Bone health and osteoporosis screening in gynecologic cancer survivors

  • Janelle N. Sobecki
    Corresponding author at: 600 Highland Ave, H4/676, Madison, WI 53792, United States.
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, United States
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  • Laurel W. Rice
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, United States
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  • Ellen M. Hartenbach
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin-Madison School of Medicine and Public Health, United States
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Published:December 11, 2020DOI:


      • Women with gynecologic cancers are at risk for bone loss.
      • Osteoporosis screening is an important component of survivor care.
      • Early screening identifies women at highest risk for cancer treatment-induced bone loss.


      Cancer treatment-induced bone loss is a known side effect of cancer therapy that increases the risk of osteoporosis and bone fracture. Women with gynecologic cancer are at increased risk of bone loss secondary to the combined effect of oophorectomy and adjuvant therapies. Data regarding bone loss in women with gynecologic cancers are overall lacking compared to other cancer populations. Consequently, guidelines for osteoporosis screening in women with cancer are largely based on data generated among non-gynecologic cancer survivors. This article reviews current available data of bone health in women with gynecologic cancer, summarizes best-available guidelines for screening for osteoporosis in women with cancer, and provides guidance for osteoporosis screening in women with gynecologic cancers based on best available evidence.
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        • Ballane G.
        • Cauley J.
        • Luckey M.
        • Fuleihan G.E.-H.
        Worldwide prevalence and incidence of osteoporotic vertebral fractures.
        Osteoporos. Int. 2017; 28: 1531-1542
        • Kanis J.A.
        • Oden A.
        • McCloskey E.V.
        • Johansson H.
        • Wahl D.A.
        • Cooper C.
        A systematic review of hip fracture incidence and probability of fracture worldwide.
        Osteoporos. Int. 2012; 23: 2239-2256
        • Wright N.C.
        • Looker A.C.
        • Saag K.G.
        • Curtis J.R.
        • Delzell E.S.
        • Randall S.
        • et al.
        The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine.
        J. Bone Miner. Res. 2014; 29: 2520-2526
        • Roodman G.D.
        Mechanisms of bone metastasis.
        N. Engl. J. Med. 2004; 350: 1655-1664
        • Reuss-Borst M.
        • Hartmann U.
        • Scheede C.
        • Weiss J.
        Prevalence of osteoporosis among cancer patients in Germany.
        Osteoporos. Int. 2012; 23: 1437-1444
        • Johansson H.
        • Oden A.
        • Johnell O.
        • Jonsson B.
        • De Laet C.
        • Oglesby A.
        • et al.
        Optimization of BMD measurements to identify high risk groups for treatment—a test analysis.
        J. Bone Miner. Res. 2004; 19: 906-913
        • Shepstone L.
        • Lenaghan E.
        • Cooper C.
        • Clarke S.
        • Fong-Soe-Khioe R.
        • Fordham R.
        • et al.
        Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial.
        Lancet. 2018; 391: 741-747
        • Yoshida T.
        • Takahashi K.
        • Yamatani H.
        • Takata K.
        • Kurachi H.
        Impact of surgical menopause on lipid and bone metabolism.
        Climacteric. 2011; 14: 445-452
        • Howland W.J.
        • Loeffler R.K.
        • Starchman D.E.
        • Johnson R.G.
        Postirradiation atrophic changes of bone and related complications.
        Radiology. 1975; 117: 677-685
        • Higham C.E.
        • Faithfull S.
        Bone health and pelvic radiotherapy.
        Clin. Oncol. 2015; 27: 668-678
        • Lee Y.
        • Kim A.
        • Kim H.Y.
        • Eo W.K.
        • Lee E.S.
        • Chun S.
        Bone density in patients with cervical cancer or endometrial cancer in comparison with healthy control; according to the stages.
        J. Cancer. 2015; 6: 686
        • Lee S.W.
        • Yeo S.G.
        • Oh I.H.
        • Yeo J.H.
        • Park D.C.
        Bone mineral density in women treated for various types of gynecological cancer.
