Maintaining bone health while on ADT for Prostate Cancer - PowerPoint Presentation

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Maintaining bone health while on ADT for Prostate Cancer

Amar MoheeConsultant Urological SurgeonManchester Royal Infirmary

Greater Manchester

Cancer

Prostate Cancer

Prostate cancer: most common cancer in men

47000/year (129 new diagnosis/day)1 in 8 men will get prostate cancer in their lifetime 11000/year die from prostate cancer

1 man every 45 minutes Around 400,000 men are living with and after prostate cancer

Metastatic Prostate Cancer

First line treatment: ADTAR blockade followed by lifelong LHRH agonistZoladex

, Prostap, Decapeptyl, Suprefact

Side effectshot flushesloss of libido and erection problemsfatigueweight gain/strength and muscle loss

breast swelling and tendernessloss of body hairbone thinningrisk of diabetes, heart disease and strokem

ood changes

Evidence: NICE

Do not routinely offer bisphosphonatesto prevent osteoporosis in men with prostate cancer having androgen deprivation therapy

Consider assessing fracture risk in menandrogen deprivation therapy

osteoporosis fragility fracture guidelines(NICE 146).

Evidence: NICE

Offer bisphosphonates On androgen deprivation therapy and have osteoporosis

Consider denosumab (HMA)if bisphosphonates are contraindicated or not

toleratedSC injection

Evidence: EAU

GP should be more involvedDiabetes (fasting glucose, HbA1c at baseline and then every 3 months) as well as blood lipid levels

Cardiology consultation should be considered in men with a history of cardiovascular disease and men older than 65 years prior to starting ADTModifying their

lifestyle (e.g. diet, exercise, smoking cessation, etc) and should be treated for any existing conditions, such as diabetes, hyperlipidaemia, and/or hypertension

Evidence: EAU

Vitamin D and calciumMonitor serum levels

Daily intake1200 mg/day of calcium1000 IU of vitamin D. Preventive therapy bisphosphonates or

denosumab initial T-score of less than -2.5 on DEXA.Bone monitoring every 2 years after castration if no risk factors

yearly if there are risk factors.

Literature Review

Medicare data (US)<10% on ADT

for CaP underwent DEXA (DOI: 10.1007/s00520-013-2008-z

)Even less received treatment (5% Calcium, 3% Vit D)UK data Baseline 41% osteoporotic, 39%

osteopenic, 20% normal BMD (DOI: 10.1111/j.1464-410X.2009.08483.x)

Literature review

Fracture incidencecase series5-13 fold increase in hip fractures

(DOI: 10.1002/cncr.20056)Pharmacotherapy better than lifestyle changes

BMD and glycemic control (DOI: 10.1038/pcan.2016.69)

DEXA Scan

1.       How much does a DEXA scan cost? 

 Less than £100Depends on which areas scanned (spine, hip, whole body)  

2.       How long is a DEXA appointment? Waiting time for appointments at the MRI is around 4-6 weeks 30

minutes for routine clinical examination of DXA hip and spine.interviewing the patientcompletion

of lifestyle

questionnaire.

m

easuring

height and

weight

performing  the DXA scans

Exam

analysis and FRAX calculation where

appropriate

Alternatives to DEXA

Any alternative test to

assess bone health?Volumetric quantitative CT bone densitometrymore

accurate way to assess bone health (regularly done at the MRI)cons of CTradiation exposure (Spine dose 200-300 uSv vs 10

uSv for DXA of the spine) availability 

Standard CT TAP

Staging for metastatic patients

with prostate

cancer

special phantom/software

is required

MDT Burden

Do all scans need to be discussed at

the MDT?The international foundation of osteoporosis all

patients with prostate cancer on ADT to be discussed in MDTwill help build experienceMDT to identify problem patientsmay not be osteoporotic based on

DEXA but who have suffered a fragility fracturehave co-morbidities that increase the risk of osteoporosis and/or falls

Fragility vs pathological #s

Pathological fracture

very hard to determine radiological evidence of fractures disease

or osteoporosis? clinically detectable #snot all will have surgery or radiotherapyHistological diagnosis of pathological fractures

tip of the icebergvery hard to gather all patients.

Implementation into pathway

Current status in GMNo standardised practiceLow priority in a patient diagnosed with cancer

Diagnosis at MDTAll patients started on hormones need recommendations wrt bone health

Improve compliance both in primary and secondary care

The way forward?

AspirationalDEXA for all patients? Is it cost effective?

PragmaticTreatment for all patients?Primary care to monitor?Aligning with breast cancer pathway