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The information on this page will help cancer survivors, their loved ones and caregivers understand how cancer and cancer treatments affect the bones. With this knowledge, cancer survivors can make a plan to protect their bones during their treatment and beyond.
Here is an overview of how cancer and its treatments can affect the bones.
Different types of cancer and cancer treatments affect the bones in different ways.
Choose from the section below which type of cancer you would like to learn more about.
Watch this recorded webinar to explore the connection between breast cancer and bone health. You will learn strategies to reduce your risk and how to talk with your health care providers about bone health.
Breast cancer, and treatments for breast cancer, can impact women’s bone health in several ways. Download this overview of how breast cancer and its treatments can affect the bones.
Bone health is important for your overall well-being during your cancer treatment and beyond. Be your own best advocate. Talk to your health care team about how treatment will affect your bones and what you can do to protect your bones. Here is a downloadable list of questions for you to ask your health care provider about bone health.
Below are some details about how cancer and certain breast cancer treatments affect bone health. You will find information about how you can protect your bones during and after treatment.
Calcium is an important building block of bone. Cancer cells release a hormone that can speed up the rate at which bones release calcium. This causes a serious condition called hypercalcemia, which means a high level of calcium in the blood. Hypercalcemia may be associated with cancer and requires treatment. Tell your health care provider if you have symptoms such as nausea, loss of appetite, thirst, frequent urination, constipation, irregular heartbeat, excessive sleepiness, and confusion. In rare cases, hypercalcemia can cause a coma.
Aromatase inhibitors are hormone therapies used to treat estrogen receptor-positive breast cancer in postmenopausal women. These evidence-based treatments keep cancer cells from getting the hormones they need to grow. Side effects of aromatase inhibitors include muscle pain, joint pain, menopausal symptoms and a loss of bone density, which can lead to an increased risk of fractures (broken bones).
Estrogen is the main hormone that helps certain (estrogen-positive) breast cancer tumors develop and grow. Most estrogen is produced in the ovaries, so after menopause, estrogen levels in the body decrease greatly.
AIs block estrogen from fueling tumor growth. Estrogen, however, is essential for bone health. It regulates the bone cells and how bone tissue is broken down and rebuilt. The effects of AIs increase the risk of bone loss and fractures.
AIs do not block the estrogen produced in the ovaries; that is why they are used mostly for postmenopausal women. They can be used in premenopausal women in combination with other medicines or in women who have had their ovaries removed with surgery.
Some chemotherapy treatments lower estrogen levels and cause women to go through menopause early. For women who haven’t gone through menopause, shutting down the ovaries can help prevent breast cancer from coming back. Both of these situations can lead to bone loss and increased fracture risk.
Estrogen receptor-positive breast cancer needs estrogen to grow. Shutting down the ovaries can slow the growth of these breast cancers in premenopausal women. Ovarian suppression lowers estrogen levels and causes periods to stop. This is similar to what happens in women who go through natural menopause. Some women have their ovaries surgically removed. Other women take medicines to stop the ovaries from producing estrogen. Lower estrogen levels can cause bone loss and increase the risk of broken bones.
Premenopausal women undergoing chemotherapy can take medicines called LHRH analogs to stop their ovaries from producing estrogen. These medicines include Zoladex® (goserelin) and Lupron® (leuprolide). The ovaries typically begin working normally again after the woman stops taking an LHRH analog medicine.
You might be sent to a radiation oncologist for radiation therapy to treat your breast cancer. This therapy is used to kill cancer cells that may be left in the breast after surgery. Radiation therapy can cause bone loss and fracture risk. In radiation therapy to treat breast cancer, radiation exposure to the ribs increases the risk of rib fractures.
Before you begin treatments for breast cancer that can weaken the bones as described above, you should get your bone density checked. The standard test for bone density is called a DXA. You lie fully clothed on an open table and get a low-dose X-ray. This test will establish your baseline bone density. That way, your health care provider can check your bone density again a few years later to see whether you are losing bone during your treatment.
