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Is bone health being overlooked in men on ADT for prostate cancer?

JAMA Network Open
Reuters Health - 08/04/2022 - A new study suggests a gap in bone-health management and fracture prevention in men with prostate cancer receiving androgen-deprivation therapy (ADT).

Rates of dual-energy x-ray absorptiometry (DXA) screening to assess bone-mineral density (BMD) have increased since the early 2000s, but remain low, the study found.

Prostate cancer accounts for 26% of all new cancers in men and ADT is the mainstay of treatment, which can adversely affect bone health.

"Given the deleterious impact of fractures for morbidity and mortality, implementation strategies are needed to increase the uptake of current guidelines for bone health management among men with prostate cancer," write Dr. Maria E. Suarez-Almazor of the University of Texas MD Anderson Cancer Center in Houston and colleagues in JAMA Network Open.

"Early intervention with bone-modifying agents could potentially reduce the burden of illness associated with fractures among older men who are survivors of prostate cancer," they add.

Their cohort study of nearly 55,000 older men with prostate cancer who initiated ADT between 2005 and 2015 found low nationwide rates of DXA screening (7.9%), with only small increases over the years, from 6.8% in 2005 to 8.4% in 2015.

Factors associated with DXA screening included older age, history of osteoporosis or fractures, more advanced or high-risk cancer, and a greater number of comorbid conditions.

Lower rates of DXA screening were found in single and non-Hispanic Black men and men living in small urban areas of areas with lower educational levels and treatment with nonsteroidal androgens.

Fracture rates remained high, with 17.5% of men developing any fracture after starting ADT and 7.7% of men developing a major fracture.

BMD testing was "significantly associated with a decreased risk of developing major osteoporotic fractures after adjustment for covariates," the study team reports.

The authors of an editorial note that almost all guidelines have been updated to reference DXA screening since 2015, which was the final year with data available in this analysis.

"Thus, DXA screening rates in more recent years may be higher," write Dr. Amar Kishan of the University of California Los Angeles and colleagues.

Nonetheless, they say this analysis demonstrates that there is "substantial room for improvement" in evaluating bone health among patients with prostate cancer receiving ADT.

"The low rate of DXA screening and the disparities in the use of DXA screening are concerning. It is particularly problematic that low rates of DXA screening were identified among men who were non-Hispanic Black, single, or residing in areas with lower socioeconomic status and lower educational levels, suggesting that more research into these patterns is needed to fully understand the associated dynamics and implement appropriate strategies to increase bone health screening when indicated in these populations," the editorialists say.

While the association between DXA screening and major fractures was "modest, it is possible that a simple intervention, such as supplemental vitamin D and calcium, could optimize bone health," Dr. Kishan and colleagues say.

Based on phase-3 trial data, denosumab may be indicated in men receiving more than 12 months of ADT who are either 70 years and older or younger than 70 years with low bone-mineral density or history of osteoporotic fracture, they write.

"Thus, an increased rate of DXA screening among men receiving long-term ADT, along with appropriate use of bone-modifying agents based on those results, may meaningfully reduce the chance of osteoporosis-related fractures," they conclude.

SOURCE: https://bit.ly/36GCTqN and https://bit.ly/3K0fajN JAMA Network Open, online April 1, 2022.

By Reuters Staff

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