Osteoporosis and breast cancer treatment Factsheet

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1 Osteoporosis and breast cancer treatment Factsheet This factsheet is for people who have been treated for breast cancer and may be concerned or want more information about their risk of osteoporosis.

2 2 What is osteoporosis? Some treatments for breast cancer can increase your risk of getting osteoporosis, a condition that affects the bones. This factsheet explains what osteoporosis is, why you might be at risk if you ve had treatment for breast cancer, and how you can help protect your bones with simple lifestyle changes. What is osteoporosis? Osteoporosis literally means porous bones. The bones in our skeleton are made of a thick outer shell and a strong inner mesh filled with collagen (protein), calcium salts and other minerals. The inside looks like a honeycomb, with blood vessels and bone marrow in the spaces between struts of bone. Osteoporosis means some of these struts become thin or snap and the bones then become fragile and can break (fracture) with little or no force. Often osteoporosis isn t found until a fracture happens. The wrist, hip and spine are the sites where fractures most commonly occur. Although osteoporosis cannot be cured, treatments are available to try to keep bones strong and less likely to break. What causes osteoporosis? Around the age of 35, bone loss increases as part of the natural ageing process, and this in itself can lead to osteoporosis. About half the population will have osteoporosis by the age of 75. The female hormone oestrogen protects against bone loss and helps to maintain bone density and strength. Women who have gone through the menopause are at increased risk of osteoporosis because their ovaries no longer produce oestrogen (low levels of oestrogen are still produced in body fat).

3 Visit 3 Some breast cancer treatments can cause an early menopause, increasing the risk of osteoporosis. Other treatments can reduce the amount of oestrogen circulating in the body. Breast cancer treatment and bone health Women who have not yet gone through the menopause (pre-menopausal) may have an increased risk of developing osteoporosis due to the treatment they are given. This includes chemotherapy, ovarian suppression and ablation, and tamoxifen. Women who have gone through the menopause (post-menopausal) may also be at increased risk of developing osteoporosis if they take an aromatase inhibitor as part of their treatment. Chemotherapy Chemotherapy can affect the function of the ovaries, causing an early menopause in some women. This means less oestrogen is produced which can lead to a reduction in bone density. Ovarian suppression and ablation Temporarily or permanently stopping the ovaries from working may be offered as a treatment for breast cancer. This can be done using a type of hormone therapy, surgery or radiotherapy. This causes a reduction in oestrogen that is more sudden than a natural menopause and which can lead to a loss of bone density. Tamoxifen Tamoxifen can be given to both pre-menopausal and post-menopausal women to block the effect of oestrogen on breast cancer cells. In pre-menopausal women, taking tamoxifen may cause a slight increase in bone loss, although this is unlikely to lead to osteoporosis unless treatments to stop the ovaries from working are given as well.

4 4 Breast cancer treatment and bone health When taken by post-menopausal women, tamoxifen slows down the process of bone loss and can reduce the risk of osteoporosis. Aromatase inhibitors Aromatase inhibitor drugs (including anastrozole, letrozole and exemestane) are used to treat breast cancer in post-menopausal women. These drugs reduce the amount of oestrogen circulating in the body, which may lead to a reduction in bone density. However, the risk depends on how healthy the bones were before breast cancer treatment. People with good bone density levels before having breast cancer are much less likely to develop osteoporosis while taking an aromatase inhibitor, which is usually taken for up to five years. How is osteoporosis diagnosed? Osteoporosis is diagnosed with a bone density scan, often referred to as a DEXA (dual energy x-ray absorptiometry) or DXA scan. This type of scan can also be done to assess the risk of osteoporosis developing. Other factors, such as your age, family history of osteoporosis or whether you have broken a bone in the past, will also help predict your risk of breaking a bone. The DEXA scan is used to measure bone mineral density (BMD). BMD is the amount of calcium and other minerals in an area of bone and is a measurement of bone strength. The lower your bone mineral density, the higher your risk of fracture. A DEXA scan is quick and painless and uses only a small amount of radiation. While you are lying down, the scanner passes x-rays through the body. Some of the x-rays will be absorbed and some will travel through the body. The amount of radiation which passes through specific bones (usually the hip and lower spine) is measured. The result is given as a T-score. This is a measure of how your BMD compares to a range of young healthy adults with average BMD.

