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  • Osteoporosis Treatment?

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    Old 11-23-2021, 09:35 AM   #1
    john_ct1
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    Osteoporosis Treatment?

    My MO ordered a baseline DEXA scan since I'm beginning ADT. To my surprise, at 57, I have pre-existing Osteoporosis (though it runs in my family, including my father). I saw an endocrinologists, blood tests where all normal include Vitamin D level. He offered two medication treatment choices... Once a year Reclast infusion or a 6 month Prolia injection. Both seem equally efficacious. Does anyone have any experience with these medications or can comment on their pros and cons?

    Thanks,

    -John
    __________________
    57 yo, family history of PCa, PSA 5.7, Free PSA 8.43%, DRE Neg, 5/26/21 Biopsy: Gleason 9, Grade 5, 16 of 20 cores positive mix of 5+4 and 4+5. Stage IVa, cT2N1M0, CT shows a 3cm x 2cm diseased pelvic lymph node, Bone scan neg, 6/16/20 1st Firmagon injection, 7/14/21 switched to 4 month Eligard injection, 9/15/21 started Zytiga+Prednisone, 10/20/21 completed 23 fractions of Proton VMAT/IMRT, 11/01/21 HDR Brachy Boost, 10/21/21 47 gene mutations tested all negative.

     
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    Old 11-23-2021, 11:36 AM   #2
    DjinTonic
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    Re: Osteoporosis Treatment?

    Hi John,

    I've been taking weekly alendronate (generic Fosamax), which is in the same drug class (bisphosphonates) as Prolia. I recently had my first (2-yr) bone scan, which showed an improvement, so I'm continuing on it (plan is for 5 years' treatment). I was also able to get my vit. D3 up into normal values with a supplement. I've had no problem with the Fosamax, but have no other info to offer. At diagnosis we did testing to rule out a parathyroid issue.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    quincy (11-24-2021)
    Old 11-25-2021, 02:51 PM   #3
    IADT3since2000
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    Re: Osteoporosis Treatment?

    Hi again John,

    As a veteran of 87 months of intermittent ADT, I am convinced that those of us on long-term ADT - the kind of ADT that reduces testosterone, not antiandrogens - need to be on a bone mineral density medication to protect against the decrease in density that otherwise going to occur. (I suspect such medication is not needed for men on short-term ADT, such as 4 months, to support radiation for intermediate risk cases.)

    While my own 25 hydroxy vitamin D level was considered normal, my first DEXA scan (the common scan used to detect decreased bone density) was at the nine month point after I had started Lupron. It showed that my bones, on average, were already in the osteopenia range, which, as you may know, is a milder stage of decreased bone density, and the L3 and L4 vertebrae were already well into the osteoporosis range. This was in the context of a healthy Mediterranean diet and a lot of weight bearing exercise - not enough to prevent loss of density.

    Medical practice has hopefully changed for ADT patients, hopefully routine ordering of baseline DEXA scans when patients first begin long-term ADT. Back in 2000, my team of well-regarded urologists was just not aware of the bone density threat for ADT patients. I was learning about the bone threat from what I was reading, but in a number of monthly consultations/Lupron shots when I asked if I needed to do something for my bones, they were not dismissive but clearly regarded bone health, while on ADT, as a low priority. My concern grew stronger over the summer, and that concern as well as my interest in adding Proscar/finasteride to my treatment - something they were also cool toward, led them to refer me to a medical oncologist. He immediately ordered the DEXA and put me on Fosamax, which DjinTonic mentioned, before even getting the scan results - he appreciated the threat and knew what needed to be done. And that first scan confirmed his judgment: while I was diagnosed with osteopenia based on the average of all findings, two of my lumbar vertebrae were already in the osteoporosis zone. I have come to believe that while you don't want your medical oncologist to be your surgeon, you also don't usually get your best treatment if your surgeon doubles as your drug guy when drugs are key to your strategy. (From that point on, my medical oncologist was in charge of my care.)

