Management of Bone Health in Breast Cancer Survivors

Breast cancer survivors (BCS) face a significantly higher risk of treatment-induced bone loss compared with the general population. Despite clinical guidelines, baseline bone mineral density (BMD) screening and indicated pharmacologic interventions remain consistently underutilized in this population.

This review synthesizes current evidence regarding the pathophysiology and incidence of bone loss in BCS. We evaluate the impact of cytotoxic and endocrine therapies on skeletal health and summarize contemporary guidelines for the screening, prevention, and management of cancer treatment-induced bone loss.

Up to 80% of patients with breast cancer experience bone loss during treatment, primarily driven by iatrogenic estrogen depletion. Fewer than half of patients starting endocrine therapy with aromatase inhibitors receive a baseline dual-energy x-ray absorptiometry scan as recommended by ASCO guidelines, and nearly 50% of treatment-eligible patients remain untreated. Proactive mitigation is essential and must include baseline BMD screening and fracture risk assessment (FRAX) at the initiation of endocrine therapy, with interval monitoring frequency that is tailored by baseline risk. In patients with osteoporosis or high-risk osteopenia, antiresorptive agents effectively improve BMD and reduce fracture-associated morbidity and mortality. A multipronged approach incorporating lifestyle factors such as calcium/vitamin D supplementation, smoking cessation, and weight-bearing exercise is critical for optimizing long-term skeletal health.

Bone loss is a nearly universal consequence of breast cancer therapy. Integrating proactive BMD monitoring, standardized FRAX, and timely initiation of antiresorptive therapy into survivorship care is vital to improve long-term outcomes and functional independence in BCS.