5 Visit 5 If a DEXA scan shows a decrease in BMD that isn t low enough to be diagnosed as osteoporosis, you may have a condition called osteopenia. If this happens you will be given advice about changes you can make to your lifestyle, such as diet and exercise. You won t usually need treatment, but your doctor will discuss this with you. You can read more about having a DEXA scan on the National Osteoporosis Society website How will I know if I m at risk? The National Institute for Health and Care Excellence (NICE) an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health recommends that women at risk of developing osteoporosis should have their BMD assessed. If your specialist team has a concern about your risk of developing osteoporosis they may suggest a bone mineral density scan to check your bone health before you start treatment. If you are being treated with an aromatase inhibitor then additional bone density scans may be recommended during your treatment. Risk factors for osteoporosis include: increasing age low levels of the hormone oestrogen because of an early (before the age of 45) natural menopause or hysterectomy with removal of the ovaries, treatment for cancer (such as chemotherapy, hormone therapy and ovarian ablation or suppression) or the eating disorder anorexia nervosa a family history of osteoporosis or hip fracture previous wrist, spine or hip fracture resulting from little or no trauma long-term use of corticosteroid tablets (for conditions such as arthritis and asthma) medical conditions that affect the absorption of foods, such as Crohn s disease, coeliac disease or ulcerative colitis conditions that leave you immobile for a long time

6 6 How will I know if I m at risk? low body weight regularly drinking more than the recommended amount of alcohol (see page 7) smoking a diet that is low in calcium (calcium can help to maintain bone mass). NICE recommends that people with early invasive breast cancer should have a DEXA scan to assess bone mineral density if they: are starting aromatase inhibitor treatment have treatment-induced menopause are starting ovarian ablation or suppression therapy. Looking after your bones Bone health is important throughout life, but it becomes more important as we get older or if illness or treatment for illness cause bone problems. Some simple changes to your lifestyle can help keep your bones strong and healthy. If there is already bone thinning, changes to diet can t cure the problem but may help stop it getting worse. Food and drink for healthy bones A varied balanced diet will give you the nutrients that are important for strong, healthy bones. A healthy balanced diet should include: some starchy carbohydrate foods such as bread, potatoes, pasta and cereals plenty of fruit and vegetables some protein-rich foods such as meat, fish, eggs, beans, lentils and nuts some milk and dairy foods not too much fat, salt or sugar.

7 Visit 7 It s recommended that you eat at least five portions of fruit and vegetables every day. This includes fresh, frozen, tinned or dried fruit and vegetables. Drinking too much alcohol can have a damaging effect on your bones. It s recommended that women should drink no more than 2 to 3 units of alcohol a day, and men no more than 3 to 4 units a day. One unit of alcohol is about half a pint of beer, one 125ml glass of wine or a single 25ml measure of spirits. Calcium Calcium is a vital mineral for teeth and bones because it gives them strength and hardness. Our bodies contain about 1kg of calcium and 99% of it is found in our bones. Our main dietary source of calcium is dairy produce. Most people are able to get enough calcium through a healthy diet which includes dairy products. If you don t eat or drink any dairy products, it s important to ensure you still get enough calcium in your diet from other non-dairy sources. You may need to take a calcium supplement if you don t get enough calcium from diet alone. Good sources of calcium include: milk and dairy products (including low-fat varieties) such as yoghurt, fromage frais and cheese calcium-fortified breakfast cereals dried fruit such as apricots and figs fish with edible bones such as anchovies, sardines, pilchards and whitebait green leafy vegetables like broccoli, watercress and curly kale pulses, beans and seeds such as kidney beans, green beans, baked beans and tofu (a vegetable protein made from soya beans) nuts and seeds such as almonds, brazil nuts, hazelnuts and sesame seeds okra.

