Delayed and Selective Bone Health Assessment Following Cancer Diagnosis: A Real-World Gap in Survivorship Care

Background : Cancer treatment–induced bone loss (CTIBL) is well recognized in hormone-sensitive malignancies such as breast and prostate cancer but is less consistently implemented in patients with other solid tumors and hematologic malignancies. Furthermore, the long-term skeletal effects of newer systemic therapies, including immune checkpoint inhibitors and targeted agents, remain incompletely characterized. Although bone mineral density (BMD) assessment by dual-energy X-ray absorptiometry (DXA) is recommended for patients at increased skeletal risk, real-world utilization patterns remain poorly characterized. Objectives: To evaluate DXA utilization, timing, BMD results, and associated clinical characteristics following a new cancer diagnosis in a large real-world cohort. Methods: We conducted a retrospective cohort study using the MDClone platform, including adults with a first cancer diagnosis between January 1, 2015, and December 31, 2024, treated at Assuta Medical Centers in Israel. DXA completion, timing, BMD and T-scores, and prevalence of osteopenia and osteoporosis were analyzed. Results: Results: Among 21,112 patients with newly diagnosed cancer (77.0% women; mean age 60.2 ± 13.1 years), 7,496 (35.5%) underwent DXA at any time following diagnosis. DXA utilization was significantly lower in men than in women (15.0% vs. 41.7%). Early DXA assessment within 6 months of diagnosis was uncommon (1,550 patients; 7.3% of the total cohort), and only 14.1% underwent DXA within the first 12 months. Median time from cancer diagnosis to DXA was 14.8 months. DXA utilization varied by cancer type and was highest in breast cancer (39.7%), compared with prostate cancer (27.6%) and other malignancies (27.8%). Among patients undergoing DXA, 40.2% had normal BMD, 45.2% had osteopenia, and 14.5% met criteria for osteoporosis. Conclusions : In our real-world experience within a large private healthcare network, DXA assessment after cancer diagnosis is infrequently performed and often delayed, with marked disparities by sex and cancer type. A substantial burden of low bone mass is already present at the time of evaluation, highlighting missed opportunities for early skeletal risk identification.