Osteoporosis and Breast Cancer

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo.

Jamie DePolo: Hello, thanks for listening. Our guest is Dr. Anupama Shahane, associate professor of rheumatology at the Perelman School of Medicine at the University of Pennsylvania, where she is also director of the Penn Osteoporosis Program.

Certain breast cancer treatments, including the aromatase inhibitors, which are medicines that stop the body from making estrogen, and certain chemotherapy medicines, can lead to osteoporosis. Dr. Shahane joins us to discuss osteoporosis and osteopenia and how the conditions are treated in someone diagnosed with breast cancer.

Dr. Shahane welcome to the podcast.

Dr. Anupama Shahane: Great. Thank you, Jamie. Thank you for inviting me here. I’m happy to be here today and talk about osteoporosis and help people learn about how to prevent osteoporosis and just learn about how to manage osteoporosis.

Jamie DePolo: Yeah, because I think when people receive breast cancer treatment, I mean, obviously being diagnosed, very stressful, very fearful, and then some of the more common side effects, nausea, fatigue, and they don’t necessarily think about osteoporosis, but it can have some long-term effects.

So, before we kind of get into all of that, could you tell us, you know, exactly what is osteoporosis and osteopenia and what the differences are between the two conditions?

Dr. Anupama Shahane: That’s a great start.

So, osteoporosis is, first of all, the most common bone disease that exists. Osteoporosis is the result of thinning of bone over time, so there’s a change in the bone microtexture and it results in the bone getting thinner as we get older with the result of an increased risk of fracture.

So, to begin with this is actually a normal physiologic process that we all go through. The risk is higher in women than in men, partly because of the hormonal effect of estrogen, which will link us back to the breast cancer and breast treatment, and the most bone loss happens, of course, after menopause. Again, which will link us back to why this is more relevant in women with breast cancer and treatment for cancer. 

So, it is a condition that is common, that is naturally-occurring as a physiologic change with age, but unfortunately it’s amplified with treatment of breast cancer. The risk of developing osteoporosis is actually the fact that it puts you at risk for fractures.

Now, what is the difference between osteoporosis and osteopenia? So, osteoporosis by itself does not cause any symptoms. It is… you cannot know that you have osteoporosis unless you look for it. It is diagnosed, and we might get into some of this in a little bit detail later, but it is diagnosed by testing and there are some definitions that are numbers based on testing, which differentiates osteoporosis and osteopenia. 

So, osteoporosis is when you hit a certain number on testing and the recommendation is that you start treatment to decrease your risk of fracture, whereas osteopenia, or low bone mass, is where you are just below that, but at risk of developing osteoporosis. So, there’s a slight difference between the two terms.

Jamie DePolo: Okay. So, osteopenia it sounds like is not necessarily treated, but somebody would know that perhaps, okay, you’re at higher risk for osteoporosis, now let’s take some steps. 

Dr. Anupama Shahane: That’s exactly correct. That is correct in the large population. People with breast cancer or treatment of breast cancer, and I’m assuming we will get into this a little bit later, we do tend to look at women with osteopenia and potentially actually start interventions before they get to the osteoporosis stage.

Jamie DePolo: Okay, that makes sense. That makes sense. Are there factors, aside from treatment, say someone’s going to start breast cancer treatment, are there other risk factors that can put somebody at higher risk of developing osteoporosis, so those people might start monitoring even sooner, like, as soon as they start treatment?

Dr. Anupama Shahane: Yeah, absolutely. So, there’s a couple of things. So, we look at risk factors as modifiable risk factors and non-modifiable risk factors.

So, the risk factors that we cannot change, the main thing is genetics. There is some role of family history and your own genetics that could make you a little bit more prone to losing bone quicker. A person’s size matters as well. Women that tend to be smaller-boned tend to lose bone more or just tend to have lower bone to begin with -- bone density -- to begin with, so these are some things that we actually cannot change, but these could affect your risk, your eventual risk. The other thing I would say is age. 

