Skeletal health after continuation, withdrawal, or delay of alendronate in men with prostate cancer undergoing androgen-deprivation therapy

Bone complications of cancer treatment

With the advancements in conventional treatment modalities such as radiation, chemotherapy, and surgery, as well as the emergence of immunotherapy, the overall cure rate for solid tumor malignancies has experienced a significant increase. However, it is unfortunate that exposure to cancer treatments can have detrimental effects on the function of osteoblasts and osteoclasts, disturbing bone metabolic homeostasis in patients, as well as causing damage to bone marrow cells and other bone tissues. Consequently, certain tumor treatment options may pose a risk for subsequent bone diseases. Common bone disorders associated with cancer treatment include osteonecrosis, bone loss, and secondary bone tumors. (1)Cancer treatment-related osteonecrosis is primarily linked to the use of radiation therapy and certain chemicals, such as bisphosphonates, denosumab, antiangiogenic agents, and immunomodulators. It has been observed that high-dose radiation therapy is more likely to result in osteonecrosis. (2)Chemicals and hormones, particularly sex hormones, glucocorticoids, and thyroid hormones or thyrotropic hormones, are among the factors that can contribute to cancer treatment-related bone loss. (3)Secondary bone tumors differ from metastases originating from primary tumors, and radiotherapy plays a significant role in their development, while chemotherapy may also exert some influence. Radiogenic secondary bone tumors are predominantly malignant, with osteosarcoma being the most common type. Chemotherapy may be a risk factor for the relatively rare occurrence of secondary Ewing sarcoma of the bone. These treatment-related bone disorders have a considerable adverse impact on the prognosis of cancer patients. Hence, it is imperative to prioritize the bone health of patients undergoing cancer treatment and give it further attention.

Bone health and body composition in prostate cancer: Meet-URO and AIOM consensus about prevention and management strategies

BACKGROUND

Prostate cancer (PCa) treatments are associated with a detrimental impact on bone health (BH) and body composition. However, the evidence on these issues is limited and contradictory. This consensus, based on the Delphi method, provides further guidance on BH management in PCa.

MATERIALS AND METHODS

In May 2023, a survey made up of 37 questions and 74 statements was developed by a group of oncologists and endocrinologists with expertise in PCa and BH. In June 2023, 67 selected Italian experts, belonging to the Italian scientific societies Italian Association of Medical Oncology and Italian Network for Research in Urologic-Oncology (Meet-URO), were invited by e-mail to complete it, rating their strength of agreement with each statement on a 5-point scale. An agreement ≥75% defined the statement as accepted.

RESULTS

In non-metastatic hormone-sensitive PCa, the panel agreed that androgen deprivation therapy (ADT) alone implies sufficient fracture risk to warrant antifracture therapy with bone-targeting agents (BTAs) for cancer treatment-induced bone loss (CTIBL) prevention (79%). Therefore, no consensus was reached (48%) for the treatment with BTAs of patients receiving short-term ADT (<6 months). All patients receiving active treatment for metastatic hormone-sensitive PCa (75%), non-metastatic castration-resistant PCa (89%) and metastatic castration-resistant PCa (mCRPC) without bone metastases (84%) should be treated with BTAs at the doses and schedule for CTIBL prevention. All mCRPC patients with bone metastasis should be treated with BTAs to reduce skeletal-related events (94%). In all settings, the panel analyzed the type and timing of treatments and examinations to carry out for BH monitoring. The panel agreed on the higher risk of sarcopenic obesity of these patients and its correlation with bone fragility.

CONCLUSIONS

This consensus highlights areas lacking major agreement, like non-metastatic hormone-sensitive prostate cancer patients undergoing short-term ADT. Evaluation of these issues in prospective clinical trials and identification of early biomarkers of bone loss are particularly urgent.

Management of cancer treatment-induced bone loss in patients with breast and hormone sensitive prostate cancer: AIOM survey

PURPOSE

Cancer treatment-induced bone loss is a side effect of hormonal therapy that can severely affect patients' quality of life. The aim of this survey was to obtain an updated picture of management of bone health in patients with breast cancer undergoing adjuvant hormonal therapy and in patients with hormone sensitive prostate cancer according to Italian oncologists.

METHODS

Our survey was made up of 21 multiple-choice questions: the first part dealt with the respondents' characteristics, while the second with management of bone health in the described setting. An invitation to complete the survey was sent by e-mail to 2336 oncologists, members of Italian Association of Medical Oncology, in October 2022.

RESULTS

Overall, 121 (5.2%) Italian oncologists completed the survey. In most cases (57%) the oncologist personally took charge of the management of bone health in patients at risk for cancer treatment-induced bone loss. At the beginning of hormonal therapy, most respondents reported to require bone health diagnostic exams, such as dual-energy X-ray absorptiometry (89%), repeated with different timing. Main reported reasons (not mutually exclusive) for prescribing antiresorptive drugs were modifying fracture risk (87%), densitometry values (75%) or prognosis (34%). Answers about the management of antiresorptive therapy were heterogeneous.

CONCLUSION

A heterogeneous approach on the management of cancer treatment-induced bone loss in Italy arises from this survey. This scenario highlights the need for a major consensus of the Italian scientific community on the diagnostic and therapeutic approach of cancer treatment-induced bone loss and for a greater awareness of this topic among Italian oncologists.

Bone Metastases and Health in Prostate Cancer: From Pathophysiology to Clinical Implications

Clinically relevant bone metastases are a major cause of morbidity and mortality for prostate cancer patients. Distinct phenotypes are described: osteoblastic, the more common osteolytic and mixed. A molecular classification has been also proposed. Bone metastases start with the tropism of cancer cells to the bone through different multi-step tumor-host interactions, as described by the "metastatic cascade" model. Understanding these mechanisms, although far from being fully elucidated, could offer several potential targets for prevention and therapy. Moreover, the prognosis of patients is markedly influenced by skeletal-related events. They can be correlated not only with bone metastases, but also with "bad" bone health. There is a close correlation between osteoporosis-a skeletal disorder with decreased bone mass and qualitative alterations-and prostate cancer, in particular when treated with androgen deprivation therapy, a milestone in its treatment. Systemic treatments for prostate cancer, especially with the newest options, have improved the survival and quality of life of patients with respect to skeletal-related events; however, all patients should be evaluated for "bone health" and osteoporotic risk, both in the presence and in the absence of bone metastases. Treatment with bone-targeted therapies should be evaluated even in the absence of bone metastases, as described in special guidelines and according to a multidisciplinary evaluation.

