Bone complications of androgen deprivation therapy: screening, prevention, and treatment:

Implementing and Evaluating the Impact of BoneRx: A Healthy Bone Prescription for Men with Prostate Cancer Initiating Androgen Deprivation Therapy

Background: The initiation of Androgen Deprivation Therapy (ADT) results in rapid and profound hypogonadism, resulting in significant bone and muscle loss, increasing the risk for osteoporosis (OP), falls, and fractures. Despite this, there exist very low rates of guideline adherent care regarding bone health in this population. We developed and implemented a healthy bone prescription tool entitled BoneRx to facilitate the uptake of guideline-concordant bone health care into practice and increase patient awareness and promote the uptake of health bone behaviours (HBBs). Methods: We conducted a cross-sectional pre-BoneRx implementation (n = 143) vs. post-implementation (n = 149) cohort study to evaluate the impact on (i) bone health care, patient engagement in HBB, and patient knowledge and health beliefs regarding OP. Results: There was a significant difference pre- vs. post BoneRx implementation on receipt of baseline BMD (34.7% vs. 59.5%, p < 0.0001) and bone health counselling (32.4% vs. 59.9%, p < 0.0001). More participants in the post-BoneRx implementation cohort reported taking vitamin D supplements 57% vs. 81% (p < 0.001) and calcium supplements 39% vs. 61% (p < 0.001). Physical activity levels also significantly increased (p = 0.021). No differences were detected in OP knowledge or feelings of OP susceptibility, seriousness, or health motivation. Conclusion: BoneRx is a simple, cost-effective, and acceptable strategy that could improve the care of PCa survivors receiving ADT.

Bone health care for patients with prostate cancer receiving androgen deprivation therapy

Patients with prostate cancer often receive androgen deprivation therapy (ADT) as part of their treatment regimen. However, treatment with ADT causes multiple side effects, including reduced bone mineral density (BMD), lower lean body mass, and a higher risk for fractures. Several organizations provide clinical practice guidelines for osteoporosis screening, prevention, and treatment in this population, but adherence to these guidelines remains low. Areas for improvement in provider adherence include baseline and follow-up BMD testing, as well as counseling regarding healthy bone behaviors such as calcium/vitamin D intake, lifestyle changes, and physical exercise. Comparison of osteoporosis care in breast cancer and non-oncology populations shows that suboptimal bone health care is not isolated to prostate cancer. A summary of the literature examining improvements in patient adherence and provider delivery of bone health care is included in this review, but high-quality studies are lacking. Patients may be the most receptive to written educational information delivered at or near the time of ADT initiation. Involvement of a primary care practitioner and oncologist in care delivery is associated with higher BMD test use. Institution-level programs that automatically initiate osteoporosis screening and management may be effective at reducing the incidence of hip fracture. Lastly, suggestions are provided for future approaches to knowledge translation and quality of care studies to improve bone health.

The impact of bone mineral density testing, fracture assessment, and osteoporosis education in men treated by androgen deprivation for prostate cancer: a pilot study

PURPOSE

Men receiving androgen deprivation therapy for prostate cancer have low knowledge of osteoporosis (OP) and engage in few healthy bone behaviors (HBBs). A multicomponent intervention was piloted in this population. Changes in OP knowledge, self-efficacy, health beliefs, and engagement in HBBs were evaluated.

METHODS

A pre-post pilot study was performed in a convenience sample of men recruited from the Princess Margaret Cancer Centre. Men were sent personalized letters explaining their dual x-ray absorptiometry (DXA) results and fracture risk assessment with an OP-related education booklet. Participants completed questionnaires assessing OP knowledge, self-efficacy, health beliefs, and current engagement in HBBs at baseline (T1) and 3 months post-intervention (T2). Paired t tests and McNemar's test were used to assess changes in outcomes.

RESULTS

A total of 148 men completed the study. There was an increase in OP knowledge (9.7 ± 4.3 to 11.4 ± 3.3, p < 0.0001) and feelings of susceptibility (16.5 ± 4.3 to 17.4 ± 4.7, p = 0.015), but a decrease in total self-efficacy (86.3 ± 22.9 to 81.0 ± 27.6, p = 0.007) from baseline to post-intervention. Men made appropriate changes in their overall daily calcium intake (p ≤ 0.001), and there was uptake of vitamin D supplementation from 44 % (n = 65) to 68 % (n = 99) (p < 0.0001). Men with bone loss (osteopenia or OP) had a greater change in susceptibility (1.9 ± 4.3 vs. -0.22 ± 4.2, p = 0.005) compared to men with normal bone density.

CONCLUSIONS

Our results provide preliminary evidence that a multicomponent intervention such as the one described can lead to increased knowledge and feelings of susceptibility regarding OP and can enhance uptake of some HBBs.

Osteoporosis knowledge, health beliefs, and healthy bone behaviours in patients on androgen-deprivation therapy (ADT) for prostate cancer

OBJECTIVES

To describe in patients with prostate cancer, receiving androgen-deprivation therapy (ADT): (i) knowledge, self-efficacy (SE), and health beliefs about osteoporosis (OP); (ii) current engagement in healthy bone behaviours (HBBs). To explore the relationships between knowledge, SE, and health beliefs, and engagement in HBBs.

