Cancer-associated bone disease


Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.

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Fig. 1
Fig. 2



Austrian Breast & Colorectal Cancer Study Group


Androgen deprivation therapy


Aromatase inhibitor


Alkaline phosphatase


American Society of Clinical Oncology


Arimidex, Tamoxifen Alone or in Combination


Adjuvant Zoledronic Acid to Reduce Recurrence


Bone turnover marker


Bone mineral density


Confidence interval


Cyclophosphamide–methotrexate–5 fluorouracil


Computed tomography


Cross-linked terminal telopeptide


Dickkopf-related protein


Dual-energy X-ray absorptiometry


Estrogen receptor




European Society for Clinical and Economical Aspects of Osteoporosis and Osteoarthritis






Fibroblast growth factor


WHO fracture risk assessment tool


Gonadotropin-releasing hormone


Hazard ratio


Insulin-like growth factor


Intergroup Exemestane Study






Magnetic resonance imaging


National Comprehensive Cancer Network


N-terminal telopeptide


Osteonecrosis of the jaw




Platelet-derived growth factor-BB


Positron emission tomography


Prostate-specific antigen


Parathyroid hormone-related protein


Receptor activator of nuclear factor kappa-B


Receptor activator of nuclear factor kappa-B ligand


Randomized controlled trial


Relative risk


Study of Anastrozole with the Bisphosphonate Risedronate


Selective oestrogen receptor modulator


Secreted frizzled-related protein


Skeletal-related event


Transforming growth factor-beta


Tumour necrosis factor-alpha


Tartrate-resistant acid phosphatase


Thyroid-stimulating hormone


Vascular endothelial growth factor


Vertebral fracture assessment


World Health Organization

Z-Fast and ZO-Fast:

Zometa-Femara Adjuvant Synergy Trials


Alpha cross-linked telopeptides type


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The authors thank Ms Aida Farha, Medical Information Specialist, Saab Medical Library, American University of Beirut, for her assistance in designing comprehensive and complex searches of the various medical literature resources.

Conflicts of interest

René Rizzoli has received speaker or advisory board fees from Amgen, MSD, GSK, Servier, Danone and Takeda. Jean-Jacques Body has received speaker and consulting fees from Amgen and Novartis. Jorge B. Cannata-Andía has received research grants and speaker or advisory board fees from Amgen, Abbott, Servier and Shire. David Kendler has received honoraria for speaking, consulting and/or research grants from Amgen, Novartis, GSK, Eli Lily, Merck, Johnson&Johnson, Pfizer and Roche. Alexandra Papaioannou has been a consultant, or on a speaker’s bureau, or received unrestricted grants from Amgen, Eli Lilly, Merck Canada Inc., Novartis, Pfizer and Warner Chilcott. Tobias J de Villiers has received speaker or advisory board fees from Amgen, Merck, Adcock Ingram and Pfizer. Catherine Van Poznak has received research support from Amgen and Novartis. Ghada El-Hajj Fuleihan has received grants to support courses on osteoporosis from Novartis Pharmaceuticals and Les Laboratoires Servier. Abdellah El Maghraoui, Nicola Napoli, Dominique D Pierroz and Maria Rahme have no conflict of interest.

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This position paper has been endorsed by the Committee of Scientific Advisors of IOF

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Rizzoli, R., Body, JJ., Brandi, ML. et al. Cancer-associated bone disease. Osteoporos Int 24, 2929–2953 (2013).

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  • Bone
  • Cancer
  • IOF
  • Skeletal-related events