Bone health in cancer: perspective on the use of osteoanabolic agents

Cancer negatively impacts bone health through various mechanisms, including treatment-induced bone loss and malignant bone lesions, often leading to increased fracture risk and higher morbidity and mortality. Antiresorptive agents (bisphosphonates and denosumab) are the current standard of care to reduce the risk of skeletal-related events and prevent treatment-related fragility fractures in patients with cancer. While there is strong evidence to support their benefits in cancer, there is potential room for further reduction in the risk of pathologic and fragility fractures. This narrative review explores the potential role and theoretical concerns regarding the use of osteoanabolic agents in cancer. We also discuss management challenges, such as recurrent pathologic fractures, fragility fractures, and osteonecrosis of the jaw that may arise in clinical practice, prompting consideration of the use of osteoanabolic agents in patients with a history of cancer. Preclinical studies have shown conflicting outcomes regarding the effects on cancer with parathyroid hormone treatment, but promising results with the use of anti-sclerostin antibody in cancer models. Definitive conclusions cannot be drawn from available preclinical and clinical data. Theoretical risks exist for both cancer survivors and patients with advanced cancer in the bone. Therefore, the risk-benefit ratio should be carefully considered when evaluating the use of an osteoanabolic agent in the cancer context.