Maintaining bone health while on ADT for Prostate Cancer Greater Manchester Cancer Maintaining bone health while on ADT for Prostate Cancer Amar Mohee Consultant Urological Surgeon Manchester Royal Infirmary

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: ADT AR blockade followed by lifelong LHRH agonist Zoladex, Prostap, Decapeptyl, Suprefact Side effects hot flushes loss of libido and erection problems fatigue weight gain/strength and muscle loss breast swelling and tenderness loss of body hair bone thinning risk of diabetes, heart disease and stroke mood changes

Evidence: NICE Do not routinely offer bisphosphonates to prevent osteoporosis in men with prostate cancer having androgen deprivation therapy Consider assessing fracture risk in men androgen deprivation therapy osteoporosis fragility fracture guidelines(NICE 146).

Evidence: NICE Offer bisphosphonates Consider denosumab (HMA) On androgen deprivation therapy and have osteoporosis Consider denosumab (HMA) if bisphosphonates are contraindicated or not tolerated SC injection

Evidence: EAU GP should be more involved Diabetes (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 ADT Modifying 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 calcium Monitor serum levels Daily intake 1200 mg/day of calcium 1000 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) UK data <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 incidence case series 5-13 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 £100   Less than £100 Depends 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 patient completion of lifestyle questionnaire. measuring 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 densitometry more accurate way to assess bone health (regularly done at the MRI) cons of CT radiation 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 MDT will help build experience MDT to identify problem patients may not be osteoporotic based on DEXA but who have suffered a fragility fracture have 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 #s not all will have surgery or radiotherapy Histological diagnosis of pathological fractures tip of the iceberg very hard to gather all patients.

Implementation into pathway Current status in GM No standardised practice Low priority in a patient diagnosed with cancer Diagnosis at MDT All patients started on hormones need recommendations wrt bone health Improve compliance both in primary and secondary care

The way forward? Aspirational Pragmatic DEXA for all patients? Is it cost effective? Pragmatic Treatment for all patients? Primary care to monitor? Aligning with breast cancer pathway