Anabolics in Cancer Patients: To Use or Not to Use?

With improving cancer survival, the management of osteoporosis in cancer survivors has become increasingly important. Cancer treatment-induced bone loss and aging place many survivors at high risk of fragility fractures. Anabolic agents, including parathyroid hormone (PTH) receptor agonists and the anti-sclerostin antibody romosozumab, effectively stimulate bone formation and reduce fracture risk in the general population. However, their use in cancer patients remains limited because of safety concerns and insufficient clinical evidence. Preclinical studies suggested a potential risk of osteosarcoma with PTH analogues and possible effects on tumor growth or bone metastasis through modulation of the bone microenvironment, although long-term human studies have not demonstrated an increased malignancy risk. In clinical practice, PTH analogues are generally avoided in patients with active malignancy, bone metastases, hypercalcemia, or a history of osteosarcoma. In selected cancer survivors with a sufficiently long diseasefree interval, their cautious use may be considered depending on recurrence risk. Romosozumab may represent another potential option, although supporting evidence remains limited. Overall, the use of anabolic therapy in cancer patients should be individualized, carefully balancing fracture risk against potential oncologic safety concerns.