Cancer treatment and recovery pose many challenges for a fitness client, including an increased risk for bone loss. Knowing the risks as well as the impact on a survivor’s health will help fitness professionals to go the extra mile while navigating these challenges.

Surgery, chemotherapy, radiation, and hormonal therapy have side effects, which exacerbate the problems faced by cancer patients. Surgery can create adhesions that can limit range of motion (ROM), cause pain, numbness and tightness.

Removal of lymph nodes creates scars and may decrease ROM and lead to lymphedema. Chemotherapy may affect balance, a patient’s immune system, and cause nausea, light-headedness, vertigo, neuropathy, fatigue, sarcopenia (loss of muscle mass), and anemia.

Radiation can cause fatigue, tightness, and stiffness. Hormonal therapy can cause joint pain, early menopause, and the side effects associated with menopause.

An unexpected but important artifact of surgery, chemotherapy, and radiation is an increased risk of developing osteoporosis, or bone loss that increases risk of fracture.

Breast cancer and prostate cancer patients need to be made aware of their increased risk of osteoporosis and how to decrease their risk.

Osteoporosis means “porous bone” and is a chronic disease that weakens the bones. It is a serious health issue. With osteoporosis, bone density decreases and the bones become fragile and break easily. Although it can cause a break in any bone, the most common sites for breaks are the hips, spine and wrist. A broken hip or spine usually requires a hospital stay or surgery and can lead to permanent pain, disability, or death. 

Bone loss occurs in everyone with age. The leading causes of osteoporosis are decreased estrogen in women at menopause and lowered testosterone levels in men. Bones loss speeds up during and after menopause as the protective effect of estrogen in the body declines. In fact, a woman can lose about 20 percent of her bone mass in the five to seven years after menopause.

The most common breast cancer is estrogen-based.  Cancer treatments work by starving the cancer of estrogen. The combination of the high incidence of breast cancer together with increased survival rates will increase the percentage of those suffering from breast cancer and osteoporosis.

The following cancer treatments can lead to a loss of bone density:

  1. Aromatase Inhibitors

Aromatase inhibitors are used in post-menopausal women diagnosed with hormone-receptor-positive cancer to reduce the risks of cancer recurrence. This treatment decreases estrogen levels, increasing the risk of osteopenia/osteoporosis and fractures.

The aromatase inhibitors are: anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)

  1. Androgen Deprivation Therapy

Androgen Deprivation Therapy (ADT) is a hormone therapy which leads to numerous side effects that can be abated through exercise. The side effects of ADT include loss of muscle, increase in fat mass and osteoporosis. A patient’s risk for diabetes and heart disease also increases. Men with prostate cancer who receive androgen deprivation therapy risk loss of bone density and fractures. 

  1. Chemotherapies

Chemotherapy has a major impact on bone health by shutting down the ovaries and causing early menopause in premenopausal women. The decreased estrogen state has a negative impact on bone density. Doxorubicin (Adriamycin), methotrexate (Trexall), cyclophosphamide (Cytoxan) and 5-fluorouracil can cause premature menopause.

  1. Oophorectomy  

The surgical removal of the ovaries will induce early menopause, again decreasing estrogen levels and increasing risk for bone loss.  

  1. Medically shutting down the ovaries

Used for hormone-receptor-positive breast cancer.  Shutting down the ovaries decreases estrogen, in order to decrease cancer growth. Unfortunately, this leads to lower bone density, especially if the ovaries are shut down at an early age.

  1. Use of corticosteroids

Some medications used to prevent nausea and vomiting may also have a negative impact on bone health.

  1. Sedentary lifestyle due to cancer fatigue 

Resistance exercise is associated with an increase in bone density. However, if cancer fatigue decreases motivation to exercise, the lack of weight-bearing challenges may increase risk for bone loss.

Cancer Treatment and Exercise Considerations


In addition to cancer survivors being at high risk for osteoporosis due to chemotherapy and cancer medications, balance issues are common. Balance can suffer after surgical procedures and treatments. Neuropathy, a common side effect of chemotherapy, can make the feet numb and affect balance.

Poor balance is of particular concern to those with brittle bones. This is especially acute with the TRAM flap procedure where the rectus abdominus is altered. Poor core strength, caused by the change in placement of the rectus abdominus, has a negative effect on balance.

After a TRAM flap operation, it is necessary to learn how to compensate for this change of muscle placement through a series of exercises designed to strengthen the remaining muscles, such as the obliques. Balance exercises can counter some of the effects of muscle imbalances and body asymmetry after surgery.

Falls and fall-related injuries, such as a hip fracture, can have serious consequences. Balance and strength exercises can help prevent falls by improving the ability to control and maintain body position whether in motion or stationary.

Fear of falling and fracturing might cause one to withdraw from daily activities and decrease quality of life. Stability exercises can help to enhance both steadiness and leg strength. Balance exercises will help one regain function and mobility for activities of daily living and are a key component for recovery after cancer treatments.

Posture and Muscle Imbalance

In addition to balance changes, cancer surgery may lead to faulty body posture. After surgery, cancer survivors have a tendency to protect the area where they had the surgery such as the chest area after breast surgery causing the cancer survivor to compensate by rounding the shoulders.

Muscles are shortened because of the surgery and there is scar tissue. Nerves may be irritated, which can result in numbness and tingling. It is important to learn the essential stretches for the pectoral muscles and shoulders. Eventually, incorporate strength training with an emphasis on strengthening the upper back muscles. This will help decrease the chance of developing round shoulders with a forward head posture.

Some of the reconstruction processes also change muscle placement, which may affect the posture of a cancer survivor. Whenever there is a change in muscle placement, it is advisable to have a postural assessment. In addition, abdominal surgery can result in abdominal tightness, which in turn creates an initial tendency to walk leaning forward. The good news is that most posture issues due to surgery and treatments are easily corrected with proper stretching and strengthening exercises.

Postural exercise is important. A goal is to decrease the risk of rounded shoulders and spinal fractures. Postural exercises can help align the body properly and can be performed a few times per day. Ideal postural alignment places less stress on the spine. This will help one to maintain good posture, which can help improve hyperkyphosis. Keeping muscles strong and flexible will also help with spinal stability.

The Personal Trainer’s Role

Prevention of osteoporosis is key and exercise, diet, and lifestyle changes should be emphasized to help prevent bone loss. Osteoporosis is typically less prevalent in people who are active, and exercise may also prevent osteopenia from becoming osteoporosis.  Proper body mechanics should be used throughout the day and during exercise sessions that include strength training, weight-bearing, stress reduction, posture, and balance exercises.


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Carol Michaels

Carol is a nationally recognized, highly educated cancer exercise specialist and consultant and has been a fitness professional for more than 20 years. She is the 2016 Idea Personal Trainer of the Year recipient. Check out the course that she worked with NFPT to develop: Cancer Recovery Specialist.