Bisphosphonate Treatment for Men with Non-Metastatic Prostate Cancer Treated With ADT

The current standard of care for men with non-metastatic prostate cancer who are on hormone therapy (ADT) does not include the use of any of the bisphosphonate drugs (zoledronic acid aka Zometa or denosumab aka Firmagon). 

Bisphosphonates, or bone health drugs, are effective in improving bone mineral density (BMD), but there is little or no evidence that they prevent fractures, according to a new systematic review and meta-analysis.

However, a recent article still recommends that clinicians prescribe these drugs to men who have a high level of risk for developing a bone fracture.

According to Shabbir Alibhai, MD, from McMaster University in Hamilton, Ontario, Canada men with osteoporosis are at the highest risk, followed by those with low bone mass for having a fracture. 

He said that it is important, even for men with non-metastatic prostate cancer to pay attention to their bones if they are on ADT.   He pointed out that it ADT can cause "significant" bone loss and increased risk for fragility fractures akin to that of people with osteoporosis.

ADT weakens bones and as many as one in five men will develop a fracture within six years of starting ADT.  Despite this statistic, bone health care in men with non-metastatic prostate cancer is not given adequate attention.

Cancer Care Ontario in Canada assembled a working group to summarize "recent changes in bone health and bone-targeted therapy."  They focused on the interventions that reduce osteoporosis-related outcomes in men with non-metastatic prostate cancer.

They analyzed 27 clinical trials.  They found that bisphosphonates were effective in increasing BMD, but none of these trials was sufficiently powered to detect any reduction in fractures.

In one trial, they found that denosumab improved BMD and reduced the incidence of new radiographic vertebral fractures.

The more common interventions used for men with non-metastatic prostate cancer, such as calcium and vitamin D supplements, lacked trials that were placebo controlled.  They also concluded that lifestyle interventions were ineffective.

The Canadian group found, "More trials studying fracture outcomes are needed in this population." Their conclusions were published online August 7 in Annals of Internal Medicine.

If you have non-metastatic prostate cancer and are on ADT what should you do to improve your care?

Your first step should be to have an assessment of your BMD levels since it is a good surrogate for fracture risk.  If you are at either moderate or high risk for fractures, discuss with your doctors the pros and cons of taking one of the bisphosphonate drugs. 

If you are at low risk, you should make sure that you take calcium and vitamin D as well as recheck your BMD in 1 to 2 years to ensure their risk has not increased.

For a complete discussion see

Joel T. Nowak, MA, MSW wrote this Post.  Joel is the CEO/Executive Director of Cancer ABCs.  He is a Cancer Thriver diagnosed with 5 primary cancers - Thyroid, Metastatic Prostate, Renal, Melanoma and a rare cancer, Appendiceal Cancer.