Bone Health Guide for Breast Cancer Survivors

Bone health is important for overall health and wellness—and even more so for breast cancer patients and survivors. Breast cancer survivors had a 68 percent higher risk of osteoporosis and osteopenia compared with cancer-free women in a Breast Cancer Research study.

Hormonal therapy for breast cancer can also increase rates of bone fractures—yet another reason it is critical to pay attention to bone health. As breast cancer survival rates increase and survivors live longer, good bone health remains a vital part of maintaining quality of life.

The more you know about your risk of osteoporosis, the more you can focus on protecting your bones before, during, and after treatment. In this guide, we’ll cover the ins and outs of osteoporosis, the link between breast cancer treatment and osteoporosis, and how to take care of your bone health properly to reduce the risk of getting osteoporosis. 

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Jump to:

What is Osteoporosis?
The Link Between Breast Cancer and Osteoporosis
Breast Cancer Treatments that can Impact Bone Health
Signs of Bone Loss Due to Breast Cancer Treatments
Discussing Your Bone Health with Your Physician
Managing Bone Health After Breast Cancer Treatment

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What is osteoporosis?

Osteoporosis is a condition where bones lose strength and density following hormonal changes, quality of bone changes, and vitamin D3 or calcium deficiency, leading to an increased risk of fractures. While you can’t reverse bone damage caused by osteoporosis, you can improve bone density and prevent fractures.

Osteoporosis is a silent disease that often lacks symptoms: You may not know you have it until you fall and break a bone. Globally, 1 out of 3 women and 1 out of 5 men over the age of 50 will suffer a fracture related to osteoporosis. In the United States, more than 53 million people either have osteoporosis or are at high risk due to low bone mass, according to the National Institutes of Health.

For those diagnosed with osteoporosis, the risk of breaking a bone is based on family history, medical conditions, and medications, among other factors. The Bone Health & Osteoporosis Foundation’s 10-Year Fracture Risk Calculator can help you assess your 10-year fracture risk.

What causes osteoporosis?

As with many conditions, the risk of osteoporosis increases with age and is related to your family medical history. Another key factor is lower estrogen levels, which can be impacted by breast cancer treatment. Estrogen protects against bone loss, so women who have gone through menopause, had their ovaries removed, or experienced various breast cancer treatments have an increased risk of osteoporosis. We will cover this topic in greater detail later in this guide.

Other risk factors for osteoporosis include previous fractures not caused by injury, immobility, smaller size/body weight, certain medications and medical conditions, including diabetes, Crohn’s disease, celiac disease, and hyperthyroidism.

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The link between breast cancer and osteoporosis

Research has shown that breast cancer and osteoporosis are inextricably linked. Breast cancer can weaken bones by causing inflammation that spurs the breakdown of bones and slows new bone growth. This is another reason why breast cancer awareness efforts and breast cancer early detection programs are vitally important.

Does breast cancer increase the risk of osteoporosis?

Breast cancer itself does not cause osteoporosis. However, some breast cancer treatments can reduce bone density and increase the risk of osteoporosis and fractures.

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Breast cancer treatments that can impact bone health

Several common breast cancer treatments can affect both premenopausal and menopausal women in terms of bone health and strength.

Chemotherapy

Some chemotherapy treatments lower estrogen levels and can lead to early menopause. For women who have not yet experienced menopause, shutting down the ovaries can help prevent breast cancer from recurring. However, this can also result in bone loss and increased risk of fractures.

Ovarian suppression

Ovarian suppression treatments stop the ovaries from making estrogen, reducing bone strength. Estrogen production does resume when the medications are discontinued.

Breast cancer treatment can also include surgical removal of the ovaries, which is a permanent form of ovarian suppression that can increase the risk of osteoporosis.

Radiation therapy

Radiation therapy is used to kill cancer cells that may be left in the breast after surgery, and it can also increase the risk of bone loss and fractures, including a greater risk of rib fractures due to radiation exposure in that area.

Tamoxifen

Tamoxifen is a medication used to prevent estrogen from helping cancer grow. For those who haven’t reached menopause, it slightly increases the risk of osteoporosis. However, it reduces the risk for postmenopausal women.

Aromatase inhibitors

Aromatase inhibitors are hormone therapies that prevent the formation of estrogen and are sometimes 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 can include muscle and joint pain, menopausal symptoms, and loss of bone density, which can increase the risk of fractures.

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Signs of bone loss due to breast cancer treatments

Interestingly, most people don’t know they have bone loss until they experience a fracture—just one of the reasons that screening is so important.

While the general recommendation for osteoporosis screening is age 65 for women and 70 for men, anyone who has had treatments known to affect bone loss or density, or those who have experienced fractures not caused by an injury, should be checked earlier.

A bone density scan can help track the trajectory of potential loss during breast cancer treatment. If you are uncertain, ask your doctor if you should be screened for osteoporosis.

Measuring bone health

A variety of tools can assess bone health and provide baseline information, before, during, and after breast cancer treatment.

Physical exam

In addition to your medical history, a physical exam focused on bone health may include a spine exam and measurement to determine if you have lost height since your last assessment.

Urine and blood tests

Blood and urine tests can help to pinpoint potential causes of bone loss. They can take a closer look at blood calcium levels, thyroid function, vitamin D3 levels, a 24-hour urine calcium measurement, and various biomarker tests. These tests can also help your doctor determine if another medical condition may be contributing to bone loss.

Bone-density scans

Bone-density scans use X-rays to measure bone strength, predict the likelihood of fracture, and diagnose osteoporosis. The gold standard and most common test is known as a DEXA scan, or dual-energy X-ray absorptiometry, which is quick, safe, and painless. A scanner, using low X-ray levels, passes over the body to measure bone mineral density, particularly in the spine and hip. It calculates bone density based on the amount of radiation absorbed by the bone; an osteoporosis diagnosis indicates that bone density is below the expected range (or a T-score of less than -2.5).

