Osteoporosis management in prostate cancer patients treated with androgen deprivation therapy

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.

Osteoporosis Preventive Practice Between Veteran and Nonveteran Older Adults: Findings From Patient-Reported Data

BACKGROUND

Veterans are prone to bone-related illnesses due to multiple risk factors such as prior injuries. The aim of this study was to compare trends in osteoporosis preventive practices between veteran and nonveteran older adults.

METHODS

This was a secondary data analysis using selected baseline data and discussion postings from an online bone health trial including participants (N = 866) recruited from My HealtheVet (MHV) and SeniorNet (SN). Data were analyzed using descriptive statistics, parametric statistics, and content analysis.

FINDINGS

Overall, MHV participants were younger and included more men than SN participants. However, they reported higher rates of bone health issues, spent less time exercising, took fewer calcium and vitamin D supplements, and were less likely to discuss bone health with their care providers. More MHV participants discussed pain and disability as barriers to bone health behaviors and fear of deteriorating health as motivators. In addition, more MHV participants found that participating in the original study was helpful for changing health behaviors.

CONCLUSION

Overall, the findings suggest a disparity in bone health between veterans and nonveterans and a significant potential for using eHealth programs for veterans.

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.

Development and validation of a prognostic index for fracture risk in older men undergoing prostate cancer treatment

OBJECTIVES

Men treated with androgen deprivation therapy (ADT) or radiation therapy (RT) for prostate cancer have an increased risk for fractures. Given uncertainty as to whether specific clinical factors can identify men at increased risk, we sought to develop a prognostic index for risk of fracture in this population.

MATERIALS AND METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify men who received ADT or RT after being diagnosed with localized prostate cancer in 2007-2009. Cox proportional hazards models tested the association of potential risk factors with fracture. In a derivation group, hazard ratios were used to assign points for factors independently related to fracture. The prognostic index was then applied to a validation group.

RESULTS

The sample of 5824 men had a median age of 73.0 years; 82.9% were white and 8.6% had a fracture within 2 years of treatment for prostate cancer. The Cox model identified 8 variables (age, race, hormone treatment, Elixhauser score, anxiety, Parkinson's, fall-inducing medications and disability status) independently associated with fracture. In the derivation cohort, 4.3% of the sample experienced a fracture in the low-risk group, 8.9% in the intermediate group, and 19.2% in the high-risk group (C statistic, 0.749). The index was applied to the validation cohort (C statistic, 0.782).

CONCLUSION

The prognostic index can help to identify patients at increased risk for fracture. This underscores the importance of identifying risk factors for fracture, given the substantial variation in fracture risk in men treated with ADT or RT.

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

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

Health disparities and the cancer survivor

Disparities on the basis of race and ethnicity have been described in a variety of survivorship outcomes, including late and long-term effects of treatment, surveillance and health maintenance, and psychosocial outcomes. However, the current body of literature is limited in scope and additional research is needed to better define and address disparities among cancer survivors.

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 densitometric assessment and management of fracture risk in Indian men of prostate cancer on androgen deprivation therapy: Does practice pattern match the guidelines?

Objective:

Estimation of baseline bone mineral density (BMD) at the time of instituting androgen deprivation therapy (ADT) for metastatic prostate cancer is recommended by several specialty groups and expert panels. The present study was carried out to analyze the practice pattern of Indian urologists with regard to bone densitometric assessment and management of fracture risk in men of prostate cancer on ADT, and their degree of adherence to currently available guidelines

Materials and Methods:

Telephonic interviews of 108 qualified urologists, randomly selected from the member database of Urological Society of India was carried out with a predefined questionnaire. The responses were analyzed and compared with the available evidences and recommendations.

Results:

Only 19.4% urologists routinely perform a baseline BMD before starting ADT. Although majority of them prescribe calcium and vitamin D supplementation, only few tell regarding fracture risk and life-style modification to their patients. While 59.6% of the respondents use Zoledronic acid (ZA) in their patients on ADT, half of them prescribe it without knowing the BMD status, which may lead to overuse of ZA.

Conclusion:

Majority of the urologists in India do not follow the guidelines for BMD measurement in prostate cancer. A baseline BMD may help in reducing the unnecessary use of ZA.

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.

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.