So, post-menopausal bone loss happens over time, so when you hit menopause naturally, it’s over a few years, one says usually about five years or so. Breast cancer treatment often puts women into menopause, but that’s sudden. And that sudden change in your hormonal status, going from having a quote-unquote “normal” estrogen to suddenly not have, being very estrogen deprived, actually causes larger amounts of bone loss.

The other factors that do matter and that we can control are primarily based on lifestyle.

So, the number one thing is smoking. We know that smoking increases your risk of bone loss and it is highly recommended do not smoke. So, if you are smoking this is a good time to stop. 

The second thing is alcohol intake. We don’t really worry too much about, you know, small amounts, a drink here and there, it does not really affect bone loss too much, but moderate to high amounts of alcohol consumption have been shown to decrease bone density. So, we have smoking and we have alcohol.

Exercise. We know that bone strengthening exercises, which includes high-impact exercises, but also just cardio, decreases your risk of bone loss. When you exercise, you’re straining the muscles and the bones and that’s putting pressure on the bones and stimulating them to actually grow, or sort of keep their metabolism going. So, exercise is the third thing that we can control and can help lower bone loss. 

Nutrition is the fourth one. Two things that are key in nutrition are calcium levels and vitamin D. We know that if you are deficient in calcium and vitamin D, your speed of bone loss can go up. It is recommended for women, you know, actually the Cancer Society also recommends that women who are going through these treatments and evaluations take a calcium supplement, so the daily recommended calcium intake is approximately 1,200 milligrams a day. It does not have to be a supplement of 1,200 milligrams, it could be a combination of foods and supplement, and actually it is better for the body to absorb natural calcium. So, maybe dairy, green leafy vegetables, nuts, which are a good source of calcium, and then you supplement the rest through your diet. 

And then vitamin D supplementation is recommended to about 800 international units per day. Vitamin D we get through the sun, but it can often be challenging to get vitamin D through diet, and so supplementation is helpful and key. So, the four things that I would say that we can control is smoking, alcohol intake, exercise, and nutrition levels. 

Jamie DePolo: I have a question about the exercise, because you mentioned cardio can help build bone strength. I have read and been told that it’s really weight-bearing exercise, but it sounds like you’re saying it could be both. So, maybe running, bicycling, skating, I don’t know, things like that can also help improve bone density?

Dr. Anupama Shahane: So, typically we do recommend weight-bearing exercise, but the reason I mentioned cardio as well is running is a weight-bearing exercise as well.

Jamie DePolo: I guess that’s true, right.

Dr. Anupama Shahane: You are doing high-impact. Now, we don’t typically recommend high-impact exercises, you know, beyond a certain age because of the effect it can have on joints, but high-impact exercises are arguably even more sort of stimulating for bone growth. But while we say weight-bearing is key, I think cardio counts, so my usual recommendation is get some exercise, get exercise that works the best for you. We’re not looking to you know train for a marathon or compete in the Olympics.

Jamie DePolo: Right.

Dr. Anupama Shahane: You know, we’re looking to do practical exercises that you can do while you may be going through some treatments that could be harsh on the body. So, if you can walk; walking is great. You could do some elliptical, do some small weights, two to five pounds. The key is consistency, not necessarily the intensity. You could use lower weights, but do more repetitions. So, that’s kind of how I approach exercise.

Jamie DePolo: Okay. Okay, thank you. Now, you said osteoporosis doesn’t really have any symptoms, so how is it diagnosed?

Dr. Anupama Shahane: One of the main, one of the critical things to understand is exactly this is that you don’t know you have osteoporosis, unless you, until you have that first fracture, which is exactly what we want to try to avoid.

