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

Abstract

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.

Bone Targeting Agents in Patients with Metastatic Prostate Cancer: State of the Art

“…It has to be underlined that denosumab (120 mg subcutaneous, monthly) has not been investigated in the hormone-sensitive setting and should not be used for this indication [ 47 , 51 ].…”

“…In about 80% of metastatic PCa patients there is a relevant deterioration of quality of life due to skeletal affection and cancer treatment-induced bone loss. The management of bone metastasis plays a key role in nowadays clinical practice in CRPC patients with bone metastases [ 51 , 52 , 53 , 54 , 55 ].…”

Pathophysiology of Bone Loss in Patients with Prostate Cancer Receiving Androgen-Deprivation Therapy and Lifestyle Modifications for the Management of Bone Health: A Comprehensive Review

“…FRAX is utilized mainly for patients aged older than 40 years and estimates the ten-year risk of hip and major osteoporotic fractures. Risk factors that are accounted for by FRAX include demographics, comorbidities, initial BMD, long-term use of corticosteroids, alcohol or tobacco intake, medical history of fractures, and familial history [54,55].…”

“…According to recent expert opinion, evaluations of bone alkaline phosphatase, vitamin D, serum calcium, and PTH levels should be performed at baseline and then every 12-18 months afterward to monitor ADT-induced adverse bone effects [54]. Moreover, the study emphasized that it is important not to overlook back pain and height loss, and to perform spinal radiographical examinations to early identify vertebral fractures [54].…”

“…Summary of clinical guidelines for the assessment and monitoring of adverse skeletal events.BMD assessment with DXA scan and subsequent scoring with FRAX[49] DXA scan or FRAX score only is not recommended. The following factors should be incorporated[49,53,54] …”