Standing Strong | Rebuilding Bone Health After Cancer
By Rebekah Rotstein
Cancer treatment has made great strides in saving lives and offering hope for patients worldwide. But alongside these life-saving interventions come side effects to the skeletal system. Addressing bone health before, during, and after cancer treatment is a crucial yet often overlooked aspect of survivorship. Understanding how bones are affected by cancer treatment along with proactive steps to protect them through exercise can equip you to take action toward fracture prevention.
How cancer treatment affects bone health
Cancer treatments can disrupt the normal metabolic activity of bone and lead to bone loss, osteonecrosis, or secondary bone tumors. Bone loss stems from diminished bone density (the amount of mineral in your bones) along with compromised bone quality (the microarchitecture and composition contributing to the strength of bone). This means increased risk of fractures now and in future years. Chemotherapy is systemic and can interfere with bone remodeling and induce early menopause (which lowers estrogen levels that otherwise protect bone). Radiation directly weakens the bones at or near the target sites, damaging bone-forming cells and decreasing blood supply to the bone, which can impair healing and increase fracture risk. Surgery may not directly affect bone but it can limit mobility during recovery, leading to bone loss from inactivity. Immunotherapy can cause bone loss and secondary osteoporosis with long-term corticosteroid use.
Beyond direct treatment effects, bone health may also be affected by secondary causes for those who are or have undergone cancer treatment. Hormone therapies like aromatase inhibitors in breast cancer or androgen deprivation in prostate cancer, which drastically lower hormone levels and accelerate bone loss. Additionally, reduced physical activity during treatment means less bone stimulation from gravity and other forces in daily life. Furthermore, nutritional deficiencies that can occur from appetite loss, nausea, or dietary restriction, can also negatively impact your bones.
Exercise strategies to protect and strengthen your bones
So how can you tackle your bone health and reduce fracture risk through exercise amidst all this? Here are a few tips:
1. Resistance training
Among the research and guidelines on bone health and osteoporosis, resistance training stands out as the most powerful tool for maintaining, and even increasing, bone density. This involves progressively increasing the demand on your body to produce adaptive changes with muscle mass and strength, which in turn, stimulate the bone. This can be done with bands or bodyweight, but ideally using weights for the additional load and stimulus that bones need – and always building up to those loads. Resistance training should be performed at least twice a week, including axial loading, meaning in a weight-bearing upright orientation for the hips and spine. Consider working the site specific areas of the spine, hips, and wrists which are most susceptible to fracture from bone loss, and their surrounding muscles, while also addressing the entire body as a functional unit. The intensity and loads can vary depending on your individual circumstances although bone may respond to greater than lesser stimulus. Work with a trainer to customize a plan for you and your unique needs, and to guide you on proper form and technique.
2. Impact training
Impact is essential to provide the mechanical stress and in the weight-bearing capacity that’s needed for bone building. It should be progressively introduced, starting with low impact (like stomping) and if possible, increasing to high impact (like jumping) over time to enable your bones to adapt and be able to tolerate the force. In the presence of bone loss or osteoporosis, the amount of impact that’s appropriate, and whether you should do high impact, varies based on the individual, your functional capacity, and your medical history. If you’ve had fractures or spinal metastases, impact might not be advised by your healthcare team.
3. Balance and agility
Balance and coordination, while not directly related to bone density or bone strength, are essential to fall prevention and therefore are essential to avoiding fractures. Practice dynamic balance, where you maintain your balance with motion, in addition to static balance (standing on one leg), along with reactive balance (reacting to outside forces). Close your eyes, move your head, stand on soft or unsteady surfaces. Include dual-tasking where you simultaneously do another task with the balance task, such as counting backwards. Balance training should be included at least twice a week. This is also where yoga, Pilates, and tai chi shine as structured mind-body exercise forms that have been shown to assist in preventing falls. This stems from the neuromuscular control and proprioceptive training involved, thanks to their slow, deliberate movements, specifically aiding core control and posture awareness, along with joint mobility and muscle endurance. On the other end of the spectrum, footwork speed and changes of direction though agility training can help with reaction time and your ability to catch yourself if falling off balance.
4. Cardiorespiratory training
The newly published 2025 Physical activity guidelines in oncology: A systematic review of the current recommendations highlights the inclusion of aerobic training in exercise programming for cancer patients. This can range from 3 or more 20-30 minute sessions/week or 150 minutes/week of moderate-intensity aerobic training or 75 minutes of vigorous-intensity. This along with resistance training is recommended for a host of other reasons from improving fatigue and quality of life to reducing anxiety.
5. Modifications may be necessary
Due to the effects of treatment on your bones, certain motions might not be appropriate for you. For safety, you might need to modify or avoid movements where your spine flexes or rounds forward when they are repetitive or sustained, loaded, forceful, or at end-range, or when combined with twisting. Note that these motions can be common in yoga and Pilates so advising the teacher of your situation is important.
6. Consistency and enjoyment
Exercise is only as helpful as your consistency with it. Just like brushing your teeth, you have to stick with it for it to be effective. And part of that key to consistency is enjoyment. Don’t overextend yourself, especially if experiencing fatigue. Consider physical activity as well that you enjoy such as dancing, group classes, nature walks and hikes, all of which are also weight-bearing. Find a workout buddy, a community, a program or coach that encourages you to continue and provides support.
Other considerations
Ask your doctor about getting a DEXA scan (the gold standard of bone density testing) if it has not been mentioned. This can detect osteoporosis or osteopenia or just serve as a baseline for future monitoring. For insight into the bone quality and microarchitecture, inquire if the TBS (Trabecular Bone Score) is included which is a validated, FDA-approved tool used in conjunction with DEXA.
While the primary goal of cancer treatment is to save lives, it's equally important to consider quality of life during and after treatment. Exercise can play a vital role in enabling joint mobility, pain reduction, stress relief, and emotional well-being.
Whether you're currently undergoing treatment or are a long-term survivor, consider ways to incorporate bone health into your care plan. Your bones deserve your attention and exercising for them can pay off now and in the long run.
Consult your oncologist before beginning a new exercise regimen before, during, or after treatment.
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Rebekah Rotstein, NCPT, CPT, is the founder of the Buff Bones® exercise method for bone and joint health with virtual coaching, online programming, and live classes, with trained instructors in more than 30 countries.
She’s taught courses at locations like Johns Hopkins Rehabilitation Network and oversees a free public education webinar series with UCLA Health as the health sponsor. Rebekah is an industry leader for movement education, bone health, and Pilates for more than 20 years, with a background in dance and sports medicine.
She has contributed to several books including Myths of Menopause and serves on committees and working groups with the Bone Health and Osteoporosis Foundation, the Medical Advisory Committee of the National Menopause Foundation, and the Society for Women’s Health Research.