Raoul S. Concepcion, MD, FACS
Spurred both by the desire to provide the full spectrum of care to prostate cancer patients and by the emergence of treatments to address bone health in these patients, urologists across the country have begun to integrate bone health clinics into their practices. These clinics assess and treat the bone health of patients with prostate cancer at all stages of disease, allowing for better continuity and coordination of care.
The treatment of prostate cancer within urology clinics is a recent development that has occurred over the last two years, according to Raoul S. Concepcion, MD, director of Clinical Research at Urology Associates in Nashville, Tennessee. And with that development, urology practices are finding that they are also faced with the need to address the skeletal effects of prostate cancer, which leaves men at risk for bone loss and fractures.
Bone Health in Men
About 12 million men are at risk for osteoporosis, and another 2 million already have this bone degenerative disease because of the increased incidence of prostate cancer.
Metastasis to the bone is typical in prostate cancer; the median time to bone metastasis is approximately 25 months for patients with nonmetastatic castration-resistant prostate cancer.1
Bone metastasis causes osteoporosis, osteopenia, escalating bone pain, and bone marrow compromise.
In addition, treatment of prostate cancer can have adverse skeletal effects: androgen-deprivation therapy (ADT) increases the risk of bone loss and osteoporosis. After just one year of ADT, prostate cancer patients can have significant changes in their bone mineral density (BMD). A review of approximately 50,000 men with prostate cancer revealed that a significantly higher proportion of men who received ADT had a fracture compared with men who did not undergo ADT over a four-year period (19% vs 13%, respectively; P
The chance of fracture increased with longer duration of ADT.
These effects are especially worrisome because patients may stay on ADT for several years. Furthermore, with better screening methods and more awareness, earlier detection of prostate cancer is leading to longer medication use—and more bone loss. These patients are at much higher risk for spontaneous fractures, even without a significant injury or impact. Hip fractures are a particular concern, since about 30% of men die within the first year of breaking a hip.
Preventing and Addressing Skeletal Effects
Several treatments are now available to delay time to a first skeletal- related event, including zoledronic acid (Zometa, Novartis) and denosumab (Xgeva, Amgen). In fact, the current large-scale trend to integrate bone health clinics into urology practices was stimulated by the approval of denosumab, Concepcion believes. The drug was approved in 2010 to prevent skeletal-related events in patients with bone metastases.
“Many of us had interest in bone clinics prior to 2010,” Concepcion said. The reason is that one of the standards of care for prostate cancer, luteinizing hormone-releasing hormone (LHRH) therapy, results in significant bone density loss and complications. “Urologists started saying, ‘We have created this issue, and we actually have to start managing this issue,’” Concepcion said.
The urology-bone clinic integration makes it easier for patients to have a BMD assessment prior to starting ADT—a current recommendation in prostate cancer guidelines. All prostate cancer patients need to have their BMD monitored and understand the preventive options available, according to a Canadian study.3