Musculoskeletal
Prevention and Therapy
Prevention and Therapy for osteoporosis
The causes of osteoporosis need to be addressed:
- Calcium and Vitamin D deficiency can occur due to many conditions which both affect children with cancer and the general population:
- Malabsorption
- Malnutrition
- Lack of sun exposure
- Liver or renal disease
- Physical inactivity
In a study of ALL patients only 70% had sufficient calcium intake
Recommendations:
- Dietary advice is often necessary (recipes like this
turkey quiche) or to prescribe supplementation - 500 mg calcium and 400 IU vitamin D/day
- Physical activity: Regular exercise is very important
- Exercise and weight-bearing activities cause mechanical stress that stimulates new bone formation
- Physical fitness is an important factor in developing and preserving normal bone mass in adult survivors of childhood ALL
Links to sites with advice on bone health:
Bone Health for Life: The Jean Hailes Foundation
The National Osteoporosis Foundation
Therapy of osteoporosis:
There may be a role for:
Inhibit bone turnover by decreasing bone resorption
- Inhibit the recruitment and function of osteoclasts
- Stimulate osteoblasts to produce an inhibitor of osteoclast formation
- Shorten the life span of osteoblasts
Bisphosphonate therapy is effective in:
- Patients with postmenopausal osteoporosis
- Glucocorticoid-induced osteoporosis in adults
- Severe primary osteoporosis in childhood
- Children with connective tissue disease and chronic juvenile arthritis – short term studies have been published with promising results
- Children on chronic steroid therapy with pathological fractures:
- Pamidronate increased BMD and decreased skeletal pain
- Linear growth progressed normally during bisphosphonate therapy and bone biopsies showed normal mineralization
Biphosphonate Side Effects:
- Bisphosphonates may cause an acute phase reaction after intravenous and oral administration characterized by:
- High temperature
- Musculoskeletal pain
- Vomiting
- Gastrointestinal side effects have been reported with all orally administered bisphosphonates
- Severe hypocalcemia can rarely occur after intravenous administration of pamidronate
Reversible sclerotic epi- and metaphyseal bands have been reported following bisphosphonate therapy in children.
Only a few publications are available on the use of bisphosphonates in children with cancer, but this therapy has the potential to increase BMD.
Other:
Treatment of predisposing conditions that are more likely in survivors of childhood cancer is recommended:
- Hormonal replacement therapy for hypogonadism
- Growth hormone replacement therapy for deficiency
- Correction of chronic metabolic acidosis (this accelerates bone loss).
Patients with osteoporosis should see an endocrinologist in consultation for a thorough evaluation of this problem.
Skeletal Abnormalities secondary to hypoplasia:
If there is any significant abnormality on examination (limb length discrepancy or spinal scoliosis) secondary to radiation therapy (RT), survivors should be referred to see an expert orthopedic surgeon.
Survivors who have previously been given RT to their spine or paravertebral regions should be advised not to lift heavy weights. They are at increased risk of spinal osteoporosis and arthritis.
If high dose RT was given to a limb and involved a long bone, they should be counseled about the increased risk of bone fracture.