You should also find out your family bone health history. Tell your health care provider if anyone in your family had osteoporosis or broken bones after age 50.
Assess your risk factors using the Bone Health & Osteoporosis Foundation Fracture Risk Calculator™ (developed by American Bone Health). Print a copy of your results, and share the report with your health care provider. Knowing your level of risk will help you and your care team create a bone health plan.
Your health care provider may prescribe a medicine to prevent bone loss and fractures caused by aromatase inhibitors. There are two types of these “anti-resorptive” medicines:
Bisphosphonates: These medicines are commonly used to treat osteoporosis. Cancer survivors take a larger dose. Bisphosphonates such as alendronate and risedronate are taken daily by mouth. Zoledronate is taken once a year by injection.
Denosumab: This is a monoclonal antibody taken by injection at a medical office two or more times a year. Its brand name is Prolia®. It is very important not to stop taking this medicine without starting a bisphosphonate. Stopping denosumab can cause rapid bone loss that has been shown to increase the risk of broken bones in the spine.
Studies have shown that both of these types of medicines can prevent bone loss and even help increase bone density. Data show that denosumab can help prevent fractures.
A balanced diet of whole foods, including protein, fats and carbohydrates, is important for bone health. Try to include a variety of foods on your plate to get your essential nutrients. You should be able to get most of the nutrients your body needs from your diet rather than from supplements.
Good nutrition will not only keep your bones strong but also help you keep up your weight, which is important for preventing fractures.
There are three nutrients that are especially important for bone health. You need to pay special attention to make sure you get enough of these nutrients.
You should consume protein with every meal. Protein helps build and repair muscles. Keeping your muscles strong will support your bones as you age. Good muscles help prevent falls and injuries.
How much protein you need depends on your age and weight. The USDA recommends .36 gram per pound of body weight. A person who weighs 150 pounds needs about 54 grams of protein a day, according to that formula. People who are more active need more protein.
Protein from lean meats and dairy products is higher quality than protein from plants. Animal proteins contain all the necessary amino acids. To get complete proteins from a plant-based diet, you need to combine foods to get all your amino acids. For example, pair black beans with brown rice or whole-grain bread.
Quit smoking and vaping. Limit alcohol to no more than one drink per day.
Weight-bearing exercise can help preserve your bone health. Some examples are running, jumping rope and weight training (such as calisthenics or weightlifting). 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.”
Bicycling and swimming are good cardiovascular activities, but they don’t put weight on the bones, so they don’t build bone strength.
Start exercising at a level that is right for you, and then work up from there. If you’re walking, pick up the pace. If you’re running, try adding higher-impact activities. Consult a health care provider before starting an exercise program. Work with a professional on any activity that adds load to your bones.
Avoid exercises that increase your risk of falls. Be careful about flexing or extending your spine to avoid vertebral fractures.
Check your balance. If you can’t stand on your dominant leg for 11 seconds, that means you are at risk of falling and getting injured.
Exercises can improve your balance and leg strength. Consider tai chi or yoga. Some instructors offer courses designed specifically to be safe on the bones.
There are more than 3.8 million breast cancer survivors in the United States. This includes people who are undergoing treatment and people who have completed treatment. Most of them are women who have gone through menopause and would already be at risk of osteoporosis and fractures. Some treatments for breast cancer, however, increase the risk of fractures even more than natural menopause.
As breast cancer survival rates increase, and as survivors live longer, good bone health remains a vital part of maintaining quality of life. Preventing fractures will help survivors stay mobile and independent and able to enjoy the life they fought so hard to save.
Cancer that has spread to other parts of the body is called metastatic cancer. Breast and prostate cancer most commonly spread — or “metastasize” — to the bones. Nearly all types of cancer can spread to the bones, including lung, kidney, and thyroid cancers.
When cancer spreads to the bones, it is called bone metastases, or “bone mets.” The most common bones for bone metastases are the spine, skull, ribs, pelvis, and long bones in the arms and legs.