Dual-energy x-ray absorptiometry assessment of bone health in Australian men with prostate cancer commencing androgen deprivation therapy

OBJECTIVE

To determine the prevalence in Australia of bone health assessment of men with prostate cancer by dual-energy x-ray absorptiometry (DXA), from six months before to twelve months after initiation of androgen deprivation therapy (ADT).

DESIGN, SETTING

Cross-sectional national study; linkage of de-identified Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data.

PARTICIPANTS

Men (18 years or older) first dispensed PBS-subsidised ADT during 1 May 2017 - 31 July 2020.

MAIN OUTCOME MEASURES

Prevalence of MBS-subsidised DXA assessments undertaken from six months before to twelve months after first ADT prescription.

RESULTS

Of 33 836 men with prostate cancer commencing ADT therapy during 2017-20, 6683 (19.8%) underwent DXA bone heath assessments between six months before and twelve months after commencing ADT; the mean time from first ADT dispensing to DXA scanning was +90 days (standard deviation, 134 days). The proportion of men aged 54 years or younger who had scans (66 of 639, 10%) was smaller than that of men aged 70-84 years (4528 of 19 378, 23.4%; adjusted odds ratio, 0.36; 95% CI, 0.28-0.47).

CONCLUSIONS

For about 80% of men with prostate cancer commencing ADT in Australia, therapy initiation was not accompanied by DXA assessment of bone health. Given the excellent long term prognosis for men with prostate cancer and the availability of bone protective therapy, bone health monitoring should be a routine component of prostate cancer care for men receiving ADT.

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 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.

Guidance for the assessment and management of prostate cancer treatment-induced bone loss. A consensus position statement from an expert group

CONTEXT AND OBJECTIVE

Incidence of prostate cancer (PC) is increasing, but androgen deprivation therapy (ADT) and other therapies are substantially improving survival. In this context, careful consideration of skeletal health is required to reduce the risk of treatment-related fragility fractures and their associated morbidity and mortality. This risk is currently not well-managed. ADT causes significant loss of bone mineral density (BMD). In the metastatic setting, systemic treatments (e.g. chemotherapy, abiraterone, enzalutamide) are used alongside ADT and may require concomitant glucocorticoids. Both ADT and glucocorticoids pose significant challenges to skeletal health in a population of patients already likely to have ongoing age-related bone loss and/or comorbid conditions. Current PC guidelines lack specific recommendations for optimising bone health. This guidance presents evidence for assessment and management of bone health in this population, with specific recommendations for clinical practitioners in day-to-day PC management.

METHODS

Structured meetings of key opinion leaders were integrated with a systematic literature review. Input and endorsement was sought from patients, nursing representatives and specialist societies.

SUMMARY OF GUIDANCE

All men starting or continuing long-term ADT should receive lifestyle advice regarding bone health. Calcium/vitamin D supplementation should be offered if required. Fracture risk should be calculated (using the FRAX® tool), with BMD assessment included where feasible. BMD should always be assessed where fracture risk calculated using FRAX® alone is close to the intervention threshold. Intervention should be provided if indicated by local or national guidelines e.g. UK National Osteoporosis Guideline Group (NOGG) thresholds. Men requiring bone protection therapy should be further assessed (e.g. renal function), with referral to specialist centres if available and offered appropriate treatment to reduce fracture risk. Those near to, but below an intervention threshold, and patients going on to additional systemic therapies (particularly those requiring glucocorticoids), should have FRAX® (including BMD) repeated after 12-18 months.

PATIENT SUMMARY

Modern treatments for prostate cancer have led to significant improvements in survival and quality of life. However, some of these treatments may lead to weakening of patient's bones with risk of fracture and it is therefore important to monitor patients' bone health and provide bone protection where needed. This paper provides specific guidance to clinical teams, based on the most recent research evidence, to ensure optimal bone health in their patients.

Denosumab for cancer-related bone loss

INTRODUCTION

Prolonged use of anti-cancer treatments in breast and prostate tumors alters physiological bone turnover leading to adverse skeletal related events, such as osteoporosis, loss of bone mass, and increased risk of fractures. These complications known as cancer treatment-induced bone loss (CTIBL) should be managed with bone targeting agents such as the bisphosphonates and denosumab. The latter is a monoclonal antibody against the receptor activator of nuclear factor-kB ligand (RANKL) that suppresses osteoclasts function and survival increasing bone mass.

AREAS COVERED

This review will focus on the mechanisms associated with bone loss induced by cancer treatments and the most recent evidence about the use of denosumab as preventive and therapeutic strategy to protect bone health. Moreover, we will discuss several key aspects regarding the clinical practical use of denosumab to optimize the management of CTLIB in breast and prostate cancer.

EXPERT OPINION

Denosumab treatment strongly prevents cancer therapies-related skeletal issues in breast and prostate cancer with a good safety profile. Adjuvant six-monthly denosumab delays the time to first fracture onset in early stage breast cancer patients with normal or altered bone mineral density (BMD). Similarly, denosumab treatment is able to prevent fractures and BMD loss in nonmetastatic prostate cancer patients.

A randomized, open-label, controlled trial of monthly oral minodronate or semiannual subcutaneous injection of denosumab for bone loss by androgen deprivation in Asian men with prostate cancer: the PRevention of Osteopenia with Minodronate And DEnosumab (PROMADE) study

There is still a lack of evidence that minodronate or denosumab prevents bone loss due to androgen deprivation therapy (ADT) in non-Western patients. This study showed that both drugs significantly improved lumbar spine and total hip bone mineral density in Asian men with prostate cancer who received ADT.

INTRODUCTION

To evaluate whether monthly oral minodronate or semiannual subcutaneous injection of denosumab improves bone mineral density (BMD) in Asian men with prostate cancer (PCa) receiving ADT.

