Metabolic bone diseases are disorders of bone strength, and can sometimes be caused by abnormalities of minerals. Often patients undergoing cancer treatments may have some side effects involving their bone density. City of Hope is opening a Metabolic Bone Disease Center to offer evaluation and treatment of patients with metabolic bone diseases. Osteoporosis patients will also find the help they are looking for at City of Hope.
Azar Khosravi, MD, endocrinologist at City of Hope, is here to help you better understand Metabolic Bone Diseases and how City of Hope is there to help you to care for your bones.
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Metabolic Bone Disease in Cancer Patients
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Learn more about Dr. Azar Khosravi
Azar Khosravi, MD
Dr. Azar Khosravi graduated from medical school from the Shahid-Behesthi University in Tehran, Iran. She moved to the United States in 2000, and first worked as a Research Assistant at San Francisco General Hospital, in the Department of Family Medicine. Dr. Khosravi went on to complete a residency in Internal Medicine at Saint Vincent Hospital in Worcester Massachusetts, followed by a Fellowship in endocrinology at the National Institutes of Health in Bethesda, MD, from 2004 through 2007. She then served as an instructor in Endocrinology and the Associate Director of the Osteogenesis Imperfecta Department within the Kennedy Krieger Institute at Johns Hopkins, where her research focus was on bone and mineral metabolism. She also served as a Clinical Associate, in the Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch at NIDCR, NIH. She is board certified in Internal Medicine, and in Endocrinology and Metabolism. Her research focuses on metabolic bone diseases.Learn more about Dr. Azar Khosravi
Transcription:
Metabolic Bone Disease in Cancer Patients
Melanie Cole (Host): Metabolic bone diseases are disorders of bone strength and can sometimes be caused by abnormalities of minerals or by other factors. My guest today is Dr. Ozar Khosravi. She’s an endocrinologist at City of Hope. Dr. Khosravi welcome to the show and tell us about your new clinic at the Center for Metabolic Bone Diseases at City of Hope.
Dr. Ozar Khosravi (Guest): Thank you very much. We are launching a new clinic with a focus on metabolic bone diseases in the context of a cancer hospital mostly dealing with bone loss that happens after cancer, whether it’s the cancer itself or treatments or even survivors for a long time after the diagnosis of the cancer and the completion of therapy. We have a department that has trainees. We have endocrinology fellows at City of Hope and also other institutes that come here. Apart from the cancer patients, we also have another focus for general metabolic bone diseases that are usually rare genetic conditions but of interest to endocrinologists apart from cancer patients but the vast majority of the focus is bone loss in cancer patients.
Melanie: Why does that happen, Dr. Khosravi? Bone loss in cancer patients--is this a common occurrence as a result of treatment?
Dr. Khosravi: It’s very common, especially at the onset of diagnosis or as a result of therapy. There are some cancers that by themselves can cause bone loss, even before any treatment is started. Breast, prostate and gastric, thyroid, liver, brain, lymphoma, leukemias. Some of them, like leukemia, can actually present with spine fractures in very, very young patients and could be a presenting symptom. Apart from that, as you mentioned, the treatments also can cause a lot of damage to the bone which could be lasting for a long time. Chemotherapy, especially in pre-menopausal women, are the biggest insult. Radiation therapy – sometimes we think that radiation is focused on one area, it wouldn’t harm the bone in general, which is an incorrect concept. If the treatments affect sex hormones--in women estrogen and in men testosterone--that could be an added insult to the bone. Those are another big treatment strategy that is used for a lot of cancers but it also has a lot of effects on the bone, directly and indirectly. Physical activity changes during treatment for cancers, so that’s also another reason. Immobility, long hospitalizations and changes in diet--these are all things that can affect bone in short-term and long-term.
Melanie: We hear about osteoporosis as we age, Dr. Khosravi, and the media, things about Boniva and keeping your bones strong, do you deal with osteoporosis in these associated patients that are dealing with cancer treatment the same way you would deal with osteoporosis in just an average aging individual without cancer?
Dr. Khosravi: That’s a great question because there are a lot of things that are different. Sometimes you are dealing with very young patients, so the focus in these patients and, basically, in all patients, the first and foremost, is lifestyle optimization and making sure their diet is calcium rich and trying to get them get their calcium from diet rather than supplements. Also, exercises that are bone focused. In our clinic, before the patients even see the physician, they go through nutrition and physical fitness evaluations and then see us and we talk about medications. That’s probably one of the best opportunities to modify a patient’s diet in the right direction. Also, the medications play a very major role and one of the ways it’s different from the general population is that we actually have lower thresholds to start patients on treatment because it has been shown in population studies that women who were on osteoporosis treatment mostly bisphosphonates, Fosamax, Boniva, Actonel, Zemeda – all those medications--had a third less risk of breast cancer in the future. There seems to be some anti-cancer effect from these medications. So, in the right patient that needs medical treatment, we usually have lower thresholds to start them on these treatments. The other thing that is different is that some of these changes in bone are temporary. If you have a younger patient or children, they lose a lot of bone during treatment but they could restore some of that bone structure later, given the right guidance. It’s a very dynamic issue depending on what phase of the treatment you see the patient. As a result, the strategies are going to be different. What is constant is lifestyle optimization.
