Bone Health For Cancer Survivors

This information explains how you can improve your bone health after cancer treatment. 

Osteopenia and Osteoporosis

Osteopenia is a condition in which your bone mass density is lower than normal.  Having osteopenia can lead to osteoporosis, a disease in which your bones become weak and more likely to fracture (break).

Osteoporosis is often called a silent disease because there are usually no symptoms in the early stages.  However, once osteoporosis has caused bones to become weak and brittle, a person may experience back pain (often caused by a compression fracture or collapsed vertebra), loss of height over time, stooped posture or curved upper back, or a broken bone that happens more easily than expected, such as after a minor injury.

Primary osteoporosis can be caused by the normal process of aging, menopause, or both. Secondary osteoporosis can develop as a side effect of cancer treatment.

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Causes of Osteopenia and Osteoporosis

Your body is constantly making new bone and shedding old bone.  Osteoporosis develops when the amount of bone that your body makes is less than the amount of bone that it sheds.

Both men and women can develop osteoporosis, but it is more common in women, especially after menopause.

Lifestyle and other risk factors that can increase the risk of osteoporosis for both men and women include:

  • Lack of exercise
  • Eating a diet low in nutrients, especially calcium and vitamin D
  • Eating a diet high in sodium
  • Drinking too much alcohol (more than 2 drinks per day for women or 3 drinks per day for men)
  • Consuming too much caffeine (more than 3 cups of coffee a day)
  • Smoking
  • Having a small body frame or low body weight
  • Being over 65 years old
  • Being of Caucasian or Asian ethnicity 

Other things that can lead to bone loss include:

  • Bone marrow or connective tissue disorders
  • Diseases that affect hormone levels, such as estrogen and testosterone
  • Thyroid disorders
  • Certain medications, that you may have taken as part of your cancer treatment including, but not limited to:
    • Steroids
    • Heparin
    • Tacrolimus
    • Cyclosporine
    • Some anticonvulsants (medications for seizures) including phenytoin (Dilantin®) or phenobarbital (Luminal®)
    • Some medications for heartburn, including aluminum-based medications (such as Maalox® and Mylanta®),  esomeprazole (Nexium), omeprazole (Prilosec®), and  lansoprazole (Prevacid®)
    • Methotrexate
  • Hormonal therapy for prostate and breast cancers
  • Going through menopause or taking medications like leuprolide (Lupron®) or goserelin (Zoladex®) that stop your ovaries from producing estrogen or your testes from producing testosterone.
  • Certain chemotherapy medications
  • Radiation therapy
  • Being on long-term bed rest and not being active 
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Managing Osteopenia or Osteoporosis

If your healthcare provider believes that you are at risk for osteopenia or osteoporosis, he or she will recommend that you have a bone density test (DXA). This test measures bone density in your wrist, spine, and hip. It is a painless test that is similar to an x-ray. The amount of radiation exposure from a DXA is less than a regular x-ray and less than that of an airline flight from California to New York and back.

There are things you can do to decrease the chance that osteopenia will progress to osteoporosis, as well as reduce your risk for fractures.

Lifestyle changes

You can make changes in your lifestyle in order to reduce your risk of osteoporosis and its effects.

