Fracture risk in patients with prostate cancer on androgen deprivation therapy

The effects of exercise on body composition of prostate cancer patients receiving androgen deprivation therapy: An update systematic review and meta-analysis

Androgen deprivation therapy is a common treatment for prostate cancer. However, this therapy is associated with various adverse effects, such as increased body fat and decreased bone mineral density. Exercise may be useful for ameliorating these adverse effects, although it is not completely effective. This review aimed to clarify how exercise interventions influenced body composition and bone mineral density and to explore the most effective exercise program among prostate cancer patients who received androgen deprivation therapy. We searched the PubMed, EMBASE, Web of Science, EBSCO, and Cochrane Library databases for reports of randomised controlled trials that were published until October 2021. All studies involved prostate cancer patients who received androgen deprivation therapy and completed aerobic exercise, resistance exercise, and/or impact exercise training. Outcomes were defined as lean body mass, body fat mass, body fat rate, regional and whole-body bone mineral density. Thirteen reports regarding 12 randomised clinical trials (715 participants) were included. Relative to the control group, exercise intervention provided a higher lean body mass (mean difference: 0.88, 95% confidence interval: 0.40 to 1.36, P<0.01), a lower body fat mass (mean difference: -0.60, 95% confidence interval: -1.10 to -0.10, P<0.05), and a lower body fat rate (mean difference: -0.93, 95% confidence interval: -1.39 to -0.47, P<0.01). Subgroup analyses revealed greater efficacy for exercise duration of ≥6 months (vs. <6 months) and exercise immediately after the therapy (vs. delayed exercise). No significant differences were observed in the bone mineral density outcomes. Exercise can help ameliorate the adverse effects of androgen deprivation therapy in body composition, with combination exercises including resistance exercise, 8–12 repetition maximum of resistance exercise intensity, prolonged exercise duration, and performing exercise immediately after therapy providing better amelioration. And the combination of resistance and impact exercise appears to be the best mode for improving the bone mineral density.

Risk of Fracture During Androgen Deprivation Therapy Among Patients With Prostate Cancer: A Systematic Review and Meta-Analysis of Cohort Studies

Background: Androgen deprivation therapy (ADT) suppresses the production of androgen, and ADT is broadly used for intermediate or higher risk disease including advanced and metastatic cancer. ADT is associated with numerous adverse effects derived from the pharmacological properties. Previous meta-analysis on fracture risk among ADT users possessed limited data without further subgroup analysis. Risk estimation of updated real-world evidence on ADT-related fracture remains unknown. Objectives: To assess the risk of fracture and fracture requiring hospitalization associated with ADT among prostate cancer population on different disease conditions, treatment regimen, dosage level, fracture sites. Methods: The Cochrane Library, PubMed, and Embase databases were systematically screened for eligible cohort studies published from inception to March 2020. Two authors independently reviewed all the included studies. The risks of any fracture and of fracture requiring hospitalization were assessed using a random-effects model, following by leave-one-out, stratified, and sensitivity analyses. The Grading of Recommendations Assessments, Development and Evaluations (GRADE) system was used to grade the certainty of evidence. Results: Sixteen eligible studies were included, and total population was 519,168 men. ADT use is associated with increasing fracture risk (OR, 1.39; 95% CI, 1.26-1.52) and fracture requiring hospitalization (OR, 1.55; 95% CI, 1.29-1.88). Stratified analysis revealed that high-dose ADT results in an elevated risk of fracture with little statistical heterogeneity, whereas sensitivity analysis restricted to adjust for additional factors indicated increased fracture risks for patients with unknown stage prostate cancer or with no restriction on age with minimal heterogeneity. The GRADE level of evidence was moderate for any fracture and low for fracture requiring hospitalization. Conclusion: Cumulative evidence supports the association of elevated fracture risk with ADT among patients with prostate cancer, including those with different disease conditions, treatment regimens, dose levels, and fracture sites. Further prospective trials with intact information on potential risk factors on fracture under ADT use are warranted to identify the risky population.

Bone health management in the continuum of prostate cancer disease: a review of the evidence with an expert panel opinion

Bone health impairment is a frequent detrimental consequence of the high bone tropism of prostate cancer (PCa) cells. It is further worsened by administration of androgen-deprivation therapy (ADT), the current standard of care in the management of advanced PCa, through a rapid and dramatic increase in bone turnover and body mass changes. As a result, patients may experience substantial pain and poor quality of life (QoL) and have an increased risk of death. Notwithstanding the importance of this issue, however, bone health preservation is not yet a widespread clinical goal in daily practice.

To address this urgent unmet need, following a thorough discussion of available data and sharing of their clinical practice experience, a panel of Italian experts in the field of bone health and metabolism formulated a number of practical advices for optimising the monitoring and treatment of bone health in men undergoing ADT during all phases of the disease. The rationale behind the venture was to raise awareness on the importance of bone preservation in this complex setting, while providing an instrument to support physicians and facilitate the management of bone health.

Current evidence regarding the effects on bone health of ADT, of novel hormone therapies (which improve progression delay, pain control and QoL while consistently carrying the risk of non-pathological fractures in both non-metastatic and metastatic PCa) and of bone turnover inhibitors (whose use is frequently suboptimal) is reviewed. Finally, the expert opinion to optimise bone health preservation is given.

Osteoporotic fracture rates in chronic hemodialysis and effect of heparin exposure: a retrospective cohort study

Background

Patients receiving chronic hemodialysis treatments are at a higher risk of fracture compared to the general population. While the use of heparin during dialysis is crucial to avoid thrombosis of the extracorporeal circuit, the association of unfractionated heparin (UFH) and the risk of osteoporotic fracture has been shown for many years. However, this association was not as clear for low-molecular-weight heparin (LMWH) and the few collected data originated from studies among pregnant women. Our aim was to measure osteoporotic fracture rate among hemodialysis patients and to evaluate the association of LMWH compared to UFH in hemodialysis.

Methods

A retrospective cohort study was conducted on data extracted from the RAMQ and Med-Echo databases from January 2007 to March 2013 with patients chronically hemodialyzed in 21 participating centers. Incidence rates for each fracture sites were measured per 1000 patient-year (p-y) and their 95% confidence intervals (CI). Osteoporotic fracture risk for a first event with LMWH compared to UFH was estimated using a cox proportional hazard model using demographics, comorbidities and drug use as covariates.

Results

4796 patients undergoing chronic hemodialysis were identified. The incidence rate for all fracture sites was 22.7 /1000 p-y (95% CI: 19.6–26.1) and 12.8 /1000 p-y (95% CI: 10.5–15.4) for hip and femur fractures. We found a similar risk of osteoporotic fracture for LMWH compared to UFH (adjusted HR = 1.01; 95%CI: 0.72–1.42). Age and malignancy increased the risk of fracture while cerebrovascular disease decreased the risk of fracture.

Conclusions

Compared to UFH, LMWH did not change the risk of osteoporotic fracture when used for the extracorporeal circuit anticoagulation in chronic hemodialysis.

Risk of fracture incidence in prostate cancer survivors: a nationwide cohort study in South Korea

PURPOSE

We analyzed the risk of fracture in prostate cancer (PC) survivors compared to that in the general population in South Korea and according to the primary treatment.

METHODS

From 2007 to 2013, a total of 41,733 PC survivors newly diagnosed with PC in South Korea were identified and matched to non-cancer controls. Cox proportional hazards regression analysis was performed to determine the relative risk of fracture.

RESULTS

Compared to the matched controls, PC survivors had a higher risk of fracture (adjusted hazard ratio (aHR) 1.39; 95% confidence interval (CI) 1.33-1.45). Compared to the matched controls, the active surveillance/watchful waiting and radiotherapy group showed a similar risk of fracture (aHR 1.08; 95% CI 0.98-1.20, and aHR 1.04; 95% CI 0.63-1.73, respectively). PC survivors who underwent surgery showed a lower risk of fracture (aHR 0.89; 95% CI 0.82-0.96), while those who underwent surgery + androgen deprivation therapy (ADT) (aHR 1.41; 95% CI 1.26-1.57), radiotherapy + ADT (aHR 1.86; 95% CI 1.50-2.32), and only ADT (aHR 1.92; 95% CI 1.82-2.02) showed a higher risk of fracture than the control group.