METHODS

A multicenter, open-label, randomized, controlled study including patients with hormone-sensitive PCa without bone metastasis receiving ADT was performed. Patients were randomized (1:1:1) to minodronate, denosumab, or no agent control groups. The primary end point was the mean percentage change in BMD at the lumbar spine at 12 months. Secondary end points were the mean percentage change in BMD at the femoral neck and total hip and changes in bone turnover markers. Statistical comparison was performed using analysis of covariance.

RESULTS

Of the 147 subjects enrolled in this study, 102 were randomly assigned into the minodronate (n = 36), denosumab (n = 36), and control (n = 30) groups. The percentage change in BMD at the lumbar spine was significantly improved in the minodronate (2.5%, p < 0.05) and denosumab groups (4.0%, p < 0.01) compared with that in the control group (- 0.1%). Denosumab increased BMD at the femoral neck and total hip at 12 months, whereas minodronate only increased BMD at the total hip compared with controls (all p < 0.05). The percentage change in bone turnover markers at 12 months was significantly lower in the minodronate and denosumab groups compared with that in the control group (both p < 0.01).

CONCLUSION

Minodronate or denosumab can be used for preventing bone loss related to ADT in Asian patients with PCa.

Bone Health in Men with Prostate Cancer: Review Article

PURPOSE OF REVIEW

The improvement in prostate cancer survival over time, even in those with advanced disease, has led to an increasing recognition of the impact of prostate cancer and its treatment on bone health. Cancer treatment-induced bone loss (CTIBL) is a well-recognized entity but greater awareness of the risks associated with CTIBL and its treatment is required.

RECENT FINDINGS

The principal culprit in causing CTIBL is hormonal ablation induced by prostate cancer treatment, including several new agents which have been developed in recent years which significantly improve survival, but may cause CTIBL. This review discusses the impact of prostate cancer and its treatment on bone health, including published evidence on the underlying pathophysiology, assessment of bone health, and strategies for prevention and treatment. It is important to recognize the potential cumulative impact of systemic prostate cancer treatments on bone health.

Management of Osteoporosis in Survivors of Adult Cancers With Nonmetastatic Disease: ASCO Clinical Practice Guideline

PURPOSE

The aim of this work is to provide evidence-based guidance on the management of osteoporosis in survivors of adult cancer.

METHODS

ASCO convened a multidisciplinary Expert Panel to develop guideline recommendations based on a systematic review of the literature.

RESULTS

The literature search of the 2018 systematic review by the US Preventive Services Task Force in the noncancer population was used as the evidentiary base upon which the Expert Panel based many of its recommendations. A total of 61 additional studies on topics and populations not covered in the US Preventive Services Task Force review were also included. Patients with cancer with metastatic disease and cancer survival outcomes related to bone-modifying agents are not included in this guideline.

RECOMMENDATIONS

Patients with nonmetastatic cancer may be at risk for osteoporotic fractures due to baseline risks or due to the added risks that are associated with their cancer therapy. Clinicians are advised to assess fracture risk using established tools. For those patients with substantial risk of osteoporotic fracture, the clinician should obtain a bone mineral density test. The bone health of all patients may benefit from optimizing nutrition, exercise, and lifestyle. When a pharmacologic agent is indicated, bisphosphonates or denosumab at osteoporosis-indicated dosages are the preferred interventions.

The skeletal impact of cancer therapies

Both cancer and therapies used in the treatment of cancer can have significant deleterious effects on the skeleton, increasing the risks for both bone loss and fracture development. While advancements in cancer therapies have resulted in enhanced cancer survivorship for patients with many types of malignancies, it is increasingly recognized that efforts to reduce bone loss and limit fractures must be considered for nearly all patients undergoing cancer therapy in order to diminish the anticipated future skeletal consequences. To date, most studies examining the impact of cancer therapies on skeletal outcomes have focused on endocrine-associated cancers of the breast and prostate, with more recent advances in our understanding of bone loss and fracture risk in other malignancies. Pharmacologic efforts to limit the adverse effects of cancer therapies on bone have nearly universally employed anti-resorptive approaches, although studies have frequently relied on surrogate outcomes such as changes in bone mineral density or bone turnover markers, rather than on fractures or other skeletal-related events, as primary study endpoints. Compounding current deficiencies for the provision of optimal care is the recognition that despite clearly written and straightforward society-based guidelines, vulnerable eligible patients are very often neither identified nor provided with appropriate treatments to limit the skeletal impact of their cancer therapies.

A retrospective study of alendronate for the treatment of ankylosing spondylitis

This retrospective study assessed the effect of alendronate for treating patients with ankylosing spondylitis (AS).Eighty-six patients with AS were included in this retrospective study, and were divided into 2 groups. Forty-six patients in the intervention group received alendronate plus vitamin D (400 mg/day) and calcium (500 mg/day), while 40 patients in the control group received vitamin D and calcium only, the same dose as the intervention group. The primary outcome included bone densitometry. The secondary outcomes consisted of quality of life, measured by Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire, disease activity, measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and functional status, measured by Bath Ankylosing Spondylitis Functional Index (BASFI), as well as the adverse events (AEs).At the end of 6-month treatment, patients in the intervention group were not superior to the patients in the control group in bone densitometry (hip, P = .47; lumbar, P = .53), quality of life (P = .32), disease activity (P = .39), and functional status (P = .41). Moreover, no significant differences in AEs were found between 2 groups.The results of the present study showed that alendronate can neither be used to treat bone loss, nor to enhance the quality of life, disease activity, and functional status.

The prevention of fragility fractures in patients with non-metastatic prostate cancer: a position statement by the international osteoporosis foundation

Androgen deprivation therapy is commonly employed for the treatment of non-metastatic prostate cancer as primary or adjuvant treatment. The skeleton is greatly compromised in men with prostate cancer during androgen deprivation therapy because of the lack of androgens and estrogens, which are trophic factors for bone. Men receiving androgen deprivation therapy sustain variable degrees of bone loss with an increased risk of fragility fractures. Several bone antiresorptive agents have been tested in randomized controlled trials in these patients. Oral bisphosphonates, such as alendronate and risedronate, and intravenous bisphosphonates, such as pamidronate and zoledronic acid, have been shown to increase bone density and decrease the risk of fractures in men receiving androgen deprivation therapy. Denosumab, a fully monoclonal antibody that inhibits osteoclastic-mediated bone resorption, is also effective in increasing bone mineral density and reducing fracture rates in these patients. The assessment of fracture risk, T-score and/or the evaluation of prevalent fragility fractures are mandatory for the selection of patients who will benefit from antiresorptive therapy. In the future, new agents modulating bone turnover and skeletal muscle metabolism will be available for testing in these subjects.

