Bone Health and Androgen Deprivation Therapy For Advanced Prostate Cancer: A Clinical Audit Report of Baseline FRAX Scores


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Jonathan Martin1, Simon Crabb2, Vanessa Basketter2
1University of Southampton, 2University Hospital Southampton NHS Foundation Trust

Abstract

Background

Men with advanced prostate cancer (APC) are at increased risk of bone fracture due to long term use of androgen deprivation therapy (ADT). Careful assessment and monitoring of bone fracture risk is therefore required. The fracture risk assessment tool (FRAX) was developed to evaluate 10-year probability of major osteoporotic or hip fracture. Its validity in cancer patients is less well defined. We evaluated FRAX in APC patients with respect to risk stratification, selection of further investigation (including DEXA scanning) and treatment selection.

Method

We reviewed electronic patient records (CHARTS) and FRAX prostate cancer database at University Hospital Southampton NHS Foundation Trust (UHS). We identified patients with advanced prostate cancer who had a FRAX assessment during our audit period. If not done, patients were reclassified as having ‘secondary osteoporosis’, due to ADT use, with recalculation of their FRAX assessment.

Results

We identified 124 APC patients with a FRAX assessment between November 2016 and July 2019. Our initial FRAX assessment showed that 66% were low risk, 30% intermediate risk, 1% high risk and 3% lacked documentation. Our recalculated FRAX assessment showed that 7 men (6%) of the low risk patients should have been calculated as intermediate risk. Of the 45 men who should have had a DEXA scan (intermediate/high risk), only 29 (64%) had a DEXA scan and subsequent management plan.

Conclusion

Our findings indicate a need to improve the surveillance of bone health in APC patients on ADT. We have since updated UHS guidelines to ensure that all patients starting ADT commence vitamin D and calcium supplementation, receive lifestyle advice and undertake a correct FRAX assessment (with secondary osteoporosis as a risk factor). All intermediate/high risk patients have a DEXA and if this shows osteopenia / osteoporosis, commence a bisphosphonate therapy.

Impact statement

This clinical audit has highlighted improvements to be made in bone health management and has led to a change of practice guidelines in our trust for APC patients.