SIOG 2014

Hip fracture complications of prostate cancer treatment

Sara Faithfull - University of Surrey, Guildford, UK

The reason that we were looking at this is that a lot of men after they’ve had prostate cancer survive now. So we’re talking about 70% survival and they go on to get older. A lot of them have hormone therapy that affects their bones and it’s not something that normally men are aware of, the skeletal problems. If you go on to get a hip fracture men are more likely to die. So it’s a real risk factor if you have a hip fracture as a man. We don’t quite know why but if you do get that hip fracture then you may die within five years.

You started looking at all of the men coming in with hip fractures?

Part of the reason is it’s a bit like trying to find the needle in the haystack because if you have a hip fracture four or five years after you’ve had prostate cancer you may not put the link together and you may not think, ‘Oh, this was due to the treatment I had,’ and different doctors manage it. So nobody joins these things together. So what we did was we looked at this really good hip fracture database that’s collected nationally, looked at a regional area and then matched it against the cancer registrations for men with prostate cancer. This then gave us the data about who had had prostate cancer treatment and then did they go on to get a fracture. What we found was that 7% of the men in the database had prostate cancer and had had prostate cancer treatment and that is higher than you would expect normally. What we also found was that those men had a mortality that was similar to other men, so it’s not related to the prostate cancer, but that very few of them had actually had any preventative management. This is quite problematic, which means that they hadn’t been picked up and screened.

The clinical implication is that this number of fractures is completely preventable if those men had had some preventative management. So if you escalated the numbers from our local area of 7% it would roughly mean about 1,100 men would have had, across the UK, fractures that were preventable. Now, hip fractures are most probably under-representing the full case of fractures because men also get vertebral fractures but very few of them were on screening measures or bisphosphonates or had had DEXA scans and this is something that is simple to put in place but we’re not doing.

Doctors should be looking out for this following treatment for prostate cancer?

The guidance is that when doctors put patients on androgen deprivation that they should consider screening and should use scanning technology, DEXA scans. But the trouble is that they are quite hard to get an appointment and there’s a waiting list, that sort of thing, and often it’s forgotten and everyone thinks everybody else is doing that screening. So what happens is that the man will go out from treatment three or four years later and what we found the average fracture time period was about 4½ years after they had had their therapy, which is quite a long time from the actual treatment. So people might not put the two together.

Could you have successful treatment for prostate cancer but die due to a fracture?

Exactly, exactly. And also a hip fracture can give you terrible disability, it can give you a lot of pain and also it’s very costly to health services. It does raise the health economics in terms of the management and long-term care of someone who then may be more disabled. Also, the other thing to consider is that a lot of the evidence for management of osteoporosis is based on women and it’s not based on men. We’re most probably under-reporting the incidence of fractures and problems because we’re focussing very much on the particular biology rather than thinking about broader issues for men who are maybe more elderly. So, for example, falls are very common in men who are over 74; you’ve got frailty issues; you’ve got issues around mobility and these all contribute to hip fractures.

What is the take-home message for cancer doctors?

We’ve got to look beyond the bones. We know that we should be doing DEXA scans and they should be being put in place. But what we need to be looking at is things like vitamin D, nutritional status, supplementation, but also things like if you have androgen deprivation your muscles are very weak, there are exercises you can do very simply to build the strength of those muscles and some simple exercises around hopping and more physical activity can really improve some of those frailty issues but also improve falls risk management.