CONCLUSION

The risk of fracture differed according to the primary treatment method for PC; survivors who underwent surgery had a lower risk of fracture compared to that of the general population. However, PC survivors treated with ADT showed a higher risk of fracture than the other PC treatment groups or the general population. Therefore, more attention and preventive bone care are required for PC survivors who receive ADT.

Associations Between Bone Impact Microindentation and Clinical Risk Factors for Fracture

Impact microindentation (IMI) measures bone material strength index (BMSi) in vivo. However, clinical risk factors that affect BMSi are largely unknown. This study investigated associations between BMSi and clinical risk factors for fracture in men. BMSi was measured using the OsteoProbe in 357 men (ages 33 to 96 years) from the Geelong Osteoporosis Study. Risk factors included age, weight, height, body mass index (BMI), femoral neck bone mineral density (BMD), parental hip fracture, prior fracture, type 2 diabetes mellitus (T2DM), secondary osteoporosis, smoking, alcohol consumption, sedentary lifestyle, medications, diseases, and low serum vitamin D levels. BMSi was negatively associated with age (r = -0.131, P = 0.014), weight (r = -0.109, P = 0.040), and BMI (r = -0.083, P = 0.001); no correlations were detected with BMD (r = 0.000, P = 0.998) or height (r = 0.087, P = 0.10). Mean BMSi values for men with and without prior fracture were 80.2 ± 6.9 vs 82.8 ± 6.1 (P = 0.024); parental hip fracture, 80.1 ± 6.1 vs 82.8 ± 6.9 (P = 0.029); and T2DM, 80.3 ± 8.5 vs 82.9 ± 6.6 (P = 0.059). BMSi did not differ in the presence vs absence of other risk factors. In multivariable models, mean (± SD) BMSi remained associated with prior fracture and parental hip fracture after adjusting for age and BMI: prior fracture (80.5 ± 1.1 vs 82.8 ± 0.4, P = 0.044); parental fracture (79.9 ± 1.2 vs 82.9 ± 0.4, P = 0.015). No other confounders were identified. We conclude that in men, BMSi discriminates prior fracture and parental hip fracture, which are both known to increase the risk for incident fracture. These findings suggest that IMI may be useful for identifying men who have an increased risk for fracture.

Attitudes and Experiences of Men With Prostate Cancer on Risk in the Context of Injuries Related to Community-Based Football-A Qualitative Study

Although football training may be a potent strategy for health promotion in older men, the considerable risk of injuries may constitute a barrier for referral of clinical populations. The current study explored the attitudes of men with prostate cancer on risk in the context of injuries related to participating in a community-based football program. Four videotaped focus group interviews and three individual in-depth telephone interviews were carried out with men with prostate cancer (n = 35; mean age = 68.8). The thematic networks technique was used to derive the global theme Injury-induced reinforced masculinity comprising five subthemes: "part of the game," "a good story to tell," "like boys again," "an old, carefree body," and "camaraderie." Collectively, these themes explained how football injuries may reflect masculine ideals in some men with prostate cancer. The study indicates that injuries are largely acceptable to men with prostate cancer, especially those in search of a means for expressing their masculinity.

Protocol for a phase III RCT and economic analysis of two exercise delivery methods in men with PC on ADT

BACKGROUND

Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer. However, side effects of ADT often lead to reduced quality of life and physical function. Existing evidence demonstrates that exercise can ameliorate multiple treatment-related side effects for men on ADT, yet adherence rates are often low. The method of exercise delivery (e.g., supervised group in-centre vs. individual home-based) may be important from clinical and economic perspectives; however, few studies have compared different delivery models. Additionally, long-term exercise adherence and an understanding of predictors of adherence are critical to achieving sustained benefits, but such data are lacking. The primary aim of this multi-centre phase III non-inferiority randomized controlled trial is to determine whether a home-based delivery model is non-inferior to a group-based delivery model in terms of benefits in fatigue and fitness in this population. Two other key aims include examining cost-effectiveness and long-term adherence.

METHODS

Men diagnosed with prostate cancer of any stage, starting or continuing on ADT for at least 6 months, fluent in English, and living close to a study centre are eligible. Participants complete five assessments over 12 months (baseline and every 3 months during the 6-month intervention and 6-month follow-up phases), including a fitness assessment and self-report questionnaires. Biological outcomes are collected at baseline, 6, and 12 months. A total of 200 participants will be randomized in a 1:1 fashion to supervised group training or home-based training supported by smartphones, health coaches, and Fitbit technology. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Outcomes include fatigue, quality of life, fitness measures, body composition, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report and utilities via the EQ-5D.

DISCUSSION

To disseminate publicly funded exercise programs widely, clinical efficacy and cost-effectiveness have to be demonstrated. The goals of this trial are to provide these data along with an increased understanding of adherence to exercise among men with prostate cancer receiving ADT.

TRIAL REGISTRATION

The trial has been registered at clinicaltrials.gov (Registration # NCT02834416 ). Registration date was June 2, 2016.

Androgen deprivation therapy and fracture risk in Chinese patients with prostate carcinoma

OBJECTIVE

Androgen deprivation therapy (ADT) increases fracture risk in men with carcinoma of the prostate, but little is known about the fracture risk for different types of ADT. We studied the fracture risk amongst Chinese patients with carcinoma of the prostate prescribed different ADT regimens.

SUBJECTS AND METHODS

This was a single-centered observational study that involved 741 patients with carcinoma of the prostate from January 2001 to December 2011.

RESULTS

After a median follow-up of 5 years, 71.7% of the study cohort received ADT and the incidence rate of fracture was 8.1%. Multivariable Cox regression analysis revealed that use of ADT was significantly associated with risk of incident fracture (Hazard Ratio [HR] 3.60; 95% Confidence Interval [95% CI] 1.41-9.23; p = 0.008), together with aged >75 years and type 2 diabetes. Compared with no ADT, all three types of ADT were independently associated with the risk of incident fracture: anti-androgen monotherapy (HR 4.47; 95% CI 1.47-13.7; p = 0.009), bilateral orchiectomy ± anti-androgens (HR 4.01; 95% CI 1.46-11.1; p = 0.007) and luteinizing hormone-releasing hormone agonists ± anti-androgens (HR 3.16; 95% CI 1.18-8.43; p = 0.022). However, there was no significant difference in the relative risks among the three types of ADT.

CONCLUSIONS

Fracture risk increases among all types of ADT. Clinicians should take into account the risk-benefit ratio when prescribing ADT, especially in elderly patients with type 2 diabetes.

Mortality and Androgen Deprivation Therapy as Salvage Treatment for Biochemical Recurrence after Primary Therapy for Clinically Localized Prostate Cancer

PURPOSE

Androgen deprivation therapy is often used as salvage treatment in men with rising prostate specific antigen after initial radical prostatectomy or radiotherapy for clinically localized prostate cancer. Given the lack of evidence from general practice, we examined the association of salvage androgen deprivation therapy with mortality in an observational cohort study.

MATERIALS AND METHODS

From 3 managed care organizations we assembled a retrospective cohort of all 5,804 men with newly diagnosed localized prostate cancer from 1995 to 2009 who had a prostate specific antigen increase (biochemical recurrence) after primary radical prostatectomy or radiotherapy. The main outcomes were all-cause and prostate cancer specific mortality. We used Cox proportional hazards models to estimate mortality with salvage androgen deprivation therapy as a time dependent predictor.

