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AQUA IN ACTION: Baseline Bone Density Evaluation among Men on Androgen Deprivation Therapy

By: Daniel Lee, MD, MS; Shannon Gallagher, MPH | Posted on: 01 Mar 2022

There is an increased use of androgen deprivation therapy (ADT) for prostate cancer in recent years, exposing more men to the potential treatment toxicity of osteoporosis and skeletal fractures. Receipt of ADT for greater than a year is associated with rapid bone density deterioration with an estimated 13% decrease per year1 and an almost fourfold increase in the risk of skeletal fractures.2 Skeletal fractures in patients with prostate cancer have been associated with a sevenfold increase in mortality risk.3 Practice guidelines recommend assessing baseline bone density in patients diagnosed with prostate cancer with an expected duration of ADT of at least 6 to 12 months. Prior studies have demonstrated low uptake of this recommendation.4–6 We used the AUA Quality (AQUA) Registry to evaluate current trends in utilization of dual-energy x-ray absorptiometry (DEXA) scans in patients with prostate cancer receiving prolonged ADT.

In the AQUA Registry, we identified 25,762 patients with a diagnosis of prostate cancer and at least 12 months of followup available, with evidence of either bilateral orchiectomy or receipt of ADT for at least 12 months. A total of 1,297 (5.0%) had evidence of a CPT code for a DEXA scan 24 months before the start of castration to 3 months after. Of those undergoing surgical castration, only 1.0% (15/1,442) had a DEXA scan in the relevant timeframe. Overall trends were then investigated in patients with ADT injections. In patients older than 80 years who are at the highest risk of fracture, 3.6% had a DEXA scan. Black men were less likely to undergo DEXA scans (5.2%) compared to White men (6.5%). When evaluating trends in DEXA utilization over time in this population, there was a general increase in DEXA scan use from 2.8% in 2008 to 20.6% in 2019 (see figure). However, only 1.6% of men on ADT in 2020 had evidence of a DEXA scan.

Figure. DEXA scans by first year of ADT.

DEXA scans are an important diagnostic tool to address a known potential treatment complication of prolonged castration, and appropriate utilization represents a key quality metric in urology. The overall low rates of DEXA scans seen in this study are consistent with prior reports, although the trends suggest improvement over time. This presents a potential opportunity to improve outcomes in patients diagnosed with prostate cancer, especially in higher-risk groups such as the very elderly. In addition, the precipitous drop of DEXA scan utilization in 2020 likely reflects the previously described decline in elective health care utilization due to the COVID-19 pandemic restrictions; considerations should be made on how to address bone density monitoring for this cohort.

  1. Smith MR, McGovern FJ, Zietman AL et al: Pamidronate to prevent bone loss during androgen-deprivation therapy for prostate cancer. N Engl J Med 2001; 345: 948.
  2. López AM, Pena MA, Hernández R et al: Fracture risk in patients with prostate cancer on androgen deprivation therapy. Osteoporos Int 2005; 16: 707.
  3. Oefelein MG, Ricchiuti V, Conrad W et al: Skeletal fractures negatively correlate with overall survival in men with prostate cancer. J Urol 2002; 168: 1005.
  4. Shahinian VB and Kuo YF: Patterns of bone mineral density testing in men receiving androgen deprivation for prostate cancer. J Gen Intern Med 2013; 28: 1440.
  5. Morgans AK, Smith MR, O’Malley AJ et al: Bone density testing among prostate cancer survivors treated with androgen-deprivation therapy. Cancer 2013; 119: 863.
  6. Suarez-Almazor ME, Peddi P, Luo R et al: Low rates of bone mineral density measurement in Medicare beneficiaries with prostate cancer initiating androgen deprivation therapy. Support Care Cancer 2014; 22: 537.