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

The implications of baseline bone-health assessment at initiation of androgen-deprivation therapy for prostate cancer

OBJECTIVES

To assess bone-density testing (BDT) use amongst prostate cancer survivors receiving androgen-deprivation therapy (ADT), and downstream implications for osteoporosis and fracture diagnoses, as well as pharmacological osteoporosis treatment in a national integrated delivery system.

PATIENTS AND METHODS

We identified 17 017 men with prostate cancer who received any ADT between 2005 and 2014 using the Veterans Health Administration cancer registry and administrative data. We identified claims for BDT within a 3-year period of ADT initiation. We then used multivariable regression to examine the association between BDT use and incident osteoporosis, fracture, and use of pharmacological treatment.

RESULTS

We found that a minority of patients received BDT (n = 2 502, 15%); however, the rate of testing increased to >20% by the end of the study period. Men receiving BDT were older at diagnosis and had higher-risk prostate cancer (both P < 0.001). Osteoporosis and fracture diagnoses, use of vitamin D ± calcium, and bisphosphonates were all more common in men who received BDT. After adjustment, BDT, and to a lesser degree ≥2 years of ADT, were both independently associated with incident osteoporosis, fracture, and osteoporosis treatment.

CONCLUSIONS

BDT is rare amongst patients with prostate cancer treated with ADT in this integrated delivery system. However, BDT was associated with substantially increased treatment of osteoporosis indicating an underappreciated burden of osteoporosis amongst prostate cancer survivors initiating ADT. Optimising BDT use and osteoporosis management in this at-risk population appears warranted.

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.

Bone health management in men undergoing ADT: examining enablers and barriers to care

The study determined prostate cancer specialists' knowledge and concordance to guidelines regarding the diagnosis, management, and prevention of androgen deprivation therapy-induced osteoporosis. Despite high knowledge regarding bone health, most respondents did not routinely measure bone mineral density or use fracture risk assessment tools, suggesting a significant gap in the screening/monitoring of bone health.

INTRODUCTION

The purpose of this study was to determine prostate cancer specialists' knowledge, practices, self-perceived competencies and barriers to providing guideline-concordant care in the diagnosis, prevention, and management of androgen deprivation therapy (ADT)-induced osteoporosis (OP).

METHODS

A number of 73 Canadian radiation oncologists and 83 urologists completed questionnaires assessing (i) knowledge regarding OP and consensus guidelines for bone health management in men receiving ADT, (ii) self-assessed competencies regarding bone health management, (iii) current practices regarding OP prevention and management, and (iv) self-perceived barriers to providing guideline-concordant care.

RESULTS

The majority of respondents were able to correctly identify the guideline-concordant frequency of repeat dual-energy X-Ray absorptiometry (DXA) scans (76.3%), vitamin D (70.3%), and calcium (53.2%) intake and that bisphosphonates/denosumab should always be considered for patients with a history of one low-trauma fracture (57.6%). Just under 1/3 (32.5%) reported routinely measuring bone mineral density (BMD) prior to starting ADT and routinely measuring BMD 1-2 years following the initiation of ADT (36.6%). Only 4.6% of respondents routinely used a validated fracture risk assessment tool. Lowest self-assessed competency levels were reported in providing self-management education to patients to foster the uptake of healthy bone behaviors (HBBs) and managing patients who present with or develop osteopenia and OP. The most significant barriers to providing OP prevention and management were lack of time and lack of supporting structures.

CONCLUSIONS

Despite high knowledge about appropriate bone health care among prostate cancer specialists, there remain significant gaps in screening and monitoring of bone health, suggesting the need to develop innovative strategies to overcome barriers to implementation.

Patterns of bone mineral density testing in men receiving androgen deprivation for prostate cancer

BACKGROUND

Practice guidelines recommend bone mineral density (BMD) monitoring for men on androgen deprivation therapy (ADT) for prostate cancer, but single center studies suggest this is underutilized.

OBJECTIVE

We examined determinants of BMD testing in men receiving ADT in a large population-based cohort of men with prostate cancer.

DESIGN

Retrospective cohort study.

PARTICIPANTS

We used the Surveillance, Epidemiology and End-Results (SEER)-Medicare database to identify 84,036 men with prostate cancer initiating ADT from 1996 through 2008.

