Bone health and cancer

Some cancer treatments may affect your bones. Find tips to help you maintain healthy bones and improve your bone strength.
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About bone health and cancer

This information is about bone health. It is for people who have had or are having cancer treatments that may affect their bones.

The information is not about bone cancer. We have separate information about:

To understand bone health, it is helpful to know more about the bones and how having cancer and cancer treatment can affect them.

Bones are made from:

  • a protein called collagen
  • a mineral called calcium
  • other minerals and bone cells.

Your bones:

  • provide structure, support and protection for your internal organs – for example, the ribs protect the heart and lungs
  • work with your muscles so your body can move
  • store calcium and other minerals
  • contain bone marrow, which is where blood cells are made.

Types of bone

There are 2 types of bone:

  • Compact bone is the hard, rigid outer layer on the outside of the bones.
  • Cancellous bone is inside the compact bone. Under the microscope it looks like a honeycomb or mesh with a lot of spaces. It is sometimes called spongy bone because the spaces look like a sponge.

The structure of a long bone

The structure of a long bone
Image: The illustration shows a cross section of part of a bone. The outer part of the bone is labelled as compact bone. Inside this at the end of the bone is an area of spongy (cancellous) bone and the very centre of the bone is labelled as the bone marrow.

Bone growth and repair

Bones are living tissue. They have a blood and nerve supply to keep them healthy. Bones are constantly being renewed. This helps maintain their strength and shape.

Inside the bones, there are 2 types of bone cell:

  • Osteoclasts which break down and remove old bone.
  • Osteoblasts which build new bone.

Our bones stop growing in length by the time we are about 18 years old, but they may continue to grow into our early to mid 20s. Bones continue to increase in strength and thickness (density) until our late 20s and stay about the same until our mid-30s.

After our mid-30s and as we get older, bone density slowly decreases. This is because osteoclasts remove more bone tissue than osteoblasts make. This is called bone loss or bone thinning.

Cancer treatments and bone health

The risk of bone thinning can increase if you have or have had cancer. This can be because of cancer or its treatment. Some cancer treatments can affect your bone health, and cause more bone loss than usually happens with age.

Some cancer treatments can reduce the levels of the hormones oestrogen or testosterone in the body. This can cause bone thinning. The treatments that can cause this include some:

Some of these treatments may cause an early menopause and this can affect bone health.

If a treatment or a drug is likely to affect your bone health, your doctor will talk to you about this. They may do a test called a bone mineral density scan (BMD scan) to check the density of your bones. This may also be called a DEXA scan. It can show if the bone density is below normal or at risk of a fracture. They may give you treatments to protect you from osteoporosis. This is to prevent a bone from breaking.

There are also other things you can do to look after your bones can also help to reduce your risk.

Hormone therapy for breast cancer

Some drugs that treat breast cancer work by reducing oestrogen levels. They include:

Taking these drugs for several months or more can cause bone thinning and increase the risk of fractures.

Not all hormone therapies for breast cancer cause bone thinning. The hormone therapy drug tamoxifen slows down bone loss if taken after menopause. If tamoxifen is taken before having menopause, it is unlikely to lead to osteoporosis.

Ovarian suppression

If you have not been through menopause, your doctor may suggest treatment to stop the ovaries working. Ovarian suppression is treatment that stops the ovaries making oestrogen and causes a temporary menopause. For example, you may be offered the drug goserelin. If you take tamoxifen with goserelin, the risk of bone loss is higher. It is also higher if you are under 45 and your periods have stopped for at least 1 year.

We have more information about these hormone therapies and ovarian suppression.

Hormone therapy for prostate cancer

The hormone testosterone stimulates most prostate cancers. Some drugs used to treat prostate cancer work by reducing testosterone levels. A side effect of these drugs is bone loss. These drugs include:

Chemotherapy drugs

Some chemotherapy drugs affect how the ovaries or testicles work. They can reduce the levels of oestrogen or testosterone in the body. The effect may be temporary or permanent.

Having lower than normal levels of these hormones before the age of 50 can lead to bone thinning. Your cancer doctor or specialist nurse can tell you if your chemotherapy treatment is likely to affect your hormone levels or cause an early menopause.