        Asia-Pacific J. Clin. Oncol. 2016; 12: e398-e404
        • National Comprehensive Cancer Network
        NCCN Clinical Practice Guidelines in Oncology, Genetic/Familial High-Risk Assessment: Breast and Ovarian (Version 2.2019).
        • Garcia C.
        • Lyon L.
        • Conell C.
        • Littell R.D.
        • Powell C.B.
        Osteoporosis risk and management in BRCA1 and BRCA2 carriers who undergo risk-reducing salpingo-oophorectomy.
        Gynecol. Oncol. 2015; 138: 723-726
        • Looker A.
        • Isfahani N.S.
        • Fan B.
        • Shepherd J.
        Trends in osteoporosis and low bone mass in older US adults, 2005–2006 through 2013–2014.
        Osteoporos. Int. 2017; 28: 1979-1988
        • Hibler E.
        • Kauderer J.
        • Greene M.H.
        • Rodriguez G.C.
        • Alberts D.S.
        Bone loss following oophorectomy among high-risk women: an NRG oncology/gynecologic oncology group study.
        Menopause (New York, NY). 2016; 23: 1228
        • Gralow J.R.
        • Biermann J.S.
        • Farooki A.
        • Fornier M.N.
        • Gagel R.F.
        • Kumar R.
        • et al.
        NCCN task force report: bone health in cancer care.
        J. Natl. Compr. Cancer Netw. 2013; 11: S1-50
        • Douchi T.
        • Kosha S.
        • Kan R.
        • Nakamura S.
        • Oki T.
        • Nagata Y.
        Predictors of bone mineral loss in patients with ovarian cancer treated with anticancer agents.
        Obstet. Gynecol. 1997; 90: 12-15
        • Hui S.K.
        • Khalil A.
        • Zhang Y.
        • Coghill K.
        • Le C.
        • Dusenbery K.
        • et al.
        Longitudinal assessment of bone loss from diagnostic computed tomography scans in gynecologic cancer patients treated with chemotherapy and radiation.
        Am. J. Obstet. Gynecol. 2010; 203 (353. e1-. e7)
        • Stavraka C.
        • Maclaran K.
        • Gabra H.
        • Agarwal R.
        • Ghaem-Maghami S.
        • Taylor A.
        • et al.
        A study to evaluate the cause of bone demineralization in gynecological cancer survivors.
        Oncologist. 2013; 18: 423
        • Schmeler K.M.
        • Jhingran A.
        • Iyer R.B.
        • Sun C.C.
        • Eifel P.J.
        • Soliman P.T.
        • et al.
        Pelvic fractures after radiotherapy for cervical cancer: implications for survivors.
        Cancer: Interdiscip. Int. J. Am. Cancer Soc. 2010; 116: 625-630
        • Nishio K.
        • Tanabe A.
        • Maruoka R.
        • Nakamura K.
        • Takai M.
        • Sekijima T.
        • et al.
        Bone mineral loss induced by anticancer treatment for gynecological malignancies in premenopausal women.
        Endocrine Conn. 2013; 2: 11-17
        • Mehmood Q.
        • Beardwood M.
        • Swindell R.
        • Greenhalgh S.
        • Wareham T.
        • Barraclough L.
        • et al.
        Insufficiency fractures in patients treated with pelvic radiotherapy and chemotherapy for uterine and cervical cancer.
        Eur. J. Cancer Care. 2014; 23: 43-50
        • Salcedo M.P.
        • Sood A.K.
        • Jhingran A.
        • Eifel P.J.
        • Klopp A.H.
        • Iyer R.B.
        • et al.
        Pelvic fractures and changes in bone mineral density after radiotherapy for cervical, endometrial, and vaginal cancer: a prospective study of 239 women.
        Cancer. 2020; 126: 2607-2613
        • Razavian N.
        • Laucis A.
        • Sun Y.
        • Spratt D.E.
        • Owen D.
        • Schonewolf C.
        • et al.
        Radiation-induced insufficiency fractures after pelvic irradiation for gynecologic malignancies: a systematic review.
        Int. J. Radiat. Oncol. Biol. Phys. 1 November 2020; 108: 620-634
        • Ethier J.-L.