RESULTS

Overall salvage androgen deprivation therapy was not associated with all-cause or prostate cancer specific mortality in the prostatectomy cohort (HR 0.97, 95% CI 0.70-1.35 or HR 1.18, 95% CI 0.68-2.07) or in the radiotherapy cohort (HR 0.84, 95% CI 0.70-1.01 or HR 1.06, 95% CI 0.80-1.40, respectively). Among men with prostate specific antigen doubling time less than 9 months after the prostate specific antigen rise, salvage androgen deprivation therapy was statistically significantly associated with a decreased risk of all-cause and prostate cancer specific mortality in the prostatectomy cohort (HR 0.35, 95% CI 0.20-0.63 and HR 0.43, 95% CI 0.21-0.91) and in the radiotherapy cohort (HR 0.62, 95% CI 0.48-0.80 and HR 0.65, 95% CI 0.47-0.90, respectively).

CONCLUSIONS

We found no association of salvage androgen deprivation therapy with all-cause or cause specific mortality in most men with biochemical recurrence after primary radical prostatectomy or radiotherapy for clinically localized prostate cancer. Men with quickly progressed disease may derive a clinical benefit from salvage androgen deprivation therapy.

Androgen Deprivation in Veterans with Prostate Cancer: Implications for Skeletal Health

Background:

Common risk factors for osteoporosis in older men include smoking, heavy use of alcohol, propensity to falls, and use of bone-toxic medications such as prednisone. There is also increasing appreciation of the skeletal risk faced by men receiving androgen deprivation therapy (ADT) for prostate cancer. Measures to prevent bone loss in such patients are available.

Objective:

To test the following hypotheses in a population of veterans receiving ADT for prostate cancer: (1) fracture risk factors in addition to androgen deprivation would be found in most patients, (2) bone mass measurements would be assessed in a minority of patients, and (3) a minority of the subjects would receive bisphosphonate therapy or have contraindications for such treatment.

Methods:

We conducted a retrospective chart review of male veterans receiving ADT from 1993 through 2001, at the Veterans Affairs Medical Center, Madison, WI.

Results:

One hundred and seventy-four subjects met study criteria, with a mean age of 76 years and median duration of 21 months of ADT. Eighty-one percent had risk factors in addition to ADT. Only 13% underwent bone density measurement by dual energy X-ray absorptiometry (DXA) and, of those measured, more than half had osteoporosis. Only 19% of the men received both calcium and vitamin D supplements. Antiresorptive therapy was provided to 11% of men, although more than two-thirds had no contraindications to therapy. A total of 24 men sustained a fracture after starting ADT. For men who did undergo bone density measurement, 77% received antiresorptive therapy. Of those who exhibited osteoporosis by DXA scan, 85% received antiresorptive therapy.

Conclusions:

Male veterans receiving ADT for prostate cancer received inadequate evaluation and treatment for osteoporosis. Based on our data, a simple and practical strategy to prompt further evaluation and improved care may be to undertake bone density measurements in men prior to or soon after commencing ADT.

Cardiovascular risk after androgen deprivation therapy for prostate cancer: an Asian perspective

Androgen deprivation therapy (ADT) plays an important role in managing prostate cancer. However, ADT may result in major cardiovascular events and potentially lead to fatal consequences. Cardiovascular disease is the leading cause of mortality and it is a very important health condition to look into. Asians and Caucasians differ both physiologically and genetically, and they may have display different cardiovascular profiles. In this article, we reviewed the literature focusing on the cardiovascular risk after ADT for prostate cancer in the Asian population. We would discuss about the pathogenesis of ADT leading to cardiovascular events, summarize the findings concerning cardiac and stroke risks after ADT, compare between the different modalities of ADT and also provide genetic basics which are unique to Asians. We hope this article would provide more insights into the cardiovascular risk after ADT for prostate cancer in an Asian perspective.

Risk of fracture in men with prostate cancer on androgen deprivation therapy: a population-based cohort study in New Zealand

BACKGROUND

Androgen deprivation therapy (ADT) administered as a prostate cancer treatment is known to exert multiple side effects including bone deterioration leading to bone fracture. The current analysis is to evaluate the burden of fracture risk in the New Zealand prostate cancer (PCa) population treated with ADT, and to understand the subsequent risk of mortality after a fracture.

METHODS

Using datasets created through linking records from the New Zealand Cancer Registry, National Minimal Dataset, Pharmaceutical Collection and Mortality Collection, we studied 25,544 men (aged ≥40 years) diagnosed with PCa between 2004 and 2012. ADT was categorised into the following groups: gonadotropin-releasing hormone (GnRH) agonists, anti-androgens, combined androgen blockade (GnRH agonists plus anti-androgens), bilateral orchiectomy, and bilateral orchiectomy plus pharmacologic ADT (anti-androgens and/or GnRH agonists).

RESULTS

Among patients receiving ADT, 10.8 % had a fracture compared to 3.2 % of those not receiving ADT (p < 0.0001). After controlling for age and ethnicity, the use of ADT was associated with a significantly increased risk of any fracture (OR = 2.83; 95 % CI 2.52-3.17) and of hip fracture requiring hospitalisation (OR = 1.82; 95 % CI 1.44-2.30). Those who received combined androgen blockade (OR = 3.48; 95 % CI 3.07-3.96) and bilateral orchiectomy with pharmacologic ADT (OR = 4.32; 95 % CI 3.34-5.58) had the greatest risk of fracture. The fracture risk following different types of ADT was confounded by pathologic fractures and spinal cord compression (SCC). ADT recipients with fractures had a 1.83-fold (95 % CI 1.68-1.99) higher mortality risk than those without a fracture. However, after the exclusion of pathologic fractures and SCC, there was no increased risk of mortality.

CONCLUSIONS

ADT was significantly associated with an increased risk of any fracture and hip fracture requiring hospitalisation. The excess risk was partly driven by pathologic fractures and SCC which are associated with decreased survival in ADT users. Identification of those at higher risk of fracture and close monitoring of bone health while on ADT is an important factor to consider. This may require monitoring of bone density and bone marker profiles.

Management of endocrine disease: Secondary osteoporosis: pathophysiology and management

Osteoporosis is a skeletal disorder characterized by decreased mass and compromised bone strength predisposing to an increased risk of fractures. Although idiopathic osteoporosis is the most common form of osteoporosis, secondary factors may contribute to the bone loss and increased fracture risk in patients presenting with fragility fractures or osteoporosis. Several medical conditions and medications significantly increase the risk for bone loss and skeletal fragility. This review focuses on some of the common causes of osteoporosis, addressing the underlying mechanisms, diagnostic approach and treatment of low bone mass in the presence of these conditions.

Risk of new-onset diabetes after androgen deprivation therapy for prostate cancer in the Asian population

BACKGROUND

The associations of androgen deprivation therapy (ADT) with its adverse events in the Asian population remained largely unknown. We investigated the risk of new-onset diabetes mellitus (DM) after ADT for prostate cancer in the Asian population.

METHODS

All prostate cancer patients who were treated primarily with radical prostatectomy or radiotherapy, with or without further ADT from 2000 to 2009 were reviewed. Clinical parameters including age, clinical T stage, Gleason score, hypertension, dyslipidemia, impaired fasting glucose, ischemic heart disease, history of stroke, new-onset DM, follow-up duration, form and duration of ADT were reviewed. The risk of DM after ADT was analyzed with Kaplan-Meier method and multivariate Cox regression analysis.

RESULTS

A total of 388 patients were included, consisting of 169 patients in the non-ADT group and 219 patients in the ADT group. Upon Kaplan-Meier analysis, the ADT group had a higher risk of new-onset DM (P = 0.011). Upon multivariate Cox regression analysis, dyslipidemia (HR 2.32, 95% CI 1.07-5.00, P = 0.032), impaired fasting glucose (HR 5.92, 95% CI 1. 2.27-15.45, P < 0.001) and the use of ADT in the form of GnRH agonist (HR 3.34, 95% CI 1.19-9.39, P = 0.022) and bilateral orchiectomy (HR 6.49, 95% CI 1.48-28.55, P = 0.013) were associated with increased risk of new-onset DM.

CONCLUSIONS

There was increased risk of new-onset DM after ADT for prostate cancer in the Asian population. Regular screening of DM can be considered after the initiation of ADT, especially in patients with known history of dyslipidemia and impaired fasting glucose.