Metastatic cancer that has spread to the bones is not bone cancer. For example, breast cancer that has spread to the bones is still breast cancer, and it is treated with breast cancer medicines.
You might find out you have bone metastasis years after starting cancer treatment. On the other hand, if you have certain types of cancer, bone metastasis might be the first sign you have cancer.
When cancer cells spread to the bones, they can form lesions. These lesions cause complications in the bones called “skeletal-related events,” or SREs. Here are some types of skeletal-related events:
There are two types of lesions that affect the bones. People can have one or both types of lesions:
Osteolytic, or lytic: These lesions break down bone without replacing it. That weakens the bones and causes them to break easily.
Osteoblastic, or blastic: These lesions make bone thick and rigid. These areas of the bone break more easily than normal bone.
People with metastatic cancer are living longer, so it’s important to prevent skeletal-related events.
Sometimes, bone metastasis causes no signs or symptoms. When signs and symptoms do occur, they include:
The bone complications from metastatic cancer can lead to severe pain, loss of mobility, and poor quality of life.
See your health care provider if you experience signs or symptoms that worry you. Imaging tests are used to investigate symptoms that may indicate bone metastasis. Your individual situation will determine which tests you get. Tests may include:
Your health care provider also might take a sample of tissue to examine. This is called a biopsy.
Health care providers may prescribe bone-strengthening medicines to protect your bones and reduce skeletal-related events. You take these medicines by infusion in a doctor’s office or clinic.
Using these bone-strengthening medicines can:
Acute phase reaction: This is the most common risk after an infusion of zoledronic acid. You might have a fever, muscle and joint pain, and fatigue. It usually starts about six hours after the first dose and lasts two or three days. Taking acetaminophen before and after your infusion can reduce the risk of this side effect.
You might also get side effects after a denosumab injection, including fatigue and joint pain. They will go away after a few days.
Osteonecrosis of the jaw: ONJ is a rare dental condition found mostly among cancer patients taking bone-strengthening medicines. ONJ occurs most often after a major dental procedure in which the bone in the jaw does not heal after eight weeks of appropriate dental care.
Atypical femoral fracture (AFF): Taking high doses of bisphosphonates for more than four years increases your risk of AFF. This is a rare but serious break of the thigh bone. It is like a stress fracture. It develops slowly from everyday activities. Tell your health care provider if you feel an ache in your groin or thigh. They can schedule an MRI or CT scan to see if the bone is in danger of breaking.
According to clinical studies, the benefits of taking high doses of bisphosphonates or denosumab to reduce skeletal-related events are much greater than the risk of these side effects.
You might be sent to a radiation oncologist for radiation treatment. Targeted doses of radiation can relieve pain where you have bone mets and help prevent bone fractures. Even short courses of radiation treatment can help with the pain. These courses last from one to five days. Radiation therapy also can lead to bone loss and fracture risk.
Surgical procedures can help stabilize a bone that is at risk of breaking or repair a bone that has broken.
You should get your bone density checked before you start cancer treatments that will weaken the bones. The standard test for bone density is called a DXA, which is a type of X-ray performed while you lie, fully clothed, on an open table. This test will establish your baseline bone density. That way, your health care provider can check your bone density again a few years later to see whether you are losing bone during your treatment.
You should also find out your family bone health history. Tell your health care provider if anyone in your family had osteoporosis or broken bones.
A balanced diet of whole foods, including protein, fats and carbohydrates, is important for bone health. Try to include a variety of foods on your plate to get your essential nutrients. You should be able to get most of the nutrients your body needs from your diet rather than from supplements.
Good nutrition will not only keep your bones strong but also help you keep up your weight, which is important for preventing fractures.
There are three nutrients that are especially important for bone health. You need to pay special attention to make sure you get enough of these nutrients.
You should consume protein with every meal. Protein helps build and repair muscles. Keeping your muscles strong will support your bones as you age. Good muscles help prevent falls and injuries.
How much protein you need depends on your age and weight. The USDA recommends .36 gram per pound of body weight. A person who weighs 150 pounds needs about 54 grams of protein a day, according to that formula. People who are more active need more protein.