Calcium and vitamin D supplementation during androgen deprivation therapy for prostate cancer: a critical review

BACKGROUND

Loss of bone mineral density is an unintended consequence of androgen deprivation therapy in men with prostate cancer. Supplementation with calcium and/or vitamin D in these men seems logical and is advocated by many lay and professional groups.

METHODS

We reviewed guidelines for calcium and vitamin D supplementation and the results of clinical trials of calcium and vitamin D supplementation on bone mineral density in men with prostate cancer undergoing androgen deprivation therapy.

RESULTS

Whether supplementation of men undergoing androgen deprivation therapy with calcium and/or vitamin D results in higher bone mineral density than no supplementation has not been tested. The results of 12 clinical trials show that, at the doses commonly recommended, 500-1,000 mg calcium and 200-500 IU vitamin D per day, men undergoing androgen deprivation lose bone mineral density.

CONCLUSION

The doses of calcium and vitamin D that have been tested are inadequate to prevent loss of bone mineral density in men undergoing androgen deprivation therapy. In light of evidence that high levels of dietary calcium and calcium supplement use are associated with higher risks for cardiovascular disease and advanced prostate cancer, intervention studies should evaluate the safety as well as the efficacy of calcium and vitamin D supplementation in these men.

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.

A new era for castrate resistant prostate cancer: a treatment review and update

PURPOSE

The purpose of this review article is to present the current treatment options for castrate resistant prostate cancer in addition to the recently approved agents and their role in treatment.

SUMMARY

The biology of prostate cancer and the data supporting the use of traditional chemotherapeutic options in castrate resistant prostate cancer are reviewed. The newly approved agents, sipuleucel-T, cabazitaxel, and abiraterone, are presented as well. The studies that led to the approval of these three agents are discussed in this article as well as their current and potential roles in the treatment of castrate resistant prostate cancer.

CONCLUSION

New mechanisms, drugs, and clinically relevant molecular targets show survival advantage and are new options available for patients after traditional chemotherapy. The roles of these new agents have yet to be further clarified in future studies.

Regulation of postnatal trabecular bone formation by the osteoblast endothelin A receptor

Endothelin-1 (ET-1) is a potent vasoconstrictor that also stimulates cells in the osteoblast lineage by binding to the endothelin A receptor (ETAR). ET-1 ligand is widely secreted, particularly by the vasculature. However, the contributions of ETAR signaling to adult bone homeostasis have not been defined. ETAR was inactivated in osteoblasts by crossing ETAR-floxed and osteocalcin-Cre mice. Histomorphometric analyses were performed on 4-, 8-, and 12-week-old osteoblast-targeted ETAR knockout (KO) and wild-type (WT) male and female mice. Tibial trabecular bone volume was significantly lower from 12 weeks in KO versus WT mice in both males and females. Bone-formation rate, osteoblast density, and in vitro osteoblast differentiation were reduced by targeted inactivation of ETAR. A separate longitudinal analysis was performed between 8 and 64 weeks to examine the effect of aging and castration on bone metabolism in ETAR KO mice. Hypogonadism did not change the rate of bone accrual in WT or KO females. However, eugonadal KO males had a significantly larger increase in tibial and femoral bone acquisition than WT mice. Male mice castrated at 8 weeks of age showed the reverse: KO mice had reduced rates of tibial and femoral BMD acquisition compared with WT mice. In vitro, ET-1 increased osteoblast proliferation, survival, and differentiation. Dihydrotestosterone also increased osteoblast differentiation using a mechanism distinct from the actions of ET-1. These results demonstrate that endothelin signaling in osteoblasts is an important regulator of postnatal trabecular bone remodeling and a modulator of androgen effects on bone.

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 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.

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.

A perspective on male osteoporosis

Osteoporosis and fragility fracture become common with advancing age in men. The incidence of osteoporosis-related fracture is similar to myocardial infarction and exceeds that of lung and prostate carcinoma combined. These fractures cause substantial morbidity, and the mortality following hip fracture is greater in men than in women. A decline in sex steroids and glucocorticoid and alcohol use, among other factors, contribute to bone loss and fracture risk. Approaches to reduce fracture risk in men are very similar to that in women - recognising and addressing muscle weakness/falls risk and optimising nutrition, with emphasis on calcium and vitamin D and medications when appropriate. Despite the high prevalence, osteoporosis remains largely undiagnosed and undertreated. Hopefully, increased recognition of male osteoporosis by health-care providers and the men themselves, in combination with recent consensus recommendations for treatment based on fracture-risk estimation, will reduce the burden of fragility fracture in men.