Managing bone metastases and reducing skeletal related events in prostate cancer

Advanced-stage prostate cancer is associated with skeletal complications related to metastatic disease and its treatment. On the one hand, metastatic disease to bone is commonly associated with skeletal-related events (SREs); on the other hand, treatment with androgen-deprivation therapy (ADT) leads to loss in bone mineral density (BMD) and increased risk of fracture. Despite osteoblastic appearance on radiography, bone metastases from prostate cancer are associated with increased osteoblast and osteoclast activity providing the rationale for treatment with osteoclast-targeted agents. The bisphosphonate zoledronic acid and the monoclonal antibody denosumab reduce the incidence of SREs in metastatic castration-resistant prostate cancer (mCRPC). A number of agents prevent loss of BMD associated with ADT, but only denosumab is approved to reduce fractures in patients with non-metastatic prostate cancer. Another recently approved agent-radium-223-improves survival and delays SREs in mCRPC. The inhibitors of androgen receptor signalling, abiraterone and enzalutamide, improve survival in mCRPC and delay SREs, although the latter is likely related to control of disease rather than a direct effect on bone. Finally, the tyrosine kinase inhibitor cabozantinib shows promising activity in bone metastases from mCRPC. This Review addresses the skeletal morbidity associated with prostate cancer and the therapeutic options that exist to treat it.

Causes, consequences, and treatment of osteoporosis in men

Men undergo gradual bone loss with aging, resulting in fragile bones. It is estimated that one in five men will suffer an osteoporotic fracture during their lifetime. The prognosis for men after a hip fracture is very grim. A major cause is reduction of free testosterone. Many other factors result in secondary osteoporosis, including treatment for other diseases such as cancer and diabetes. Patients should be screened not only for bone density but also assessed for their nutritional status, physical activity, and drug intake. Therapy should be chosen based on the type of osteoporosis. Available therapies include testosterone replacement, bisphosphonates, and nutritional supplementation with calcium, vitamin D, fatty acids, and isoflavones, as well as certain specific antibodies, like denosumab and odanacatib, and inhibitors of certain proteins.

Androgen deprivation therapy impact on quality of life and cardiovascular health, monitoring therapeutic replacement

INTRODUCTION

Androgen deprivation therapy (ADT) is commonly utilized in the management of both localized and advanced adenocarcinoma of the prostate. The use of ADT is associated with several adverse events, physical changes, and development of medical comorbidities/mortality.

AIM

The current article reviews known adverse events associated with ADT as well as treatment options, where available. Current recommendations and guidelines are cited for ongoing monitoring of patients receiving ADT.

METHODS

A PubMed search of topics relating to ADT and adverse outcomes was performed, with select articles highlighted and reviewed based on level of evidence and overall contribution.

MAIN OUTCOME MEASURES

Reported outcomes of studies detailing adverse effects of ADT were reviewed and discussed. Where available, randomized trials and meta-analyses were reported.

RESULTS

ADT may result in several adverse events including decreased libido, erectile dysfunction, vasomotor symptoms, cognitive, psychological and quality of life impairments, weight gain, sarcopenia, increased adiposity, gynecomastia, reduced penile/testicular size, hair changes, periodontal disease, osteoporosis, increased fracture risk, diabetes and insulin resistance, hyperlipidemia, and anemia. The definitive impact of ADT on lipid profiles, cardiovascular morbidity/mortality, and all-cause mortality is currently unknown with available data. Treatment options to reduce ADT-related adverse events include changing to an intermittent treatment schedule, biophysical therapy, counseling, and pharmacotherapy.

CONCLUSIONS

Patients treated with ADT are at increased risk of several adverse events and should be routinely monitored for the development of potentially significant morbidity/mortality. Where appropriate, physicians should reduce known risk factors and counsel patients as to known risks and benefits of therapy.

Toxicities following treatment with bisphosphonates and receptor activator of nuclear factor-κB ligand inhibitors in patients with advanced prostate cancer

CONTEXT

Advanced prostate cancer (PCa) is associated with skeletal complications, both as a result of bone metastases and because of fractures associated with fragility due to androgen-deprivation therapy (ADT). Osteoclast inhibitors are commonly used to reduce skeletal complications but are associated with a number of potential adverse events.

OBJECTIVE

To review clinical trials of osteoclast inhibitors in advanced PCa, to discuss the adverse event profile of these agents, and to discuss strategies to address specific adverse events.

EVIDENCE ACQUISITION

PubMed was searched for reports of clinical trials of osteoclast inhibitors in advanced PCa. As zoledronic acid and denosumab are used most commonly in this disease, these trials were the focus. The literature was reviewed to identify key publications addressing the prevention and management of adverse events associated with these drugs.

EVIDENCE SYNTHESIS

The major findings of the trials and the adverse events are discussed. Prevention and management of common adverse events are addressed.

CONCLUSIONS

Zoledronic acid prevents loss of bone mineral density associated with ADT and delays skeletal-related events in metastatic castration-resistant PCa (mCRPC). Denosumab reduces the incidence of fragility fractures associated with ADT, delays the onset of bone metastases in nonmetastatic castration-resistant disease, and is superior to zoledronic acid in the prevention of skeletal complications in mCRPC. Adverse events associated with both agents include osteonecrosis of the jaw and hypocalcemia. Hypocalcemia is more common with denosumab. Zoledronic acid requires dose modifications for renal insufficiency, is contraindicated in severe renal insufficiency, and has been associated with deterioration of renal function. Appropriate patient selection with close attention to dental health, supplementation with calcium and vitamin D, and monitoring of laboratory values are effective strategies to minimize the impact of adverse events associated with osteoclast inhibitors in advanced PCa.

The side effects of hormonal therapy at the patients with prostate cancer

Prostate cancer is one of most frequent malignant tumours at men. The androgen-deprivation therapy is the part of cancer treatment. It could be used both in the early stage of prostate cancer and in the bone metastates. From this reason the antiandrogen drugs waste systematically grows. Unfortunately androgen-deprivation therapy has numerous side effects such as: the inferior quality of live, sexual disturbances, the fatigue, the anaemia, the bone mineral density loss and the increase of the risk of breaks the bone, the increase of body mass, insulinresistance, hypercholesterolemia, the increase risk of cardiac disorders. The aim of this article is the introduction of the reader with possibly complications androgen-deprivation therapy and with possibilities in diagnosis and treatment.

Anti-androgenic effects of S-40542, a novel non-steroidal selective androgen receptor modulator (SARM) for the treatment of benign prostatic hyperplasia

BACKGROUND

Selective androgen receptor modulators (SARMs) would provide alternative therapeutic agent for androgen-related diseases. We identified a tetrahydroquinoline (THQ) derivative, 1-(8-nitro-3a, 4, 5, 9b-tetrahydro-3H-cyclopenta[c]quinolin-4-yl) ethane-1, 2-diol (S-40542) as a novel SARM antagonist.

METHODS

Affinity for nuclear receptors of S-40542 was evaluated in receptor-binding studies. Androgen receptor (AR) transcriptional activity of S-40542 was investigated by luciferase reporter assay in DU145AR cells. Normal and benign prostatic hyperplasia (BPH) model rats were repeatedly treated with S-40542 and flutamide. The tissue weights of prostate and levator ani muscle as well as blood levels of testosterone and luteinizing hormone were measured.

RESULTS

S-40542 bound to the AR with high affinity. S-40542 at relatively high concentrations increased the transcriptional activity. This agent also showed a concentration-dependent AR antagonistic action in the presence of 1 nM 5α-dihydrotestosterone. Repeated treatment with S-40542 and flutamide decreased dose-dependently the weights of the prostate to a similar extent. In contrast, the tissue weight-reducing effect by S-40542 treatment on the levator ani muscle was much weaker than that of flutamide. S-40542 had little effect on the blood level of testosterone and luteinizing hormone, whereas flutamide increased the level of both hormones. Furthermore, S-40542 decreased dose-dependently prostate weight of BPH rats.

