Page 6 - Metastatic castration-naive and castration-sensitive prostate cancer: CUA/CUOG

So et al

Prevention of osteoporosis Timing of initiation and choosing the optimal systemic

therapy from a multitude of options requires careful consid-
All men with mCNPC/mCSPC treated with ADT should eration of several different clinical factors, such as eligibility
be assessed for fracture risk. All men treated with ADT of chemotherapy, side effect profile of medications, disease
require vitamin D supplementation (800–1200 IU daily) burden, symptoms, and presence of visceral metastases.
and calcium supplementation (800–1000 mg total intake Since treatment may require a multifaceted approach, opin-
daily). Those at high risk of fractures should be treated ions from urology, medical oncology, and radiation oncol-
(zoledronic acid 5 mg once a year, alendronate 70 mg ogy may be required to provide optimal care for mCNPC/
weekly, denosumab 60 mg every six months). mCSPC patients. Additionally, as mCNPC /mCSPC continues
Due to the evolution of combined therapy with ADT to treat to be an incurable disease, strong consideration should be
mCNPC, the survival of men with de novo PC is increasing given to inclusion of patients in clinical trials.
and the length of time bone is exposed to the effects of ADT
is also increasing. As such, these men are at risk of signifi- Conclusions
cant bone loss, osteoporosis, and fragility fractures. Bone loss
occurs quickly while on ADT; within one year, men can lose The last five years has seen a significant growth of life-
up to 10% of their bone mineral density (BMD). 36-38 Men with extending therapies for patients that has changed the land-
mCNPC initiating ADT should have baseline BMD with dual- scape of treatment for mCNPC/mCSPC. These range from
energy x-ray absorptiometry (DXA), as well as use of fracture treatment of the primary cancer with EBRT to chemotherapy.
risk calculators such as FRAX. DXA should be performed at All men with mCNPC should be considered for treatments
39
least every two years and more often in untreated patients at that are combined with ADT; those with high-risk/high-vol-
high risk or if there is a history of osteoporosis/osteopenia. ume disease should be given systemic therapy and those
Men with mCNPC/mCSPC treated with ADT should be with low-risk/low-volume should be strongly considered for
encouraged to take vitamin D (1000 IU daily) and total calcium prostate radiation therapy and/or systemic therapy.
intake of at 800–1000 mg daily, and to make specific lifestyle
changes, including smoking cessation, reduction in alcohol Competing interests: Dr. So has been an advisory board member for Abbvie, Amgen, Astellas,
and caffeine intake, and increase in weight-bearing exercises. Bayer, Janssen, Ferring, and TerSera; and has participated in clinical trials supported by Astellas,
If DXA scanning shows any evidence of osteopenia (T-score Ferring, and Janssen. Dr. Chi has received honoraria from Astellas, Bayer, Janssen, and Sanofi; and
of <-1 and > -2.5) or osteoporosis (T-score of less than -2.5), has participated in clinical trials supported by Astellas, AstraZeneca, Bayer, Eli Lilly, Essa, Janssen,
men should be started on a bone-targeted therapy to improve Merck, Novartis, Pfizer, Roche, and Sanofi. Dr. Danielson has received advisory board honoraria
and speaker fees from Amgen, Astellas, Bayer, and Janssen. Dr. Fleshner has been a consultant or
BMD and reduce the risk of fragility fractures (zoledronic acid advisory board member for Abbvie, Amgen, Astellas, Bayer, Ferring, Hybridyne Health, Janssen, and
5 mg once a year, alendronate 70 mg weekly, denosumab Sanofi; and has participated in clinical trials supported by Astellas, Bavarian Nordic, Bayer, Ferring,
60 mg every six months). 37,38,40 Bone-targeted therapy at these Janssen, Medivalion, Nucleix, Progenics Pharmaceutical, Sanofi, and Spectracure AB. Dr. Kapoor
doses are much lower than those to prevent skeletal-related has been an advisory board member for BMS, Eisai, Ipsen, Merck, Novartis, Pfizer, and Roche; a
events (SREs) in mCRPC and, therefore, are associated with speakers’ bureau member for Eisai, Ipsen, Novartis, and Roche; and has received grants/honoraria
significantly reduced side effects; incidence of clinically signifi- from BMS, Eisai, Ipsen, Merck, Novartis, Pfizer, and Roche. Dr. Niazi has received research grants
cant hypocalcemia and osteonecrosis of the jaw is rare using and honoraria from Abbvie, Amgen, Astellas, Astra Zeneca, Bayer, Janssen, and Sanofi; and has
denosumab or zoledronic acid at these lower doses. 41,42 participated in clinical trials supported by Astellas, Ferring, Janssen, and Sanofi. Dr. Pouliot has been
an advisory board member for Amgen, Astellas, Bayer, and Janssen; has received payment from
Treatment of oligo-metastatic disease Abbott, Amgen, Astellas, Astra Zeneca, Bayer, Ferring, Janssen, and Sanofi; has received grants
from Astra Zeneca and Sanofi; and has participated in clinical trials supported by Astellas, Bayer,
Ferring, and Janssen. Dr. Rendon has been an advisory board and speakers’ bureau member for,
There is evolving evidence of the role of radiation to treat and has received honoraria from Abbvie, Amgen, Astellas, Astra Zeneca, Bayer, Ferring, Jansen, and
asymptomatic distant metastases, especially in low-burden Sanofi. Dr. Shayegan has been an advisory board member for Astellas, Bayer, and Janssen; and has
“oligometastatic” disease. received a research grant from Janssen. Dr. Sridhar has been an advisory board member for Astellas,
Currently, there is limited data to provide general recom- AstraZeneca, Bayer, Janssen, Merck, and Roche; and has participated in several pharma-supported
mendations; however, consideration in a multidisciplinary clinical trials. Dr. Vigneault has been an advisory board member for Abbvie, Bayer, Ferring, and
setting would provide the best setting to determine optimal Sanofi. Dr. Saad has been an advisory board member for and has received payment/honoraria from
management consideration on a case-by-case basis. Abbvie, Amgen, Astellas, Bayer, Janssen, and Sanofi; and has participated in clinical trials supported
by Amgen, Astellas, Bayer, Janssen, and Sanofi.
Multidisciplinary consultation

Men with mCNPC/mCSPC should be assessed in a multi- Prior to publication, this guideline underwent review by the CUA Guidelines Committee, CUA members
disciplinary manner whenever possible (Level of evidence at large, the CUAJ Editorial Board, and the CUA Executive Board.
3, strong recommendation).

22 CUAJ • February 2020 • Volume 14, Issue 2