Melanie: Before we get to lifestyle optimization, do you then routinely check bone density to see if osteopenia has started or if there is developing osteoporosis, even if it’s dynamic and possibly temporary?
Dr. Khosravi: Yes. It is x-ray based but I have to say DEXA scans use very, very low radiation. It’s pretty much equivalent to going to the beach for one day. So, there’s not much of a risk to the patient to be having DEXA scans once a year or every other year. That is usually our tool to gauge the bone loss and also the follow up to see, with whatever treatment that we suggested, if it has been effective and that we are going in the right direction. That’s absolutely one of the first and foremost tools that we have.
Melanie: How do you work with people on diet and exercise while they’re going through treatments for something else to keep track of this and hopefully keep it at bay just a little bit?
Dr. Khosravi: It’s usually not very difficult. The calcium rich diet is not hard to reach unless somebody’s diet is particularly unhealthy. Dairy has a lot of calcium, if patients are inclined to have dairy or can tolerate it, but there are a lot of vegetables, especially dark, leafy, green stuff that have plenty of calcium. Vegetables like kale, chard, collard greens and turnip greens have a lot of calcium. There are some fatty fish like tuna and even tilapia that has a lot of calcium. It is not difficult to get calcium, if they eat the right amount of vegetables, particularly. Some fruits and citrus, also, has a lot of calcium. There are also some fortified sources of calcium in the foods but I think if we stick to the natural foods that we have without fortification, we should be able to get enough calcium. Vitamin D is the other component of bone structure. Sun exposure is a great source of Vitamin D formation but a lot of people end up getting some supplementation depending on the season and where they live, their age and even skin color, it could determine their Vitamin D levels. A good percentage of people end up needing some Vitamin D supplementation.
Melanie: In just the last few minutes, wrap it up for us Dr. Khosravi and tell us about this new center Clinic for Metabolic Bone Disease that you’re starting there at City of Hope and why they should come for their care. Tell us a little bit about your team.
Dr. Khosravi: We have recognized for a long time that every cancer center needs a bone center because a great number of patients, apart from those that get bone metastasis from the cancer have a lot of bone loss, especially immediately after treatment or even during treatment. The consequences of bone loss and osteoporosis could be severe. It could result in chronic pain, loss of lung volume, if it is significant, spine fractures and, unfortunately, even death if it is in elderly and they get a hip fracture. I think, a lot of times, we lose sight of the grave consequences of osteoporosis that remains untreated so we want to raise awareness and also promote a healthy lifestyle, first and foremost, which is important for any condition, including the bone. We think that it is an opportunity to make people aware that not necessarily as we age, we shrink. If we maintain a healthy lifestyle we should be able to go through old age without losing our height and bone density.
Melanie: Thank you so much, Dr. Khosravi. It’s absolutely fascinating and I applaud all the great work that you are doing at City of Hope. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Metabolic Bone Disease in Cancer Patients
Melanie Cole (Host): Metabolic bone diseases are disorders of bone strength and can sometimes be caused by abnormalities of minerals or by other factors. My guest today is Dr. Ozar Khosravi. She’s an endocrinologist at City of Hope. Dr. Khosravi welcome to the show and tell us about your new clinic at the Center for Metabolic Bone Diseases at City of Hope.
Dr. Ozar Khosravi (Guest): Thank you very much. We are launching a new clinic with a focus on metabolic bone diseases in the context of a cancer hospital mostly dealing with bone loss that happens after cancer, whether it’s the cancer itself or treatments or even survivors for a long time after the diagnosis of the cancer and the completion of therapy. We have a department that has trainees. We have endocrinology fellows at City of Hope and also other institutes that come here. Apart from the cancer patients, we also have another focus for general metabolic bone diseases that are usually rare genetic conditions but of interest to endocrinologists apart from cancer patients but the vast majority of the focus is bone loss in cancer patients.
Melanie: Why does that happen, Dr. Khosravi? Bone loss in cancer patients--is this a common occurrence as a result of treatment?
Dr. Khosravi: It’s very common, especially at the onset of diagnosis or as a result of therapy. There are some cancers that by themselves can cause bone loss, even before any treatment is started. Breast, prostate and gastric, thyroid, liver, brain, lymphoma, leukemias. Some of them, like leukemia, can actually present with spine fractures in very, very young patients and could be a presenting symptom. Apart from that, as you mentioned, the treatments also can cause a lot of damage to the bone which could be lasting for a long time. Chemotherapy, especially in pre-menopausal women, are the biggest insult. Radiation therapy – sometimes we think that radiation is focused on one area, it wouldn’t harm the bone in general, which is an incorrect concept. If the treatments affect sex hormones--in women estrogen and in men testosterone--that could be an added insult to the bone. Those are another big treatment strategy that is used for a lot of cancers but it also has a lot of effects on the bone, directly and indirectly. Physical activity changes during treatment for cancers, so that’s also another reason. Immobility, long hospitalizations and changes in diet--these are all things that can affect bone in short-term and long-term.