CONCLUSIONS

The current results indicate that S-40542 possesses the prostate-selective SARM activity, suggestive of clinical benefit against benign prostate hyperplasia. THQ compounds may be useful for the research of mode of action of SARMs and for the development of safe SARM antagonists.

AST-induced bone loss in men with prostate cancer: exercise as a potential countermeasure

Androgen suppression treatment (AST) for men with prostate cancer is associated with a number of treatment-related side effects including an accelerated rate of bone loss. This loss of bone is greatest within the first year of AST and increases the risk for fracture. Pharmaceutical treatment in the form of bisphosphonates is currently used to counter the effects of hormone suppression on bone but is costly and associated with potential adverse effects. Recently, exercise has been shown to be an important adjuvant therapy to manage a range of treatment-related toxicities and enhance aspects of quality of life for men receiving AST. We propose that physical exercise may also have an important role in not only attenuating the bone loss associated with AST but in improving bone health and reducing fracture risk. In this review, the rationale underlying exercise as a countermeasure to AST-induced bone loss is provided.

Clinical review. Risk factors for low bone mass-related fractures in men: a systematic review and meta-analysis

CONTEXT

Testing men at increased risk for osteoporotic fractures has been recommended.

OBJECTIVE

The aim of this study was to estimate the magnitude of association and quality of supporting evidence linking multiple risk factors with low bone mass-related fractures in men.

DATA SOURCES

We searched MEDLINE, EMBASE, Web of Science, SCOPUS and Cochrane CENTRAL through February 2010. We identified further studies by reviewing reference lists from selected studies and reviews.

STUDY SELECTION

Eligible studies had to enroll men and quantitatively evaluate the association of risk factors with low bone density-related fractures.

DATA EXTRACTION

Reviewers working independently and in duplicate determined study eligibility and extracted study description, quality, and outcome data.

DATA SYNTHESIS

Fifty-five studies provided data sufficient for meta-analysis. The quality of these observational studies was moderate with fair levels of multivariable adjustment and adequate exposure and outcome ascertainment. Statistically significant associations were established for age, low body mass index, current smoking, excessive alcohol use, chronic corticosteroid use, history of prior fractures, history of falls, history of hypogonadism, history of stroke, and history of diabetes. Statistical heterogeneity of the meta-analytic estimates of all associations was significant except for chronic corticosteroid use. None of these associations were of large magnitude (i.e. adjusted odds ratios were generally <2). No evidence supporting a particular effective testing or screening strategy was identified.

CONCLUSIONS

Multiple risk factors for fractures in men were identified, but their usefulness for stratifying and selecting men for bone density testing remains uncertain.

Long-term health outcomes in a British cohort of breast, colorectal and prostate cancer survivors: a database study

Background:

The community-based incidence of cancer treatment-related long-term consequences is uncertain. We sought to establish the burden of health outcomes that have been associated with treatment among British long-term cancer survivors.

Methods:

We identified 26 213 adults from the General Practice Research Database who have survived 5 years or more following breast, colorectal or prostate cancer. Four age-, sex- and general practice-matched non-cancer controls were selected for each survivor. We considered the incidence of treatment-associated health outcomes using Cox proportional hazards models.

Results:

Breast cancer survivors had an elevated incidence of heart failure (hazards ratio (HR) 1.95, 95% confidence interval (CI) 1.27–3.01), coronary artery disease (HR 1.27, 95% CI 1.11–1.44), hypothyroidism (HR 1.26, 95% CI 1.02–1.56) and osteoporosis (HR 1.26, 95% CI 1.13–1.40). Among colorectal cancer survivors, there was increased incidence of dementia (HR 1.68, 95% CI 1.20–2.35), diabetes (HR 1.39, 95% CI 1.12–1.72) and osteoporosis (HR 1.41, 95% CI 1.15–1.73). Prostate cancer survivors had the highest risk of osteoporosis (HR 2.49, 95% CI 1.93–3.22).

Conclusions:

The study confirms the occurrence of increased incidence of chronic illnesses in long-term cancer survivors attributable to underlying lifestyle and/or cancer treatments. Although the absolute risk of the majority of late effects in the cancer survivors cohort is low, identifying prior risk of osteoporosis by bone mineral density scanning for prostate survivors should be considered. There is an urgent need to improve primary care recording of cancer treatment.

Risk stratification in the hormonal treatment of patients with prostate cancer

Prostate cancer (PCa) is the most common type of cancer found in American men, other than skin cancer. The American Cancer Society estimates that there will be 186,320 new cases of prostate cancer in the United States in 2008. About 28,660 men will die of this disease this year and PCa remains the second-leading cause of cancer death in men. One in six men will get PCa during his lifetime and one in 35 will die of the disease. Today, more than 2 million men in the United States who have had PCa are still alive. The death rate for PCa continues to decline, chiefly due to early detection and treatment, and improved salvage therapy such as hormone therapy (HT). HT continues to be a mainstay for primary-recurrent PCa and locally-advanced PCa. However, HT is associated with many undesirable side effects including sexual dysfunction, osteoporosis and hot flashes, all of which can lead to decreased quality of life (QOL). These risks are seen in both long- and short-term HT regimens. Additionally, research in recent years has revealed trends related to clinico pathological variables and their predictive ability in HT outcomes. Awareness of the potential adverse effects, the risks associated with HT and the prognostic ability of clinical and pathological variables is important in determining optimal therapy for individual patients. A rigorous evaluation of the current scientific literature associated with HT was conducted with the goal of identifying the most favorable balance of benefits and risks associated with HT.

Vertebral fractures and the misclassification of osteoporosis in men with prostate cancer

Androgen deprivation therapy (ADT) has become the cornerstone of treatment for both advanced and nonmetastatic prostate cancer. The presence of a nontraumatic vertebral fracture (VF) identifies a patient who has clinical osteoporosis. Vertebral fracture analysis (VFA), a dual-energy X-ray absorptiometry (DXA)-based technology identifies VFs in conjunction with a standard bone mineral density (BMD) examination. The objective of this study was to determine if VFA would increase the diagnosis of osteoporosis in men with prostate cancer on ADT. One hundred sixteen men aged ≥ 60yrs with nonmetastatic prostate cancer receiving ADT for ≥ 6mos underwent DXA of the spine, hip, and 1/3 distal radius, VFA, and conventional vertebral X-rays. Approximately 40% of the men had clinically defined osteoporosis. The use of conventional DXA criteria (spine and hip) alone resulted in the misdiagnosis of approx 75% of patients. VFA and addition of the 1/3 distal radius site performed by DXA both increased the rate of diagnosis and reduced the misclassification of osteoporosis in men with prostate cancer, compared with conventional DXA criteria alone. Analysis indicated that VFA assessment of mild, moderate, and severe fractures from all readable vertebrae (T5-L4) had a kappa statistic, sensitivity, and specificity of 0.92, 100%, and 95%, respectively, with semiquantitative radiography. Men with prostate cancer on ADT should be screened for osteoporosis at the initiation of therapy, and evaluation should include DXA of the 1/3 distal radius in addition to the spine and hip, as well as evaluation for VFs.

Bone continuum of cancer

Many patients with solid tumors, especially breast and prostate cancers, and with multiple myeloma will develop bone metastases or other skeletal complications. The management of bone loss and symptomatic bone metastases is an important issue in the care and maintenance of quality of life for these patients. Morbidity caused by skeletal complications include pain (bone metastases are known as the most common cause of cancer-related pain), hypercalcemia, pathologic fracture, compression of the spinal cord or cauda equine, and spinal instability. Currently, the only Food and Drug Administration-approved therapy for metastatic bone disease is bisphosphonate therapy. A greater understanding of the biomolecular pathways that govern the bone continuum of cancer has helped identify novel targets for drug development. New therapeutic options are currently being investigated for the treatments of bone loss and symptomatic bone metastases. Some of these new drugs and modalities are in advanced stages of clinical development and may soon reach the clinic.

