New guidelines to prevent skeletal events in metastatic prostate cancer

[Maxone73]

They are basically discussing denosumab and zoledronic acid in PCa with bone metastasis

urotoday.com/video-lectures...

[Seasid]

Here are the key points from the page:

- **Bone Health Guidelines**: The NCCN guidelines emphasize the importance of bone health in prostate cancer patients, particularly those with bone metastasis, recommending agents like **denosumab** and **zoledronic acid**.

- **Efficacy and Safety**: Denosumab has shown superior efficacy in delaying skeletal-related events compared to zoledronic acid but has higher risks of **hypocalcemia** and **osteonecrosis of the jaw**.

- **Dosing Frequency**: Studies suggest that **every 12-week dosing** of zoledronic acid is as effective as every 4-week dosing, with fewer adverse events.

- **Combination Therapy**: Combining bone protective agents with treatments like **radium-223** and **abiraterone** can reduce fracture risk, but careful consideration is needed to avoid increased fracture rates.

[Seasid]

Here are some questions you might consider asking about this page:

1. **Efficacy Comparison**: How do denosumab and zoledronic acid compare in terms of preventing skeletal-related events in bone metastatic CRPC patients?[^1^][1]

2. **Adverse Events**: What are the key adverse events associated with denosumab and zoledronic acid, and how do they differ?[^2^][2]

3. **Dosing Frequency**: What evidence supports the recommended dosing frequencies for denosumab and zoledronic acid?[^3^][3]

4. **Bone Health Guidelines**: How have the NCCN guidelines for bone health in prostate cancer patients evolved, and what are the key recommendations?[^4^][4]

[Seasid]

Here are the key points from the page:

- **Bone Health Guidelines**: The NCCN guidelines now include sections on bone health for prostate cancer patients, focusing on preventing symptomatic skeletal-related events in bone metastatic CRPC patients.

- **Denosumab vs. Zoledronic Acid**: Both agents are effective in preventing skeletal complications, with denosumab showing a slightly better efficacy but higher risks of hypocalcemia and osteonecrosis of the jaw.

- **Dosing Frequency**: Studies suggest that zoledronic acid can be administered every 12 weeks instead of every 4 weeks without losing efficacy, potentially reducing adverse events.

- **Combination Treatments**: Combining bone protective agents with other treatments like radium-223 and abiraterone can reduce fracture risk, but careful consideration is needed to avoid increased fracture rates.

[Seasid]

I wish to say that denosumab (prolia) is what I was offered and the advantage of the denosumab is that it is kind on the kidney and because it is a protein it will interfere less with the future possible lutetium PSMA treatment etc. the problem could be that you can't stop denosumab. You can just convert to zoledronic acide infusions or tablets. Therefore better if you tolerate zoledronic acide otherwise you are in trouble.

[GoBucks in reply to Seasid]

Why can't you stop denosumab? I did over 2 years ago.

[Jewelrylady in reply to GoBucks]

Were you weaned off of it? Why did you decide to stop it?

[GoBucks in reply to Jewelrylady]

After 4.5 years of <0.01 I decided to stop lupron, abiraterone and xgeva. I did not "wean". I simply did not take my next 6 month shot. I did wean off the prednisone. Following this trial: dana-farber.org/clinical-tr...

[Seasid in reply to GoBucks]

If you stop denosumab you should transfer yourself to the zoledronic acide otherwise you could brake a bone. Therefore you could see that if you are forced to stop denosumab because of the necrosis of the jaw you are in trouble.

It is especially crazy to start zoledronic acide infusions or denosumab in a hormone sensitive prostate cancer treatment phase of your metastatic prostate cancer setting. Doctors don't understand this very well.

[GoBucks in reply to Seasid]

Well I stopped everything. Not only was I undetectable, my dexascan showed improvement in my osteopenia. I know I'm very lucky.

[Seasid in reply to GoBucks]

Good luck for you. How intensive was your denosumab treatment?

[GoBucks in reply to Seasid]

Memory says a 6 month shot for about 4 years. Alternated every 3 months with 6 month lupron shot.

[Seasid in reply to GoBucks]

Therefore you received Prolia (60 mg of denosumab) every six months. Ok that was reasonable but still you should star only if you have osteoporosis or if you are osteoporotic in a castrate resistant phase or if you start abiraterone with prednisolone or if you plan to receive xofigo infusions after developed bone pain. Ol of these stuff should be considered carefully. In a hormone sensitive prostate cancer treatment phase you are much better of to avoid falls make your home fall proof and don't carry heavy stuff around like myself.

[85745]

my oncologist wants to put me on zoledronic acid, After reading possible SE's I am holding off. Wonder how many here with bone mets are taking it . I think she said every 12 weeks.

[Maxone73 in reply to 85745]

Monthly for me

[Seasid in reply to Maxone73]

Here is a private message from our member who was on zoledronic acide for six years about bone medication:

"lol ….. bone treatment/s stuff like zoledronic acid and densosumap are off the table for me now. That and my medical team is holding their breath on that one.

I had zoledronic acid drips “ every month “ for nearly 6 years. Prolly nearly 60 of them. This before anyone noticed I was being waaaaaaaay overdosed with it and stopped it. I had around 5 oncologist changes in 5 years ( big oncologist turnover at Kaiser Hospitals. ) They won’t be giving me any additional treatments unless they see something on a bone density scan. They are holding their breaths that I don’t have leg bone or esp pelvic bone fractures or splitting from too much zoledronic acid. Every Zometa infusion I received was intensely painful and debilitating for days after the infusion.'