MAIN MEASURES

Rates of BMD testing within the period 12 months prior to 3 months after initiation of ADT were assessed and compared to matched controls without cancer and to men with prostate cancer not receiving ADT. A logistic regression model was performed predicting use of BMD testing, adjusted for patient demographics, indications for ADT use, year of diagnosis and specialty of the physician involved in the care of the patient.

KEY RESULTS

Rates of BMD testing increased steadily over time in men receiving ADT, diverging from the control groups such that by 2008, 11.5 % of men were receiving BMD testing versus 4.4 % in men with prostate cancer not on ADT and 3.8 % in the non-cancer controls. In the logistic regression model, year of diagnosis, race/ethnicity, indications for ADT use and geographic region were significant predictors of BMD testing. Patients with only a urologist involved in their care were significantly less likely to receive BMD testing as compared to those with both a urologist and a primary care physician (PCP) (odds ratio 0.71, 95 % confidence interval 0.64-0.80).

CONCLUSIONS

There has been a sharp increase in rates of BMD testing among men receiving ADT for prostate cancer over time, beyond rates noted in contemporaneous controls. Absolute rates of BMD testing remain low, however, but are higher in men who have a PCP involved in their care.

Luteinizing hormone--releasing hormone agonists: a quick reference for prevalence rates of potential adverse effects

Men with prostate cancer (PCa) frequently undergo androgen deprivation therapy (ADT), typically in the form of a depot injection of luteinizing hormone-releasing hormone agonists (LHRHa). LHRHa are associated with many adverse effects (eg, hot flashes, sexual dysfunction, loss of muscle mass, osteopenia, metabolic syndrome), which drastically impact patient quality of life. This literature review, which includes a comprehensive table documenting prevalence rates, provides a quick reference for health care professionals involved in the care of men undergoing ADT with LHRHa. Primary sources were acquired from PubMed using the search terms "androgen deprivation therapy" and each potentially adverse effect (eg, "androgen deprivation therapy and hot flashes"). Commonly cited review articles were also examined for citations of original studies containing prevalence rates. More than 270 articles were reviewed. In contrast to many existing reviews, rates are cited exclusively from original sources. The prevalence rates, obtained from original sources, suggest that more than half of documented adverse effects are experienced by as many as 40% or more of patients. A critique of the literature is also provided. Although there is a vast literature of both original and review articles on specific adverse effects of LHRHa, the quality of research on prevalence rates for some adverse effects is subpar. Many review articles contain inaccuracies and do not cite original sources. The table of prevalence rates will serve as a quick reference for health care providers when counseling patients and will aid in the development of evidence-based patient education materials.

Bone density testing among prostate cancer survivors treated with androgen-deprivation therapy

BACKGROUND

Androgen-deprivation therapy (ADT) causes bone loss and fractures. Guidelines recommend bone density testing before and during ADT to characterize fracture risk. The authors of the current report assessed bone density testing among men who received ADT for ≥ 1 year.

METHODS

Surveillance, Epidemiology, and End Results/Medicare data were used to identify 28,960 men aged > 65 years with local/regional prostate cancer diagnosed from 2001 to 2007 who were followed through 2009 and who received ≥ 1 year of continuous ADT. Bone density testing was documented in the 18-month period beginning 6 months before ADT initiation. Logistic regression was used to identify the factors associated with bone density testing.

RESULTS

Among men who received ≥ 1 year of ADT, 10.2% had a bone density assessment from 6 months before starting ADT through 1 year after. Bone density testing increased over time (14.5% of men who initiated ADT in 2007-2008 vs 6% of men who initiated ADT in 2001-2002; odds ratio for 2007-2008 vs 2001-2002, 2.29; 95% confidence interval, 1.83-2.85). Less bone density testing was observed among men aged ≥ 85 years versus men ages 66 to 69 years (odds ratio, 0.76; 95% confidence interval, 0.65-0.89), among black men versus white men (odds ratio, 0.72; 95% confidence interval, 0.61-0.86), and among men in areas with lower educational attainment (P < .001). Men who visited a medical oncologist and/or a primary care provider in addition to a urologist had higher odds of testing than men who only consulted a urologist (P < .001).

CONCLUSIONS

Few men who received ADT for prostate cancer underwent bone density testing, particularly older men, black men, and those living in areas with low educational attainment. Visiting a medical oncologist was associated with increased odds of testing. Interventions are needed to increase bone density testing among men who receive long-term ADT. Data on bone density testing for nonmilitary populations of prostate cancer survivors in the United States who have received long-term androgen-deprivation therapy (ADT) have not been published. The current analysis of Surveillance, Epidemiology, and End Results/Medicare data suggests that few prostate cancer survivors who receive long-term ADT undergo bone density testing; and several key populations, including African Americans and older men, have considerably lower rates of bone density screening.

