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Androgen-deprivation-therapy-induced fractures in men with nonmetastatic prostate cancer: what do we really know?

Nature Clinical Practice Urology volume 5, pages 24–34 (2008)Cite this article

Abstract

Androgen deprivation therapy (ADT) alone or in combination with radiation therapy or other drugs is increasingly used for the treatment of localized, high-risk, or biochemical relapse of prostate cancer (PC). Bone mineral density (BMD) loss is rapid during the first year of ADT; up to 4.6% of total hip, femoral neck, and lumbar spine BMD loss has been reported in PC patients without bone metastases (nonmetastatic PC). In prospective studies, concurrent administration of a bisphosphonate or selective estrogen receptor modulator stabilized or increased BMD. Results of retrospective studies of ADT-treated patients who did not receive antiresorptive therapy have demonstrated a 21–37% increase in fracture risk. Because of the documented bone loss and increased fracture risk, patients should receive adequate counseling, monitoring, and therapy aimed at preventing or treating ADT-induced bone loss. Future studies should address the long-term impact of antiresorptive therapy on actual fracture rate and the impact on quality of life and healthcare costs.

Key Points

  • Prospective data show that ADT significantly increases the risk of BMD loss in men with nonmetastatic prostate cancer

  • Men initiating ADT should have an assessment of risk factors, calcium and vitamin D intake, lifestyle modification counseling, and baseline and follow-up BMD assessments

  • Men with established osteoporosis are candidates for treatment with a bisphosphonate; a SERM would be a reasonable alternative for those men with contraindications to bisphosphonate therapy

  • Bisphosphonate or SERM therapy to prevent further bone loss should be considered for men with osteopenia and/or other high-risk factors for bone loss

  • Prospective trials on fracture risk due to ADT have not been completed, however, low BMD is a robust predictor of fracture risk in other populations, and data from these populations should be used to inform treatment strategies until prostate cancer-specific data is available

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Figure 1: A comparison of cancer-therapy-induced bone loss versus normal bone loss in men and women.
Figure 2: Bone loss management algorithm for men with nonmetastatic prostate cancer initiating androgen deprivation therapy.

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Acknowledgements

The author thanks Stephanie Butler, Lisa Holle, and Laura Jung, who assisted with manuscript development and provided editorial services. This work was supported in part by Novartis Oncology. Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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  1. University of Washington, Seattle Cancer Care Alliance, 825 Eastlake Avenue East, Mailstop G4-830, Seattle, WA 98109, USA thigano@u.washington.edu

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  1. CS Higano is Associate Professor, Medicine and Urology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA, USA.,

    Celestia S Higano

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Higano, C. Androgen-deprivation-therapy-induced fractures in men with nonmetastatic prostate cancer: what do we really know?. Nat Rev Urol 5, 24–34 (2008). https://doi.org/10.1038/ncpuro0995

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