Osteoporosis is diagnosed by what’s called a DEXA scan, its dual x-ray absorptiometry. It’s DEXA, D-E-X-A scan that what, it’s a radiology test that’s done very quickly, it takes a few minutes, actually, and it’s a screening test, meaning there are certain guidelines and recommendations as to who should get DEXA screening. Typically, women over the age of 65 or women over 50 with some risk factors, you get a DEXA scan and then you look at what’s called a T-score. 

So, there are certain scores that are given in the DEXA scan and these scores give you standard deviations of where your bone density is in comparison to a younger woman, a 30-year-old woman, actually. And there have been large trials based on tens of thousands of women, where they have given us cutoffs at which point starting treatment is beneficial. So, the risk-benefit ratio goes towards benefit, and these are, you know it’s like calculations and there’s clear guidelines. I’m happy to go over them if that’s relevant. Maybe it helps us also to go through how we diagnose it maybe?

Jamie DePolo: Sure, sure.

Dr. Anupama Shahane: So, and again I don’t want anybody to latch on to these numbers, but this is just a little bit of understanding. So, osteoporosis is diagnosed when these T-scores are less than -2.5, so that’s two and a half standard deviations below “normal.” 

Jamie DePolo: Okay.

Dr. Anupama Shahane: And osteopenia is when your T-score falls between -1 and -2.5, so you’re one standard deviation lower, but not, you know, in the osteoporosis category. So, that’s the differentiating factor between osteoporosis and osteopenia.

Jamie DePolo: Okay, okay. And then, you know, you mentioned there are national guidelines, it sounds like women should start testing at 65 unless, like you said, they had risk factors. Would breast cancer treatment be considered a risk factor? So, say, if someone’s 40, maybe they haven’t gone through menopause yet, but they know they’re going to be getting chemo that might throw them into menopause. Is that kind of a flag that they should get tested?

Dr. Anupama Shahane: Yeah. So, that’s a great question. So, currently I think there’s some differences in practice style. So, one, there are guidelines from the Association of Cancer Clinical Oncology that are different guidelines from the British Association, there’s one from the Belgian Association. There isn’t one sort of international guideline that exists for osteoporosis, but generally speaking, what tends to happen is women that are started on aromatase inhibitors, for the most part do a screening DEXA scan at the start of treatment. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: I think the practice varies a little bit in women that might start other treatment modalities. So, if somebody is starting chemotherapy, my understanding is that it could vary from practice to practice whether that patient might get a DEXA scan, especially if they are young, but aromatase inhibitors, usually oncologists do get a screening DEXA scan. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: If you’re over the age of 50, everyone’s going to get a DEXA scan.

Jamie DePolo: Okay. Okay, that makes sense. And perhaps for the other it may depend on the chemotherapy regimen if one is known to cause more issues. 

Dr. Anupama Shahane: Right.

Jamie DePolo: Okay, that makes sense. 

Dr. Anupama Shahane: So, the awareness of osteoporosis is definitely increasing. Osteoporosis in general is more understood now, there’s more awareness, there’s more screening.

The one other factor that goes into this is that most breast cancer treatments do put women into menopause and that triggers screening for bone loss. So, even if the DEXA screening may not happen right at the onset of treatment, it probably is going to happen within the first year of treatment. 

Jamie DePolo: Okay. Okay, that’s good to know.

So, let’s move on to how is osteoporosis treated? You know, if somebody is getting the appropriate screening and it gets diagnosed, what are the treatment options? And also, if you know, are there any conflicts? If you’re receiving breast cancer treatment and you get diagnosed with osteoporosis, do you have to wait until you’re finished with breast cancer treatment before you start the other treatment?

Dr. Anupama Shahane: Sure. So, let’s maybe take this like one question at a time and break this down a little bit. 

Jamie DePolo: Sure.

Dr. Anupama Shahane: So, in terms of you know, here we are, you know, somebody’s done the screening bone density test and you have a diagnosis of osteoporosis or osteopenia. So, I would look at it as what intervention would you take maybe yourself where you’re not depending on somebody to write you a prescription?