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.

The role of distal third radius dual energy X-ray absorptiometry (DXA) and central DXA in evaluating for osteopenia and osteoporosis in men receiving androgen deprivation therapy for prostate cancer

The authors assessed the use of distal third radius dual energy X-ray absorptiometry (DXA) concomitantly with central (hip and lumbar spine) DXA to identify men with osteopenia or osteoporosis receiving androgen deprivation therapy (ADT) for prostate cancer. Initial classification with central DXA demonstrated 60 (17%) normal, 187 (55%) osteopenic, and 96 (28%) osteoporotic patients. Sixteen of 60 (27%) normal patients were reclassified as osteopenic (14) or osteoporotic (2), and 20 of 187 (11%) osteopenic patients were reclassified as osteoporotic with the combination of central DXA plus distal third radius DXA. The difference in reclassification was statistically significant. The addition of distal third radius to central DXA scanning in men with bone loss associated with ADT identifies a statistically significant number of men being reclassified as having osteopenia or osteoporosis. Combined central and distal third radius DXA scanning should be considered routine in the evaluation of all men suspected of bone loss associated with ADT. This has specific significant clinical relevance because of the large number of men with nonevaluable central DXA studies. Fracture risk prediction and treatment recommendations based on this reclassification will need to be determined by follow-up studies.

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.

The current practice of screening, prevention, and treatment of androgen-deprivation-therapy induced osteoporosis in patients with prostate cancer

Introduction. ADT is used in the management of locally advanced and metastatic disease. The detrimental effect of ADT on bone density is well documented. This study assesses care gaps in screening, prevention and treatment of osteoporosis among prostate cancer patients. Methods. We conducted a retrospective cohort study for patients diagnosed with non-metastatic prostate cancer on ADT. Charts from a tertiary oncology center were assessed for utilization of DXA scan, prescription of calcium, vitamin D, calcitonin and bisphosphonates.Bivariate analysis was used to determine the effect of patient characteristics and likelihood for osteoporosis screening. Results. 149 charts were reviewed, with 3-year mean follow-up. 58.8% of men received a baseline DXA, of which 20.3% had a repeat DXA within their follow-up periods.In all, 28% were appropriately screened and managed for osteoporosis (received repeat DXA, bisphosphonate). In bivariate analysis, the number of ADT injections which correlate with the duration of androgen suppression was significantly associated with the number of DXA scans. Conclusions. Our study found a care gap in the screening, prevention, and treatment of osteoporosis in this population. Patients receiving the most ADT injections were more likely to be screened. Our results suggest healthcare providers treating prostate cancer are insufficiently screening and treating this susceptible population. We suggest baseline measurement of BMD at the initiation of ADT with periodic reassessment during therapy.

Promoting wellness for patients on androgen deprivation therapy: why using numerous drugs for drug side effects should not be first-line treatment

The controversy over androgen deprivation therapy (ADT) for prostate cancer seems to have shifted over the past decade. The issue of adverse events or side effects now seems to dominate over that of clinical efficacy. However, this article provides evidence that questions the treatment of these side effects with numerous prescription medications that have their own unique toxicity profile in patients with nonmetastatic disease. The hope is that patients will no longer be considered passive participants in the prevention and treatment of ADT side effects, now that information is available to help mitigate many of these effects.

Bone health management in prostate cancer patients receiving androgen deprivation therapy

Purpose. Patients receiving androgen deprivation therapy undergo a rapid decline in bone mineral density during the first 6 to 12 months of initiating therapy. The World Health Organization has developed and implemented the Fracture Risk Assessment Tool (FRAX) to predict the ten year risk of a major fracture & hip fracture. Additionally, the National Comprehensive Cancer Network and the National Osteoporosis Foundation have developed osteoporosis guidelines. This study aims to characterize the fracture risk (based on the FRAX tool) and the current management of bone health based on national guidelines compliance.

Methods. A retrospective chart review of patients receiving a LHRH agonist at our institution was conducted. Data collection commenced upon Institutional Review Board approval and included demographics, past medical history, medication regimen, history of androgen deprivation therapy, bone health and its management. The ten year fracture risk calculated with the collected information using the FRAX tool.