Surgery

Hormone levels are reduced after the following surgeries:

  • An operation to remove both testicles.
  • An operation to remove both ovaries before menopause (ovarian ablation). This causes a permanent menopause.
  • Surgery for some types of brain tumour such as a pituitary gland tumour.

These reduced hormone levels can lead to bone thinning.

Radiotherapy to the ovaries

If you have pelvic radiotherapy to the ovaries before menopause, it can:

  • affect the way the ovaries work
  • reduce oestrogen levels
  • cause an early menopause.

This can increase the risk of osteoporosis.

Radiotherapy to the pelvis

Radiotherapy can sometimes cause changes to the bone in the area being treated. It is most likely to happen when radiotherapy is given to the pelvic area. This treatment may be used to treat cancer of the womb, cervix, prostate, bladder, anus or rectum.

Changes to the bone may mean the pelvis cannot cope with the normal stresses put on it. This may increase the risk of small cracks or fractures. Doctors call these pelvic insufficiency fractures (PIFs).

Steroid therapy

Some people have steroids, such as prednisolone and dexamethasone, as part of their cancer treatment. Having high doses of steroids can cause bone loss and increase the risk of fractures. The risk can increase the longer you take them.

Targeted therapies

Targeted therapies are drugs that find and attack cancer cells. Some targeted therapy drugs may affect bone health. Your cancer doctor or specialist nurse can tell you if your treatment may affect your bone health.

Other factors that affect bone health

Many factors can affect bone health and the risk of osteoporosis. There are some factors you cannot control, such as your age or family history. But there are factors you can try to manage, such as diet and physical activity.
  • Age

    Your bones are strongest in your 20s. Bone thinning begins in your 30s. The risk of a fracture because of bone thinning increases from the age of 50. Fractures are most common in:

    • women and people assigned female at birth over the age of 65
    • men and people assigned male at birth over the age of 75.
  • Menopause
    Anyone can develop osteoporosis, but it is more common after the menopause. Before menopause, the hormone oestrogen keeps bones healthy. But after menopause, oestrogen levels decrease, and the bones lose density quicker.
  • Low hormone levels

    Low levels of the hormones oestrogen or testosterone can affect bone density. Oestrogen levels naturally drop after the age of 50. Testosterone levels can also drop after the age of 50, but not as much as oestrogen.

    If you are transgender or non-binary, some gender-affirming treatments might also affect your hormone levels and bone health. Ask your GP or gender identity clinic for more information.

    Some cancer treatments can lower oestrogen or testosterone levels and increase risk of bone thinning. For example, hormonal therapies given to treat breast and prostate cancer. If these hormone levels are low, your doctors can talk to you about treatments to protect your bones.

  • Physical activity
    Being physically active when you are a young adult helps make your bones stronger and denser. Doing regular exercise throughout your life helps to keep your bones strong. Exercises such as walking, climbing stairs playing sports, dancing and weightlifting are also good for bone strength. These are called weight-bearing exercises.
  • Diet

    Eating a healthy balanced diet helps keep bones healthy. To help build bones and keep them strong, it is important to get the recommended amounts of protein, calcium and vitamin D.

    You can ask your GP, cancer doctor, specialist nurse or a dietician what foods you should try to include in your diet and if you need any supplements.

  • Family history of osteoporosis
    If one, or both, of your parents have had osteoporosis, you are more at risk of developing it. If you are worried about this, talk to your GP about how to reduce the risk.
  • Fragility fractures
    If you break a bone after falling from a standing height or less, this is called a fragility fracture. After the age of 50, it can be a sign you have weaker bones. This may make you more at risk of having a fracture in the future.
  • Weight

    People who have a low body weight for their height are more at risk of fractures than people who are a healthy weight.

    A body mass index (BMI) chart is used to measure if you are a healthy weight in relation to your height. Your BMI is based on your height and weight. Guidelines recommend that for bone health and general health, your BMI should be between 19 and 25kg/m2. Your GP, practice nurse, dietician or other health professional can work out your BMI for you.

    You can use the NHS BMI calculator to find your BMI. Speak to your GP or nurse if you are above or below the healthy weight range.

