Table 2.

Recommendations for patient diagnostic and monitoring screening

Patient assessment		Comments
Medical history	Fracture history	Previous fractures increase the risk of future fractures, regardless of BMD. It is useful to perform a spinal x-ray before starting treatment in order to detect previous asymptomatic fractures. Techniques such as CT, MRI and/or PET can be very useful in determining whether an acute fracture is a bone metastasis
	Classic risk factors	Family history of osteoporosis should be included. The FRAX® is an easily reproducible diagnostic tool developed by the University of Sheffield from a meta-analysis of a wide variety of risk factors for osteoporotic fractures (https://www.sheffield.ac.uk/FRAX/). It allows the estimation of the 10-year risk of hip fracture and major osteoporotic fracture, with or without concomitant determination of BMD, although it may underestimate the risk in cancer patients. When using the FRAX® tool in cancer patients, cancer can be considered a “secondary osteoporosis”. One limitation is that this tool does not weigh the number, severity, or location of previous fractures, or the total or cumulative GC treatment
	Medications	Treatment review for potentially osteopenizing drugs
	Fall risk estimation	Estimation of fall risk
	Vitamin D	Vitamin D deficiency is an independent risk factor for low bone mass, falls, and fractures [112]. Determination of 25-hydroxyvitamin D levels allows patients to be classified as normal (> 30 ng/ml), insufficient (20–30 ng/ml) or deficient (< 20 ng/ml)
Physical & complementary examinations	Height	Height should be measured at least once a year and whenever there is suspicion of a new vertebral compression fracture
	BRMs	Variations throughout the day explain why their reproducibility is not a critical factor in the assessment of FR in cancer patients. However, it may be useful to determine BRMs at the beginning of diagnosis or once treatment has started to gain insight into the status of bone metabolism and, above all, to monitor treatment
	BMD	DXA is recommended to measure and compare BMD with previous DXA to assess the progression of osteoporosis. The WHO recommends performing these measurements every 2 years from menopause. The standardized recommendation for menopausal women treated with AI was an annual BMD assessment for the duration of treatment, especially if there is baseline osteopenia or osteoporosis [113]. The ASCO recommends increasing the frequency of DXA follow-up screening if deemed medically necessary based on the results of BMD testing and expected bone loss [84] Fig. 2

AI aromatase inhibitors, ASCO American Society of Clinical Oncology, BMD bone mineral density, BRMs bone resorption markers, CT computed tomography, DXA dual energy X-ray absorptiometry, FRAX Fracture Risk Assessment Tool, GC glucocorticoid; FR fracture risk, MRI magnetic resonance imaging, PET positron emission tomography, PMW postmenopausal women, PrMW premenopausal women, WHO World Health Organization