Don’t doctors ask for a DEXA scan before they start ADT ?
My doctor has written Prescription for ADT and denosumab without any baseline DEXA
what if someone is already osteoporotic ? Should the bones not be strengthened BEFORE starting ADT ?
When do most do DEXA scan ? - Advanced Prostate...
When do most do DEXA scan ?
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Tinkudi
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I that we already addressed the question of bone density scans. Yes you should have such a scan right away but the ADT effect on bone density is not going to happen immediately.
Yea I got one done for dad today. Will get the report tomorrow
do you know how long it takes to start having effect on bones
Bone loss and osteoporosis due to ADT proceeds at a steady pace is my understanding. My own current bone loss is 4% per year. And I start from very strong bones and that's lucky.
But if you think about it 4% per year and if you want to live 5 years, or more, that's a lot of loss. And a growing risk of catastrophic fracture that almost inevitably leads to rapid decline to the end.
Number one strategy against catastrophic fracture risk is weight-bearing exercise. And taking properly balanced and type of calcium and vitamin D supplements.
Strategy number two is to pursue low-dose estrogen transdermal patch. As you know this has been discussed quite a lot on this forum. I have not implemented this yet.
Strategy number three is avoid denusomab and other such drugs if possible. My opinion on this is just my opinion and not mainstream. So strategy number three might alternatively be in fact to take denusomab or other anti-resorptive meds!🤯
This is just my program and may not be a good strategy for your Dad of course.
you know so much 😊
I did not know about the patches yet.
Tinkudi, if you look into the patches it is very easy to confuse low dose with high dose. There is the big PATCH trial in UK right now which is very exciting. But it is related to high-dose estradiol transdermal patches as a complete replacement for ADT.
The biochemistry of all this is very complex. And even the term transdermal is very important because previously estrogen therapies caused serious cardiovascular risk when oral pills were metabolized by the liver. However transdermal means this doesn't happen and has apparently eliminated this risk.
You can see posts by me on this forum explaining the difference and why low-dose is very interesting. Low-dose estradiol is not ADT replacement, but rather add-back for the missing estrogen which is a side effect of testosterone suppression.
Under normal circumstances, the little bit of estrogen that is needed by men, especially for bone health and other important things too, is manufactured from testosterone!
So when you suppress testosterone and circumstances of prostate cancer therapy, you suppress estrogen. It's a drive-by assassination. It's odd that this well-understood therapy is not widely in place right now.
This whole estrogen add back business gets even more confusing because apparently some men men have just got estrogen patches because of low estrogen, just like women get estrogen patches. And their physician gives it to them. And there's no fancy discussion about ADT and add-back. It's just because of human being needs a little bit of estrogen, male or female. Tall Allen mention this recently. And it may be given especially to mitigate hot flashes. It's side effect therapy, no big deal. To my mind this is exactly what we are looking for. But my medical oncologist refuse because of some risk or something. As I said it's confusing.
A lot of discussion confuses the two, replacement and add-back. And there's a lot of history here too. It seems that a lot of medical oncologist are opposed to transdermal add-back estradiol, but it's not clear that the reasons are up to date and well thought out.
We would not have known about the patches without this forum. In process of getting scrip for the low dose. Amazing more MO’s do not discuss when starting the ADT. Our Mayo guy just said no to any estrogen so we are getting from his urologist. Have read studies about the benefits. I am not a doctor of course but this seems a no-brainer. Hubs can already tell effect on bones (and we take calcium and do weights) so gotta start this.
This sounds really great PELHA.
I encourage you to plan for the appropriate blood test; apparently it is important to monitor on short intervals at least at the beginning the levels of appropriate markers in your blood, I suppose estrogen.
I also encourage you to see what else you can find. I am pursuing this path as well and haven't got a scrip yet but the the biochemistry is more complex than it's possible to imagine and there are weird feedback loops. One doesn't want to find out that taking low dose patches transdermally contributed in any way to progression or resistance.
That said I'm pursuing this.
Yes absolutely-we correspond with Jane Bob about this and he recommended the blood test after a couple weeks. Will start with .1mg/week. Then hope to double that if tests out ok. Urologist has never prescribed before so JB was also invaluable to let us know the brand names in US. Hope to get this started next week once we get the scrip.
