LOW BONE MINERAL DENSITY
This page is part of the PanCare PLAIN summaries about late effects and recommendations for long-term follow-up care for survivors of childhood, adolescent, and young adult cancer. Click here, for more information on the PLAIN summaries.
PLAIN version 3: 03/03/2025
This PLAIN summary is based on the PanCare Follow-Up guideline about “Reduced bone mineral density” [1], which is based on the consensus of different national guidelines, and the IGHG* guideline for “Bone mineral density” [2].
Low bone mineral density
All the bones in our body make up our skeleton. We need our bones to stay upright, to help us move and to protect our organs. Each bone has a hard, calcified layer of bone on the outside. Underneath this hard layer is a softer, spongy bone.
Inside the bone are bone cells, which are responsible for keeping the bone healthy. They do this by constantly removing old layers of bone and producing new bone to take its place. For this process, bone cells need oxygen and nutrients from the bloodstream.
Sometimes problems can occur with the bones when the bone cells have too little minerals. This is called low bone mineral density (BMD) and causes the bones to become weak and break more easily. This can also lead to osteoporosis where the bone cells make too little new, healthy bone to replace the old bone.
Low BMD is very rare, especially in young people. There are a number of things anyone can do to lower your risk of low BMD, such as having enough exercise and taking enough calcium and vitamin D. Often, people get enough calcium and vitamin D from their diet, but in some cases taking supplements can be helpful.
All the bones in our body make up our skeleton. We need our bones to stay upright, to help us move and to protect our organs. Each bone has a hard, calcified layer of bone on the outside. Underneath this hard layer is a softer, spongy bone.
Inside the bone are bone cells, which are responsible for keeping the bone healthy. They do this by constantly removing old layers of bone and producing new bone to take its place. For this process, bone cells need oxygen and nutrients from the bloodstream.
Sometimes problems can occur with the bones when the bone cells have too little minerals. This is called low bone mineral density (BMD) and causes the bones to become weak and break more easily. This can also lead to osteoporosis where the bone cells make too little new, healthy bone to replace the old bone.
Low BMD is very rare, especially in young people. There are a number of things anyone can do to lower your risk of low BMD, such as having enough exercise and taking enough calcium and vitamin D. Often, people get enough calcium and vitamin D from their diet, but in some cases taking supplements can be helpful.
The bone
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Hover of the numbers in the figure for more information.
The bone
Created with BioRender.com
Hover of the numbers in the figure for more information.
Nutrients
Am I at higher risk of low BMD?
Anyone, including people who have never had cancer treatment, may develop low BMD. However, there are some medical conditions and treatments that may increase the risk of having low BMD. The problems that can occur depend on the type of cancer treatment received.
The following treatments can increase the risk of low BMD:
- Radiotherapy to the brain or spinal cord or an area including the brain or spinal cord
- Radiotherapy to the entire body, also known as total body irradiation (TBI)
You can find out if you had any of these medical conditions or treatments by looking at your treatment summary. If you do not have a treatment summary or if you have any questions, do contact your treating hospital.
If you experience low BMD, it does not always mean that it is caused by your cancer treatment. Low BMD may have other causes, such as lack of calcium or vitamin D intake or little exercise.
Graft versus host disease
Stem cell transplantation is a type of cancer treatment that involves taking stem cells from the blood of a donor (‘graft’) and putting them in your body (‘host’). Sometimes these stem cells can attack your own cells because they falsely recognize them as foreign and attack them. This is called GvHD.
GvHD can have serious health implications when you are experiencing it but it can also put you at higher risk of some late effects.
Hormone
Stem cell transplantation
Stem cell transplantation means that blood stem cells are taken out of the body of a person and transplanted back into the same person (autologous) or to another person (allogeneic).
This procedure is often used to treat diseases such as leukaemia and lymphoma, and some solid tumours (such as neuroblastoma) as well as certain immune system and genetic disorders.
There are different types of stem cell transplants, including:
- Autologous Transplant: Uses the patient’s own stem cells, which are harvested before treatments like chemotherapy or radiation and then returned to the body to help recover.
- Allogeneic Transplant: Uses stem cells from a donor. The donor can be a relative (often a sibling) or someone unrelated with a matching tissue type.
The blood stem cells can be harvested in different ways. They can either be taken out of the blood stream (peripheral blood stem cell transplantation) or out of the bone marrow (bone marrow transplantation).
During the transplantation process, the patient often undergoes a treatment to kill the diseased bone marrow cells before receiving the new stem cells through an intravenous line, similar to a blood transfusion. After the transplant, it takes time for the new stem cells to grow and start producing healthy blood cells, during which the patient needs close medical care to prevent and manage potential complications, such as infections or graft-versus-host disease (in case of allogeneic transplants).