Bone Health and Bone-targeted Therapies for Prostate Cancer: a Programme in Evidence-based Care - Cancer Care Ontario Clinical Practice Guideline

AIMS

To make recommendations with respect to bone health and bone-targeted therapies in men with prostate cancer.

MATERIALS AND METHODS

A systematic review was carried out by searching MEDLINE, EMBASE and the Cochrane Library from inception to January 2016. Systematic reviews and randomised-controlled trials were considered for inclusion if they involved therapies directed at improving bone health or outcomes such as skeletal-related events, pain and quality of life in patients with prostate cancer either with or without metastases to bone. Therapies included medications, supplements or lifestyle modifications alone or in combination and were compared with placebo, no treatment or other agents. Disease-targeted agents such as androgen receptor-targeted and chemotherapeutic agents were excluded. Recommendations were reviewed by internal and external review groups.

RESULTS

In men with prostate cancer receiving androgen deprivation therapy, baseline bone mineral density testing is encouraged. Denosumab should be considered for reducing the risk of fracture in men on androgen deprivation therapy with an increased fracture risk. Bisphosphonates were effective in improving bone mineral density, but the effect on fracture was inconclusive. No medication is recommended to prevent the development of first bone metastasis. Denosumab and zoledronic acid are recommended for preventing or delaying skeletal-related events in men with metastatic castration-resistant prostate cancer. Radium-223 is recommended for reducing symptomatic skeletal events and prolonging survival in men with symptomatic metastatic castration-resistant prostate cancer.

CONCLUSIONS

The recommendations represent a current standard of care that is feasible to implement, with outcomes valued by clinicians and patients.

Quality of care provided to prostate cancer (PC) patients for prevention and treatment of osteoporosis induced by androgen deprivation therapy (ADT)

OBJECTIVES

This study aims to evaluate the quality of care (QOC) and use of validated risk algorithms provided in a specialized osteoporosis clinic to men with prostate cancer on androgen deprivation therapy (ADT) who are at risk of bone loss and fragility fractures.

PATIENTS AND METHODS

Charts for 100 consecutive men (mean age 73.0 years) on ADT referred to a tertiary osteoporosis clinic in Toronto, Canada between 2010 and 2014 were reviewed. The following QOC issues were examined: (a) bone health services provided, i.e., screening, preventing, and treating osteoporosis; and (b) use of national guidelines and fracture risk assessment tools for targeting appropriate therapy.

RESULTS

The median (IQR) duration of ADT was 21.4 (26.9) months at the baseline visit. Nineteen patients had their first bone mineral density test before starting ADT and 34 during the first year of use. At initial consultation, 83 and 30 patients were taking inadequate amounts of calcium and vitamin D, respectively. A validated fracture risk assessment tool was used in all patients; 42 had a moderate 10-year fracture risk and 12 were high risk. Sixteen (72.7 %) of sedentary patients were advised to increase physical activity. Sixty-four (77.1 %) and 28 (93.3 %) of patients not taking appropriate amounts of calcium and vitamin D, respectively, were recommended to adjust their intake to guideline levels. All patients at high fracture risk were recommended a bisphosphonate.

CONCLUSIONS

The majority of referred patients had moderate to high fracture risk. The osteoporosis clinic recommended guideline-based bone health care for the vast majority of men on ADT.

Osteoporosis and Low Bone Mineral Density in Men with Testosterone Deficiency Syndrome

INTRODUCTION

Testosterone deficiency syndrome (TDS) is a risk factor for low bone mineral density (BMD) and osteoporosis. Knowledge of the relationship between TDS and bone health, as well as the practical aspects of how to diagnose and treat low BMD, is therefore of practical importance to sexual medicine practitioners.

AIM

The aim of this study was to review the physiologic basis and clinical evidence of the relationship between TDS and bone health; and to provide a practical, evidence-based algorithm for the diagnosis and management of low BMD in men with TDS.

METHODS

Method used was a review of relevant publications in PubMed.

MAIN OUTCOME MEASURES

Pathophysiology of low BMD in TDS, morbidity, and mortality of osteoporosis in men, association between TDS and osteoporosis, indications for dual X-ray absorptiometry (DXA) scanning in TDS, evidence for testosterone replacement therapy (TRT) in men with osteoporosis, treatment for osteoporosis in the setting of TDS.

RESULTS

Sex hormones play a pleomorphic role in maintenance of BMD. TDS is associated with increased risk of osteoporosis and osteopenia, both of which contribute to morbidity and mortality in men. DXA scanning is indicated in men older than 50 years with TDS, and in younger men with longstanding TDS. Men with TDS and osteoporosis should be treated with anti-osteoporotic agents and TRT should be highly considered. Men with osteopenia should be stratified by fracture risk. Those at high risk should be treated with anti-osteoporotic agents with strong consideration of TRT; while those at low risk should be strongly considered for TRT, which has a beneficial effect on BMD.

CONCLUSION

Low BMD is a prevalent and treatable cause of morbidity and mortality in men with TDS. Utilization of a practical, evidence-based approach to diagnosis and treatment of low BMD in men with TDS enables sexual medicine practitioners to make a meaningful impact on patient quality of life and longevity. Gaffney CD, Pagano MJ, Kuker AP, Stember DS, and Stahl PJ. Osteoporosis and low bone mineral density in men with testosterone deficiency syndrome.

