1. 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

2. 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

3. 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

4. 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).

5. 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

6. 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

7. 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.

8. Literature Review Medicare data (US) UK data
<10% on ADT for CaP underwent DEXA (DOI:  /s z)
Even less received treatment (5% Calcium, 3% Vit D)
UK data
Baseline 41% osteoporotic, 39% osteopenic, 20% normal BMD (DOI:  /j X x)

9. Literature review Fracture incidence
case series
5-13 fold increase in hip fractures (DOI:  /cncr.20056)
Pharmacotherapy better than lifestyle changes
BMD and glycemic control (DOI:  /pcan )

10. 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

11. 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 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

12. 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

13. 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.

14. 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

15. 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