PATIENTS AND METHODS

175 patients receiving ADT by injection completed questionnaires assessing current HBBs, OP knowledge, SE, and health beliefs (motivation, perceived susceptibility, and seriousness). Descriptive statistics and independent samples t-tests were used to assess relationships between knowledge, SE, health beliefs, and engagement in HBBs.

RESULTS

Only 38% of patients had undergone a dual X-ray absorptiometry scan in the past 2 years. OP knowledge was low (mean [sd, range] 9.6 [4.4, 0-19]) and perceived SE moderate (84.7 [24.5, 0-120]). Health motivation was fairly high (23.6 [3.1, 6-30]), but perceived susceptibility (16.8 [4.3]) and seriousness (16.8 [4.2]) of OP were low. Few patients met the recommendations for vitamin D intake (42%) and exercise (31%), and 15% were at risk of over-supplementation of calcium. Patients taking calcium supplements (P = 0.04), and meeting guidelines for vitamin D (P = 0.008) and for exercise (P = 0.002) had significantly greater knowledge than those who did not. Patients who were engaging in less than four of five HBBs had lower knowledge (P < 0.001) and health motivation (P = 0.01) than those who were engaging in four or all five HBBs.

CONCLUSIONS

Most patients who are receiving ADT are not receiving appropriate screening, lack basic information about bone health, and are not engaging in the appropriate HBBs. These findings support the application of the Health Belief Model in this population: interventions that teach patients about the implications of bone loss, encourage proper uptake of HBBs, and promote feelings of SE could increase engagement in HBBs to prevent and manage bone loss.

Steps in prostate cancer progression that lead to bone metastasis

Prostate cancer is a complex disease in which metastasis to the bone is the main cause of death. Initial stages of metastasis are generally similar to those for most solid tumors; however, the mechanisms that underlie the homing of prostate tumor cells to the bone are not completely understood. Prostate cancer bone metastasis is also a microenvironment-driven disease, involving bidirectional interactions between the tumor and the bone microenvironment. In this review, we discuss the current understanding of the biologic processes and regulatory factors involved in the metastasis of prostate cancer cells, and their specific properties that promote growth in bone. Although many of these processes still need to be fully elucidated, a better understanding of the complex tumor/microenvironment interplay is slowly leading to more effective therapies for patients with prostate cancer bone metastases.

The crossover of bisphosphonates to cancer therapy

Bisphosphonates form a class of drugs commonly used to treat disorders of osteoclastic bone resorption, including osteoporosis, Paget's disease of the bone, rheumatoid arthritis, and bone metastases. Although long established as the therapy of choice to treat such disorders, bisphosphonates' potential in treating cancer is garnering interest. Bisphosphonates have been demonstrated to inhibit tumor growth and metastasis, induce apoptosis in tumor cells, and encourage immune reactions against tumor cells. Current applications of bisphosphonates in cancer treatment include their use to treat skeletal metastases and as an adjuvant to endocrine therapy. This review explores bisphosphonates' current clinical utility and potential as a crossover cancer therapy.

Anemia, fatigue and aging

Aging is associated with increased incidence and prevalence of both cancer and anemia. Cancer and aging may conspire in making anemia more frequent and more severe. This article reviews the causes and the consequences of anemia in the older individual. The most common causes include chronic inflammation that is a typical manifestation of aging, iron deficiency that may be due to chronic hemorrhage, malabsorption and Helicobacter pylori infection, cobalamin deficiency from malabsorption and renal insufficiency. Other causes of anemia whose prevalence is not well established include myelodysplasia, copper deficiency, hypothyroidism, and sarcopenia. Anemia is associated with increased risk of mortality, functional dependence, dementia, falls, and chemotherapy-related toxicity. When correcting the anemia of older cancer patients one should remember that the erythropoietic stimulating agents (ESA) may stimulate cancer growth and cause thrombosis. These products may be safe when given exclusively to patients receiving chemotherapy and when the hemoglobin levels are maintained below 12 g/dL.

Dendritic cell-based immunotherapy for prostate cancer

Dendritic cells (DCs) are professional antigen-presenting cells (APCs), which display an extraordinary capacity to induce, sustain, and regulate T-cell responses providing the opportunity of DC-based cancer vaccination strategies. Thus, clinical trials enrolling prostate cancer patients were conducted, which were based on the administration of DCs loaded with tumor-associated antigens. These clinical trials revealed that DC-based immunotherapeutic strategies represent safe and feasible concepts for the induction of immunological and clinical responses in prostate cancer patients. In this context, the administration of the vaccine sipuleucel-T consisting of autologous peripheral blood mononuclear cells including APCs, which were pre-exposed in vitro to the fusion protein PA2024, resulted in a prolonged overall survival among patients with metastatic castration-resistent prostate cancer. In April 2010, sipuleucel-T was approved by the United States Food and Drug Administration for prostate cancer therapy.