Bisphosphonates in the Treatment of Patients With Metastatic Breast, Lung, and Prostate Cancer: A Meta-Analysis

The purpose of this meta-analysis was to investigate whether bisphosphonates are a key therapy for bone metastases in lung cancer, breast cancer, and prostate cancer by comparing all randomized controlled trials that appraised the effects of bisphosphonates on risk of skeletal-related events (SREs).PubMed, Embase, and Medline databases (up to December 2014) were used to search all related articles. Using the data from 19 available publications, the authors examined the efficacy in treating or reducing the risk of SREs in lung cancer, breast cancer, and prostate cancer by meta-analysis.Bisphosphonates have demonstrated efficacy in treating or reducing the risk of SREs in lung cancer [odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.69-0.95, P = 0.008], breast cancer (OR = 0.62, 95% CI = 0.54-0.71, P = 0.000), and prostate cancer (OR = 0.62, 95% CI = 0.45-0.86, P = 0.004).This meta-analysis suggests that bisphosphonates have demonstrated efficacy in treating or reducing the risk of SREs in lung cancer, breast cancer, and prostate cancer.

Androgen-deprivation therapy and bone loss in prostate cancer patients: a clinical review

Androgen-deprivation therapy (ADT) has become a standard of care in the management of advanced prostate cancer or as an adjunct therapy. However, ADT is associated with a well-known deleterious effect on bone health, resulting in a decrease in bone-mass density (BMD) and increased risk for fracture. With the longer life expectancy of prostate cancer patients, improvement of the quality of life has become increasingly important. Therefore, adequate screening, prevention and treatment of BMD loss is paramount. Zoledronic acid and denosumab have shown promising results in recent studies, which has led to the Food and Drug Administration approval of these treatment options in various settings throughout the course of the disease, including the prevention of ADT-associated bone loss. This review focuses on the various parameters that impact BMD loss in men initiating ADT, on the specific effect of ADT on bone health and on various lifestyle modifications and treatment options such as bisphosphonates, osteoclast-targeted therapy and selective estrogen-receptor modulators that have shown promising results in recent studies.

Antiresorptive therapy in the management of cancer treatment-induced bone loss

Cancer treatment-induced bone loss treatment has an important role to prevent bone loss-related events like fracture, significant morbidity, mortality, disfigurement and loss of self-esteem, and health-care expenditure. Numerous factors, including treatment regimens and bone metastasis, increase the risk of osteoporosis or local bone destruction in most breast and prostate cancer patients. Cytotoxic chemotherapies, radiation, and hormonal therapies can lead to premature menopause and decrease bone mineral density. Over 60 % of breast cancer patients within 1 year of beginning postoperative adjuvant chemotherapy experience ovarian failure. Also, ovarian ablation and aromatase inhibitors used to treat breast cancer and orchiectomy and androgen deprivation therapy (ADT; to treat prostate cancer) cause substantial bone loss. In this article, we will focus mainly on antiresorptive therapy in the management of cancer treatment-induced bone loss (CTIBL). An understanding of CTIBL is critical for determining how to assess the risk and identify which patients may benefit from preventive therapy.

Muscle and bone effects of androgen deprivation therapy: current and emerging therapies

Prostate cancer and treatment with androgen deprivation therapy (ADT) affect significant numbers of the male population. Endocrine effects of ADT are a critical consideration in balancing the benefits and risks of treatment on long-term survival and quality of life. This review highlights the latest advances in androgen manipulation in prostate cancer with an emphasis on the effects of ADT on muscle and bone, which universally affects the health and well-being of men undergoing ADT for prostate cancer. Muscle mass declines with ADT; however, the evidence that this correlates with a decrease in muscle strength or a decrease in physical performance is discordant. Cortical bone decay also occurs in association with an increase in fracture risk, hence optimization of musculoskeletal health in men undergoing ADT is crucial. The role of exercise, and current and emerging anabolic therapies for muscle as well as various new strategies to prevent loss of bone mass in men undergoing ADT are discussed. Future well-designed, prospective, controlled studies are required to elucidate the effects of ADT on physical performance, which are currently lacking, and larger randomized controlled trials are required to test the efficacy of medical therapies and exercise interventions to target proven deficits and to ensure safety in men with prostate cancer.

Contemporary pharmacotherapy for the prevention of skeletal complications in patients with prostate cancer

INTRODUCTION

Bones represent the most common metastatic sites in prostate cancer (PCa) patients, and in addition with androgen deprivation therapy, they represent the causative reasons of bone mineral density loss and the onset of skeletal-related events.

AREAS COVERED

An extensive search of PubMed/Medline was performed to identify randomized, Phase II/III controlled trials reporting results regarding the prevention of skeletal morbidity in patients with PCa.

EXPERT OPINION

Preventing bone health is an imperative issue for preserving quality of life and elongate survival and, thus, a concerted effort should be made to monitor skeletal changes and to apply treatment for preventing bone loss. Although several agents have received approval for routine use, it is of paramount importance to identify the appropriate patients who would mostly be benefited by the use of these agents with attention to documenting the toxicity and economic implications. Additionally, it remains to be justified the frequency of administration in order to balance the efficacy and the potential complications.

Androgen deprivation therapy complications

Androgen deprivation therapy (ADT) is increasingly used to treat advanced prostate cancer and is also utilised as adjuvant or neo-adjuvant treatment for high-risk disease. The resulting suppression of endogenous testosterone production has deleterious effects on quality of life, including hot flushes, reduced mood and cognition and diminished sexual function. Cross-sectional and longitudinal studies show that ADT has adverse bone and cardio-metabolic effects. The rate of bone loss is accelerated, increasing the risk of osteoporosis and subsequent fracture. Fat mass is increased and lean mass reduced, and adverse effects on lipid levels and insulin resistance are observed, the latter increasing the risk of developing type 2 diabetes. ADT also appears to increase the risk of incident cardiovascular events, although whether it increases cardiovascular mortality is not certain from the observational evidence published to date. Until high-quality evidence is available to guide management, it is reasonable to consider men undergoing ADT to be at a higher risk of psychosexual dysfunction, osteoporotic fracture, diabetes and cardiovascular disease, especially when treated for extended periods of time and therefore subjected to profound and prolonged hypoandrogenism. Health professionals caring for men undergoing treatment for prostate cancer should be aware of the potential risks of ADT and ensure appropriate monitoring and clinical management.

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.