Results. A total of 174 subjects included with a mean age of 65.5 years, 71.8% had stage II prostate cancer, 97.7% received the LHRH agonist leuprolide for a mean of 13.8 ± 18.1 months. In addition to ADT, 57% of patients had ≥ 2 risk factors for developing osteoporosis. The risk of sustaining a major facture increased from 4% to 5.6% after the initiation of ADT (P = <0.001). The risk for sustaining a hip fracture rose from 1.3% to 2.2% (P = <0.001). National guideline compliance was found to be 9%, 5% and 3% respectively for obtaining Dual Energy X-ray Absorptiometry (DEXA) scans, calcium supplementation, and vitamin D supplementation.

Conclusion. In addition to predisposing risk factors for osteoporosis, ADT significantly increases the fracture risk in the prostate cancer population. There is room for improvement in the management of bone health as some intervention could have been made in over 90% of patients evaluated.

Cost-effectiveness of fracture prevention in men who receive androgen deprivation therapy for localized prostate cancer

BACKGROUND

Androgen deprivation therapy (ADT) increases the risk for fractures in patients with prostate cancer.

OBJECTIVE

To assess the cost-effectiveness of measuring bone mineral density (BMD) before initiating ADT followed by alendronate therapy in men with localized prostate cancer.

DESIGN

Markov state-transition model simulating the progression of prostate cancer and the incidence of hip fracture.

DATA SOURCES

Published literature.

TARGET POPULATION

A hypothetical cohort of men aged 70 years with locally advanced or high-risk localized prostate cancer starting a 2-year course of ADT after radiation therapy.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

No BMD test or alendronate therapy, a BMD test followed by selective alendronate therapy for patients with osteoporosis, or universal alendronate therapy without a BMD test.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained.

RESULTS OF BASE-CASE ANALYSIS

The ICERs for the strategy of a BMD test and selective alendronate therapy for patients with osteoporosis and universal alendronate therapy without a BMD test were $66,800 per QALY gained and $178,700 per QALY gained, respectively.

RESULTS OF SENSITIVITY ANALYSES

The ICER for universal alendronate therapy without a BMD test decreased to $100,000 per QALY gained, assuming older age, a history of fractures, lower mean BMD before ADT, or a lower cost of alendronate.

LIMITATIONS

No evidence shows that alendronate reduces actual fracture rates in patients with prostate cancer who receive ADT. The model predicted fracture rates by using data on the surrogate BMD end point.

CONCLUSION

In patients starting adjuvant ADT for locally advanced or high-risk localized prostate cancer, a BMD test followed by selective alendronate for those with osteoporosis is a cost-effective use of resources. Routine use of alendronate without a BMD test is justifiable in patients at higher risk for hip fractures.

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.

Management of decreased bone mineral density in men starting androgen-deprivation therapy for prostate cancer

OBJECTIVE

To determine whether clinicians discuss bone-specific side-effects with patients on androgen-deprivation therapy (ADT) for prostate cancer, or prescribe lifestyle and pharmacological interventions for low bone mineral density (BMD), as decreased BMD is a common side-effect of ADT, leading to increased risk of fracture.

PATIENTS AND METHODS

Sixty-six men (mean age 70.6 years) with non-metastatic prostate cancer and starting continuous ADT were enrolled in a prospective longitudinal study. BMD was determined by dual X-ray absorptiometry (DXA) at baseline. Patients were interviewed to obtain their medical histories, and charts were reviewed to determine whether clinicians documented potential bone side-effects in clinic notes, and made lifestyle and/or medication recommendations. Both were done at the start of ADT, and 3 and 6 months later. Patients were classified based on DXA T-score as having normal BMD, as osteopenic, or osteoporotic.

RESULTS

At baseline, 53% of patients had osteopenia and 5% had osteoporosis. Within 6 months of starting ADT, general side-effects and bone-specific side-effects of ADT were documented as being discussed with 26% and 15%, respectively. Clinicians recommended lifestyle interventions to 11% of patients. Pharmacological interventions (calcium, vitamin D, and/or bisphosphonates) were recommended to 18% of all patients within 6 months of starting ADT, and to 26% and 67% of osteopenic and osteoporotic patients, respectively.

CONCLUSIONS

A minority of patients is being informed of bone-specific side-effects of ADT. Lifestyle and drug interventions to prevent declines in BMD were recommended uncommonly. Practices around bone health for men starting ADT are suboptimal.