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Some hormone treatments for breast and prostate cancer thin the bones and raise the chance of a fracture. When you start an aromatase inhibitor or treatment that stops the ovaries working, a bone density scan is offered; on prostate hormone therapy your fracture risk may be checked. Exercise, a good diet and not smoking help, and bone-strengthening medicine is offered if the bones are thin.
Aromatase inhibitors, treatment-induced menopause, ovarian suppression and androgen deprivation therapy (ADT) accelerate bone loss. NICE NG101 offers a baseline DEXA scan to women with invasive breast cancer not receiving adjuvant bisphosphonates who start an aromatase inhibitor, have treatment-induced menopause or start ovarian suppression, and not to those on tamoxifen alone; bisphosphonates are offered to those identified by the 2008 UK expert group algorithms. Men with breast cancer starting testicular suppression with an aromatase inhibitor also have bone density assessed (NG101, 2025). Separately, adjuvant bisphosphonates for postmenopausal women with node-positive disease are offered to reduce recurrence, and also protect bone.
For prostate cancer on ADT, NICE NG131 advises against routine bisphosphonates to prevent osteoporosis, suggests considering fracture risk assessment in line with NICE's osteoporosis guidance, offers bisphosphonates to those with osteoporosis and suggests denosumab if bisphosphonates are not suitable. ASCO (2019) asks clinicians to assess fracture risk with established tools, to measure bone density where the risk is substantial, to advise nutrition, exercise and lifestyle for everyone, and, where a drug is needed, to use bisphosphonates or denosumab at osteoporosis doses. Before starting a bone-modifying drug, see the protocol on dental assessment and jaw osteonecrosis.
Why: Treatment adds to the person's own risk from age, previous fractures, steroids, smoking and family history; a tool puts these together.
“Clinicians are advised to assess fracture risk using established tools.”
Why: These treatments lower oestrogen, which speeds bone loss; a baseline scan shows who needs protection.
“Offer a baseline dual-energy X-ray absorptiometry (DEXA) scan to assess bone mineral density in women with invasive breast cancer who are not receiving bisphosphonates as adjuvant therapy and who:”
Why: NICE found no need for a routine scan in people taking tamoxifen on its own.
“Do not offer a DEXA scan to people with invasive breast cancer who are receiving tamoxifen alone.”
Why: The combination lowers sex hormones and puts bone at risk in the same way.
“On starting testicular function suppression in combination with an aromatase inhibitor, assess bone mineral density in people with ER-positive invasive breast cancer who have male reproductive organs”
Why: ADT lowers testosterone, which speeds bone loss over years of treatment.
“Consider assessing fracture risk in people with prostate cancer who are having androgen deprivation therapy, in line with the NICE guideline on osteoporosis: risk assessment .”
Why: These help bone in everyone and cost little.
“The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle.”
Why: Treatment is aimed at people whose bones are already thin, where it prevents fractures.
“Offer bisphosphonates to people who are having androgen deprivation therapy and have osteoporosis.”
Why: Denosumab is an injection that strengthens bone by another route.
“Consider denosumab for people who are having androgen deprivation therapy and have osteoporosis if bisphosphonates are contraindicated or not tolerated.”
Why: These are the drugs with evidence for preventing fractures; the doses used for bone metastases are higher and carry more risk.
“When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.”
Why: These drugs rarely cause bone in the jaw to break down; a dental check before starting is part of preventing it.
“Discuss the benefits and risks of bisphosphonate treatment with women, particularly the risk of osteonecrosis of the jaw, atypical femoral fractures and osteonecrosis of the external auditory canal.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
NICE (NG101 for breast, last updated 2025; NG131 for prostate) and ASCO (2019) agree on assessing risk when bone-thinning hormone therapy starts, on lifestyle measures for all, and on bisphosphonates or denosumab when the bones are thin. They differ in how the risk is measured: NICE offers a baseline DEXA scan to every woman starting an aromatase inhibitor or ovarian suppression who is not already on adjuvant bisphosphonates, whereas ASCO starts with a fracture risk tool and measures bone density only where the risk is substantial; for men on ADT, NICE suggests a fracture risk assessment rather than a routine scan and advises against routine bisphosphonates. The ESMO 2020 bone health guideline could not be read.
NICE 2018 · NICE 2019 · ASCO, Journal of Clinical Oncology 2019 · ESMO, Annals of Oncology 2020
Where it differs: Uses an established fracture risk tool for everyone and orders a bone density test only for those at substantial risk, rather than a baseline scan for all women starting an aromatase inhibitor.
Evidence: ASCO built its recommendations on the US Preventive Services Task Force review in the general population plus 61 studies in people with cancer; read as an abstract, so grades are not given.
Where it differs: Offers zoledronic acid or sodium clodronate after surgery to reduce recurrence in postmenopausal women with node-positive disease, and considers them in node-negative disease at high risk; women on these do not need the baseline DEXA scan.
Evidence: NICE recommendation [2018]; the use was off-label in March 2025, as NICE notes.
Where it differs: A prostate-specific bone health guideline covering fracture risk on ADT through to bone metastases, endorsed in full by ASCO.
Evidence: Read as an abstract; its individual recommendations are not given here.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Baseline DEXA for women starting an aromatase inhibitor, ovarian suppression or with treatment-induced menopause, not on adjuvant bisphosphonates | not graded (NICE); dated [2009, amended 2018] | NICE 2018 |
| No routine bisphosphonates to prevent osteoporosis on ADT “Do not routinely offer bisphosphonates to prevent osteoporosis in people with prostate cancer having androgen deprivation therapy.” | not graded (NICE); dated [2008] | NICE 2019 |
| Bisphosphonates for people on ADT with osteoporosis | not graded (NICE); dated [2014] | NICE 2019 |
Shares Bone-modifying agents (bisphosphonates, denosumab), Denosumab, Zoledronic acid, National Institute for Health and Care Excellence and the tags protocol, bone-health.
Shares Treatment-induced bone loss, Aromatase inhibitor, Anastrozole, Bone-modifying agents (bisphosphonates, denosumab) and the tag survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO), Breast cancer (all types) and the tags protocol, survivorship.
Shares Goserelin / leuprolide (ovarian function suppression), National Institute for Health and Care Excellence, Letrozole (and other aromatase inhibitors), American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares National Institute for Health and Care Excellence, American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.
Shares American Society of Clinical Oncology (ASCO) and the tags protocol, survivorship.