    Now about Reclast, also known as Zometa or zoledronic acid: it's good, but there are some risks and some alternatives, which also applies to Prolia. When Zometa was first emerging, leading medical oncologists who were dedicated to prostate cancer were thinking it was the greatest thing since sliced bread - even worth going abroad to get it before it was approved by the FDA in the US. It was definitely more potent than Fosamax and similar bisphosphonate drugs like Boniva and Actonel, and it seemed to be helpful in combatting metastases (probably to the bones). Then these early adopter doctors began to notice a really bad side effect in some of their patients: their jaw bones were deteriorating, a condition that soon came to be known as ONJ - osteonecrosis of the jaw. At first, no one knew why. Then an association with dental surgery was noticed. Today, these advanced drugs, also including denosumab (as either half dose Prolia or full dose Xgeva), are appreciated for their potency but given with warnings to avoid dental surgery or have it done before starting the drugs. Also, while my impression is that ONJ is infrequent if not rare, I know two women in my old neighborhood who both developed it while taking Zometa during breast cancer therapy. I have not carefully reviewed the landscape of drugs to preserve bone mineral density, but my impression is that while there is probably some risk of ONJ with all the bone density drugs except for estradiol, the more potent drugs, Reclast/Zometa and Prolia/Xgeva, have a substantially greater risk of ONJ.

    Some of us don't need the high potency drugs; the older, much less expensive, more convenient (oral tablet) bisphosphonate drugs or estrogen will do just fine. My BMD was well protected with Fosamax once weekly, and later Boniva, monthly - greater convenience, and even later estradiol Vivelle skin patches. A plus for the estradiol patches is that there is no added risk of ONJ, and there are some other benefits as you are getting a hormone that partially functions as testosterone used to before we started drugs to minimize it. On the downside, most, maybe all of us, will grow some additional breast tissue - not Mae West, but unfortunately maybe noticeable, and there may be some tenderness or soreness. My doctors advised the switch as I had been on the bisphosphonates for more than five years total during my intermittent ADT therapy, and there is some evidence of a possible link to unusual fractures in the femur bones among patients who are on bisphosphonates for more than five years.

    A small minority of patients on the more potent drugs will experience one of more bothersome side effects. Unfortunately, really bothersome pain can be one of these effects. I know someone who experienced very great pain when on these drugs, which went away when not on the drugs. I'm thinking as a real amateur here that a six month shot would be better as it would give an option for stopping the drug and switching to something else if things went poorly, rather than an annual shot that could stick you with pain for an additional half year. The patient I know found Prolia intolerable.

    I'm wondering how many of us really need the more potent bone density drugs. Surely some of us do, but I've a suspicion that doctors often are pressured from the drug companies to use the "latest and greatest" drug versions when a far less expensive version will do just fine. I don't know the extent that could be true for the bone density drugs, but it's worth considering whether the kind of drug that I and DjinTonic were on would do the job. I'm thinking that a patient with identified or suspected bone mets would want to be on one of the more potent drugs.

    Good luck to you!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA, for some reason based on a less sensitive test on 7/20/2021 was <0.05, still apparently cured in my ninth year since radiation (PSA as of 12/2/2020 was <0.01). (T 93 as of 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. I have also had 225 undergraduate classroom hours just in statistics and experimental design, plus more in graduate school, which dwarfs what most doctors have, and that has made my “hard knocks” experience more meaningful. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 11-29-2021, 07:14 AM   #4
    john_ct1
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    Re: Osteoporosis Treatment?

    Jim, belated thanks for the feedback!
    -John
    __________________
    57 yo, family history of PCa, PSA 5.7, Free PSA 8.43%, DRE Neg, 5/26/21 Biopsy: Gleason 9, Grade 5, 16 of 20 cores positive mix of 5+4 and 4+5. Stage IVa, cT2N1M0, CT shows a 3cm x 2cm diseased pelvic lymph node, Bone scan neg, 6/16/20 1st Firmagon injection, 7/14/21 switched to 4 month Eligard injection, 9/15/21 started Zytiga+Prednisone, 10/20/21 completed 23 fractions of Proton VMAT/IMRT, 11/01/21 HDR Brachy Boost, 10/21/21 47 gene mutations tested all negative.

     
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