Use of dual-energy x-ray absorptiometry (DXA) screening during initiation of androgen deprivation therapy (ADT) for localized or regional prostate cancer may reduce the risk for fractures, but not enough patients receive the screening, according to investigators.
In a study of 54,953 patients older than 65 years receiving Medicare who were initiating ADT for localized or regional disease, only 4362 patients (7.9%) received DXA screening within 12 months before and 6 months after their first ADT claim, Maria E. Suarez-Almazor, MD, PhD, of the University of Texas MD Anderson Cancer Center, Houston, Texas, and colleagues reported in JAMA Network Open. The DXA screening rate increased from 6.8% in 2005 to 8.4% in 2015.
The odds of DXA screening were significantly decreased among men who were single, Black, and living in small urban areas and census areas with less than a high school education, despite DXA coverage through Medicare. Patients receiving nonsteroidal antiandrogens had significant 43% decreased odds for DXA screening compared with those receiving leuprolide only.
Having osteoporosis and fracture prior to ADT initiation was significantly associated with 16.0- and 1.2-fold increased odds of DXA screening, respectively, the investigators reported. Men with regional (vs localized) prostate cancer, high grade disease, or a Charlson Comorbidity Index score of 1 or higher also had increased odds of DXA screening.
Of the full cohort, a fracture of any type occurred in 17.5% of patients, and a major fracture (fracture of the hip, spine, wrist, or humerus) occurred in 7.7% after ADT initiation, Dr Suarez-Almazor’s team reported. The median time to first fracture was 31 months. Men who were older than 80 years, single, or had 2 or more comorbidities had increased odds of any fracture and major fractures. Regional and high grade prostate cancer and use of 2 or more types of ADT were also associated with increased odds for any and major fractures. Duration of ADT use was unknown. Full or partial state buy-in status was another factor. Overall survival at 5 years was significantly lower among men with than without a major fracture: 74% vs 78%.
Among men without prior osteoporosis or fracture, DXA screening was associated with a borderline significant 9.1% decreased risk of major fractures, the investigators pointed out.
Research suggests bone-modifying agents may reduce bone loss in men with prostate cancer. Among the 27,402 patients in this study with Medicare Part D coverage, only 854 (3.1%) received bone-modifying agents such as bisphosphonates. Use of these therapies was significantly higher among men who received DXA screening: 18.8% vs 1.8%. Due to small numbers, the investigators could not assess the use of these therapies with fracture risk.
“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,” Dr Suarez-Almazor’s team wrote. “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.”
‘Substantial Room for Improvement’
In an accompanying editorial, Amar U. Kishan, MD, University of California, Los Angeles, and colleagues noted that the purpose of DXA screening is to initiate early treatment for osteopenia or osteoporosis with the ultimate goal of avoiding fractures. They noted that guidelines on ADT use have changed since 2015.
“Overall, this work highlights the fact 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.”
Disclosure: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original references for a full list of authors’ disclosures.
Suarez-Almazor ME, Pundole X, Cabanillas G, et al. Association of bone mineral density testing with risk of major osteoporotic fractures among older men receiving androgen deprivation therapy to treat localized or regional prostate cancer. JAMA Netw Open. Published online April 1, 2022. doi:10.1001/jamanetworkopen.2022.5432
Kishan AU, Kamran SC, Soerensen SJC, Leppert JT. Dual X-ray absorptiometry screening for men receiving androgen deprivation. JAMA Netw Open. Published online April 1, 2022. doi:10.1001/jamanetworkopen.2022.5439