  • Do not smoke. If you need help quitting, contact the MSK Tobacco Treatment Program at 212-610-0507.
  • Limit your intake of alcohol to no more than 2 drinks a day if you are a woman and 3 drinks a day if you are a man.
  • Exercise regularly.
    • Your healthcare provider may recommend exercises to strengthen your bones and muscles. These may be weight-bearing exercises that help increase bone density, such as walking, jogging, or running. They may also be non-weight-bearing exercises such as swimming (see “Exercise for Strong Bones”).
    • Always talk with your healthcare provider before starting a new exercise routine. If you have trouble establishing an exercise routine, talk with your healthcare provider about whether physical therapy may be right for you.
  • Eat a diet rich in calcium and vitamin D.
    • Make sure that you are getting enough calcium. Most adults need 1,000 to 1,500 milligrams of calcium daily, but your healthcare provider can tell you how much is right for you. The best way to get calcium is through food (see the table “Foods Rich in Calcium”). If you don’t get enough calcium from your diet, you may need to take a calcium supplement. 
    • You need to get enough vitamin D to absorb and use calcium. Adults younger than 70 years of age need at least 600 international units (IU) of vitamin D daily, while adults 70 and older need 800 IU daily. Your body can use sunlight to make vitamin D, but you can only get enough if you spend time outside and don’t wear sunscreen. Sunscreen is important for skin cancer prevention, so we recommend that you get vitamin D from food (see the table “Foods Containing Vitamin D”). If you are not getting enough vitamin D, you may need to take a vitamin D supplement.
      • If you have low levels of vitamin D, your healthcare provider may recommend that you take supplements with higher amounts of vitamin D. This can bring your levels up to normal. 
  • Ask your healthcare provider about taking supplements.
    • Calcium supplements come in different forms, including calcium carbonate and calcium citrate. Calcium citrate may be the best option because it can be taken with or without food.
    • Spread out your calcium intake throughout the day. Your body only absorbs about 500 milligrams of calcium at a time. If you take a multivitamin with calcium or have a meal with a lot of calcium, take your calcium supplement a few hours later.
    • Ask your healthcare provider about Citracal® Slow Release supplement, which only needs to be taken once a day.
    • If you take thyroid medications like levothyroxine (Synthroid®), make sure that you take it at least 4 hours before or after you take your calcium supplement.
  • Talk with your healthcare provider about medications.
    • There are prescription medications, such as bisphosphonates, available for preventing and treating osteoporosis. This class of medications includes risedronate (Actonel®) and alendronate (Fosamax®). If necessary, your healthcare provider will discuss your options with you and prescribe one that best meets your needs.
    • Certain medications for heartburn, such as omeprazole (Prilosec®), can affect bone health if taken for a long period of time. Speak about this risk with your healthcare provider and discuss other options.
  • Prevent falls.
    • Falling is the main cause of fractures for people with osteoporosis. Make your home safe to prevent falls. Here are some things you can do:
      • Remove throw rugs or secure them to the floor.
      • Install safety rails on stairs and grab bars in your shower or tub.
      • Apply nonskid tape or decals to your shower or tub floor.
      • Make sure the rooms in your house or apartment are well lit.
      • Wear sturdy shoes.
      • Stand up slowly after sitting or lying down so that your body can adjust to the new position.
      • Use a cane or walker to improve your balance.
      • When you bend over, bend at your knees, not at your waist.

Reading food labels


Food labels list a percent daily value amount of calcium. This amount describes how much of the average calcium requirement is provided in 1 serving of the food. For calcium, 100% of the daily value is 1,000 mg. If you are over 50 years old, your calcium need is 1,200 mg daily, so you need to eat 120% of the daily value to get enough calcium.

To find out how many milligrams of calcium are in 1 serving of food, multiply the percent daily value by 1000. If a food contains 30% daily value of calcium in 1 serving, that means that it has 300 milligrams of calcium (30% daily value multiplied by 1000 milligrams equals 300 milligrams). 

Vitamin D

Food labels also list a percent daily value amount of vitamin D. For vitamin D, 100% of the daily value is 400 IU. If you are younger than 70, you need 600 IU every day, which is 150% of the daily value. If you are over 70 years old, you need to eat 800 IU every day, which is 200% of the daily value.

To find out how many IUs of vitamin D are in 1 serving of a food, multiply the percent daily value by 400. If a food has 25% daily value of vitamin D in 1 serving, that means that it has 100 international units per serving (25% daily value multiplied by 400 IU equals 100 IU). 

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Foods Rich in Calcium

Food Portion size Calcium in portion (milligrams) Calories in portion
Dairy foods      
Yogurt, plain, nonfat 1 cup (8 ounces) 265 150
Cheddar cheese 1½ ounces 307 171
Gruyere cheese 1½ ounces 430 176
Parmesan cheese 1½ ounces 503 167
Milk, low-fat 1 cup (8 ounces) 305 102
Milk, whole 1 cup (8 ounces) 276 149
Non-dairy alternatives      
Soy milk, plain, calcium-fortified 1 cup (8 ounces) 301 80
Rice milk, plain, calcium-fortified 1 cup (8 ounces) 283 113
Almond milk, vanilla, calcium-fortified 1 cup (8 ounces) 451 91
Sardines, canned in oil, with bones, drained 2 sardines 92 50
Salmon, sockeye, canned, drained 4 ounces 263 189
Ocean perch, Atlantic, cooked 4 ounces 39 109
Mussels, steamed 4 ounces 37 195
Fruits and vegetables      
Collards, cooked ½ cup 134 31
Turnip greens, cooked ½ cup 104 29
Kale, cooked ½ cup 47 18
Bok choy (Chinese cabbage), raw 1 cup 74 9
Brussels sprouts ½ cup 28 28
Figs, fresh 2 medium figs 35 74
Nuts, beans, and soy      
Almonds 1/4 cup 96 207
White beans, canned ½ cup 96 150
Edamame (soybeans), prepared ½ cup 49 95
Tofu, firm, prepared with calcium sulfate* ½ cup 253 88
Other foods and beverages      
Fortified, ready-to-eat cereals (various)** ¾ cup to 1 cup 250-1,000 100-210
Orange juice, calcium fortified** 1 cup 500 117
Oatmeal, plain, instant, fortified** 1 packet prepared 98 101
Mineral water (e.g., San Pellegrino®, Perrier®) 1 cup (8 ounces) 33 0
Basil, dried 1 teaspoon 31 3

*Calcium content is for tofu processed with a calcium salt. Tofu processed with other salts does not provide significant amounts of calcium.