Treatment thresholds for osteoporosis in men on androgen deprivation therapy: T-score versus FRAX

Men treated by androgen deprivation therapy (ADT) for localized prostate cancer are at risk for fracture, but it is not known which men require pharmacologic treatment. We found that 33% of men on ADT had osteoporosis of spine, hip, or forearm by dual-energy X-ray absorptiometry (DXA), thus requiring treatment. Using the new fracture prediction algorithm (FRAX) tool with corrected femoral neck T-score identified only 17% requiring treatment, and, if calculated without femoral neck, 54% were identified to need treatment.

INTRODUCTION

Men treated with androgen deprivation therapy (ADT) for prostate carcinoma live long enough to fracture. A new fracture prediction method, FRAX, is based on femoral neck DXA plus risk factors. Thus, DXA or FRAX could determine which men should receive osteoporosis therapy.

METHODS

Of 115 men undergoing ADT referred for DXA testing, those with bone mineral density (BMD) in spine, hip, or forearm of >or=2.5 standard deviations below a normal male ethnicity-adjusted mean were considered treatment candidates. Using FRAX with and without femoral neck BMD, men were treatment candidates if the 10-year hip fracture risk was >or=3% or the major osteoporotic fracture risk was >or=20%.

RESULTS

The men averaged 77 years old; 58% were African-American, and 14.8% were current smokers. Mean femoral neck T-score was -1.4. Using DXA, 38 (33%) men would need treatment. When FRAX was calculated including the femoral neck T-score, only 20 men met criteria for treatment. However, when FRAX was calculated without the T-score, 62 men met criteria for treatment. Overlap among the groups was surprisingly modest.

CONCLUSIONS

DXA and FRAX identify different ADT men for treatment.

Correlates of trabecular and cortical volumetric BMD in men of African ancestry

QCT provides a measure of volumetric BMD (vBMD) and distinguishes trabecular from cortical bone. Few studies have determined the factors related to vBMD in men, especially among men of African heritage. This study evaluated the relationship of anthropometric, medical, and behavioral factors and vBMD in a population-based cohort of men of African ancestry (n = 1901) >or=40 yr of age who had undergone screening for prostate cancer for the first time. Trabecular and cortical vBMD were measured at the radius and tibia by pQCT. Multiple linear regression analysis identified age, height, body weight, cigarette smoking, history of diabetes, fracture, and prostate cancer as the independent correlates of vBMD. However, associations with several variables differed between cortical and trabecular vBMD and between the radius and tibia. Longitudinal studies are needed to gain a better understanding of the mechanisms underlying these differential associations that may show new insight into the etiology of trabecular and cortical bone loss in men.

Frequency of zoledronic acid to prevent further bone loss in osteoporotic patients undergoing androgen deprivation therapy for prostate cancer

OBJECTIVE

To evaluate the efficacy of zoledronic acid (ZA) in osteoporotic patients with prostate cancer receiving either luteinizing hormone-releasing hormone agonists (LHRHA, which accelerate bone loss) or bicalutamide (which preserves bone mineral density, BMD) as androgen-deprivation therapy is the mainstay of treatment for advanced prostate cancer, and many patients are osteoporotic at presentation, with others becoming so on treatment.

PATIENTS AND METHODS

Fifty-eight osteoporotic men with non-metastatic prostate cancer were followed for 3 years. Patients were randomly assigned to receive either LHRHA (29) or bicalutamide (29). All received 4 mg ZA 3-monthly for 1 year. BMD was measured by dual energy X-ray absorptiometry at four times: 1 year before ZA; immediately before ZA; after five infusions; and 1 year afterwards. Bone turnover markers (BTMs) were measured at 3-monthly intervals on ZA and 1 year later. All patients had radiography of the thoracolumbar spine at baseline and after ZA.

RESULTS

Patients on LHRHA showed a 4.9% decrease in BMD before ZA, a 1.6% increase after ZA and a 3.0% decrease 1 year later, compared to 2.0% increase, 7.8% increase and 1.9% decrease, respectively, in those on bicalutamide. BTMs decreased significantly after ZA. Seven patients (12%) had vertebral fractures at baseline, with none deteriorating at 1 year; two (3.5%) developed mandibular osteonecrosis.

CONCLUSION

Before ZA, BMD decreased on LHRHA, but was maintained on bicalutamide. Treatment with 3-monthly ZA increased BMD and suppressed BTMs in osteoporotic patients both on LHRHA and bicalutamide, but to a greater extent in the latter. However, 1 year after the last infusion, BMD declined, suggesting that annual administration is inadequate in these patients. The optimum frequency might be related to BMD at time of bisphosphonate initiation.

Review of major adverse effects of androgen-deprivation therapy in men with prostate cancer

Androgen-deprivation therapy (ADT) is a common treatment for men with prostate cancer. Although ADT is effective at suppressing prostate-specific antigen (PSA), stabilizing disease, alleviating symptoms in advanced disease, and potentially prolonging survival, it is not without serious side effects. However, to the authors' knowledge, there is lack of a systematic review of its major adverse effects to date. The authors of this report systematically reviewed and quantitatively assessed the literature on skeletal and cardiac side effects associated with ADT in men with prostate cancer. The PubMed database was searched for relevant published articles from 1966 to May 2008, and 683 articles were reviewed systematically from an original 20 different Medical Subject Heading search combinations. The focus of the review was on bone-related and cardiovascular-related outcomes. When appropriate, results were pooled from articles on specific adverse outcomes, summary risk estimates were calculated, and tests of heterogeneity were performed. Fourteen articles were identified that met inclusion criteria from the original 683 studies. Men who underwent ADT for prostate cancer had a significantly increased risk of overall fracture of 23% (summary relative risk, 1.23; 95% confidence interval [95% CI], 1.10-1.38) compared with men who had prostate cancer but who did not undergo ADT. Furthermore, men who underwent ADT had a 17% increase in cardiovascular-related mortality compared with men who did not undergo with ADT (summary hazards ratio, 1.17; 95% CI, 1.07-1.29). Significant elevations in the risk of diabetes also were observed from 2 large studies. ADT was associated with an increased risk of skeletal fracture, incident diabetes, and cardiovascular-related mortality, although the absolute risk of these events was low. Preventive measures against these adverse effects and careful assessment of patient's baseline health status should be considered.

Fracture risk in patients with different types of cancer

BACKGROUND

Few studies on the risk of fractures in patients with cancer exist, and little is known on the mechanisms of fractures in patients with cancer. We studied the risk of fracture in patients with various types of cancer.

SUBJECTS AND METHODS

Case control study. There were 124,655 fracture cases and 373,962 age and gender matched controls.

RESULTS

An increased risk of fractures, primarily within the first year after diagnosis was seen in patients with primary bone cancer (OR=3.51, 95% CI: 1.54-8.01), multiple myeloma (OR=5.21, 95% CI: 2.96-9.19), metastases to the bone (OR=5.28, 95% CI: 3.58-7.79), metastases to other organs than bone (OR=1.85, 95% CI: 1.50-2.29), lung cancer (OR=1.90, 95% CI: 1.51-2.38), and cancer of the liver, gall bladder and pancreas (2.14, 95% CI: 1.39-3.31). For patients with prostate cancer an increase in the risk of fractures was seen with time. Other cancer types were not associated with an increased risk of fractures.

CONCLUSIONS

A high risk group regarding fractures includes cancers primarily affecting the bone (primary bone cancer, multiple myeloma, metastases to the bone, metastases to other organs than bone, lung cancer, and cancer of the liver, gall bladder and pancreas, and prostate cancer). The main increase in risk of fractures in this group was seen within the first year following diagnosis. A low risk group for fractures included all other cancer types (e.g. cancer of the breast, colon, skin etc). This may have implication for which patients should be selected for prevention against fractures.