PS. I (the wife) get Biote hormone pellets from this same urologist so he is up to date on their value. The huge irony in all this is my testosterone is now way above husbands - well his is almost zero due to the f…g Lupron so of course it is! Didn’t mean to swear - if it works we gotta go with it but that’s one powerful f…g drug. There I go again!!
I had my first DEXA scan a month after I started ADT. My second DEXA scan was 2 years later and I showed 0 (zero) bone density loss. My third DEXA scan will be performed this coming August. Well see what awaits as far as BMD is concerned.
Were you taking xgeva ?
No. I was taking Eligard and Casodex to start. The switched to Eligard and Abiraterone Acetate (zytiga) + Prednisone for 2 years. Since being dx'd 5 years ago, I've been on some form of hormone therapy for 4 of the years. Currently on Mono enzalutimide after being on Eligard for 18 months after my BCR.
That is very unusual. I will warn you that arthritis of the hip and back can cause artifacts that make bone density look better than it really is. When you look at the 4 vertebrae are they close to the same or are 1 or 2 really high. Are you doing a lot of weight bearing exercises?
When you look at the 4 vertebrae are they close to the same or are 1 or 2 really high.
Can you clarify this question? Are you referring to DEXA scans or the actual vertebrae. I have to lay confidence in the MD who's reading the scans... I've had other scans as well...CT, bone that are also referenced when determining BMD.
To get this data you have to look at the original data which you can get from the place you did the scan. It will give you a density for each vertebrae 1-4. If arthritis is affecting the score then usually one or two of them will be much higher than the others.
From September 2020 report:
The lumbar spine demonstrates a bone mineral density of 1.079 G/cm2 corresponding to a T-score of 0.3.
From Sept 2022 report:The lumbar spine demonstrates a bone mineral density of 1.071 G/cm2 corresponding to a T-score of 0.2 with no significant change.
I think it's safe to assume I have no BMD loss.
I'm due for my 3rd DEXA scan the September. We'll see what another 2 years of ADT has wrought....I'm expecting the same reading though.
So, you’ve been able to have good bone density even without taking something like Zometa or Xgeva for bone loss? My husband is in the process of having a dental implant that will take several months so those drugs are contraindicated presently. He’s even a bit worried afterward because of osteonecrosis of the jaw that can be a side effect. It would be great if his DEXA stays normal even on ADT.
Proper diet and physical activity ( heavy weights, cardio of various forms) will help keep muscle and BMD. I hardly take any supplements. I get everything thru diet.
Great question.. ADT reduces BMD the most in the first 6-12 months. I've read that the rate of loss is 3x compared to those that are menopausal. But wait, there's more. Smoking accelerates BMD too. I learned of my osteopenia a few months after ADT commenced and my MO has me on Prolia 6 month shots ever since. DEXA scans hereabouts are do-able every 2 years. I have yet to get my 2nd DEXA (due late this year.) I take vitamins and supplements several of which are aimed at BMD health, and exercise a lot (of which certain forms are known to promote bone health.)
I did a baseline scan just as I started treatment. Just had a second scan a few weeks ago and for now all is good.
Same here. I was on ADT for a full year before my DEXA scan was ordered. Furthermore, according to my urologist, most of the damage is done it the first year of receiving the ADT. My results did show some weakening and therefore increased risk. I was just prescribed vitamin D and Alendronic acid.
Did your DEXA show Osteopenia? I had -1.3 in right femur which is why I was prescribed Alendronic Acid, in addition to Adcal-d3. It’s now 2 years later and another dexa is being planned.
What is Alendronic acid?
It’s a drug to build bone density. It was prescribed after my Dexa scan showed Osteopenia in my left femur.
Thanks. Did it have side effects
Will it cause osteonecrosis of the jaw like the others?
I hope not. Seems there is no free lunch in this business. Meaning you have to monitor, so another Dexa is being planned for me after 2 years.
My husband had his first DEXA concurrently with starting ADT and abiraterone/pred. His bones were fine so no bone meds were prescribed. He has been exercising and taking calcium, vitamin D, and vitamin K the whole time. Had second DEXA several months ago (about a year into treatment) - guess what? His DEXA score was actually slightly BETTER than baseline! So be sure to include the weight-bearing exercise and the calcium/D/K regimen - it seems to help.
there are side effects to denosumab. It is not generally recommended until bone density gets close to osteoporosis which is determined on DEXA. It can be used to prevent fractures from prostate cancer when people have bone Mets that are not responding to therapy.