**Check product labels, as amount of calcium varies.

Source: USDA National Nutrient Database for Standard Reference

Available at:

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Foods Containing Vitamin D

Food Portion size Vitamin D in portion (IU) Calories in portion
Cod liver oil 1 tablespoon 1,360 123
Salmon, sockeye, canned, drained 4 ounces 953 189
Ocean perch, Atlantic, cooked 4 ounces 66 109
Tuna fish, light, canned in water, drained 4 ounces 53 97
Sardines, canned in oil, drained 2 sardines 46 50
Orange juice fortified with vitamin D* 1 cup (8 ounces) 100 117
Milk, low-fat vitamin D-fortified 1 cup (8 ounces) 117 102
Egg, including yolk 1 large egg 44 78
Shiitake mushrooms, dried 4 mushrooms 23 44
Chanterelle mushrooms, raw ½ cup 114 21

*Check product labels, as amount of added vitamin D varies.

Source: USDA National Nutrient Database for Standard Reference

Available at:

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Exercise for Strong Bones

Exercise can improve or maintain bone mass, improve muscle strength, flexibility, posture, coordination, body awareness, and energy levels. It can also decrease the risk of falls and fractures.

If you haven’t exercised for a while, check with your healthcare provider before beginning a new exercise program. If you have osteoporosis, avoid high impact exercises (exercises in which both of your feet leave the ground at the same time, such as running or jumping). You should also avoid deep bending and twisting with activities such as golf, tennis, and deep crunches.  Consider working with a physical therapist to develop a safe exercise program.

Weight-bearing exercises

Weight-bearing exercises are exercises with your bones supporting your weight.  These exercises include activities that make you move against gravity while staying upright. Do a 30-minute session or multiple sessions spread out throughout the day most days of the week.

High-impact weight-bearing exercises

High-impact weight-bearing exercises help build bones and keep them strong. If you have broken a bone due to osteoporosis or are at risk of breaking a bone, you may need to avoid high-impact exercises. If you’re not sure what these are, check with your healthcare provider. Examples of high-impact weight-bearing exercises are:

  • Dancing
  • High-impact aerobics
  • Hiking
  • Jogging or running
  • Jumping rope
  • Climbing stairs
  • Tennis

Low-impact weight-bearing exercises

Low-impact weight-bearing exercises can also help keep bones strong and are a safe alternative if you can’t do high-impact exercises. Examples of low-impact weight-bearing exercises are:

  • Using elliptical training machines
  • Low-impact aerobics
  • Using a stair-step machine
  • Walking fast on a treadmill or outside

Muscle-strengthening exercises

Muscle-strengthening exercises include activities where you move your body, a weight, or some other resistance against gravity. They are also called resistance exercises.

Do these exercises 2 to 3 days per week. They include:

  • Lifting weights
  • Using elastic exercise bands
  • Using weight machines
  • Lifting your own body weight, such as doing push-ups or pull-ups
  • Functional movements, such as standing and rising up on your toes

Yoga and pilates can also improve strength, balance, and flexibility; however, certain positions may not be safe for people with osteoporosis or those at increased risk of broken bones. For example, exercises that have you bend forward may increase the chance of breaking a bone in the spine. Ask your healthcare provider or physical therapist which exercises are safe for you. 

Non-impact exercises

Non-impact exercises can help you improve balance, posture, and how well you move in everyday activities. These exercises can also help increase muscle strength and decrease your risk of falls and broken bones. 

Do non-impact exercises every day or as often as needed. Some of these exercises include:

  • Balance exercises, which can help strengthen your legs, improve your balance, and decrease your risk of falls. T’ai Chi and yoga are examples of balance exercises.
  • Posture exercises, can help improve your posture and reduce rounded or “sloping” shoulders. They help decrease the chance of breaking a bone, especially in the spine.
  • Functional exercises, which can help improve how you perform everyday activities and decrease your chance of falling and breaking a bone. For example, if you have trouble getting up from a chair or climbing stairs, you should do these activities as exercises.

A physical therapist can teach you balance, posture, and functional exercises. Speak with your doctor or nurse if you would like to have a consultation with a physical therapist.  

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