Elderly patients with non-Hodgkin lymphoma who receive chemotherapy are at higher risk for osteoporosis and fractures

To determine risk of osteoporosis and fractures associated with chemotherapy among elderly non-Hodgkin's lymphoma (NHL) patients, a cohort of 13 570 patients aged >/=65 years with incident NHL was identified from SEER-Medicare data with up to 11 years of follow-up. One year prior to the diagnosis, significantly fewer patients had fracture and osteoporosis claims in the chemotherapy group versus no chemotherapy group. However, after NHL diagnosis, patients who received chemotherapy had significantly higher rates of fracture (31% versus 19%, P < 0.001) and osteoporosis (10% versus 8%, P < 0.001), compared with those who did not. The risk of having fracture (odds ratio = 2.24, 95% CI = 2.04 - 2.45) and osteoporosis (odds ratio = 1.27, 95% CI = 1.12 - 1.45) was significantly higher in patients receiving chemotherapy compared with those who did not, after controlling for demographic and tumor factors. In conclusion, use of chemotherapy was significantly associated with increased risk of fracture and osteoporosis in elderly patients with NHL.

Natural history and correlates of hip BMD loss with aging in men of African ancestry: the Tobago Bone Health Study

Little is known about the magnitude, pattern, and determinants of bone loss with advancing age among men, particularly among those of African descent. We examined the rate of decline in hip BMD and identified factors associated with BMD loss among 1478 Afro-Caribbean men >or=40 yr of age. BMD was measured at baseline and after an average of 4.4 yr by DXA. The rate of decline in femoral neck BMD was 0.29 +/- 0.81%/yr in the total sample (p < 0.0001). However, a U-shaped relationship between advancing age and the rate of decline in BMD was observed. The rate of decline in BMD at the femoral neck was -0.38 +/- 0.77%/yr among men 40-44 yr of age, decelerated to -0.15 +/- 0.81%/yr among men 50-54 yr of age, and then accelerated to -0.52 +/- 0.90%/yr among those 75+ yr of age (all p < 0.003). Men who lost >or=5% of their body weight during follow-up had significantly greater BMD loss than those who remained weight stable or gained weight (p < 0.0001). The relationship between weight loss and BMD loss was more pronounced among men who were older and leaner at study entry (p < 0.03). We also observed a strong impact of advanced prostate cancer and its treatment with androgen deprivation on BMD loss. Men of African ancestry experience substantial BMD loss with advancing age that seems to be comparable to the rate of loss among white men in other studies. Additional studies are needed to better define the natural history and factors underlying bone loss with aging in men of African ancestry.

Implementation of osteoporosis screening guidelines in prostate cancer patients on androgen ablation

Androgen ablation (AA) therapy is one of the modalities used to treat prostate cancer. It is well known that AA therapy increases the risk of osteoporosis and fractures. In 2004, the British Columbia Cancer Agency published guidelines regarding bone health in these patients. A key recommendation was to arrange for bone mineral density (BMD) testing if AA was to be used for 6 mo or longer. Our objective was to evaluate how well these guidelines were implemented by reviewing the number of BMDs performed in patients who had been treated at one of the 4 cancer centers in British Columbia. We found that the overall number of BMDs documented after the implementation of the guidelines was significantly greater than the number documented before (25% vs 7.5%, p value < 0.0001). There appeared to be regional differences in implementation, with the greatest effect seen at the Vancouver center, which serves as the chief academic center for the province. The greater effect of guidelines at this center suggests a need for more effective dissemination peripherally. The care gap remaining at even the most impacted center indicates a need for greater efforts to both implement guidelines and monitor their implementation over time.

Mapping the prescriptiome to fractures in men--a national analysis of prescription history and fracture risk

SUMMARY

A nationwide case-control study was performed in 62,865 men aged 50+ using fracture data from the national hospital discharge register to screen all redeemed prescriptions in the past 5 years for significant mapping to fracture risk, employing measures to control for false discovery rate.

INTRODUCTION

Osteoporosis in men is frequently related to alcohol abuse, hypogonadism, hypercalciuria, or the use of glucocorticoids. Very limited information is available on the impact of other medications on fracture risk in men.

METHODS

We conducted a nationwide population-based case-control study collecting fracture data from the Danish National Hospital Discharge Register and prescriptions from the National Prescriptions Database (1995-2000). We included men aged 50+ years, with hospital-treated fractures in the year 2000 (n = 15,716), and age- and sex-matched controls (n = 47,149).

RESULTS

We identified 3.2 million redemptions of prescriptions for 1,073 different drugs. The analysis confirmed associations between fracture risk and use of sedatives, anti-epileptics, anti-psychotics, anxiolytics, SSRI, opioids and other analgesics, loop diuretics, and glucorticoids. New associations were also found. We observed an odds ratio (OR [95% CI] for any fracture) for fracture in users of dopaminergic agents (1.6 [1.3-1.9]) and iron compounds (1.2 [1.1-1.5]). The largest impact on fracture risk at population level was exerted by loop diuretics and analgesics.

CONCLUSIONS

An array of drugs is associated with fracture risk in men. The "prescriptiome" analysis can be used as a surveillance tool for drug-induced osteoporosis and in the planning of preventive measures.

Management of chronic pain in cancer survivors

Chronic pain is a frequent complication of cancer and its treatments and is often underreported, underdiagnosed, and undertreated. Pain in cancer survivors is caused by residual tissue damage from the cancer and/or the cancer therapy. This pain can be divided into 3 pathophysiologic categories: somatic, visceral, and neuropathic. The most common treatment-induced chronic pain syndromes are neuropathies secondary to surgery, radiation therapy, and chemotherapy. Comfort and function are optimized in cancer survivors by a multidisciplinary approach using an individually tailored combination of opioids, coanalgesics, physical therapy, interventional procedures, psychosocial interventions, and complementary and alternative modalities. Management of chronic pain must be integrated into comprehensive cancer care so that cancer patients can fully enjoy their survival.

Cancer treatment-induced bone loss in breast and prostate cancer

PURPOSE

Bone loss resulting from the treatment of breast and prostate cancer is an emerging problem. Bisphosphonates have a potential role in the prevention of this cancer treatment-induced bone loss (CTIBL).

METHODS

Studies evaluating the incidence and prevalence of CTIBL in early breast and prostate cancer patients and trials evaluating the preventative role of bisphosphonates were identified by a search of the PubMed and Cochrane Library databases through the end of March 2008. Reference lists from retrieved articles were cross referenced, and further information was obtained from relevant scientific meetings.

RESULTS

Several therapies commonly used in the treatment of women and men with breast and prostate cancers, in particular the aromatase inhibitors (AIs) for breast cancer and androgen deprivation therapy (ADT) for prostate cancer, are associated with significant bone loss and with an increase in fracture risk. The use of bisphosphonates seems to attenuate the bone loss, although the long-term impact remains unclear because of insufficient follow-up.

CONCLUSION

Adjuvant endocrine therapy with an AI or androgen deprivation can be considered a risk factor for the development of osteopenia, osteoporosis, and bone fracture, which can be mitigated by appropriate bisphosphonate therapy. Clear identification of risk factors for osteoporosis in individual patients should aid treatment decisions about whether to use bisphosphonates when starting or switching to an AI or ADT. Patients need to be educated about this risk and other measures to avoid this complication, including lifestyle modifications that may benefit their general and bone health.

Vertebral Fracture Assessment: the 2007 ISCD Official Positions

Vertebral fracture assessment (VFA) is an established, low radiation method for detection of prevalent vertebral fractures. Vertebral fractures are usually not recognized clinically at the time of their occurrence, but their presence indicates a substantial risk for subsequent fractures independent of bone mineral density. Significant evidence supporting VFA use for many post-menopausal women and older men has accumulated since the last ISCD Official Position Statement on VFA was published. The International Society for Clinical Densitometry considered the following issues at the 2007 Position Development Conference: (1) What are appropriate indications for Vertebral Fracture Assessment; (2) What is the most appropriate method of vertebral fracture detection with VFA; (3) What is the sensitivity and specificity for detection of vertebral fractures with this method; (4) When should additional spine imaging be performed following a VFA; and (5) What are the reporting obligations for those interpreting VFA images?