Protein from lean meats and dairy products is higher quality than protein from plants. Animal proteins contain all the necessary amino acids. To get complete proteins from a plant-based diet, you need to combine foods to get all your amino acids. For example, pair black beans with brown rice or whole-grain bread.
Quit smoking and vaping. Limit alcohol to no more than one drink per day.
Weight-bearing exercise can help preserve your bone health. Some examples are running, tennis or pickleball, and weight training (such as calisthenics or weightlifting). 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.”
Bicycling and swimming are good cardiovascular activities, but they don’t put weight on the bones, so they don’t build bone strength.
Start exercising at a level that is right for you, and then work up from there. If you’re walking, pick up the pace. If you’re running, try adding higher-impact activities.
Exercises can improve your balance and leg strength. Consider tai chi or yoga. Some instructors offer courses designed specifically to be safe on the bones.
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.
Check your balance. If you can’t stand on your dominant leg for 11 seconds, that means you are at risk of falling and getting injured.
Falling is a key risk factor for breaking a bone. Someone who falls often is more likely to break a bone than someone who doesn’t fall, even if the person who doesn’t fall has more risk factors.
Here are some things you can do at home to reduce your risk of falling:
As metastatic cancer survivors live longer, good bone health remains a vital part of maintaining quality of life. Reducing skeletal-related events will help survivors stay mobile and independent and able to enjoy the life they fought so hard to save.
Prostate cancer, and some treatments for prostate cancer, can impact men’s bone health in several ways. Bone health is important for your overall well-being during your cancer treatment and beyond. Be your own best advocate. Talk to your health care team about how treatment will affect your bones and what you can do to protect your bones.
This section covers the effects on the skeleton of prostate cancer and some treatments for prostate cancer. Most men diagnosed with prostate cancer are 65 and older. That means they are at an age where their risk of bone loss and osteoporosis is increasing. By 70, men lose bone as fast as women that age.
Your health care provider might prescribe hormone therapy as part of your prostate cancer treatment. Hormone therapy adds, blocks, or removes hormones. In prostate cancer treatment, hormone therapy blocks or disrupts the male sex testosterone, which causes prostate cancer tumors to grow. Hormone therapy can slow tumor growth or shrink the tumor for a time.
Hormone therapy can be surgical (removal of the testicles) or systemic (involving the whole body). Systemic therapies target specific hormones that can fuel tumor growth. Here are the different systemic therapies used to treat prostate cancer.
LHRH agonists: Medicines that stop the testicles from making testosterone.
LHRH antagonists: Medicines that block the pituitary gland from making LHRH, causing the testicles to stop making testosterone.
Anti-androgens: Medicines that stop the receptors on cancer cells from receiving testosterone.
Corticosteroids: Medicines that slow progress of prostate cancer, control pain, or offset side effects of other therapies.
Androgen synthesis inhibitors: Medicines that block androgen production.
Hormones like testosterone protect against bone loss. Blocking these hormones makes the bones less dense and more likely to break easily.
One type of hormone therapy used to treat prostate cancer is androgen deprivation therapy. This type of treatment blocks or suppresses the amount of male sex hormones in the body. Androgen deprivation therapy deprives cancer cells of the male hormones (called androgens) that cancer needs to grow.
ADT includes three of the therapies mentioned above. Other hormone therapies are not considered ADT.
ADT causes hypogonadism, which means the glands produce little or no male sex hormone. This can cause high bone turnover, faster bone loss, and increased fracture risk.
Side effects of hormone therapy are not inevitable. They depend on factors including:
Weakening or thinning bones (osteoporosis) and fracture risk increase the longer you are on androgen deprivation therapy.
Other side effects from ADT include weight gain, loss of muscle mass, diabetes and heart disease.
LHRH agonists can cause an increase in testosterone in the body for several weeks. This increase is called a “flare.” Flare can cause bone pain if metastatic bone tumors can be detected on imaging scans. This pain doesn’t mean the cancer is growing. You might be given a medicine to control the flare.
