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Editorials

Long term androgen deprivation therapy in prostate cancer

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1361 (Published 22 September 2008) Cite this as: BMJ 2008;337:a1361

Osteoporosis in Patients with Prostate Cancer on Long-Term Androgen Deprivation

We read with interest this editorial regarding the potential
cardiovascular effects of long term androgen deprivation therapy. Also
important and at present under-recognised is the risk of osteoporosis
amongst this patient group. At present few guidelines exist to assist with
detection and management of bone loss in males receiving long term
androgen deprivation therapy.

The use of a gonadotrophin-releasing hormone (GnRH) agonist with
radical radiotherapy for two to three years in high risk prostate cancer
offers significant improvement in disease free and overall survival (1,2).
As treatments for prostate cancer advance, even in poor risk disease,
osteoporosis and its complications are likely to become increasingly
common. A large retrospective study has considered the fracture rate in
over 50,000 males with prostate cancer and revealed a significant
relationship between number of doses of GnRH agonist and fracture risk
(3). This is important as there is clear evidence that the development of
a fracture in a male with prostate cancer is an independent, adverse
predictor of survival (4).

There is a need for more consistent, effective and evidence-based
management of potential bone loss in such patients. Patients commenced
upon ADT and their general practitioners should be given clear information
and lifestyle advice to reduce their risk of osteoporosis as much as
possible. This should emphasise the need for exercise, reducing smoking,
limiting alcohol consumption along with a diet including calcium and
vitamin D. Exercise and diet are particularly important in this context
given that the other effects of long term ADT include loss of muscle bulk
and increased body fat.

In the absence of guidelines, teams managing prostate cancer need to
formulate and implement coherent strategies to minimise potential
morbidity from ADT. Dual-energy X-ray
absorptiometry (DXA) scans are cheap, relatively easy to perform and
currently underutilised in this patient group in the UK. We recommend that
a DXA scan be considered for all men commencing long term ADT.

1. Bolla M, Gonzalez D, Warde P, Dubois JB, Mirimanoff RO, Storme G,
et al. Improved survival in patients with locally advanced prostate cancer
treated with radiotherapy and goserelin [see comments]. N Engl J Med
1997;337(5):295-300.

2. Widmark A, Klepp O, Solberg A, Damber JE, Angelsen A, Fransson P,
et al. Endocrine treatment, with or without radiotherapy, in locally
advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III
trial. Lancet 2009;373(9660):301-8

3. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of fracture
after androgen deprivation for prostate cancer. N Engl J Med
2005;352(2):154-64.

4. Oefelein MG, Ricchiuti V, Conrad W, Resnick MI. Skeletal fractures
negatively correlate with overall survival in men with prostate cancer. J
Urol 2002;168(3):1005-7.

Competing interests:
Janet Brown has received speakers bureau honoraria from Novartis and Amgen and has served as a consultant
and/or on advisory boards for Novartis, Amgen, Roche, and Bristol- Myers Squibb.
Jennifer Sherriff has no competing interests.
Nicholas D. James has received research funding from and has carried out consultancy work for Novartis, Sanofi
Avantis and Pfizer.

Competing interests: No competing interests

01 January 2010
Jennifer M Sherriff
Specialist Registrar Clinical Oncology
Janet E. Brown, Nicholas D. James
University Hospital Birmingham NHS Trust. B15 2TH