Hypogonadism
Radiotherapy
Your treatment summary can tell you which areas of your body were irradiated. If you do not have a treatment summary or if you don’t understand what is written about the radiotherapy you received, do contact your treating hospital.
Radiotherapy is a treatment for cancer which uses high-energy radiation to destroy cancer cells and to shrink tumours. The radiation comes from a machine outside the body (external beam radiotherapy) or occasionally from radioactive material that is placed in the body near cancer cells (intracavitary or interstitial radiotherapy). The aim of radiotherapy is to treat only one area of the body, around and near the cancer or where the cancer was before it was removed by surgery and as far as possible to protect unaffected areas. For example, if you have cancer in your lung, you will have radiation only to your chest, not to your whole body.
External beam radiotherapy is painless and takes only a few minutes. It is given once or occasionally twice a day often for several weeks. A radiation beam is like an invisible light beam. The machines which produce the radiation beam can be moved so that the beam enters the body from different directions, ‘spotlighting’ on the area to be treated. This means that the tumour is given a high dose whilst normal areas get either a lower or no dose at all.
Since the early 1980’s computers and other technical advances have improved radiotherapy. Before this there were not many ways to protect normal tissues which were in the path of a radiation beam. Even now, whilst modern techniques allow doctors to target the cancer cells more precisely than older techniques, healthy cells may still get damaged. This can result in some of the late effects covered in the PLAIN summaries. It will help you and your follow up specialist to know what long term effects there might be after your radiotherapy if you and they have your treatment summary.
Your treatment summary can tell you which areas of your body were irradiated. If you do not have a treatment summary or if you don’t understand what is written about the radiotherapy you received, please contact your treating hospital.
There are symptoms and signs that can tell you if you might have low BMD. You might not have these symptoms and signs at the moment, but it is important to be aware of them in case they may develop in the future.
Symptoms and signs of low BMD or osteoporosis (and its complications) are:
- Breaking bones easily
- Sudden, severe back pain or chronic back pain, for example due to breaking vertebrae.
- Loss of height
If you recognise any of these symptoms or signs in yourself, please contact your general practitioner or follow-up care specialist. These symptoms and signs are often caused by something else.
Symptoms and signs
Pain
From a physical point of view, pain is a life-sustaining biological reaction to damaging influences – even if tissue damage has not yet occurred. Due to its function as a damage indicator or warning, pain is usually associated with negative feelings so that we pay sufficient attention to it and learn as quickly as possible when it is dangerous for us. How intensely we feel a pain stimulus, whether it causes us to feel fear and panic, depends not only on the pure nerve signal, but is an interplay of biological, psychological and social factors.
All pain whose duration exceeds the extent of an acute (recent) cause and lasts for an incomprehensibly long time is called chronic pain. Strong and prolonged pain stimuli can make the transmitting nerve cells of the spinal cord and brain more sensitive to subsequent pain stimuli. This means that even mild stimuli can be perceived as severe pain. Under certain circumstances, these nerve cells, which have become hypersensitive
I am at higher risk of low BMD. What tests should I have and when?
If you are at higher risk of low BMD, it is advised to:
- Discuss your medical history and whether you experience(d) any symptoms and signs of reduced bone mineral density with your general practitioner or follow-up care specialist at least every 5 years. They may also discuss other risk factors for bone mineral density with you, such as poor intake of vitamin D or calcium.
- Have a DXA scan (bone density scan) once at entry into long-term follow-up (LTFU) and/or once at 25 years of age and more often if needed.
What happens if I have low BMD?
If you have low BMD, your general practitioner or follow-up care specialist will probably refer you to a specialist. Depending on the symptoms and/or signs you experience, you may be referred to an:
- Endocrinologist (physician specialised in hormones and metabolism)
- Rheumatologist (physician specialised in autoimmune and inflammatory diseases that affect the muscles and joints)
The specialist may help you interpret the results of your tests and discuss different treatment options with you. Sometimes it may be necessary to repeat the DXA scan again after some years.
Autoimmune disease
What else can I do?
Knowing that you may be at increased risk of low BMD can be difficult. Talking to friends and family can be helpful as well as specialist counselling and/or contact with support groups, such as patient organisations. For more information on taking care of your mental health, please read: Mental health problems.