Low rates of bone mineral density measurement in Medicare beneficiaries with prostate cancer initiating androgen deprivation therapy

BACKGROUND

Men with prostate cancer who undergo androgen deprivation therapy (ADT) are at risk for bone loss and fractures. Our objective was to determine if Medicare beneficiaries with prostate cancer in the state of Texas underwent DXA scans when initiating ADT.

METHODS

We identified men diagnosed with prostate cancer between 2005 and 2007 in the Texas Cancer Registry/Medicare linked database, and who received parenteral ADT or orchiectomy. We identified DXA claims within 1 year before or 6 months after starting ADT. We examined use of bone conservation agents in the subgroup of patients enrolled in Medicare Part D. Multivariate logistic regression models were used to examine determinants of DXA use.

RESULTS

The analysis included 2,290 men (2,262 parenteral ADT, 28 orchiectomy); 197 (8.6 %) underwent DXA within 1 year before and 6 months after starting ADT. Men aged 75 years or older were more likely to undergo DXA than men aged 66-74 years (OR 1.5; 95 % CI 1.1-2.1). Those living in small urban areas were less likely to undergo DXA than those in big areas (OR 0.40; 95 % CI 0.19-0.82). Of the 1,060 men enrolled in Medicare part D, 59 (5.6 %) received bone conservation agents when starting ADT; 134 (12.6 %) either received bone conservation agents or underwent DXA.

CONCLUSIONS

Fewer than one in ten Medicare beneficiaries with prostate cancer initiating ADT underwent a DXA exam. Variation in utilization was also related to residence area size. Further research is needed to identify whether the use of DXA in patients with prostate cancer receiving ADT will result in fracture prevention.

Osteoporosis and cancer

Cancer is a major risk factor for bone loss and fractures. This is due both to direct effects of cancer cells on the skeleton and to deleterious effects of cancer-specific therapies on bone cells. Marked improvements in survival for many cancers mean that strategies to limit bone loss and reduce fracture risk must be incorporated into the care plans for nearly all patients with cancer. The vast majority of effort thus far has focused on bone loss in patients with breast and prostate cancers, with comparatively few studies in other malignancies. Antiresorptive therapies have proven nearly universally effective for limiting bone loss in cancer patients, although few studies have been powered sufficiently to include fractures as primary endpoints, and patients are frequently neither identified nor treated according to published guidelines. Nonpharmacologic approaches to limit falls, particularly in elderly patients, are also likely important adjunctive measures for most cancer patients.

A randomized phase II trial evaluating different schedules of zoledronic acid on bone mineral density in patients with prostate cancer beginning androgen deprivation therapy

OBJECTIVE

To assess the effects of timing and schedule of zoledronic acid (ZA) administration on bone mineral density (BMD) in patients beginning androgen deprivation therapy (ADT) for the treatment of recurrent prostate cancer.

PATIENTS AND METHODS

In this randomized, 3-arm trial, we evaluated changes in BMD after 3 different ZA administration schedules in men with recurrent prostate cancer who were beginning ADT. Forty-four patients were enrolled and randomized to receive a single dose of ZA given 1 week before beginning ADT (arm 1), a single dose of ZA given 6 months after beginning ADT (arm 2), or monthly administration of ZA starting 6 months after beginning ADT, for a total of 6 doses (arm 3).

RESULTS

Patients who received ZA before ADT had a significant improvement in BMD at the total proximal femur and trochanter after 6 months compared with the other groups. In addition, only patients in the arm that received multiple doses improved lumbar spine BMD while on ADT, with these findings persisting to 24 months. However, this group also experienced more grade 1 adverse events.

CONCLUSIONS

Analysis of these data suggests that ZA administration before initiation of ADT was superior to treatment 6 months after starting ADT in maintaining BMD. In addition, monthly ZA administration can increase BMD above baseline but is associated with more adverse events. Further study is needed to examine whether the timing and frequency of ZA therapy in patients on ADT can reduce fracture risk.

Vertebral fractures and trabecular microstructure in men with prostate cancer on androgen deprivation therapy

Androgen deprivation therapy (ADT), a treatment for prostate cancer, is associated with bone loss and fractures. Dual-energy X-ray absorptiometry (DXA)-measured bone mineral density does not assess vertebral fractures (VF). High-resolution micro-magnetic resonance imaging (HR-MRI) assesses bone microarchitecture and provides structural information. To determine if VF identification increased the diagnosis of osteoporosis beyond DXA and if HR-MRI demonstrated skeletal deterioration in men with VF, we cross-sectionally studied 137 men aged ≥ 60 years with nonmetastatic prostate cancer on ADT for ≥ 6 months. Vertebral fracture assessment (VFA) by DXA was confirmed with X-rays. HR-MRI of the wrist included bone volume to total volume (BV/TV), surface density (trabecular plates), surface/curve ratio (plates/rods), and erosion index (higher depicts deterioration). VF were found in 37% of men; the majority were unknown. Seven percent of participants were classified as osteoporotic by hip or spine DXA. Thirty-seven percent of men without osteoporosis by DXA had VF identified, suggesting that 90% of patients with clinical osteoporosis would have been misclassified by DXA alone. By ANOVA comparison across VF grades, the BV/TV, surface density, and spine, hip, and wrist DXA were lower, and erosion index was higher in men with moderate-severe VF compared with lesser grades (all p < 0.05). By unadjusted ROC analysis, the addition of HR-MRI to DXA at the spine, hip, and femoral neck added substantially (AUC increased 0.831 to 0.902, p < 0.05) to prediction of moderate-severe vertebral fracture. HR-MRI indices were associated with spine, hip, and wrist DXA measures (p < 0.01). Longer duration of ADT was associated with lower BV/TV, surface density, and surface/curve ratio (p < 0.05). ADT for men with prostate cancer is associated with silent VF. DXA alone leads to misclassifications of osteoporosis, which can be avoided by VF assessment. HR-MRI provides a novel technique to assess deterioration of structural integrity in men with VF and adds micro-structural information.

A phase 3, double-blind, randomised, parallel-group, placebo-controlled study of oral weekly alendronate for the prevention of androgen deprivation bone loss in nonmetastatic prostate cancer: the Cancer and Osteoporosis Research with Alendronate and Leuprolide (CORAL) study

BACKGROUND

Androgen-deprivation therapy (ADT) induces loss of bone mineral density (BMD) and increases the risk of fractures in patients with prostate cancer (PCa). We sought to determine whether a weekly dose of alendronate, an oral bisphosphonate, could reduce this unwanted side-effect.