8 8 Looking after your bones The calcium content of drinking water varies greatly across the UK. Some bottled mineral waters are calcium enriched (and are healthier than fizzy drinks). How much calcium do I need? Adults need around 700mg of calcium a day, although someone with osteoporosis may be advised to have around 1,000mg a day. See the table below for a guide to the calcium values of some common foods (all figures are approximate). Food Semi-skimmed milk Cheddar cheese Sardines in oil Tinned salmon Stir-fried okra Watercress Baked beans Dried figs Sesame seeds White bread Wholemeal bread mg of calcium per 100g 120mg (per 100ml) 739mg 500mg 91mg 220mg 170mg 53mg 250mg 670mg 177mg 106mg Vitamin D Vitamin D is needed to help your body absorb calcium. The best source is sunlight, which your body uses to make this vital vitamin in your skin. About minutes exposure to sun a day during the summer will usually provide most people with enough vitamin D for the year. The body stores vitamin D for use during the winter months. If you regularly go walking, do gardening or any other outdoor activity, you probably get enough exposure to sunlight without even thinking about it. However, as you get older the body is less able to make vitamin D from sunlight and so your dietary intake becomes more important. For people over 65, a vitamin D supplement may be necessary.

9 Visit 9 Other sources of vitamin D include: margarine low-fat spreads egg yolks oily fish such as herrings and sardines cod liver oil vitamin D fortified breakfast cereals. If you think you may not be getting enough vitamin D or calcium in your diet, your GP (local doctor) or specialist team can prescribe supplements or refer you to a dietitian for further advice. Physical activity Regular weight-bearing exercise helps stimulate growth and strength of the bones. Weight-bearing exercises include: skipping aerobics tennis dancing brisk walking The type of activity you do will depend on your individual needs and current abilities (such as your fitness levels, any effects of treatment or other health problems you might have). However, if you have osteoporosis you should avoid high-impact exercise such as running because of a higher chance of injury. In addition to helping strengthen bones, exercise after treatment for breast cancer may also improve some of the other side effects of treatment such as cancer-related fatigue and weight gain and some studies have shown that it may also help reduce the risk of breast cancer coming back.

10 10 Looking after your bones It s recommended that adults should do at least 150 minutes (2 hours 30 minutes) of moderate-intensity activity a week. How you do this is up to you. For example, you could do 30 minutes of activity on five days a week. If you want to do shorter periods of activity, you could do 10 minutes three times a day on each of these days. Any amount of activity is better than none, so try to minimise the time you are inactive as much as you can. Moderate-intensity activity should make your heart beat faster. You ll feel warmer and breathe slightly harder, but you should still be able to hold a conversation. If you choose an activity that you enjoy, you re more likely to do it regularly. You should consult your doctor before starting any new exercise routine. If you need some ideas on how to start introducing exercise, our DVD Eat well, keep active after breast cancer features an exercise class that is suitable for people who have had treatment for breast cancer. It also features the experiences of other people getting back to activity after breast cancer. Smoking Smoking has been linked to a higher risk of osteoporosis, so it s a good idea to stop or cut down if you smoke. If you need help to stop smoking, speak to your GP or visit the NHS Smokefree website smokefree.nhs.uk Treatment for osteoporosis Although osteoporosis cannot be cured, treatments are available to try to stop the bones getting any weaker and to make them less likely to fracture. Osteoporosis in people who have had breast cancer is most commonly treated with a group of drugs called bisphosphonates.

11 Visit 11 These drugs may also be prescribed alongside an aromatase inhibitor (exemestane, letrozole or anastrozole) to help protect against its effects on the bones. Bisphosphonates aim to strengthen existing bone by slowing down the process of bone loss while allowing the production of new bone. Denosumab is a drug that may be recommended for the prevention of fracture. It is given as an injection twice a year and slows the process of bone loss in osteoporosis. It s a treatment for post-menopausal women who are unable to take certain bisphosphonates and who have particular risk factors for fracture. Strontium ranelate is another drug that may occasionally be used to treat severe osteoporosis in post-menopausal women. It is taken as granules dissolved in water. Like denosumab, it can only be prescribed in certain circumstances, such as in people who are at high risk of fracture. The National Osteoporosis Society has more information on these drugs on its website If you are found to have osteoporosis, you will be advised about appropriate drug treatment and given guidance on any changes to your diet or lifestyle that may be helpful. Bisphosphonates and denosumab are also used to treat breast cancer that has spread to the bones (secondary breast cancer in the bone). This is not the same as having osteoporosis.