Androgen deprivation therapy and estrogen deficiency induced adverse effects in the treatment of prostate cancer

Androgen deprivation therapy (ADT) is the standard of care for metastatic prostate cancer and is increasingly used to treat asymptomatic patients with prostate-specific antigen recurrence after failed primary therapy. Although effective, ADT is associated with multiple adverse effects, many of which are related to the estrogen deficiency that occurs as a result of treatment. These include increased fracture risk, hot flashes, gynecomastia, serum lipid changes and memory loss. By providing clinicians with a greater awareness of the estrogen deficiency induced adverse effects from ADT, they can proactively intervene on the physical and psychological impact these effects have on patients.

Cancer treatment-related bone disease

Bone health may be impaired in many patients being treated for cancer. Primary tumors that reside in or form metastases to bone can result in compromised skeletal integrity. It has also been increasingly recognized that patients undergoing therapies for treatment of cancer are at higher risk of bone loss. These include androgen-deprivation therapy for prostate cancer and aromatase inhibitor therapy for breast cancer, among others. Hypogonadism induced by many of these cancer treatments results in bone loss and increases the risk of osteoporosis and fractures. Progress has been made in identifying the role of oral and intravenous bisphosphonates to prevent bone loss in these patients. This review discusses bone loss associated with cancer treatments, with a focus on breast cancer, prostate cancer, and survivors of childhood malignancies.

Effects of voluntary wheel running on goserelin acetate-induced bone degeneration

A common treatment option for many breast and prostate cancer patients is the use of a luteinizing hormone-releasing hormone agonist such as goserelin acetate (GA) which reduces sex hormone levels. This treatment, however, is associated with bone degeneration, and exercise has been suggested as a means of preventing this side effect. Little is known about the effects of low intensity, low volume exercise on GA-induced bone loss. The purpose of this study, therefore, was to investigate the effects of voluntary wheel running on bone architecture in growing male (M) and female (F) rats receiving GA treatment. Rats received an 8-week GA treatment or placebo (CON) and were either housed in cages equipped with voluntary running wheels (WR) or remained sedentary (SED) in standard cages throughout the experimental period. Following treatments, tibiae were excised and analyzed for cortical bone (cross-sectional volume, cortical volume, marrow volume, cortical thickness) and cancellous bone (bone volume/total volume, trabecular number, trabecular thickness, trabecular spacing) using micro-computed tomography. Treatment with GA resulted in a significant reduction in running wheel distances in both sexes throughout the study period (P<0.05). GA treatment had no effect on cortical bone architecture in neither sex (P>0.05). Cancellous bone degeneration, however, was observed in M and F SED+GA (P<0.05). No significant differences were observed in M WR+GA animals in bone volume/total volume, trabecular number and trabecular spacing when compared to M SED+CON (P>0.05). In F WR+GA, trabecular thickness did not differ from that of F SED+CON (P>0.05), and trabecular spacing was found to be significantly lower than F SED+GA (P<0.05). The current report indicates that 8 weeks of GA treatment promotes cancellous bone degeneration, and voluntary wheel running provides no clear osteoprotection in growing male and female rats.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

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.

Roles of prohibitin in growth control and tumor suppression in human cancers

Tumor formation results from alterations in the normal control of cell proliferation. In the past decade, much attention in cancer research has been focused on the function of proto-oncogenes and tumor suppressors. Prohibitin is a potential tumor suppressor which was originally identified because of its anti-proliferative activities. Subsequent investigations led to the discovery of prohibitin mutations in sporadic breast cancers. Recent studies established that prohibitin directly regulates E2F-mediated transcription and growth suppression Prohibitin further attracted the attention of the translational cancer research community when it was recently connected to the regulation of estrogen receptor and androgen receptor activity. Prohibitin was shown to be required for the growth suppression of breast cancer cells induced by estrogen antagonists, and for therapeutic responses to androgen antagonists in prostate cancer. Through the application of new molecular technologies, additional novel functions of prohibitin have been revealed, demonstrating diverse and essential roles of this highly-conserved protein in regulating cell growth.