To lower your risk of low BMD, it is very important to live a healthy lifestyle. In particular, it is important to exercise to strengthen your bones. It is advised to do exercises (such as cycling, tennis or doing housework) for at least 150 minutes a week. For adolescents, it is recommended to spend at least 60 minutes a day with moderate- to vigorous-intensity exercise (such as hiking, swimming or dancing). Taking care of your mental health may be beneficial; even small changes to your lifestyle can have a positive impact on both your physical and mental health. For more information on taking up a healthier lifestyle, please read: Health promotion.
The nutrients calcium and vitamin D are especially important to keep your bones strong. Calcium rich foods include dairy products, nuts, kale and bread. Fatty fish, margarine, halvarine and mushrooms are great sources of vitamin D. The body also produces its own vitamin D when exposed to sunlight. However, be aware that too much sun exposure can be harmful. If you cannot get enough of these nutrients through your diet, it might be necessary to take supplements with calcium and vitamin D. It is advised to consume at least 10 micrograms (µg) of vitamin D per day and at least 500 milligrams (mg) of calcium per day.
It is important to be aware of other potential risk factors that may cause low BMD:
- Cancer treatment with corticosteroids for 4 weeks or longer
- Hypogonadism, where the testes or ovaries produce too little sex hormones
- Growth hormone deficiency, where the pituitary gland in the brain produces too little growth hormone
- Low Body Mass Index (BMI) or underweight. For more information on BMI and weight after cancer treatment, please read: Overweight and obesity.
- Male sex
- White race
- Lack of physical activity
- Smoking
At this moment, there is not enough evidence to give recommendations to recommend BMD screening for these risk factors. Please discuss these risk factors with your general practitioner or follow-up care specialist.
It is also important to consider fall prevention. This can involve making sure that your home is safe and has no fall hazards, having your vision regularly checked on and wearing appropriate footwear.
It is important that you are aware of the possibility of developing low BMD and that you know the symptoms and signs. If you have any further questions or if the information in this brochure concerns you, please contact your general practitioner or follow-up care specialist.
Body Mass Index (BMI)
- With metric units: weight (kg) ÷ height2 (m)
- With imperial units: weight (lbs) ÷ height2 (inches) × 703
You can also use the BMI calculator on the website of the National Health Service of the UK (NHS).
For adults a normal BMI usually ranges between 18.5 and 25. A BMI below 18.5 or above 25 increases the risk of health problems. When the BMI is between 25 and 30, we consider someone to be overweight. When the BMI is above 30, we speak about obesity. It is important to consider that there are exceptions. For example, when you are pregnant, breastfeeding or have a lot of muscle mass, a BMI above 25 is not necessarily unhealthy.
It is important to keep in mind that the BMI score has limitations. It does not take into account how much of your weight is fat and how much is muscle mass. Furthermore, it also does not take the distribution of the fat in your body into account. That’s why healthcare professionals usually use the BMI together with other measuring systems (e.g. waist circumference) to assess your health.
Healthy lifestyle
- Having a healthy diet
- Drinking less (or no) alcohol
- Exercising regularly
- Quitting smoking (if you smoke)
Your follow-up care specialist or general practitioner may give you additional advice tailored to your individual situation for maintaining a healthy lifestyle. For more information on taking up a healthier lifestyle, please read: Health promotion.
Where can I find more information?
You may find more information about bone problems online. However, it is important to be aware that this information is not always up to date or accurate.
On this website, you can also find more information related to this topic:
Please note
This PLAIN summary is based on the PanCare Follow-up guideline about “Reduced bone mineral density” [1], which is based on the consensus of different national guidelines, and the IGHG* guideline for “Bone mineral density” [2].
While the PanCare PLAIN information group strives to provide accurate and complete information that is up-to-date as of the date of publication, you can check with your general practitioner or follow-up care specialist if this summary reflects the most up-to-date information available and whether it is relevant for you.
Please do not rely solely on this information. It is best to also seek the advice of a qualified medical practitioner if you have questions regarding a specific medical condition, disease, diagnosis or symptom.
No warranty or representation, expressed or implied, is made concerning the accuracy, reliability, completeness, relevance, or timeliness of this information. PanCare has produced the English version and PanCare is not responsible for the translated versions of this summary.
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.
*International Guideline Harmonization Group for Late Effects of Childhood Cancer
[1] van Kalsbeek, R. et al. (2021) European PANCAREFOLLOWUP recommendations for surveillance of late effects of childhood, adolescent, and Young Adult Cancer, European journal of cancer. Available at: https://www.ejcancer.com/article/S0959-8049(21)00368-3/fulltext
[2] Van Atteveld, J.E. et al. (2021) 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. Available at: https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00173-X/fulltext