So, I would go back and reemphasize the importance of lifestyle. You know, I really want to encourage everybody to eat the best you can, and it can be challenging when you’re going through harsh treatments and maybe you’re not feeling so great, but you know eat the best you can, take care of yourself, hydrate, and stay active. 

I think, you know, again the best you can. It doesn’t have to be an exercise regimen. It does not have to be going to the gym. You’re probably, you know, going through some treatments and side effects, but if you could go for a walk, if you, you know, have two-pound dumbbells at home, or you might have a stretch band that you can, you know, get quite easily and just do some upper body strengthening, core strengthening.

So, I think I wouldn’t wait for a diagnosis of osteopenia or osteoporosis to start these interventions, I would do it regardless, but especially if you find yourself going through treatment for cancer, I think this should be in the back of your mind. 

So, exercise and sort of nutritional supplements, I would say don’t wait. Don’t wait to be screened, don’t wait to be diagnosed. As far as after having the diagnosis, so there’s different ways to do this.

So, first let’s talk about people who do meet the osteoporosis criteria based on DEXA screening. So, these are women who are two and a half standard deviations low. There’s two main medication types that are used, so treatment, you know, that’s not lifestyle is essentially medicines. I will say that osteoporosis medications are usually well tolerated. 

There is great data on efficacy of these medications in decreasing fractures. This fracture risk can be decreased depending on, you know, which study you look at and which medication and which context, can decrease your fracture risk by 40 to up to 70 percent and in the medical world that is huge. It means that up to four or seven times that you fall you don’t break something. I think it’s important to recognize it’s not zero and I actually tell this to all my osteoporosis patients: the fracture risk is never going to be zero. So, it’s important to understand that, but medications decrease your fracture risk considerably. 

So, which medicines? There’s actually four types of osteoporosis medicines. The ones that are used in this context for treatment of osteoporosis in women who are going through breast cancer treatment are the one category is called bisphosphonates, which many people may have heard of. There are so many commercials from years ago even. I’ll just put some names out, but there’s a medicine called Fosamax, there’s a medicine called Actonel, Reclast, Zometa, don’t remember the names, this is just sort of, you know, some of them may be familiar. Some of them are by mouth, meaning you take them orally, and then some of them go by vein. 

So, oftentimes the cancer doctors will, you might go in for a treatment and they might just add on this medicine for you. And the frequency is variable. You know, one of the medicines that goes by vein, which is an infusion, is once a year, one of them is every three months, one of them is every four months. What these medicines do is that they sort of have a protective layer on the bone and they, in some way they counter the negative effect of chemotherapy on the bone. 

So, there’s many different ways that chemotherapy and aromatase inhibitors can affect bone health. There’s hormonal aspects of doing that, which is cutting off the estrogen, but there’s also direct effect on the bone where chemotherapy can actually stimulate the cells in the bone that cause the bone to weaken. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: And what the bisphosphonates do is that they stop these, or they try to stop these particular cells from over, being overactive, and in that way they slow down the bone loss. 

Jamie DePolo: Okay, okay. And can you, can you get those treatments? I know in some cases like Zometa is sometimes used as sort of a companion to breast cancer treatment, so I’m assuming that would be okay to get during treatment, but like the others is it okay to get them both? You said sometimes that, you know, you would get it as an add-on.

Dr. Anupama Shahane: So, bisphosphonates, yes. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: Bisphosphonates are okay to get with treat… with breast cancer treatment. Honestly, it’s actually, it should be recommended to do that because, you know, osteoporosis doesn’t wait for anybody and if you have it, you treat it. You are correct that there are some of these medications, especially Zometa and Reclast, there’s some data on using them to prevent, you know, sort of distant recurrence of cancer, so they actually have a dual role. But even in the context of treating the osteoporosis, it is okay to take these medications at the same time that you’re getting cancer treatment.