Medicines such as enzalutamide, apalutamide, abiraterone can increase risk of falls. This is likely due to their effects on the central nervous system. Long-term ADT, combined with anti-androgen medicines, means greater risk of falls for men who are already at risk of fractures.1
Corticosteroids are used sometimes to prevent the adrenal glands from making testosterone. They can be used alone or in combination with chemotherapy or hormone therapy.
High doses of corticosteroids, or corticosteroids taken for a long time, can be harmful to the bones. These harmful effects happen quickly, often within three months of starting a corticosteroid. Systemic steroids affect the bone remodeling process by decreasing the activity of the bone-building cells (osteoblasts) and increasing the activity of the cells that break down bone (osteoclasts). The combination of these actions causes bone loss quickly.2
Medicines That Can Be Bad for Your Bones
Calcium is an important building block of bone. Cancer cells release a hormone that can speed up the rate at which bones release calcium. This causes a serious condition called hypercalcemia, which means a high level of calcium in the blood. Hypercalcemia may be associated with cancer and requires treatment. Tell your health care provider if you have symptoms such as nausea, loss of appetite, thirst, frequent urination, constipation, irregular heartbeat, excessive sleepiness, and confusion. In rare cases, hypercalcemia can cause a coma. Hypercalcemia is rare in prostate cancer patients compared to breast cancer patients.3
This section will provide information on how you can protect your bones during and after treatment for prostate cancer.
Some treatments for prostate cancer, like hormone therapy, can cause bone loss. Having weaker bones increases your risk of having fractures (broken bones). Before you begin treatments for prostate cancer that can weaken the bones, you should get your bone density checked. The standard test for bone density is called a DXA. You lie fully clothed on an open table and get a low-dose X-ray. This test will establish your baseline bone mineral density. You should get a follow-up DXA scan after one year to see whether you are losing bone during your treatment.
You should also assess your risk factors using the BHOF Fracture Risk Calculator™. Print a copy of your results and share the report with your health care provider. Knowing your level of risk will help you and your care team create a bone health plan.
Your health care provider may prescribe a medicine to treat bone loss and prevent fractures caused by hormone therapy. There are two types of these “anti-resorptive” medicines.
Bisphosphonates: These medicines are commonly used to treat osteoporosis. Cancer survivors take a larger dose. Bisphosphonates such as alendronate and risedronate are taken daily by mouth. Zoledronate is taken once a year by injection. These medications are also used to decrease the risk of prostate cancer metastasizing to the skeleton and causing hypercalcemia.
Denosumab: This is a monoclonal antibody taken by injection at a medical office two or more times a year. Its brand name is Prolia®. It is very important not to stop taking this medicine without starting a bisphosphonate. Stopping denosumab can cause rapid bone loss that has been shown to increase the risk of broken bones in the spine. A higher dose of denosumab, XGEVA, is also used to decrease the risk of prostate cancer metastasizing to the skeleton and causing hypercalcemia.
Studies have shown that both these types of medicines can prevent bone loss and even help increase bone density. Data show that denosumab can help prevent fractures.
Your health care provider will recommend you take a calcium and vitamin D supplement. You might take tests to monitor your kidney function and calcium levels.
Prostate cancer that has spread to other parts of the body is called metastatic prostate cancer. Like breast cancer, prostate cancer most commonly spreads to the bones. This is called “bone metastasis,” when cancer “metastasizes” to the bones. It causes bone metastases, or “bone mets.”
Bone metastasis puts your bones at risk for injury and disease, which are called “skeletal-related events.” These include:
Medicines used to treat bone metastases include:
Radium-223 is a radiopharmaceutical. That means it is a medicine that gives off radiation. Radium-223 collects in bone and gives off radiation that may kill cancer cells.
Radium-223 is used to treat prostate cancer that has spread to the bones, but not to other organs. It is used to treat patients whose cancer has not responded to hormone therapy to lower testosterone levels.