OBJECTIVE

To assess whether once-weekly oral alendronate therapy would maintain or improve BMD in men initiating ADT for localised PCa.

DESIGN, SETTING, AND PARTICIPANTS

A multicentre, double-blind, randomised, placebo-controlled study, we included hormonally naïve PCa patients initiating ADT with leuprolide acetate 30 mg intramuscularly every 4 mo.

INTERVENTION

Patients were randomised to receive either oral alendronate 70 mg once weekly or placebo for 1 yr. Both groups received daily calcium 1g and vitamin D 400 international units.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Changes in BMD (at the lumbar spine [LS] and total hip [TH]) and bone markers.

RESULTS AND LIMITATIONS

One hundred ninety-one subjects were enrolled, and 186 were randomised between alendronate (n=84) and placebo (n=102). The alendronate group demonstrated a mean spine BMD increase of 1.7% compared with -1.9% in the placebo group (p<0.0001). Alendronate also increased the BMD at the hip (percent change: 0.7%) compared to placebo (-1.6%). Median urinary N-terminal crosslinking telopeptide of type I collagen (Ntx) values decreased by 3.5% in the alendronate group and increased by 16.5% in the placebo arm, even after adjusting for centre (p=0.510) and baseline urinary Ntx (p<0.0001). Bone-specific alkaline phosphatase (BSAP) decreased a median of 2.25% in the alendronate group and increased a median of 3.12% in the placebo arm, regardless of centre or baseline BSAP or other covariates (p<0.0001). The safety and tolerability profile was similar for the two treatment groups.

CONCLUSIONS

Although the study was closed early because of slow accrual, it showed that weekly oral alendronate prevented bone loss and increased bone mass in addition to decreasing bone turnover in patients initiating ADT for localised PCa, with few related side-effects.

Treatment-induced bone loss and fractures in cancer patients undergoing hormone ablation therapy: efficacy and safety of denosumab

Hormone ablation therapy (HALT) for breast or prostate cancer accelerates the development of osteoporosis in both men and women by causing estrogen deficiency, which increases the risk for fracture by promoting bone resorption mediated by osteoclasts. Denosumab, a fully human monoclonal antibody that inhibits osteoclast formation and function, increases bone mass in patients undergoing hormone ablation therapy. In the HALT study of 1,468 men with prostate cancer on androgen-deprivation therapy, denosumab significantly reduced the risk of new vertebral fractures, increased bone mineral density (BMD), and reduced markers of bone turnover. In a study of 252 women with breast cancer undergoing adjuvant aromatase inhibitor (AI) therapy, denosumab increased BMD at 12 and 24 months, overall and in all patient subgroups. The overall rates of adverse events were similar to placebo. Clinicians should consider fracture risk assessment and therapies such as denosumab to increase bone mass in patients on hormone ablation therapy who are at high risk for fracture.

Denosumab and changes in bone turnover markers during androgen deprivation therapy for prostate cancer

Androgen deprivation therapy (ADT) for prostate cancer increases fracture risk, decreases bone mineral density, and increases bone turnover markers (BTMs) including serum type 1 C-telopeptide (sCTX), tartrate-resistant alkaline phosphatase 5b (TRAP-5b), and procollagen-1 N-terminal telopeptide (P1NP). In a prespecified exploratory analysis of a phase 3, multicenter, double-blind study, we evaluated the effects of denosumab (60 mg subcutaneously every 6 months for 3 years) versus placebo (1468 patients, 734 in each group) on BTM values. BTMs were measured at baseline, month 1, and predose at months 6, 12, 24, and 36 in the overall population. BTMs at month 1 are also reported for subgroups based on age (<  70 years versus ≥  70 years), prior duration of ADT (≤  6 months versus > 6 months), and baseline BTM (≤  median versus >  median BTM values). Treatment with denosumab provided a rapid and sustained decrease of BTM values compared with placebo. The median change in sCTX levels at month 1 was -90% in the denosumab group and -3% in the placebo group (p  <  0.0001). The median change in TRAP-5b levels at month 1 was -55% in the denosumab group and -3% in the placebo group (p <  0.0001). The maximal median change in P1NP was -64% in the denosumab group and -11% in the placebo group, (p  <  0.0001). Significantly greater decreases in BTM for denosumab were also seen in subgroup analyses based on age, prior ADT treatment, and baseline BTM values. Suppression of bone turnover markers was consistent with marked increases in bone mineral density reported previously.

Prevention and treatment of side-effects of systemic treatment: bone loss

Cancer treatment-induced bone loss (CTIBL) is generally more rapid and severe than bone loss associated with menopause in women or ageing in men and women. In premenopausal women with breast cancer, CTIBL is mainly caused by chemotherapy with resultant ovarian failure, by GnRH agonists or by tamoxifen. In postmenopausal women, steroidal and non-steroidal aromatase inhibitors (AIs) increase bone turnover, decrease bone mass and increase fracture rate (hazard ratio increased to 1.38-1.55 compared with tamoxifen). Zoledronic acid can prevent bone loss in premenopausal women receiving adjuvant therapy with goserelin in combination with either anastrozole or tamoxifen and in postmenopausal women receiving AIs. Denosumab has been shown in a placebo-controlled study to significantly increase bone mineral density in postmenopausal women under AIs. More limited studies indicate that oral bisphosphonates used at licensed doses for the treatment of postmenopausal osteoporosis can also prevent AI-induced bone loss. In prostate cancer, bone loss that occurs with androgen deprivation therapy (ADT) also leads to an increased fracture rate. The bisphosphonates pamidronate and alendronate can prevent bone loss whereas zoledronic acid can increase bone mass under ADT. As for breast cancer, delay in bisphosphonate therapy is detrimental to bone health. The protective effects of denosumab on bone loss and incidental vertebral fractures have been demonstrated in a 3-year placebo-controlled trial.

