Bone metastases in advanced prostate cancer. Management
6/20/22, 12:19 AM 17128SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMICThe COVID-19 pandemic has increased the complexity of cancer care. Important issues in areaswhere viral transmission rates are high include balancing the risk from delaying cancertreatment versus harm from COVID-19, minimizing the use of potentially immunosuppressivecancer treatments whenever possible, mitigating the negative impacts of social distancingduring care delivery, and appropriately and fairly allocating limited health care resources. Theseand other recommendations for cancer care during active phases of the COVID-19 pandemicare discussed separately. (See "COVID-19: Considerations in patients with cancer".)SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines from selected countries and regionsaround the world are provided separately. (See "Society guideline links: Diagnosis andmanagement of prostate cancer" and "Society guideline links: Cancer pain" and "Societyguideline links: Management of bone metastases in solid tumors".)INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials, "The Basics" and "Beyond theBasics." The Basics patient education pieces are written in plain language, at the 5 to 6 gradereading level, and they answer the four or five key questions a patient might have about a givencondition. These articles are best for patients who want a general overview and who prefershort, easy-to-read materials. Beyond the Basics patient education pieces are longer, moresophisticated, and more detailed. These articles are written at the 10 to 12 grade readinglevel and are best for patients who want in-depth information and are comfortable with somemedical jargon.Here are the patient education articles that are relevant to this topic. We encourage you to printor e-mail these topics to your patients. (You can also locate patient education articles on avariety of subjects by searching on "patient info" and the keyword(s) of interest.)●Basics topics (see "Patient education: Bone metastases (The Basics)")ththththSUMMARY AND RECOMMENDATIONShttps://www.uptodate.com/contents/17128/print 14/27
6/20/22, 12:19 AM 17128●●●●●Goals of treatment – The axial skeleton is the most frequent site of metastasis in menwith advanced prostate cancer. The goals of palliative treatment for men with bonemetastases include pain relief, improved mobility, and prevention of complications such aspathologic fracture or epidural spinal cord compression. (See 'Complications from bonemetastases' above.)Analgesic agents – A range of pharmacologic agents are available to treat cancer-relatedbone pain that is not adequately controlled by measures specifically directed against themetastatic disease. In addition to opioids, which are a mainstay of treatment for painfulbone metastases, these include adjuvants, such as nonsteroidal anti-inflammatory drugs,and osteoclast inhibitors, such as bisphosphonates. (See 'Analgesics' above.)Systemic anticancer therapy – Systemic anticancer therapy may control symptoms andslow progression of bone metastases. (See "Overview of systemic treatment for advanced,recurrent and metastatic castration-sensitive prostate cancer and local treatment forpatients with metastatic disease".)External beam RT – External beam radiation therapy (EBRT) is the treatment of choice formen with bone pain that is not responsive to systemic therapy and limited to one or alimited number of sites. For most men, a single fraction of 8 Gy to the involved area ispreferred over multifractionated regimens. Specific recommendations are providedseparately. (See "Radiation therapy for the management of painful bone metastases".)Bone-targeting radioisotopes – For patients with castration-resistant prostate cancer(CRPC) and multifocal symptomatic osteoblastic bone metastases that are not controllablewith systemic therapy or EBRT, bone-targeting alpha particle-emitting radioisotopes (eg,radium-223 [Ra-223]) may offer significant palliative benefit. (See 'Bone-targetedradioisotopes' above.)• Ra-223 should be restricted to men with castration-resistant symptomatic metastases,and no known visceral metastatic disease. (See 'ALSYMPCA trial' above.)Ra-223 can permanently reduce bone marrow reserves, and this may affect decisionmakingon the timing and use of this agent if a patient remains a candidate forpalliative cytotoxic chemotherapy.• For most men with advanced CRPC, we suggest against initiating Ra-223 andabiraterone at the same time (Grade 2B). A beneficial role for combining Ra-223 withsystemic therapy has not been established, and some data suggest detrimentaloutcomes when Ra-223 and abiraterone are initiated concurrently. For men alreadyhttps://www.uptodate.com/contents/17128/print 15/27
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6/20/22, 12:19 AM 17128
SPECIAL CONSIDERATIONS DURING THE COVID-19 PANDEMIC
The COVID-19 pandemic has increased the complexity of cancer care. Important issues in areas
where viral transmission rates are high include balancing the risk from delaying cancer
treatment versus harm from COVID-19, minimizing the use of potentially immunosuppressive
cancer treatments whenever possible, mitigating the negative impacts of social distancing
during care delivery, and appropriately and fairly allocating limited health care resources. These
and other recommendations for cancer care during active phases of the COVID-19 pandemic
are discussed separately. (See "COVID-19: Considerations in patients with cancer".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Diagnosis and
management of prostate cancer" and "Society guideline links: Cancer pain" and "Society
guideline links: Management of bone metastases in solid tumors".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5 to 6 grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●
Basics topics (see "Patient education: Bone metastases (The Basics)")
th
th
th
th
SUMMARY AND RECOMMENDATIONS
https://www.uptodate.com/contents/17128/print 14/27
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