Jamie DePolo: Okay, perfect. And then one thing, once you start osteoporosis treatment it’s not something that ends is it? My impression is, so once you start this is kind of what you have to do for the rest of your life. 

Dr. Anupama Shahane: Right. 

Jamie DePolo: Or no?

Dr. Anupama Shahane: Well, I’m going to rephrase that a little bit.

Jamie DePolo: Okay.

Dr. Anupama Shahane: You know, if we have a minute, I want to go back to the treatment. I think we’ll mention a couple of other medicines.

Jamie DePolo: Oh, sure, sure, go ahead.

Dr. Anupama Shahane: Bisphosphonates are sort of the preferred medications they’re tolerated well, et cetera. Another medicine category or medicine, it’s called denosumab or Prolia, is also used commonly in this, in this context. And this medication has also been shown to decrease fracture risk or, you know, decrease, slow down bone loss in women with breast cancer and going through treatment. It works a little bit differently; it works on a different molecule in the bone. It’s dosed every six months, but again, very commonly used. So the two… and can be used with breast cancer treatment. So, the two main categories of treatments that are used in women with breast cancer going through treatment are the bisphosphonates and Prolia. 

A couple of medicines that are actually not used in this context, there is a medicine called raloxifene or Evista that is a, it works on estro… it works through estrogen and it’s actually not recommended in this context. Because women are already getting some medications that work through estrogen and some of them can have countereffect, so Evista is not used. There’s a couple of other medications I might mention because people may have heard of these names. There are medicines that work through one of the hormones of the body, these are called Tymlos and Forteo, again may have seen these in commercials. 

These medications are actually not used in women with breast cancer on treatment or not on treatment because they can actually, if there are hidden bone cancer cells, these medications can actually sometimes stimulate those cells and we don’t use them.

And then the last medicine there’s something called Evenity, which is an excellent medicine, it’s very effective, but there is not enough safety data and is not used in this context. So, there’s the two medicines that are used, recommended, should be used and then these other three that are not used. 

Jamie DePolo: Okay, that’s good to know. I actually haven’t heard of that last one Evenity, so that’s good to know. So, if you start treatment are you then on this treatment for the rest of your life?

Dr. Anupama Shahane: So, the way I look at it is once you are diagnosed with osteoporosis, we don’t take the diagnosis away. Meaning even if you’re treated and your numbers improve it’s still there. It’s going to be there in the background. Treatment, though, does not continue forever. 

Jamie DePolo: Oh, okay.

Dr. Anupama Shahane: Osteoporosis treatment is done in breaks and this is especially important in young women, younger women, because you don’t want to take these medications for, continuously, for a long time, and I will explain why.

Bisphos, let’s talk about bisphosphonates first. These medications have a long what’s called half-life. Meaning when you take the medicine it stays in your system. It’s not that you stop it and tomorrow the effect is gone. No, the effect actually stays longer in your body because the medicines sort of coat your bone and just hang out. So, even when you stop the medicine, there is a protective effect you get from the medicine and it keeps your fracture risk lower. 

The other thing is there is data that there are some side effects, and you cannot talk about a medicine without addressing some of the key side effects that you should know. There are two side effects of these medications. And I mention these to every single person I prescribe the medicine to because you would rather hear it from your doctor than Dr. Google.

Jamie DePolo: Right.

Dr. Anupama Shahane: One of them is called osteonecrosis of the jaw, again people may have heard this term but it causes damage to the jawbone. And the other one is called atypical femoral fracture. It is a term, but it’s actually a break in your hipbone. So, these, these side effects are most often the result of taking these medications for too long, because remember, they stay in your system, so they stay active, and if you continue taking them, sometimes they become too effective and they have sort of a countereffect. They don’t just slow down bone loss, but they stop any metabolism in the bone and we don’t want that. 

Jamie DePolo: Okay. 

