Bone health and fitness for treatment in older adults

Dr Lara Greenstein and Dr Garrick Laudin highlight the key factors for caring for older adults with cancer.

People are living longer and are therefore more likely to live with cancer for longer or be diagnosed and treated at an older age. Cancer care isn’t solely about treating the malignancy itself, but rather caring about the whole person and ensuring that you’re fit enough to tolerate therapy and recover from side effects. 

Chronological age alone shouldn’t decide cancer treatment. Many older adults are strong and independent, while others have a reduced physiological reserve known as frailty. This means that an illness, a fall, or treatment can have a much bigger impact than expected. Frailty is not synonymous with chronological age.

Fitness ready

Improving your fitness for treatment can make a meaningful difference. Even small interventions can help you tolerate treatment better and recover more quickly. 

Key areas include:

• Physiotherapy or exercise programmes
• Nutritional support
• Optimising chronic illnesses
• Falls prevention strategies

Bone health

An often-overlooked aspect of cancer care in the older adult is bone health. Bones become weaker and thinner with age and sometimes the cancer itself or the treatment thereof exacerbates this problem. 

Weaker bones increase the risk of having a fracture, even after a fairly minor trauma. A fracture can be devastating for an older adult, leading to immobility, hospitalisation, chronic pain, and the inability to live independently. 

Weak bones result from several factors, including reduced mobility, steroid use, poor nutrition, vitamin D deficiency, and cancer spread to bone.

Many are unaware that they have osteoporosis (bones gradually lose strength, often without pain or symptoms) until a fracture occurs. Cancer and cancer treatment can worsen bone loss, making early recognition and treatment essential.

Protecting bone health supports strength and mobility during treatment. Practical steps include:

• Eating balanced meals with adequate protein and calcium.
• Maintaining vitamin D levels, often with supplementation.
• Participating in gentle weight-bearing and strengthening exercise.
• Reducing fall risk by addressing balance, vision, dizziness, and home hazards.
• Reviewing medications that may increase falls or bone loss.
• Treating osteoporosis when diagnosed.

Caring for older adults with cancer means looking beyond the diagnosis. 

By considering strength, mobility, bone health, and daily function, care can be tailored to support safety, independence, and treatment aligned with what matters most to each person.

Blood cancer and the older patient 

Most blood cancers are seen in older patients, with a median age at diagnosis of 69 years reported in 88 167 patients from a European patient registry (HAEMACARE). The most common lymphoid cancers were multiple myeloma, chronic lymphocytic leukaemia, and diffuse large B-cell lymphoma, whereas the most common myeloid malignancies were acute myeloid leukaemia, myeloproliferative neoplasms, and myelodysplastic syndromes.  

Given the older median age of patients with blood cancer, they remain underrepresented in clinical trials and subsequent decisions about treatment in the day-to-day setting are complex and challenging. However, as more older patients are enrolled in clinical trials, the body of evidence related to their treatment becomes clearer, and older patients may therefore receive more intensive treatment based on their physical fitness.

Goals and approach

A 2018 review article from The American Society of Haematology provides practical goals and an approach for assessing frailty and treatment in older patients with blood cancers: 

• Stage the patient’s age: This includes actively screening and quantifying frailty with disease specific assessment tools like the Geriatric Assessment in Haematology (GAH) tool and the International Myeloma Working Group Frailty Index (IMWG FI).
• Tailor treatment goals and treatment plans: Specific chemotherapy for older patients may require adjustment in doses to prevent toxicity, particularly heart toxicity. Patients who are fit and healthy should receive treatment with the intent to cure.   
• Improve strength and nutrition: Treatment and multi-disciplinary support in the key areas listed above. 
• Screen and address social support
• Reduce polypharmacy (concurrent use of multiple medications (typically five or more) by a single patient). 
• Screen and assess cognitive impairment.

By systematically addressing aspects of frailty, comorbidities, and social factors, your doctor can improve treatment tolerance, reduce complications, such as fractures and falls, and enable appropriately intensive therapy based on your physiological fitness rather than just chronological age. 

Dr Garrick Laudin is a specialist physician and clinical haematologist affiliated with The University of the Witwatersrand, who currently practices at Chris Hani Baragwanath Academic Hospital. His special interests are the hyperinflammatory syndromes associated with haematological malignancies, the haemolytic anaemias, and bone marrow failure syndromes.

Dr Lara Greenstein is a geriatrician at Helen Joseph Hospital in Gauteng. She is the vice president of the SA Geriatrics Society and the Academic Head of Geriatric Medicine at the University of the Witwatersrand. She has a passion for teaching.

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