If you have been diagnosed with breast cancer, your doctor will likely recommend a baseline DEXA scan prior to beginning treatment and regular scans as you get treatment for breast cancer. This information will determine if medication, lifestyle changes, or other protective measures should be taken to prevent further bone loss. If you haven’t had a bone-density scan and are recovering from breast cancer or have received treatment for breast cancer, talk with your doctor about whether you are a candidate.

Bone fracture risk assessment

Your physician can help you assess your risk for future fractures. In addition, the Bone Health & Osteoporosis Foundation’s 10-Year Fracture Risk Calculator can give you an idea of your risk factors.

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Discussing your bone health with your physician

Your doctor can answer questions you have regarding bone health and bone density and discuss potential lifestyle changes, treatments, and options.

In addition to any questions you may already have, as a breast cancer survivor, you may want to ask your physician the following:

• How can I reduce my risk of fractures?
• What changes can I make to my diet or exercise routine to better protect my bones?
• Are there any tests that I should have?
• How are my current treatments potentially affecting my bone health?
• What is the next step?

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Managing bone health after breast cancer treatment

If your bone mineral density declines during treatment for breast cancer, you can make lifestyle changes or talk with your physician about medications designed to keep your bones as strong as possible.

Lifestyle changes for healthy and strong bones

Fortunately, your lifestyle can positively impact your bone health for decades to come. Consider the following to keep your bones healthy and strong both during and after breast cancer treatment.

Diet and nutrition

A balanced diet of whole foods supports good bone health. Ideally, you should get most of your essential nutrients from your diet, rather than supplements, and enjoy a variety of colorful, whole foods. Good nutrition will not only keep your bones strong but also help you maintain your weight, also important for preventing fractures.

The following three nutrients are especially important for bone health and should be a part of your daily diet:

1. Calcium: Dairy products contain the most calcium per serving size. Calcium is also found in dark-green leafy vegetables, fish with bones, dried beans and peas, and calcium-fortified juice and cereal. Try to consume one calcium-rich food per meal, and consider taking a calcium supplement. The amount of calcium you need changes with age so make sure you are consuming an adequate amount for your current needs.
2. Vitamin D3: Although vitamin D3 can be produced when your skin is exposed to sunshine, the sun is not a reliable source of vitamin D3 for most people. To maintain a good level of vitamin D3, most adults need between 15-50 mcg (600-2,000 IU) a day. For healthy adults, the National Academy of Medicine suggests 15-20 mcg (600-800 IU). However, if you have osteoporosis, the Endocrine Society suggests a higher level of up to 50 mcg (2,000 IU) per day. The best whole-food sources include fatty fish, foods fortified with vitamin D3, beef liver, and egg yolks, as well as a vitamin D3 supplement. Low levels of vitamin D3 are also a risk factor for developing breast cancer, unrelated to one’s bone health. Discuss testing your vitamin D3 levels with your physician to determine if they are in a normal range.
3. Magnesium: This mineral helps your body regulate calcium and vitamin D3 and is found in green vegetables, nuts and seeds, legumes, whole grains, and avocados. According to the National Institutes of Health, the recommended dietary allowance of magnesium is 320 mg for adult women.

Protein is also a critical building block for bone health—it helps build and repair muscles—and it is recommended to consume protein with every meal. Keeping your muscles strong will support your bones as you age and help prevent falls and injuries. How much protein you need depends on your age and weight. The USDA recommends 0.36 grams per pound of body weight. A person who weighs 150 pounds, for example, needs about 54 grams of protein a day. People who are more active need more protein.

Lean meats and dairy products are great sources of protein, as are lentils, nuts, and seeds. To get complete proteins from a plant-based diet, you may need to combine foods to get all your amino acids. For example, you can pair black beans with brown rice or whole-grain bread.

Exercise

Weight-bearing exercise supports good bone health. Some common examples include walking, dancing, stair climbing, gardening, and strength training. When you do weight-bearing exercise, you put stress on the bones, which then triggers the cells to build more bone, leading to greater bone strength. Thirty minutes of weight-bearing exercise a day can make a big difference in your bone strength and health.

While biking and swimming are good cardiovascular activities, they don’t put weight on the bones and don’t enhance bone strength. There is no need to discontinue these activities if you enjoy them; simply add in more weight-bearing movements as well.

It is also important to avoid anything that increases your risk of falls, such as rollerblading. However, many exercises can improve your balance, such as tai chi and yoga, in particular. You may even find group fitness classes that are designed for bone health, breast cancer patients, chair work, and more.

Supplements and vitamins

In addition to a multivitamin, daily supplementation with calcium and vitamin D3 resulted in substantial hip and other fractures in studies—vitamin D3 helps the body absorb calcium, so they are a great pair. Magnesium, vitamin K, and zinc also play a role in bone health. Talk with your doctor about the best vitamins and supplements for you.

Alcohol and smoking

Both alcohol and smoking have a detrimental effect on bone density.

According to the American Academy of Orthopaedic Surgeons, smoking reduces blood supply to the bones, slows the production of bone-forming cells, impairs calcium absorption, and reduces the protective effect of estrogen. In addition, alcohol intake of greater than 3 ounces per day speeds up bone loss. If you smoke or drink alcohol, it is advisable to address these factors as part of your fracture prevention plan and seek medical attention if necessary.

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It is never too late to talk with your doctor about bone density or to focus on bone strength, particularly if you are a breast cancer survivor. Strong bones can help to prevent injuries and fractures and support your overall health and wellness.

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Sources:
Bone Health & Osteoporosis Foundation
National Institutes of Health

Content sponsored by Amgen

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