Bone Mineral Density Surveillance for Childhood, Adolescent, and Young Adult Cancer Survivors: Recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Childhood, adolescent and young adult (CAYA) cancer survivors are at increased risk of reduced bone mineral density (BMD). Clinical practice surveillance guidelines are important for timely diagnosis and treatment of these survivors, which could improve BMD parameters and prevent fragility fractures. Discordances across current late-effects guidelines necessitated international harmonization of recommendations for BMD surveillance. The International Late Effects of Childhood Cancer Guideline Harmonization Group therefore established a panel of 36 experts from 10 countries, representing a range of relevant medical specialties. The evidence of risk factors for (very) low BMD and fractures, surveillance modality, timing of BMD surveillance, and treatment of (very) low BMD were evaluated and critically appraised, and harmonized recommendations for CAYA cancer survivors were formulated. We graded the recommendations based on the quality of evidence and balance between potential benefits and harms. BMD surveillance is recommended for survivors treated with cranial or craniospinal radiotherapy, and is reasonable for survivors treated with total body irradiation. Due to insufficient evidence, no recommendation can be formulated for or against BMD surveillance for survivors treated with corticosteroids. This surveillance decision should be made by the survivor and healthcare provider together, after careful consideration of the potential harms and benefits and additional risk factors. We recommend to perform BMD surveillance using dual-energy X-ray absorptiometry at entry into long-term follow-up, and if normal (Z-score >−1), repeat at 25 years of age. Between these measurements and thereafter, surveillance should be performed as clinically indicated. These recommendations facilitate evidence-based care for CAYA cancer survivors internationally.