Dr. Anupama Shahane: So, these medications are -- and this is the guideline -- you take them for an X amount of time, that could be two years, four years. It depends on the clinical context, what the DEXA score numbers are, what the risk is, what the chemotherapy is, what the fracture risk, all of this matters when you’re deciding how long do you take these medications. And then you take what’s called a drug holiday, which means you stop the medicine and then you sort of monitor where you are with your DEXA scans, and then usually at a two-year window you revisit: Is this time to restart? 

Jamie DePolo: I see.

Dr. Anupama Shahane: Or do we take you off the medicine?

Jamie DePolo: Okay.

Dr. Anupama Shahane: So, that’s the bisphosphonates. 

Jamie DePolo: Okay. 

Dr. Anupama Shahane: I wanted to make one comment about denosumab or Prolia. Prolia does also have the same potential side effects of the jaw necrosis and less so maybe the thighbone fracture, but one of the things about Prolia, is Prolia you really shouldn’t stop abruptly.

Prolia has to be transitioned to a bisphosphonate. And again, this is just sort of getting a little too sort of medical here, but just for some context, is you do transition, but you also do take a break. So, you take breaks. So, you take the medicine for some time, you take a break. You go back on the medicine for some time, you take a break. So, even though technically you’re going to be monitored and treated, you know, forever, you’re not actually on medications for the rest of your life. 

Jamie DePolo: I see. I see. Okay, thank you for explaining that. And I did have one question, I did know that osteonecrosis of the jaw or the breakdown of the jawbone is a side effect. Are most people advised to see their dentist before starting? And then if there’s an issue, say, you suddenly find out you need a root canal and you’re taking one of these medicines, how does that work?

Dr. Anupama Shahane: Yeah, great question. So, osteonecrosis of the jaw by itself is exceedingly rare. It’s like .01 percent-ish is the chance of that occurring. The problem is that the risk is higher, and again please remember the context, higher is also still very low, but the risk is higher in women going through cancer treatment and getting chemotherapy at the same time. The initial data actually come from patients who are going through chemotherapy, so I think it’s important to be aware of this. In the general population, I don’t know that every single… I think it’s important to make sure that you’re seeing your dentist every six months. 

I always ask this question, if you have dental work pending or coming up and you know you’re going to do it, I would hold off on starting treatment. If you know you’re getting an extraction or implant, I would get that first and then I would start treatment. But also remember that regular cleanings or cavities, so what’s called non-invasive, where you’re not actually doing a surgical intervention or drilling into the bone, that’s not really where the risk comes from. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: It’s more sort of the surgical intervention that’s the risk. So, I think it is important to communicate with your dentist, oral hygiene is important. There is some data that shows that there, oftentimes there is actually a specific bacteria that’s in the mouth and could be one of the triggers as to why this happens, so that’s important, you know regular cleanings, et cetera, are important. 

Now, going to your question of what happens if you’re on treatment and you need an intervention? Because things happen. Actually, there are guidelines from the American Dental Association on how to handle this situation. The way we, so remember some of these medicines are longstanding, you get them and you’ve got it, like your year is gone, right. 

Jamie DePolo: Right.

Dr. Anupama Shahane: If you need something you go ahead and get the plan that you need. What’s important is you have close monitoring with the dentist or oftentimes actually it ends up being an oral surgeon because you want to be a little bit more involved in this. They will cover with like mouth rinse that have antibiotics. There’s oftentimes closer follow-up, you know, they see you a little bit more frequently. They make sure the healing is good. So, there are interventions that are taken, and people will get close monitoring, so it’s not a reason to not start treatment.

Jamie DePolo: Okay, that makes sense. That makes sense. And I will emphasize too, as you said, that osteonecrosis of the jaw, it’s a very rare side effect. It’s just something to be aware of and you know talk to your dentist, talk to your oncologist, make sure everyone knows what’s going on.

Dr. Anupama Shahane: Right.