[Maxone73 in reply to Seasid]

Not debilitating for me, not a bit, not for a second.

[Seasid in reply to Maxone73]

Lots of people have side effects from the zoledronic acide infusions. I booked the infusion in our infusions centre and I asked the nurses and they said to me that some people have side effects. I was thinking to get a yearly infusion but I cancelled it and I believe that in a hormone sensitive prostate cancer treatment setting it is only recommended if you are osteoporotic.

[Seasid in reply to 85745]

I may take it after I brake a bone, but not immediately only after the bone healing because zoledronic acide infusions and denosumab injections interfere negatively with bone healing. If you Mets are under control like my bone Mets are for more than six years I can't see the reason to take it except if you are really osteoporotic. The doctors don't really understand that.

You should start zoledronic acide or even better denosumab ones you are in a castrate resistant phase of your prostate cancer. Otherwise you will simply not be able to continue long enough your bone treatment.

TA is not recommending zoledronic acide because first it is too harsh on the kidneys second not recommended if you plan a future treatment with lutetium PSMA or something similar. Denosumab would be ok because it is a protein.

[Seasid in reply to Seasid]

These bone density scans are not very accurate. They should be performed by the same operator on the same machine otherwise you can't see what is really happening with your bone density. I had two bone density scans until now and was pushed multiple times by registrars, professor of Oncology and finally a professor of endocrinology to take denosumab or whatever I want to take but I refused each time because I believe that I don't need it. Maybe as I said, maybe if New bone Mets start to pop up in a castrate resistant phase of my prostate cancer treatment setting or maybe if I brake a bone and it heals.

[Maxone73 in reply to Seasid]

That TA recommendation is about kidneys because both zoledronic acid and 177 lutetium can be hard on the kidneys

[Seasid in reply to Maxone73]

We know that. But it is not the only reason why TA recommended only denosumab. The biggest concern is that zoledronic acide could interfere with the lutetium PSMA treatment.

[Maxone73 in reply to Seasid]

I will have to ask him according to which trial because I cannot find anything.

[Seasid in reply to Maxone73]

Why don't you just try to get answers from ChatGPT and you may have a better idea what is going on. I am not saying that I believe everything to the AI but I like to ask in order to train the model.

Better if you ask your doctors why did they prescribe you the bone strengthening drugs while you are still hormone sensitive and your bone metastasis are under control. All these drugs have side effects. You are in a healthcare setting where you can't even get a script for Metformin and you are not considering berberine instead. I am not saying that you should but you could get improvement in your bone density with exercise only and you should avoid dangerous life on the edge an fall proofe your home and workspace.

I am an electrical engineer studying some elective subjects from biomedical engineering therefore I was always interested in health but I am not a doctor. What my health is concerned I am realising that we all should make our informed decisions because there are different ways how to skin the cat. You should make a decision after taking to your doctors and thinking through what you are doing. It is difficult sometimes to make an informed decision because you just don't know enough plus in the so called cattle medicine the doctors just simply don't have enough time for you. You may see your medical oncologist only ones in three months for ten minutes. That is really not enough but that is a standard of care in the USA in a hormone sensitive prostate cancer treatment phase except if you are receiving chemotherapy etc.

[Seasid in reply to Maxone73]

I asked the AI and they don't know the reason why is denosumab being a protein a preferred option.

I was only recommended six monthly prolia (60 mg denosumab injections).

[Seasid in reply to Maxone73]

My information is, but I didn't check the information, that according to the British government clinical trial STAMPED there is no survivor advantage of getting zoledronic acide in a hormonal sensitive metastatic prostate cancer setting.i don't really know much but what I know is that if you for any reason brake your bone while receiving zoledronic acide or any other bone medication you will face a prolonged and more difficult bone healing.

Life is complex and everybody should make an informed decision. I have a post where everything was clarified about bone medication. Xgeva and Pluvicto

healthunlocked.com/advanced...

One more post about bone medication from TA:

healthunlocked.com/advanced...

[Seasid in reply to Maxone73]

I have some trials for you from my friend ChatGPT:

Q. Is there any proven survival benefit taking zoledronic acide in a hormone sensitive metastatic prostate cancer treatment setting?

A.The use of zoledronic acid in hormone-sensitive metastatic prostate cancer has been studied, but its primary benefit is in reducing skeletal-related events (SREs) rather than directly improving overall survival.

Several studies and clinical trials have investigated this. The Zometa European Study (ZEUS) and the STAMPEDE trial are notable examples. These trials generally found that while zoledronic acid is effective in reducing SREs, it does not provide a significant overall survival benefit in the hormone-sensitive setting.

However, the decision to use zoledronic acid should be individualized based on a patient's risk of SREs and overall health status, in consultation with their healthcare provider.

[Seasid in reply to 85745]

Q. Is there any proven survival benefit taking zoledronic acide in a hormone sensitive metastatic prostate cancer treatment setting?

A. The use of zoledronic acid in hormone-sensitive metastatic prostate cancer has been studied, but its primary benefit is in reducing skeletal-related events (SREs) rather than directly improving overall survival.

Several studies and clinical trials have investigated this. The Zometa European Study (ZEUS) and the STAMPEDE trial are notable examples. These trials generally found that while zoledronic acid is effective in reducing SREs, it does not provide a significant overall survival benefit in the hormone-sensitive setting.

However, the decision to use zoledronic acid should be individualized based on a patient's risk of SREs and overall health status, in consultation with their healthcare provider.