For people with metastatic prostate cancer, treatment with denosumab can help prevent or delay bone problems in men whose cancer has spread to the bones.
This, or another bisphosphonate medicine, may be prescribed to people with metastatic prostate cancer to help:
The Metastatic Cancer section has more information about skeletal-related events, treatments, and actions you can take to protect your bones if you have metastatic cancer.
A balanced diet of whole foods, including protein, fats and carbohydrates, is important for bone health. Try to include a variety of foods on your plate to get your essential nutrients. You should be able to get most of the nutrients your body needs from your diet rather than from supplements.
Good nutrition will not only keep your bones strong but also help you keep up your weight, which is important for preventing fractures. A healthful diet also will help prevent heart disease and diabetes linked to prostate cancer treatment.
There are three nutrients that are especially important for bone health. You need to pay special attention to make sure you get enough of these nutrients.
Calcium: Many foods contain calcium, but dairy products contain the most calcium per serving size. The amount of calcium you need changes with age. Try to consume one calcium-rich food per meal. If you don’t consume dairy products, you will need to work hard to get enough calcium in your diet. You might need to take a calcium supplement to make up the difference.
Vitamin D: Although vitamin D can be made in the skin when it is exposed to sunshine, the sun is not a reliable source of vitamin D for most people. To maintain a good level of vitamin D, people need anywhere from 15 mcg to 50 mcg (600 to 2,000 international units) a day. For healthy adults, the National Academy of Medicine suggests 15–20 mcg (600–800 IU). However, if you have a metabolic bone disease such as osteoporosis, the Endocrine Society suggests a higher level — up to 50 mcg (2,000 IU) per day. There are not many foods that are rich in vitamin D. You will probably need to take a supplement to get enough vitamin D.
Magnesium: This mineral helps your body regulate calcium and vitamin D. It is found in green vegetables, nuts and seeds, legumes, whole grains and avocados. The RDA — Recommended Dietary Allowance — for adult men is 420 mg and 320 mg for women.
You should consume protein with every meal. Protein helps build and repair muscles. Keeping your muscles strong will support your bones as you age. Good muscles help prevent falls and injuries.
How much protein you need depends on your age and weight. The USDA recommends .36 gram per pound of body weight. A person who weighs 150 pounds needs about 54 grams of protein a day, according to that formula. People who are more active need more protein.
Protein from lean meats and dairy products is higher quality than protein from plants. Animal proteins contain all the necessary amino acids. To get complete proteins from a plant-based diet, you need to combine foods to get all your amino acids. For example, pair black beans with brown rice or whole-grain bread.
Quit smoking and vaping. This will also limit your risk of death from prostate cancer. Limit alcohol to no more than one drink per day.
Physical activity can help preserve your bone health. Weight-bearing and resistance exercises are the best exercises for bone health. Weight-bearing exercises make you work against gravity. These include running, tennis or pickleball, and dancing. Resistance exercises such as weight-lifting or calisthenics also can strengthen bones. When you do weight-bearing and resistance exercises, 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.”
Bicycling and swimming are good cardiovascular activities, but they don’t put weight on the bones, so they don’t build bone strength.
Start exercising at a level that is right for you, and then work up from there. If you’re walking, pick up the pace. If you’re running, try adding higher-impact activities.
Exercises can improve your balance and leg strength. Consider tai chi or yoga. Some instructors offer courses designed specifically to be safe on the bones.
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.
Check your balance. If you can’t stand on your dominant leg for 11 seconds, that means you are at risk of falling and getting injured.
As treatments improve and survival rates increase, people with prostate cancer are living longer. Side effects from hormone therapy, like increased fracture risk, are not inevitable. Preventing broken bones is important for maintaining quality of life, mobility and independence. This will help you enjoy the life you fought so hard to save.
1 https://www.pcf.org/c/stay-bone-healthy/
2 https://americanbonehealth.org/bone-health/medications-that-can-be-bad-for-your-bones-2/
3 Goldner W. Cancer-related hypercalcemia. J Oncol Pract. 2016;12:426–432
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