And then finally, I know, you know, you mentioned treatment breaks, you know, perhaps the medicines and the lifestyle interventions, say, if somebody starts exercising so the DEXA scores go up. I guess what I’m wondering, you know, how often is somebody monitored then? Say, you know, you’ve been diagnosed with osteoporosis.

Dr. Anupama Shahane: Yeah.

Jamie DePolo: You’ve, say had, you know, you’ve been on, you’ve taken treatments for two years.

Dr. Anupama Shahane: Yeah.

Jamie DePolo: Now, it’s decided like, oh, you can take a treatment break. 

Dr. Anupama Shahane: Yeah.

Jamie DePolo: What’s, what’s the monitoring process during the break and how do you know when you start again? 

Dr. Anupama Shahane: Absolutely. So, I think, you know, the one comment I might want to make is the DEXA scans, especially if they have been done at the beginning of treatment, remember may not improve. That’s not necessarily a goal, especially if it’s a younger woman, your bone density is probably going to be good when you’re starting out, and we don’t really expect it to improve necessarily. What we’re looking for primarily -- improvement would be fantastic -- but what we are primarily looking for is that it’s not declining steadily. 

Jamie DePolo: I see, okay.

Dr. Anupama Shahane: So, a steady bone density is a win. Risk of fracture doesn’t completely correlate with the actual numbers, so our goal is that the DEXA scan numbers do not continually drop. That’s number one. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: As far as the question of how often to monitor? The standard of care typically is every two years. So, if you start treatment, unless there’s a significant change, you would get a repeat DEXA scan in two years, you’d see where you are, probably get it in two years. A change would be if somebody falls in the osteopenia category, let’s say, which is you know where the number is lower but not quite as low, and they’re not starting treatment, that may be a time where you repeat your DEXA scan in one year and you see what change has happened. And then if there’s a drop, then that’s an indication to start treatment. 

The other time that I would, I mean, this would change your plan, but if somebody were to be on treatment and were to sustain a fracture. Then that might be a time where you may not wait the two years, but you might get a DEXA scan sooner, and you’re going to change your plan. 

Jamie DePolo: I see. And I do have a question about that, is it any kind of fracture? Like, it’s clearly a situation somebody did something and anybody would have broken their arm. 

Dr. Anupama Shahane: Yeah.

Jamie DePolo: Is that a cause for concern or are there particular areas? Like, I know the femur fracture is a big one, like, that’s a problem. But if somebody breaks a finger or breaks their forearm, is that the same level of concern?

Dr. Anupama Shahane: Right. Great question, again. So, a fracture of the femur, the hip fracture, the one called hip fracture, it’s the specific part of the hip. A hip fracture or vertebral fracture, which is in the spine, so either of these fractures without trauma. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: So, if you’re standing, and you’re walking and you trip and fall and you break your hip, regardless of your bone density, it’s osteoporosis. Of course, if you fall down an entire flight of stairs, or you’re hit by a car that does not, you’re skiing, like these don’t count, that’s traumatic. So, that’s a great, so by definition when we talk about these fractures, we are talking of non-traumatic fractures, which is defined as fall from standing height. 

Jamie DePolo: I see, okay. 

Dr. Anupama Shahane: Meaning, you’re not standing on a ladder, you’re not like hit by anything, you didn’t fall and tumble down steps, et cetera. 

Jamie DePolo: I gotcha.

Dr. Anupama Shahane: So, those are the two big ones. The other ones that also are important is wrist fracture, shoulder, and pelvis. 

Jamie DePolo: Okay.

Dr. Anupama Shahane: These count. But yes, if you break a finger, if you break like a toe -- just because these bones are small and less dense anyway -- those don’t necessarily count as these particular kinds of fractures. But of course, if you’re breaking multiple bones then that’s a problem. 

Jamie DePolo: Sure. Okay, okay. Dr. Shahane, thank you so much for explaining that, for explaining everything, this has been so helpful. Thank you so much for your time.

Dr. Anupama Shahane: Absolutely, thank you so much. It was great to be here.

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