Don't assume anything. None of my doctors ever mentioned doing a DEXA scan, even as I was starting on denosumab (I had been on Lupron 15 months at that point). About six months later, I asked about doing one and we did one.
If you've never done one, ask to have it done. You need a good baseline for later.
I also never got one when I started ADT and ABI + Pred. I suffered a compression fracture 6 months later. Only then did I get the DEXA and start Prolia.
How do they get healed - the fractures
In my case, with a back brace for 6 weeks, then gentle physical therapy, and then a lot of time. I was left with a compression in the vertebrae of nearly two inches. A lot of people get a " kyphoplasty" procedure to reposition the vertebrae and cement it in place, but I had two different surgeons who do a lot of them discourage me from doing that, because they felt I did not need it to recover.
Many doctors do not order a Dexa before ADT. I would tell him I need one and why. ADT is hard on the bones. Get it yourself if need be, they’re not expensive.
The bones should be strengthened before ADT, during, after-but not with drugs, by a MO prescribing Denosumab without knowing what the bone density is. Weight bearing exercise, especially in the lower half, is your best protection. Denosumab also if needed, but not issued in a routine manner like this.
I was started on Xgeva as soon as my dentist cleared me but before a dexa scan. I had been on adt for about 15 months when my new MO took over. It took 4 months to get a dexa scan. BMD was normal but mo still wanted me on it. Yea, almost 4 gran a month. Here is what they won’t tell you. Xgeva has a 30 day half life which means when you get your 4th injection you will have almost two full doses in your system. It compromises the immune system. It can cause fatigue and shortness of breath. It can cause skin problems. For me that was fungus and body sores. Pretty sure I am one of the few to be affected like this but I shut it down after three colds and one sinus infection in 4 months. Some guys only get it once every 3 months. If you need it you need it but when fighting cancer I’ll not compromise the immune system unless there is potential for benefit. With my BMD normal it’s not a good idea imo God bless.
Xgeva is same ingredient as Prolia. Prolia is 2 shots a year and medicare covers it if done in doctor's office.
Has your doctor prescribed Prolia? Mine hasn’t offered it, only Xgeva.
The PATCH study in the UK has been comparing estrogen (estradiol) patches to Lupron ADT and they published this comparison . Men on Lupron lost bone, while the men on estrogen patches actually gained bone, over a period of 1-2 years.
Bob in New Mexico.
BMD changes vs time
That plot is from the PATCH study. So, high-dose estradiol.
husband's oncologist didn't even mention DEXA--he said "we all lose bone mass as we age"--worthless S.O.B.-- so I asked our primary doc and he ordered it, but was 2 mo. into ADT by then. Hubby had osteopenia in both hips. So, primary put him on Boniva while on ADT and Proton therapy, and he lost bone density while being on Boniva for 18 months. DON"T go on Boniva--not best for prostate cancer. Progressed to osteoporosis. Prednisone that he had to take with Zytiga ALSO causes bone loss. After the 2nd DEXA that showed bone loss, they put him on Prolia--he gets another DEXA next week to assess how Prolia has been doing for the last 18 months. fingers crossed.
My advice, get DEXA ASAP for baseline....can only repeat it every 18 or 24 months depending on insurance--but your doc can put "urgent, necessary" and other terms to get it sooner.
MORE advice: IF DEXA shows you already have osteopenia or osteoporosis, go on Prolia or something right away while on ADT. below is link and some quotes that may help
goodrx.com/conditions/prost...
"Currently, only one medication is FDA-approved to treat bone loss from ADT: Prolia (denosumab). This twice-yearly injection is a monoclonal antibody, meaning it’s a lab-made protein that looks like a part of the immune system." "Prolia can also cause low blood calcium levels. Your healthcare provider will likely ask you to have regular blood tests done to watch for this. Because of this risk, it’s recommended to take a calcium and vitamin D supplement daily while you’re taking Prolia."
I didn’t do a DEXA until I went on a Lupron vacation and wanted to have an arthritic knee replaced.
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