The NCCN recommends calcium supplementation in cancer patients at risk for bone loss and fracture from therapy or age. According to the NCCN, total daily calcium intake from food and supplements should be at least 1200mg/day for postmenopausal women, any adult older than age 50 years, and patients at risk for cancer treatment-related bone loss. Regarding vitamin D supplementation in cancer patients, the NCCN Task Force report recommends supplementation in patients who have a serum 25(OH) vitamin D level of less than 30ng/mL. Therefore, based on the case above, both calcium and vitamin D supplementation are indicated. 

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All patients with breast cancer should be evaluated for an increased risk of fractures. The World Health Organization Fracture Risk Assessment Tool (FRAX), which is used to assess a patient’s risk of fracture, is available online here.  The FRAX index is a short questionnaire in which risk factors such as patient age, history, and previous fracture are submitted. These risk factors are then used to calculate the patient’s 10-year probability of either a major osteoporotic event or hip fracture. This assessment can help determine the need for bone-directed therapy in a patient with early stage breast cancer. 

In addition to FRAX risk assessment, it is important to establish a baseline bone mineral density (BMD) using a DEXA scan. In general, treatment with bone-directed therapy would be warranted if a patient had a T-score <-2.0, 10-year probability for hip fracture ≥3%, and 10-year probability of major osteoporotic event ≥20%. Therapy would also be indicated if a patient had a T-score of ≤-2.5 at the femoral neck or spine after evaluation to exclude secondary causes, or if the patient had a hip/vertebral fracture.

Therefore, in this patient, it is important to obtain the FRAX risk assessment as well as the T-score before initiating pharmacologic therapy. The FRAX result as well as the BMD was not known in this patient. Therefore, initiating pharmacologic bone-targeted therapy is not indicated until more objective information is available. Starting bone-directed therapy based on the patient’s menopausal status and aromatase inhibitor therapy isn’t sufficient to justify therapy empirically. At this clinic visit, it would be important to remind the patient to take calcium and vitamin D supplements and to encourage lifestyle modifications such as increasing weight-bearing exercise.  


Gralow JR, Biermann JS, Farooki A, et al. NCCN Task Force Report: Bone Health in Cancer Care. J Natl Compr Canc Netw. 2009;7 Suppl 3:S1-S32; quiz S33-S35.

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