Preventing SREs in Prostate Cancer

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The detection of bone metastases in patients with prostate cancer has improved through the introduction of sodium fluoride enhanced PET/CT scans. These scans are more sensitive than traditional bone scans with similar specificity, notes A. Oliver Sartor, MD. However, with the increased sensitivity, interpretation of scan results is more important, requiring additional education for radiologists.

In addition to bone metastases, urologists should focus on bone mineral density loss associated with androgen deprivation therapy (ADT), notes Raoul S. Concepcion, MD. In order to counter bone loss, baseline supplementation with calcium and vitamin D should be considered, notes Michael E. Williams, MD. Additionally, for patients with metastatic disease, zoledronic acid (Zometa) and denosumab (Xgeva) are approved for the prevention of skeletal-related events (SREs).

In clinical trials, the administration of either zoledronic acid or denosumab resulted in approximately a 33% reduction in SREs, notes Williams. Zoledronic acid is administered via 15-minute infusion, whereas denosumab is administered by subcutaneous injection. Due to the administration route, Williams notes that he prefers denosumab.

Osteonecrosis of the jaw can occur in patients treated with zoledronic acid or denosumab, requiring special attention. Although rare, this adverse event warrants consultation with a dentist, prior to treatment, Williams advises.

Bone loss begins to occur immediately after the first dose of ADT, notes Concepcion. To counter this, vitamin D, calcium, and when appropriate denosumab or zoledronic acid should be administered simultaneously with the first dose of ADT. In addition to these treatments, Neal D. Shore, MD, recommends evaluating risk using the FRAX tool. Additionally, lifestyle changes and exercise can make a big impact on bone health.

Philippa J. Cheetham, MD, recommends reviewing bone-related side effects with patients and providing proactive education on the importance of exercise, diet, vitamin D, and calcium. In general, compliance is far better when the patient understands the symptoms and management involved, notes Cheetham.