  • Smoking
    Research has shown that smoking reduces bone density, weakens bones and increases the risk of osteoporosis. Using the NHS Stop Smoking Services improves your chances of success.
  • Alcohol

    Drinking alcohol in moderation is not harmful to bone health. But if you often drink more than the government guidelines advise, your bone density may be reduced. This can increase your risk of osteoporosis.

    NHS guidelines suggest that you should:

    • not drink more than 14 units of alcohol a week
    • spread the alcohol you drink in a week over 3 or more days
    • try to have several alcohol-free days each week.

    Drinking alcohol also causes a higher risk of falls, which are a common cause of fractures. Drinkaware has more information about alcohol and drinking guidelines.

  • Medical conditions

    Some cancer types and treatment can affect bone health. Other medical conditions that have been linked to lower bone density include:

    • diabetes (type 1 and type 2)
    • asthma
    • inflammatory rheumatic diseases, such as rheumatoid arthritis and lupus (SLE)
    • inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis
    • long-term liver or kidney disease
    • thyroid diseases – for example, an overactive thyroid gland and hyperparathyroidism
    • having ovaries removed
    • eating disorders, such as anorexia
    • dementia.

    If you have difficulty walking, or a condition that makes you less mobile, this may also lead to a lower bone density.

  • Medicines

    Some drugs may increase your risk of fractures and developing osteoporosis. These include the following:

    • Steroids – these are given to treat illnesses such as rheumatoid arthritis and asthma. They may also be used with some cancer treatments.
    • Some anti-epileptic drugs – these are used to prevent fits (seizures) if you have epilepsy.
    • Some types of cancer treatments.

Tests to check your bone health

If you think you are at risk of bone thinning or osteoporosis, talk to your GP, specialist doctor, nurse or other health care professional from your cancer team. They can do tests to check your bone health.

Fracture risk assessment tools

Doctors can use an online tool to see whether you are at risk of a fragility fracture. There are 2 fracture risk assessment tools used called FRAX® and QFracture®. Your doctor may use 1 of these tools if they are concerned about your bone health. Or if you have risk factors for thinning. The online tool can work out your risk of developing a fracture. The results will show whether you have a low, intermediate or high risk of a fracture.

When your doctor or nurse uses the online tool, they will ask about your:

  • height
  • weight
  • medical history
  • possible risk factors for osteoporosis or fragility fractures.

Dual energy x-ray absorptiometry scan (DXA or DEXA scan)

You may have a dual energy x-ray absorptiometry scan. It is sometimes called a DXA or DEXA scan. This scan may also be called a bone mineral density scan (BMD scan) or bone density scan. It checks the density of your bones. If your bone density is low, you have a higher risk of a bone fracture.

We have more information about having a DXA scan.

Treatments to protect your bones

You may have drug treatments to protect your bones if:

  • tests show you have low bone density or a high risk of fracture
  • you are having cancer treatments that are known to increase your risk of osteoporosis.

Treatments to protect your bone may include:

We have more information about these and other drug treatments to protect the bones and possible side effects.

What you can do to look after your bones

There may be changes you can make to your lifestyle to improve or maintain your bone health and reduce your risk of osteoporosis. Your doctor may advise you to:

  • eat a healthy, balanced diet
  • include enough foods in your diet that have plenty of calcium
  • get enough vitamin D in your diet, from sunlight or supplements if it is difficult to get enough vitamin D
  • keep physically active.

We have more detail in our information about keeping your bones healthy.

Share your experience

If cancer treatments have affected your bone health, you may find it helpful to talk about it with other people. Sharing your thoughts and feelings with others can help them too. Hearing about how you have coped and what you have done to manage your bone health could help someone in a similar situation.

There are also opportunities to influence future healthcare by sharing your experiences. You could do this by:

  • joining a patient group or Macmillan's Online Community
  • volunteering with a cancer charity
  • taking part in research
  • telling NHS staff what you think about the care you received, or the care you would like to have received.

About our information

This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer.

Cancer Information Development team

Author

Macmillan Centre of Clinical Expertise

Reviewer

Date reviewed

Reviewed: 01 August 2024
|
Next review: 01 August 2027
Trusted Information Creator - Patient Information Forum
Trusted Information Creator - Patient Information Forum

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