Bone metastases in advanced prostate cancer. Management
6/20/22, 12:19 AM 17128with ADT in men with bone metastases. In the CALGB 90202 trial, 645 men were randomlyassigned to zoledronic acid or placebo [36]. The trial was discontinued prematurely when thecorporate sponsor withdrew support. With a median follow-up of 24 months, there was nostatistically significant difference in the time to first SRE (median 31.9 versus 29.8 months, HR0.97). Overall survival also was not significantly different (median 38 versus 36 months, HR 0.88,95% CI 0.70-1.12).There are no data on denosumab for the prevention of SREs in patients with castration-sensitivedisease.Published guidelines from CCO and ASCO state that there is insufficient evidence to make arecommendation regarding the use of any bone-modifying agent in men with bone metastasesand castration-sensitive prostate cancer [1,2]. On the other hand, year 2020 guidelines on bonehealth from the European Society of Medical Oncology specifically recommend against theroutine use of bone targeted agents such as bisphosphonates in men with metastaticcastration-sensitive prostate cancer [3].Prevention or delay of bone metastases — We suggest against the use of osteoclastinhibitors to prevent or delay the appearance of bone metastases in men with high-risknonmetastatic prostate cancer. Randomized trials with both bisphosphonates and denosumabhave failed to demonstrate a favorable risk-benefit ratio for men with nonmetastatic CRPC. Thisposition is consistent with guidelines from CCO and ASCO [1,2].Bisphosphonates — Although preclinical data suggest that bisphosphonates have anantitumor effect in prostate cancer, the adjuvant use of bisphosphonates in men with CRPCwithout bone metastases has never been shown to significantly decrease the incidence of bonemetastases:●In the phase III ZEUS trial, 1433 patients with high-risk nonmetastatic prostate cancer(prostate-specific antigen [PSA] ≥20 ng/mL, Gleason 8 to 10, or node-positive disease)were randomly assigned to zoledronic acid (4 mg every three months) for four years [37].After a median follow-up of 4.8 years, there was no significant difference in the incidenceof bone metastases (four-year incidence 14.7 with zoledronic acid versus 13.2 percent inthe control group).●A smaller trial using clodronate also failed to demonstrate a decrease in the incidence ofbone metastases [38].Denosumab — The potential value of denosumab to prevent bone metastases wasaddressed in a phase III trial, in which 1432 men with nonmetastatic CRPC were randomlyhttps://www.uptodate.com/contents/17128/print 12/27
6/20/22, 12:19 AM 17128assigned to denosumab or placebo [35]. All patients either had undergone bilateralorchiectomy or had received continuous treatment with a gonadotropin-releasing hormoneagonist or antagonist for at least six months. Patients were castration resistant based on threeconsecutive rising PSA determinations. Patients were classified as high risk for the developmentof bone metastases based on a serum PSA ≥8 mcg/L or a PSA doubling time <10 months.Denosumab significantly increased the bone metastasis-free survival compared with placebo(29.5 versus 25.2 months, HR 0.85, 95% CI 0.73-0.98), but there was no significant difference inoverall survival (median 44 versus 45 months, HR 1.01).Osteonecrosis of the jaw was observed in 5 percent of patients treated with denosumab andwas not observed with placebo. Hypocalcemia was more common with denosumab (1.7 versus0.3 percent).Calcium and vitamin D — Calcium and vitamin D levels should be assessed, and low levelscorrected, prior to initiating therapy with an osteoclast inhibitor. If there are nocontraindications (eg, pre-existing hypercalcemia, recurrent renal stones), all patients receivingan osteoclast inhibitor should receive calcium and vitamin D supplementation to preventsecondary hyperparathyroidism and hypocalcemia and to ensure sufficient calcium for bonerepair/healing. This subject is discussed elsewhere. (See "Osteoclast inhibitors for patients withbone metastases from breast, prostate, and other solid tumors", section on 'Considerationsprior to initiating an osteoclast inhibitor' and "Osteoclast inhibitors for patients with bonemetastases from breast, prostate, and other solid tumors", section on 'Monitoring duringtherapy'.)Side effects — Although the benefits of osteoclast inhibition have been well established inlarge randomized clinical trials, these agents can cause serious toxicity in rare cases. Importantpotential side effects include:●●●Osteonecrosis of the jawHypocalcemiaRenal impairment (a concern with bisphosphonates but not denosumab)The potential risk for complications should not preclude the use of osteoclast inhibitors. Carefulpatient selection, avoidance of the use of these agents in patients in high-risk settings, andcontinued awareness of the potential for complications during treatment are important tominimize the risk of serious complications [39,40].The prevention and management of complications associated with osteoclast inhibitors(bisphosphonates and denosumab) are discussed separately. (See "Risks of therapy with boneantiresorptive agents in patients with advanced malignancy".)https://www.uptodate.com/contents/17128/print 13/27
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with ADT in men with bone metastases. In the CALGB 90202 trial, 645 men were randomly
assigned to zoledronic acid or placebo [36]. The trial was discontinued prematurely when the
corporate sponsor withdrew support. With a median follow-up of 24 months, there was no
statistically significant difference in the time to first SRE (median 31.9 versus 29.8 months, HR
0.97). Overall survival also was not significantly different (median 38 versus 36 months, HR 0.88,
95% CI 0.70-1.12).
There are no data on denosumab for the prevention of SREs in patients with castration-sensitive
disease.
Published guidelines from CCO and ASCO state that there is insufficient evidence to make a
recommendation regarding the use of any bone-modifying agent in men with bone metastases
and castration-sensitive prostate cancer [1,2]. On the other hand, year 2020 guidelines on bone
health from the European Society of Medical Oncology specifically recommend against the
routine use of bone targeted agents such as bisphosphonates in men with metastatic
castration-sensitive prostate cancer [3].
Prevention or delay of bone metastases — We suggest against the use of osteoclast
inhibitors to prevent or delay the appearance of bone metastases in men with high-risk
nonmetastatic prostate cancer. Randomized trials with both bisphosphonates and denosumab
have failed to demonstrate a favorable risk-benefit ratio for men with nonmetastatic CRPC. This
position is consistent with guidelines from CCO and ASCO [1,2].
Bisphosphonates — Although preclinical data suggest that bisphosphonates have an
antitumor effect in prostate cancer, the adjuvant use of bisphosphonates in men with CRPC
without bone metastases has never been shown to significantly decrease the incidence of bone
metastases:
●
In the phase III ZEUS trial, 1433 patients with high-risk nonmetastatic prostate cancer
(prostate-specific antigen [PSA] ≥20 ng/mL, Gleason 8 to 10, or node-positive disease)
were randomly assigned to zoledronic acid (4 mg every three months) for four years [37].
After a median follow-up of 4.8 years, there was no significant difference in the incidence
of bone metastases (four-year incidence 14.7 with zoledronic acid versus 13.2 percent in
the control group).
●
A smaller trial using clodronate also failed to demonstrate a decrease in the incidence of
bone metastases [38].
Denosumab — The potential value of denosumab to prevent bone metastases was
addressed in a phase III trial, in which 1432 men with nonmetastatic CRPC were randomly
https://www.uptodate.com/contents/17128/print 12/27
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