medwireNews: An international expert group has published recommendations for the monitoring of bone mineral density (BMD) in child, adolescent and young adult survivors of cancer.
The literature-based guidance from the International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) is intended to supplant current recommendations, which the group says “vary considerably” and are not underpinned by systematic review of the literature.
To create the current guidance, 36 experts from 10 countries looked at 74 research studies and three existing clinical practice guidelines.
Based on these, Jenneke van Atteveld (Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands) and IGHG colleagues make a strong recommendation for BMD surveillance in child, adolescent and young adult cancer survivors treated with cranial or craniospinal radiotherapy.
They also consider it “reasonable” to monitor BMD in patients treated with total body irradiation, but say there is insufficient evidence on which to base a recommendation for those treated with corticosteroids.
The group recommends use of dual-energy X-ray absorptiometry (DXA), but advises against use of quantitative computed tomography.
However, they issue some cautions with respect to use of DXA, including that it can underestimate BMD in abnormally short people and that the BMD standard deviation score (SDS) obtained can vary widely depending on the reference database used. To help combat these problems, they advise serial monitoring to determine BMD trajectory.
Atteveld and team recommend beginning BMD monitoring 2–5 years after the completion of cancer therapy, irrespective of patient age. If normal at this point, BMD should be checked again around the age of 25 years “when peak bone mass should be achieved”.
They explain that peak bone mass predicts osteoporosis later in life, so cancer survivors with reduced peak bone mass may have an increased risk for fragility fractures.
“These fragility fractures could cause substantial morbidity such as reduced mobility, chronic pain, and difficulty with performing activities of daily living”, the team writes in The Lancet Diabetes & Endocrinology.
After the age of 25 years, BMD monitoring should be based on clinical need, they add.
The guidance also contains recommendations for interventions in patients found to have a reduced BMD SDS. This includes specialist referral for those whose BMD SDS is –2.0 or lower, assessment for additional endocrine defects if BMD SDS is –1.0 or lower and counselling about bone-healthy lifestyle habits for all patients.
Finally, the literature study identified a number of knowledge gaps that Atteveld and colleagues say should be addressed to improve and refine future recommendations.
“According to our findings, future studies should investigate the risk of reduced bone mineral density after several treatment modalities and disease types (such as bone and soft tissue sarcomas) in more detail, and further develop and validate prediction models for very low bone mineral density and low-trauma fractures”, they say.
By Eleanor McDermid
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