12 12 Further support Further support Breast Cancer Care From diagnosis, throughout treatment and beyond, our services are here every step of the way. Here is an overview of all the services we offer to people affected by breast cancer. To find out which may be suitable for you call our Helpline on or contact one of our centres (details in the inside back of this leaflet). Our free, confidential Helpline is here for anyone who has questions about breast cancer or breast health. Your call will be answered by one of our nurses or trained staff with experience of breast cancer. If you prefer, we can answer your questions by instead through the Ask the Nurse service on our website. Our website gives instant access to information when you need it. It s also home to our Discussion Forum, the largest online breast cancer community in the UK, where you can share your questions or concerns with other people in a similar situation. Through our professionally hosted forum you can exchange tips on coping with the side effects of treatment, ask questions, share experiences and talk through concerns online. If you re feeling anxious or just need to hear from someone else who s been there, this is a way to gain support and reassurance from others in a similar situation. We host weekly Live Chat sessions on our website offering you a private space to discuss your concerns with others getting instant responses to messages and talking about issues that are important to you. Our map of breast cancer services is an interactive tool, designed to help you find breast cancer services in your local area wherever you live in the UK. Visit

13 Visit 13 Our One-to-One Support service can put you in touch with someone who knows what you re going through. Just tell us what you d like to talk about and we can find someone who s right for you. We run Moving Forward Information Sessions and Courses for people living with and beyond breast cancer. These cover a range of topics including adjusting and adapting after a breast cancer diagnosis, exercise and wellbeing, and managing side effects. In addition, we run Lingerie Evenings where you can learn more about choosing a bra after surgery. Our HeadStrong service can help you prepare for the possibility of losing your hair during treatment find out how to look after your hair and scalp and make the most of alternatives to wigs. We offer specific, tailored support for younger women through our Younger Women s Forums, and for people with a diagnosis of secondary breast cancer through our Living with Secondary Breast Cancer meet-ups. Our free Information Resources for anyone affected by breast cancer include factsheets, booklets and DVDs. You can order all our publications from our website or by using an order form available from the Helpline. To request a free leaflet containing further information about our services for people having treatment for breast cancer please contact your nearest centre (contact details at the back).

14 14 Further support Other organisations Macmillan Cancer Support 89 Albert Embankment London SE1 7UQ General enquiries: Helpline: Website: Textphone: or Text Relay Macmillan Cancer Support provides practical, medical, emotional and financial support to people living with cancer and their carers and families. It also funds expert health and social care professionals such as nurses, doctors and benefits advisers. National Osteoporosis Society Camerton Bath BA2 0PJ Helpline: Website: The National Osteoporosis Society is a UK-wide charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis.

15 This factsheet can be downloaded from our website, where you can also find the titles we produce as e-books. Publications are also available in large print, Braille, audio CD or DAISY format on requests by phoning This factsheet has been produced by Breast Cancer Care s clinical specialists and reviewed by healthcare professionals and people affected by breast cancer. If you would like a list of the sources we used to research this publication, publications@breastcancercare.org.uk or call Centres London and the South East of England Telephone src@breastcancercare.org.uk Wales, South West and Central England Telephone cym@breastcancercare.org.uk East Midlands and the North of England Telephone nrc@breastcancercare.org.uk Scotland and Northern Ireland Telephone sco@breastcancercare.org.uk We are able to provide our publications free of charge thanks to the generosity of our supporters. We would be grateful if you would consider making a donation today to help us continue to offer our free services to anyone who needs them. Please send your cheque/po/caf voucher to Breast Cancer Care, FREEPOST RRKZ-ARZY-YCKG, 5 13 Great Suffolk Street, London SE1 0NS Or to make a donation online using a credit or debit card, please visit All rights are reserved. No part of this publication may be reproduced, stored or transmitted, in any form or by any means, without the prior permission of the publishers.

16 Breast Cancer Care is here for anyone affected by breast cancer. We bring people together, provide information and support, and campaign for improved standards of care. We use our understanding of people s experience of breast cancer and our clinical expertise in everything we do. Visit or call our free Helpline on (Text Relay 18001). Interpreters are available in any language. Calls may be monitored for training purposes. Confidentiality is maintained between callers and Breast Cancer Care. Central Office Breast Cancer Care 5 13 Great Suffolk Street London SE1 0NS Telephone Fax info@breastcancercare.org.uk Breast Cancer Care, September 2013, BCC75 Edition 4, next planned review 2015 Registered charity in England and Wales ( ) Registered charity in Scotland (SC038104) Registered company in England ( )