Prostate Cancer

Importance of bone health

All men are at risk for prostate cancer, but it is typically diagnosed at an older age. As men get older, their risk also increases for osteoporosis, a condition in which bones become weaker, less dense and more likely to break. The combination of aging and prostate cancer creates an environment for your bone health to suffer, making it vital to understand osteoporosis, its origins and how to manage it.

Osteoporosis as a result of age

Many people think of osteoporosis as a disease affecting women, but it develops in millions of men, too. Compared with women, men tend to have larger and stronger bones and do not have abrupt hormonal changes that occur with menopause. As a result, loss of bone density in men generally begins later and advances more slowly than in women.

Osteoporosis usually causes no pain or other symptoms in its early stages. Once bones begin to weaken, the signs and symptoms of osteoporosis include a loss of height, a stooped posture, pain and/or stiffness in the back or joints and fractures (breaks in the bone). The disease usually progresses for years without symptoms until a fracture occurs. Bones in the spine, hip, wrist, pelvis, and upper arm are particularly at risk of fracture in people with osteoporosis (see Figure 1).

Figure 1

Osteoporosis as a result of treatment

Many prostate cancer treatments can affect the bone density level, or how strong your bones are. Chemotherapy can reduce the level of calcium in your blood, which can lead to bone loss. Radiation therapy also can lead to bone loss. Recent research has found a strong link between hormone therapy and osteoporosis. Also called androgen-deprivation therapy, hormone therapy deprives cancer cells of the male hormones (called androgens) that the cancer needs to grow. However, these hormones protect against bone loss. Low testosterone levels can slow prostate cancer growth, but studies show they can also lead to loss of bone density in men.

Bone health as a result of metastasis

Bone health can suffer when prostate cancer spreads to bone (bone metastasis), weakening bone and causing pain. Bone metastasis, combined with age-related bone loss and the potential bone-weakening side effects of hormone therapy, places you at an even higher risk for osteoporotic fractures.

Managing bone health

Understanding how to strengthen your bones is crucial because once bone is lost, it cannot be completely replaced.

If your treatment plan calls for therapy that increases the risk for bone loss, your doctor should order tests to establish a baseline for your bone health. The standard test is a bone density scan, which can find bone metastasis before symptoms occur. Sometimes other tests are needed as well, such as computed tomography (CT) or magnetic resonance imaging (MRI).

Weak bones may seem trivial compared with your prostate cancer. On the contrary, weak bones can cause significant problems because they break easily, often leading to a decrease in overall health. Several strategies can reduce your risk for osteoporosis or lessen its effects if you already have it.

Bone-modifying agents can help relieve pain and high calcium levels caused by bone metastasis (see Table 1). These drugs may also slow the growth of the metastases and help delay or prevent fractures. Two types of bone-modifying agents, denosumab (Prolia, Xgeva) and bisphosphonates, such as pamidronate (Aredia) or zoledronic acid (Zometa, Aclasta and Reclast), are used to prevent or manage osteoporosis related to hormone therapy. Both types of drugs have similar effectiveness in reducing skeletal-related events (fracture, spinal cord compression), but denosumab has been shown to delay the first skeletal-related event by a few months compared with zoledronic acid.

External-beam radiation therapy may relieve symptoms resulting from bone metastasis. Radiation beams target the area of the metastasis, often giving immediate relief. Radiation can also be injected into your veins with drugs known as radiopharmaceuticals. These drugs, such as radium Ra 223 dichloride (Xofigo), samarium-153 (Quadramet) and strontium-89 (Metastron), are used when many sites of painful metastases exist.

Surgery may be needed to treat a bone fracture or to relieve pressure on the spinal cord caused by bone metastasis. Your doctor also may suggest physical therapy, which can help to manage pain, decrease the chance of bone fractures and increase mobility and safety.

Calcium and vitamin D are important, whether from diet or dietary supplements. Good sources of calcium include low-fat dairy products; leafy, dark green vegetables; and calcium-fortified foods and beverages. Your doctor may prescribe a calcium supplement or multivitamin. Vitamin D plays an important role in calcium absorption and bone health. Regular exercise, such as walking, may help prevent bone loss and provide other health benefits, including reducing pain, relieving stress and making cancer treatment easier to handle.

Healthy lifestyle choices can improve bone health. Smoking is toxic to bones. In addition, smokers may absorb less calcium from their diets. Studies have found that heavy drinking (more than two drinks per day) hurts your overall health, weakens your bones and increases your risk of broken bones.

Table 1. Bone-modifying agents

Agent How administered
denosumab (Prolia, Xgeva) Injected under the skin (in the upper arm, upper thigh, or abdomen)
pamidronate (Aredia) IV infusion
zoledronic acid (Zometa, Reclast and Aclasta) IV infusion

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