        • Desautels D.N.
        • Amir E.
        • MacKay H.
        Is hormonal therapy effective in advanced endometrial cancer? A systematic review and meta-analysis.
        Gynecol. Oncol. 2017; 147: 158-166
        • Gershenson D.M.
        • Bodurka D.C.
        • Coleman R.L.
        • Lu K.H.
        • Malpica A.
        • Sun C.C.
        Hormonal maintenance therapy for women with low-grade serous cancer of the ovary or peritoneum.
        J. Clin. Oncol. 2017; 35: 1103
        • Jr Geisler
        • Haynes B.
        • Anker G.
        • Dowsett M.
        • Lønning P.E.
        Influence of letrozole and anastrozole on total body aromatization and plasma estrogen levels in postmenopausal breast cancer patients evaluated in a randomized, cross-over study.
        J. Clin. Oncol. 2002; 20: 751-757
        • Coates A.S.
        • Keshaviah A.
        • Thurlimann B.
        • Mouridsen H.
        • Mauriac L.
        • Forbes J.F.
        • et al.
        Five years of letrozole compared with tamoxifen as initial adjuvant therapy for postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1-98.
        J. Clin. Oncol. 2007; 25: 486-492
        • Cuzick J.
        • Sestak I.
        • Baum M.
        • Buzdar A.
        • Howell A.
        • Dowsett M.
        • et al.
        Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10-year analysis of the ATAC trial.
        Lancet Oncol. 2010; 11: 1135-1141
        • Jakesz R.
        • Jonat W.
        • Gnant M.
        • Mittlboeck M.
        • Greil R.
        • Tausch C.
        • et al.
        Switching of postmenopausal women with endocrine-responsive early breast cancer to anastrozole after 2 years’ adjuvant tamoxifen: combined results of ABCSG trial 8 and ARNO 95 trial.
        Lancet. 2005; 366: 455-462
        • Obstetricians ACo
        Gynecologists. Practice bulletin no. 129: osteoporosis.
        Obstet. Gynecol. 2012; 120: 718-734
        • Cosman F.
        • de Beur S.J.
        • LeBoff M.
        • Lewiecki E.
        • Tanner B.
        • Randall S.
        • et al.
        Clinician’s guide to prevention and treatment of osteoporosis.
        Osteoporos. Int. 2014; 25: 2359-2381
        • Curry S.J.
        • Krist A.H.
        • Owens D.K.
        • Barry M.J.
        • Caughey A.B.
        • Davidson K.W.
        • et al.
        Screening for osteoporosis to prevent fractures: US preventive services task force recommendation statement.
        Jama. 2018; 319: 2521-2531
        • Shapiro C.L.
        • Van Poznak C.
        • Lacchetti C.
        • Kirshner J.
        • Eastell R.
        • Gagel R.
        • et al.
        Management of osteoporosis in survivors of adult cancers with nonmetastatic disease: ASCO clinical practice guideline.
        J. Clin. Oncol. 2019; 37: 2916-2946
      1. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Breast Cancer [Available from:] Accessed August 13, 2020.

        • Runowicz C.D.
        • Leach C.R.
        • Henry N.L.
        • Henry K.S.
        • Mackey H.T.
        • Cowens-Alvarado R.L.
        • et al.
        American cancer society/American society of clinical oncology breast cancer survivorship care guideline.
        CA Cancer J. Clin. 2016; 66: 43-73
        • L-m Chen
        • Blank S.V.
        • Burton E.
        • Glass K.
        • Penick E.
        • Woodard T.
        Reproductive and hormonal considerations in women at increased risk for hereditary gynecologic cancers: Society of Gynecologic Oncology and American Society for reproductive medicine evidence-based review.
        Gynecol. Oncol. 2019; 155: 508-514
        • Pickhardt P.J.
        • Pooler B.D.
        • Lauder T.
        • del Rio A.M.
        • Bruce R.J.
        • Binkley N.
        Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications.
        Ann. Intern. Med. 2013; 158: 588-595
        • Salani R.
        Survivorship planning in gynecologic cancer patients.
        Gynecol. Oncol. 2013; 130: 389-397