Background: Androgen deprivation therapy (ADT) is a cornerstone of treatment for advanced prostate cancer (PCa); however, it accelerates the loss of bone mineral density (BMD), which increases fracture risk. Guidelines recommend BMD testing when initiating ADT to assess baseline fracture risk properly. The objective of this study was to examine the proportion of BMD testing in men initiating ADT in Quebec and to identify factors associated with receipt of this testing. Methods: The study cohort consisted of men extracted from Quebec public healthcare insurance administrative databases who initiated continuous ADT from 2000 to 2015 for >12 months. The primary study outcome was receipt of BMD testing in the period from 6 months before through 12 months after ADT initiation. Multivariable generalized linear mixed regression modeling with a logit link was performed to identify variables associated with BMD testing. Results: We identified 22,033 patients, of whom 3,910 (17.8%) underwent BMD testing. Rates of BMD testing increased from 4.1% in 2000 to 23.4% in 2015. After multivariable analyses, prior history of osteoporosis (odds ratio [OR], 1.84; 95% CI, 1.32–2.57; P<.001), rheumatoid arthritis (OR, 1.64; 95% CI, 1.15–2.34; P=.006), use of bisphosphonates (OR, 1.47; 95% CI, 1.25–1.73; P<.001), and long-term corticosteroid use (OR, 1.63; 95% CI, 1.15–2.31; P=.006) were associated with higher odds of BMD testing. Patient age >80 years (OR, 0.67; 95% CI, 0.59–0.76; P<.001), metastases (OR, 0.79; 95% CI, 0.70–0.89; P<.001), higher Charlson comorbidity score (OR, 0.65; 95% CI, 0.51–0.81; P<.001), and rural residence (OR, 0.77; 95% CI, 0.68–0.87; P<.001) were associated with lower odds of BMD testing. Conclusions: In our study population, BMD testing rates in men initiating ADT were low, although they increased over the years especially in the years after the publication of recommendations for BMD testing in these patients. Potential gaps identified include being older, more comorbid, and rural areas. Overall, additional efforts emphasizing the importance of BMD testing in PCa guidelines may be needed.
Submitted November 21, 2019; accepted for publication April 8, 2020.
Author contributions:Study concept and design: All authors. Data acquisition: Dragomir. Data analysis and interpretation: All authors. Manuscript preparation: All authors. Critical review: All authors.
Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Funding: This work was supported by funding from Fonds de Recherche du Québec - Santé (A.D., Research Scholar Junior 1).
Correspondence: Alice Dragomir, MSc, PhD, Research Institute of the McGill University Health Centre/CORE (2B.45), 5252 de Maisonneuve West, Montreal, Quebec, Canada, H4A 3S5. Email: email@example.com
Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2018. Toronto, ON: Canadian Cancer Society; 2018. Accessed July 16, 2020. Available at: cancer.ca/Canadian-Cancer-Statistics-2018-EN
EllisonLF. Progress in net cancer survival in Canada over 20 years. Health Rep2018;29:10–18.
GilbertSM, KuoYF, ShahinianVB. Prevalent and incident use of androgen deprivation therapy among men with prostate cancer in the United States. Urol Oncol 2011;29:647–653.1992631110.1016/j.urolonc.2009.09.004)| false
BollaM, Van TienhovenG, WardeP, . External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol2010;11:1066–1073.
BollaM, Van TienhovenG, WardeP, . External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study. Lancet Oncol 2010;11:1066–1073.10.1016/S1470-2045(10)70223-020933466)| false
PilepichMV, WinterK, LawtonCA, . Androgen suppression adjuvant to definitive radiotherapy in prostate carcinoma—long-term results of phase III RTOG 85-31. Int J Radiat Oncol Biol Phys2005;61:1285–1290.
JamesND, SydesMR, ClarkeNW, . Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet2016;387:1163–1177.
JamesND, SydesMR, ClarkeNW, . Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet 2016;387:1163–1177.2671923210.1016/S0140-6736(15)01037-5)| false
LevineGN, D’AmicoAV, BergerP, . Androgen-deprivation therapy in prostate cancer and cardiovascular risk: a science advisory from the American Heart Association, American Cancer Society, and American Urological Association: endorsed by the American Society for Radiation Oncology. CA Cancer J Clin2010;60:194–201.
LevineGN, D’AmicoAV, BergerP, . Androgen-deprivation therapy in prostate cancer and cardiovascular risk: a science advisory from the American Heart Association, American Cancer Society, and American Urological Association: endorsed by the American Society for Radiation Oncology. CA Cancer J Clin 2010;60:194–201.10.3322/caac.20061)| false
GreenspanSL, CoatesP, SereikaSM, . Bone loss after initiation of androgen deprivation therapy in patients with prostate cancer. J Clin Endocrinol Metab 2005;90:6410–6417.10.1210/jc.2005-018316189261)| false
AlibhaiSM, Duong-HuaM, CheungAM, . Fracture types and risk factors in men with prostate cancer on androgen deprivation therapy: a matched cohort study of 19,079 men. J Urol 2010;184:918–924.10.1016/j.juro.2010.04.068)| false
KrupskiTL, FoleyKA, BaserO, . Health care cost associated with prostate cancer, androgen deprivation therapy and bone complications. J Urol 2007;178:1423–1428.10.1016/j.juro.2007.05.13517706711)| false
KrahnMD, BremnerKE, LuoJ, . Health care costs for prostate cancer patients receiving androgen deprivation therapy: treatment and adverse events. Curr Oncol 2014;21:e457–465.10.3747/co.21.186524940106)| false
AdachiJD, LoannidisG, BergerC, . The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada. Osteoporos Int 2001;12:903–908.10.1007/s00198017001711804016)| false
DiamondTH, HiganoCS, SmithMR, . Osteoporosis in men with prostate carcinoma receiving androgen-deprivation therapy: recommendations for diagnosis and therapies. Cancer 2004;100:892–899.1498348210.1002/cncr.20056)| false
QaseemA, SnowV, ShekelleP, . Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148:680–684.10.7326/0003-4819-148-9-200805060-00008)| false
DrozJP, BalducciL, BollaM, . Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology. BJU Int 2010;106:462–469.10.1111/j.1464-410X.2010.09334.x)| false
AlibhaiSM, RahmanS, WardePR, . Prevention and management of osteoporosis in men receiving androgen deprivation therapy: a survey of urologists and radiation oncologists. Urology 2006;68:126–131.10.1016/j.urology.2006.01.05416844454)| false
CharlsonJ, SmithEC, SmallwoodAJ, . Bone mineral density testing disparities among patients with breast cancer prescribed aromatase inhibitors. J Natl Compr Canc Netw 2016;14:875–880.10.6004/jnccn.2016.009227407128)| false
BoškovićL, GašparićM, PetkovićM, . Bone health and adherence to vitamin D and calcium therapy in early breast cancer patients on endocrine therapy with aromatase inhibitors. Breast 2017;31:16–19.2781069310.1016/j.breast.2016.10.018)| false
StrattonJ, HuX, SoulosPR, . Bone density screening in postmenopausal women with early-stage breast cancer treated with aromatase inhibitors. J Oncol Pract 2017;13:e505–515.2826739210.1200/JOP.2016.018341)| false
SolomonDH, BrookhartMA, GandhiTK, . Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics. Am J Med 2004;117:919–924.10.1016/j.amjmed.2004.06.04015629730)| false
MorrisCA, CabralD, ChengH, . Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med 2004;19:783–790.10.1111/j.1525-1497.2004.30240.x15209594)| false