Incidence and prevalence of medication-induced osteoporosis: evidence-based review

(1) While a number of medications have been shown to induce bone loss, the actual incidence and prevalence of medication-induced osteoporosis has not been well quantified. (2) Oral corticosteroids contribute to an increased prevalence of osteoporosis and an increased incidence of fracture in a number of different populations. The increased incidence of fracture in patients receiving inhaled corticosteroids for respiratory disease may be attributed to disease pathogenesis rather than the effects of medication. (3) Other therapies that increase the incidence and/or prevalence of medication-induced osteoporosis and fracture include androgen-deprivation therapy, aromatase inhibitors, protease inhibitors, selective serotonin reuptake inhibitors and prolactin-raising antiepileptic agents. (4) It is difficult to make definitive conclusions on the actual increase in the prevalence and/or incidence of osteoporosis in patients receiving certain medications, as values are often reported differently and studies are mainly retrospective and are therefore open to inherent selection biases and other confounders. Furthermore, there is little available information as to whether specific medications within a class are associated with a higher rate of bone disease than others.

Cancer treatment-induced bone loss: pathophysiology and clinical perspectives

Hormone-ablative therapies for breast or prostate cancer can cause marked and rapid reductions in circulating estrogen or testosterone levels, resulting in significant effects on bone metabolism and cancer treatment-induced bone loss (CTIBL). Most patients with cancer are over the age of 65 and are already at risk for osteoporosis. Thus, accelerated bone loss from CTIBL is especially concerning in this population. Although there are currently no approved therapies for the treatment or prevention of CTIBL, oral bisphosphonates have been used in settings other than oncology to treat bone loss. New-generation i.v. bisphosphonates have demonstrated promising activity in preventing CTIBL in patients receiving hormonal therapy for breast or prostate cancer. In particular, zoledronic acid not only prevents CTIBL in both breast and prostate cancer patients but also increases bone mineral density above baseline. Such agents have the potential to delay or prevent CTIBL in patients receiving hormonal therapies.

Cancer treatment-induced bone loss

PURPOSE OF REVIEW

Patients treated for cancer may be at risk for osteoporosis and fracture. Evaluation and treatment of patients with cancer treatment-induced bone loss should lead to fewer fractures. This review will help clinicians learn to identify, evaluate and treat cancer patients at risk.

RECENT FINDINGS

Survivors of childhood cancers and patients made hypogonadal by treatment for breast or prostate cancer are clearly at risk for osteoporosis and fracture. Use of aromatase inhibitors rather than tamoxifen for breast cancer will likely lead to more osteoporosis. Bisphosphonates prevent bone loss in many patients at risk.

SUMMARY

For many cancer patients, treatment with calcium, vitamin D, and bisphosphonates will likely decrease the consequences of cancer treatment-induced bone loss, namely fractures.

Fracture risk in Danish men with prostate cancer: a nationwide register study

OBJECTIVE

To assess the risk of fracture attributable to prostate cancer, and the impact of exposure to prescribed gonadotrophin-releasing hormone agonists and antiandrogens on this risk in a nationwide, population-based case-control study.

PATIENTS AND METHODS

Data from the Danish National Hospital Discharge Register, the National Bureau of Statistics, and the National Prescriptions Database were merged. The analysis covered 15 716 men aged >50 years presenting with a fracture at any hospital in Denmark in 2000, and 47 149 age-matched control men. A previous diagnosis of prostate cancer had been recorded in 1.3% of controls and 2.5% of those with a fracture.

RESULTS

Prostate cancer was associated with an increased odds ratio (95% confidence interval) for all fractures of 1.8 (1.6-2.1), for hip fractures of 3.7 (3.1-4.4), but no increased risk of vertebral fractures. The increased fracture risk became apparent early after diagnosis and remained pronounced even in long-term survivors. Androgen deprivation therapy (ADT) with an odds ratio of 1.7 (1.2-2.5; P < 0.01) and orchidectomy, at 1.7 (1.2-2.4; P < 0.01) added to the overall fracture risk. In all, 3.1% of hip fractures in Danish men aged >50 years are attributable to prostate cancer.

CONCLUSION

Prostate cancer, orchidectomy and the use of ADT are associated with a markedly greater risk of fractures, especially of the hip. The risk of hip fracture is not confined to the very old, neither is the risk made negligible by the excess mortality in patients with advanced prostate cancer.

Osteoporosis management in prostate cancer patients treated with androgen deprivation therapy

BACKGROUND

The use of androgen deprivation therapy (ADT) for prostate cancer has increased substantially in recent years, exposing more men to potential treatment complications, including osteoporosis and fractures.

OBJECTIVE

To determine whether men treated with ADT for prostate cancer received osteoporosis screening, prevention, or treatment.

DESIGN

Cross-sectional observational study using a retrospective review of electronic medical records.

SUBJECTS

One hundred seventy-four patients with prostate cancer on ADT or status-post orchiectomy enrolled in primary care at the New Mexico Veterans Affairs Health Care System as of July 2005.

MEASUREMENTS

Patient demographics, tumor characteristics (Gleason score, stage, last PSA value, documented bone metastases), history of hip or vertebral fracture, osteoporosis risk factors (number of ADT shots, diabetes, smoking, heavy alcohol use or prescriptions for corticosteroids, thyroid hormone or dilantin). We defined recommended management as performing DXA scans or prescribing bisphosphonates, calcitonin, calcium or vitamin D.

RESULTS

Just 60 of 174 (34%) patients received recommended osteoporosis management based on DXA scans (13%) or treatment with oral or IV bisphosphonates (21%), calcitonin (1%), calcium (16%) or vitamin D (10%). On multivariate analysis, bone metastases, higher last PSA, and younger age at diagnosis were associated with recommended management, whereas Hispanic race/ethnicity was inversely associated.

CONCLUSIONS

Most men treated with ADT for prostate cancer did not receive osteoporosis screening, prevention or treatment. Evidence for advanced cancer though not risk factors for osteoporosis or fracture-was associated with receiving osteoporosis management. Further research is needed to identify optimal strategies for screening, prevention, and treatment in this population.

Non-traumatic vertebral fractures in patients with locally advanced esophageal cancer: a previously unreported, unrecognized problem

Recent studies suggest cancer therapy may compromise bone integrity. What is the rate of vertebral fractures among patients who have received trimodality therapy (radiation, chemotherapy, and surgery) for locally advanced esophageal cancer? This single-institution, retrospective study attempted to answer this question, focusing on 337 patients who had received trimodality therapy for locally advanced esophageal cancer between 1996 and 2005. Reports of serial radiographs were reviewed to identify vertebral fractures. Duration of follow-up was gathered for all esophageal cancer patients with the intention of calculating fracture incidence rates. Fracture-related symptoms, types of intervention and fracture recurrence were also gleaned from the clinical records. First-time fractures were identified in 47 patients, and 45 of these were new since the cancer diagnosis. Thus, the first-time fracture incidence rate from the time of cancer diagnosis was 12 fractures per 100 patient years. The median time from cancer diagnosis to fracture was 9 months. Fifteen (33%) patients were symptomatic. Acknowledging that a retrospective study can inadvertently result in information omission, we report that pain medications were started in only seven patients (16%), and osteoporosis medication in only six (13%). Two patients were hospitalized, and two underwent vertebroplasty. The median survival after fracture diagnosis was 36 months. This report describes a seemingly high fracture incidence rate that requires confirmation. If confirmed, future studies should focus on identifying risk factors and optimal strategies for the prevention and treatment of vertebral fractures in patients with esophageal cancer.

Hypogonadal hypogonadism and osteoporosis in men

In recent years, osteoporosis in men has become increasingly recognized as an important clinical and public health problem. Many similarities exist in various aspects of osteoporosis in men and women, but this article focuses on the sex difference, bone biology, epidemiology, and consequences of fractures. Although maintenance of bone integrity depends on the action of sex hormones in both sexes, menopause is a much more obvious indicator of estrogen deficiency than is the subtle decrease of testosterone in aging men. This often leads to delay and neglect of diagnosis. The need to identify and screen men at a particular risk for osteoporosis, as when hypogonadism is induced for treatment of prostate cancer, has become important.