Bone health in the prostate cancer patient receiving androgen deprivation therapy: a review of present and future management options

Osteoporosis and bone fractures are frequently overlooked complications of androgen deprivation therapy in men with nonmetastatic prostate cancer. All such patients should have their bone mineral density (BMD) monitored and be offered preventive measures, such as calcium and vitamin D supplementation; patients with low BMD should be offered treatment. Several agents, including bisphosphonates, are available (although this use is currently off-label), and upcoming treatments, such as denosumab and toremifene, have shown promise in reducing fracture risk in these patients.

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.

Osteoporosis in men: what has changed?

Osteoporosis in men is finally receiving some attention; it has been realized that men are more likely to die after hip fracture. Methods for screening men for osteoporosis include dual energy x-ray absorptiometry and use of fracture risk calculators such as FRAX (World Health Organization) and the Garvan nomogram. Evaluation of men will often identify secondary causes of osteoporosis as well as multiple risk factors. Alendronate, risedronate, zoledronic acid, and teriparatide are US Food and Drug Administration (FDA)--approved therapy for men. Men on androgen deprivation therapy (ADT) are at high risk for bone loss and fracture, and all the bisphosphonates have been shown to increase bone density. The new antiresorptive drug, denosumab, although FDA-approved only for postmenopausal women, has been shown in a study of men on ADT to increase bone density in spine, hip, and forearm and decrease vertebral fractures on x-ray. Thus, there is great progress in osteoporosis in men, and recognition of its importance is increasing.

An update on the changing indications for androgen deprivation therapy for prostate cancer

Quality of life has become increasingly more important for men diagnosed with prostate cancer. In light of this and the recognized risks of androgen deprivation therapy (ADT), the guidelines and use of ADT have changed significantly over the last few years. This paper reviews the current recommendations and the future perspectives regarding ADT. The benefits of ADT are evident neoadjuvantly and adjuvantly in patients treated with external beam radiation therapy for intermediate- and high-risk disease, in patients who have undergone prostatectomy with lymph node involvement, in high-risk patients after definitive therapy, and in patients who have developed progression or metastasis. Finally, this paper reviews the risks and benefits of each of these scenarios and the risks of androgen deprivation in general, and it delineates the areas where ADT was previously recommended, but where evidence is lacking for its additional benefit.

Pathologic fracture and metastatic spinal cord compression in patients with prostate cancer and bone metastases

Background

The purpose of this study was to determine the risk factors for and incidence as well as prognostic impact of pathologic fracture (PF) and metastatic spinal cord compression (MSCC) in patients with bone metastases (BM) from prostate cancer.

Methods

Retrospective cohort study including 61 consecutive patients seen at Nordland hospital's department of oncology between 2007 and 2009. The initial diagnosis of BM might have been made earlier. Twenty-nine patients (48%) received taxotere and 72% zoledronic acid after diagnosis of BM.

Results

Median actuarial survival after diagnosis of BM was 23 months. Six patients (10%) were alive at 5 years. Bone pain at baseline was present in 49% of patients. Eighty-nine percent required external beam radiotherapy and/or radioisotopes after diagnosis of BM. Seventeen patients (28%) developed at least one major skeletal complication, i.e. MSCC or PF (4 of them developed more than one). The actuarial risk was 44% at 4 and 5 years. Most events developed before treatment with zoledronic acid and/or taxotere. Median survival from diagnosis of either MSCC or PF was 11 months (5 months from MSCC). We did not identify statistically significant risk factors for development of major skeletal complications. Serum alkaline phosphatase above median value and age less than or equal to 70 years were the only risk factors approaching significance.

Conclusions

We found high rates of major skeletal complications in this unselected contemporary group of patients. Identification of risk factors might guide the development of early interventions aiming at prevention of MSCC and PF.

Biochemical markers of bone turnover and clinical outcomes in men with prostate cancer

OBJECTIVES

Disrupted skeletal homeostasis is common in patients with prostate cancer. Low bone density is common at diagnosis, and fracture risk is further elevated by the effects of androgen-deprivation therapy. Later in the disease course, bone metastases can result in skeletal morbidity. Although prostate-specific antigen (PSA) levels can provide important insights into overall disease progression, convenient, noninvasive tools for monitoring skeletal health are lacking. Biochemical markers released into serum and urine as a result of bone turnover might fulfill this unmet need. The objectives of this article are to assess current evidence examining the potential utility of bone turnover markers for monitoring skeletal health, bone disease progression, and response to antiresorptive therapies in the prostate cancer setting.

METHODS

Published articles and abstracts from major oncology or urology congresses pertaining to the use of bone turnover markers to monitor skeletal health and disease progression were identified and assessed for relevance and methodologic stringency.

RESULTS

Several randomized trials and correlative studies support the utility of bone marker level changes to assess disease progression in the metastatic setting, bone health during hormonal therapy, and response to bisphosphonate therapy. The available data support potential associations between levels of the collagen type I telopeptides (NTX and CTX) and the severity of metastatic bone disease as well as outcomes during antiresorptive therapy. Evidence linking bone marker level changes with early diagnosis of skeletal metastases is emerging. Although several markers have shown promising results in correlative studies, results from ongoing prospective trials are needed to establish the role of bone markers in this setting.

CONCLUSIONS

Bone marker levels reflect ongoing skeletal metabolism and can provide important insights into bone health and response to bisphosphonate therapy in patients with prostate cancer. The data supporting a role for bone markers to monitor skeletal disease progression and response to zoledronic acid therapy are especially strong. Bone marker assessments may complement established diagnostic and monitoring paradigms in prostate cancer.

Drug-induced osteoporosis in the older adult

The elderly population is at risk for polypharmacy and, therefore, also at risk for drug-induced osteoporosis (DIOP). Epidemiologic studies provide valuable information about medications that may place patients at risk for DIOP. While glucocorticoids are the most common cause of DIOP, the use of several other therapeutic agents can place patients at risk for significant bone loss and fracture. These medications include, but are not limited to, aromatase inhibitors, gonadotropin-releasing hormone agonists, thyroid replacement therapy, antiepileptics, antidepressants, antipsychotics, lithium, gastric acid lowering agents, thiazolidinediones, loop diuretics, heparins and warfarin, vitamin A and cyclosporine. This article provides information about their mechanism of action, studies that have evaluated these agents in DIOP and prevention and treatment strategies.