Melanie: We hear about osteoporosis as we age, Dr. Khosravi, and the media, things about Boniva and keeping your bones strong, do you deal with osteoporosis in these associated patients that are dealing with cancer treatment the same way you would deal with osteoporosis in just an average aging individual without cancer?
Dr. Khosravi: That’s a great question because there are a lot of things that are different. Sometimes you are dealing with very young patients, so the focus in these patients and, basically, in all patients, the first and foremost, is lifestyle optimization and making sure their diet is calcium rich and trying to get them get their calcium from diet rather than supplements. Also, exercises that are bone focused. In our clinic, before the patients even see the physician, they go through nutrition and physical fitness evaluations and then see us and we talk about medications. That’s probably one of the best opportunities to modify a patient’s diet in the right direction. Also, the medications play a very major role and one of the ways it’s different from the general population is that we actually have lower thresholds to start patients on treatment because it has been shown in population studies that women who were on osteoporosis treatment mostly bisphosphonates, Fosamax, Boniva, Actonel, Zemeda – all those medications--had a third less risk of breast cancer in the future. There seems to be some anti-cancer effect from these medications. So, in the right patient that needs medical treatment, we usually have lower thresholds to start them on these treatments. The other thing that is different is that some of these changes in bone are temporary. If you have a younger patient or children, they lose a lot of bone during treatment but they could restore some of that bone structure later, given the right guidance. It’s a very dynamic issue depending on what phase of the treatment you see the patient. As a result, the strategies are going to be different. What is constant is lifestyle optimization.
Melanie: Before we get to lifestyle optimization, do you then routinely check bone density to see if osteopenia has started or if there is developing osteoporosis, even if it’s dynamic and possibly temporary?
Dr. Khosravi: Yes. It is x-ray based but I have to say DEXA scans use very, very low radiation. It’s pretty much equivalent to going to the beach for one day. So, there’s not much of a risk to the patient to be having DEXA scans once a year or every other year. That is usually our tool to gauge the bone loss and also the follow up to see, with whatever treatment that we suggested, if it has been effective and that we are going in the right direction. That’s absolutely one of the first and foremost tools that we have.
Melanie: How do you work with people on diet and exercise while they’re going through treatments for something else to keep track of this and hopefully keep it at bay just a little bit?
Dr. Khosravi: It’s usually not very difficult. The calcium rich diet is not hard to reach unless somebody’s diet is particularly unhealthy. Dairy has a lot of calcium, if patients are inclined to have dairy or can tolerate it, but there are a lot of vegetables, especially dark, leafy, green stuff that have plenty of calcium. Vegetables like kale, chard, collard greens and turnip greens have a lot of calcium. There are some fatty fish like tuna and even tilapia that has a lot of calcium. It is not difficult to get calcium, if they eat the right amount of vegetables, particularly. Some fruits and citrus, also, has a lot of calcium. There are also some fortified sources of calcium in the foods but I think if we stick to the natural foods that we have without fortification, we should be able to get enough calcium. Vitamin D is the other component of bone structure. Sun exposure is a great source of Vitamin D formation but a lot of people end up getting some supplementation depending on the season and where they live, their age and even skin color, it could determine their Vitamin D levels. A good percentage of people end up needing some Vitamin D supplementation.
Melanie: In just the last few minutes, wrap it up for us Dr. Khosravi and tell us about this new center Clinic for Metabolic Bone Disease that you’re starting there at City of Hope and why they should come for their care. Tell us a little bit about your team.
Dr. Khosravi: We have recognized for a long time that every cancer center needs a bone center because a great number of patients, apart from those that get bone metastasis from the cancer have a lot of bone loss, especially immediately after treatment or even during treatment. The consequences of bone loss and osteoporosis could be severe. It could result in chronic pain, loss of lung volume, if it is significant, spine fractures and, unfortunately, even death if it is in elderly and they get a hip fracture. I think, a lot of times, we lose sight of the grave consequences of osteoporosis that remains untreated so we want to raise awareness and also promote a healthy lifestyle, first and foremost, which is important for any condition, including the bone. We think that it is an opportunity to make people aware that not necessarily as we age, we shrink. If we maintain a healthy lifestyle we should be able to go through old age without losing our height and bone density.
Melanie: Thank you so much, Dr. Khosravi. It’s absolutely fascinating and I applaud all the great work that you are doing at City of Hope. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.