine) evaluation, interpretation of BMD findings, treatment, and follow-up

In CAYA cancer survivors with a BMD Z-score ≤-1 and >-2:

  • Evaluate for the presence of endocrine defects and consult a medical bone health specialist g for further evaluation and interpretation of BMD findings as clinically indicated
  • Repeat DXA after 2 years, and thereafter as clinically indicated based on BMD change (i.e. in case of BMD decline more than the DXA machine’s least significant change) and ongoing risk assessment

Disclaimer

While PanCare strives to provide accurate and complete information that is up-to-date as of the date of publication, we acknowledge that the sequence of referral and diagnostic tests might vary according to the local and national healthcare system logistics.

It is recognised that survivors and their healthcare professionals have the final responsibility for making decisions concerning their long-term follow-up care. As such, they may choose to either adopt these recommendations or not to do so after individual informed discussion. It is good practice to document this decision.

In addition to regular surveillance, real-time awareness and prompt reporting of new symptoms and signs is essential to the early detection and timely treatment of late effects.

No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information.

The PanCare materials are free to use for anyone aiming to inform about late effects and long-term survivorship care. However, no financial advantage may be achieved. All communication should reference PanCare and link to the PanCare website.

a Further recommendations regarding surveillance of bone cancer are specified in the Consensus-based recommendation for surveillance of subsequent neoplasms.

b The bone mineral density recommendations reflects the content of the IGHG Bone Mineral Density guideline (Bone mineral density surveillance for childhood, adolescent, and young adult cancer survivors: evidence-based recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group, Lancet Diabetes & Endocrinology, 2021; accessible through https://www.ighg.org/guidelines/topics/bone-abnormalities/).

c Poor intake of vitamin D, poor intake of calcium, minimal weight-bearing exercise, comorbidities.

d The pubertal stage of the survivor should be taken into account when deciding to perform a DXA scan. It might be considered to postpone the DXA scan in pre-pubertal and pubertal survivors.

e At least 4 weeks continuously.

f The WHO global recommendation on physical activity for health for adults is 150 minutes of moderate-intensity activity (or equivalent) per week, measured as a composite of physical activity undertaken across multiple domains: for work (paid and unpaid, including domestic work); for travel (walking and cycling); and for recreation (including sports). For adolescents, the recommendation is 60 minutes of moderate- to vigorous-intensity activity daily.

g A medical bone health specialist is defined as any specialist who is caring for BMD deficits in CAYA cancer survivors, such as an endocrinologist (most settings), internist, pediatrician, rheumatologist, family physician, or general practitioner, depending on country and setting.