June 2017 Ask the Expert: Bone Health

June 1, 2017

It’s important to have strong, healthy bones. But breast cancer can make that harder. Some breast cancer treatments can weaken bones. And if breast cancer becomes metastatic, the bones are where it’s most likely to spread.

In June, Living Beyond Breast Cancer expert Adam Brufsky, MD, PhD, answered your questions about bone health and breast cancer. He addressed issues people with all stages of disease face, like keeping bones healthy during breast cancer treatment and, for those with metastatic disease, preventing and treating bone pain throughout long-term treatment.

 

 

Remember: we cannot provide diagnoses, medical consultations or specific treatment recommendations. This service is designed for educational and informational purposes only. The information is general in nature. For specific healthcare questions or concerns, consult your healthcare provider because treatment varies with individual circumstances. The content is not intended in any way to substitute for professional counseling or medical advice.

 

In what situations do doctors prescribe zoledronic acid (Zometa, Reclast) to people with breast cancer?

Generally in two situations:

  • When someone has bone metastases we give zoledronic acidinfo-icon every 3 months to block complications like bone fracture, worsening pain or need for radiationinfo-icon
    • Data from the OPTIMIZE trial recently changed how we give zoledronic acid in metastaticinfo-icon breast cancer. We used to give it monthly, but now every 3 months is the standard.
  • In early stageinfo-icon breast cancer we give zoledronic acid every 6 months to reduce bone loss from aromatase inhibitors as well as to prevent bone metastases

Are there any negative long term effects of zoledronic acid (Zometa, Reclast)? I was on it monthly for almost a decade and since 2012 have gotten it every 3 months.

I like to give my patients a year-long break after 5 years. You can get what is called atypical fracture of the femur (from brittle areas at the top of the femur bone) after 5-7 years of using zoledronic acidinfo-icon.

My ribs feel painful, especially along the area where radiation treatments were given. What is the best test to show if the bone has cancer in it or was damaged by radiation?

Probably a CT scaninfo-icon of that area. Sometimes a plain X-ray may help.

I receive eribulin (Halaven) to treat triple-negative metastatic breast cancer in the liver and lungs. A few days after my most recent treatment, I had terrible bone pain. Can this be a side effect of the medicine?

Are you on filgrastim (Neupogen) or pegfilgrastim (Neulasta) as well? Those medicines are often given with chemotherapyinfo-icon to lower the risk of infectioninfo-icon, and can sometimes cause bone pain. Eribulin rarely can cause pain as well. We recommend, if possible, to try ibuprofeninfo-icon, perhaps the night after getting chemo.

What supplements are beneficial for bone health after breast cancer treatment? Can they be taken at the same time as tamoxifen?

I recommend calcium and vitamin D. They do not interfere with tamoxifeninfo-icon.

What foods are best for bone health?

Foods high in calcium.

What kind of exercise is best for bone health and how do I do it safely?

Any exercise that has weight bearing, including running. Just be careful with the amount of weight.

I’m on an aromatase inhibitor. I eat a healthy diet and exercise, but I’m still losing bone density. What else can I do to stop bone loss?

There are drugs like bisphosphonates or denosumabinfo-icon (Proliainfo-icon, Xgevainfo-icon) that you can take.

What are the best ways to deal with joint pain from aromatase inhibitors?

Your doctor should check your vitamin D level. If low, you can take vitamin D and the achiness can go away. Some people try taking glucosamine chondroitin.

I'm on hormonal therapy and getting denosumab (Prolia) shots, which are helping with osteoporosis. Can I continue to get those shots the entire time I’m on hormonal therapy?

We like to stop after 5 years, since other complications may arise with long-term use, such as bone fractures. 

Does the bone weakness that breast cancer treatments cause make it more likely I’ll get a metastatic recurrence in my bones in the future?

Not really, although we have found that reducing bone turnover from osteoporosisinfo-icon with drugs like bisphosphonates may prevent breast cancer recurrenceinfo-icon in the bones.

I'm on monthly injections of denosumab (Xgeva) because of bone metastases in my spine. I’m also on an aromatase inhibitor. I needed to go off Xgeva for 3 months to have a root canal. What effect could temporarily stopping my denosumab shots have had on my spine metastases?

 It should have little effect. We think that these drugs are effective when given every 3 months, and there is a Swiss study recruiting that will compare every-month Xgeva to every-3-months Xgeva.

Is zoledronic acid (Zometa, Reclast) as effective in reducing risk of recurrence for women who are taking medicines that cause menopause as it is for women who are naturally postmenopausal?

Yes, it works regardless of how menopause comes about.

How do doctors distinguish between pain from arthritis and pain from metastases, and should that pain be treated differently? Scans show my disease is stable, but my pain is increasing by the week.

It can be tough to tell what's causing it, but if you have pain that continues to increase, your doctors should do more tests before other steps are taken.

Why is breast cancer so much more likely to spread to bones than it is to other places?

No one knows for sure, but it may have to do with certain receptors that breast cancer and bones both share.

Are certain subtypes of breast cancer more likely to spread to the bones than others?

Estrogen receptor-positive breast cancer tends to spread to bone more commonly than other types.

If I was diagnosed with breast cancer that is hormone receptor-negative, am I still at a higher risk for osteoporosis?

Possibly. Chemo can  cause osteoporosis, especially if it results in menopause.

I’ve heard Xgeva may prevent bone metastases from spreading to other locations. Is this true? What studies have looked at this issue?

It may prevent it from spreading to other bones. There was a study called ABCSG-18 published in 2015 in The Lancet Oncology that looked at this.

When is surgery used to treat bone metastases and how can it help?

Generally if there is a bone about to fracture from a metastasis we put a strengthening rod in it. We check x-rays for signs that a fracture is likely.

Surgery is a local treatment. It is not used to treat breast cancer cells that may be spreading throughout the body.

When is radiation used to treat bone metastases and how can it help?

Radiation is used for pain, and also to reduce tumor size and prevent bones from fracturing because of metastases.

It is a local treatment. It is not used to treat breast cancer cells that may be spreading throughout the body.

Is breast cancer more likely to spread to some bones than others?

For reasons we do not understand, bones of the ribs, spine, hips, and sternum seem to be more involved.

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