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Factors affecting bone mineral density in patients with prostate carcinoma before and after orchidectomy
Article first published online: 13 APR 2005
Copyright © 2005 American Cancer Society
Volume 103, Issue 10, pages 2042–2052, 15 May 2005
How to Cite
Agarwal, M. M., Khandelwal, N., Mandal, A. K., Rana, S. V., Gupta, V., Chandra Mohan, V. and Kishore, G. V. M. K. (2005), Factors affecting bone mineral density in patients with prostate carcinoma before and after orchidectomy. Cancer, 103: 2042–2052. doi: 10.1002/cncr.21047
- Issue published online: 28 APR 2005
- Article first published online: 13 APR 2005
- Manuscript Accepted: 13 JAN 2005
- Manuscript Revised: 22 DEC 2004
- Manuscript Received: 3 SEP 2004
- prostate carcinoma;
- computed tomography;
- androgen antagonists;
- body mass index;
- dietary calcium
Orchidectomy is an accepted form of androgen-deprivation therapy (ADT) for prostate carcinoma. Osteoporosis is common in elderly individuals and is accelerated by ADT. The authors studied changes in bone mineral density (BMD) after ADT and factors that affected those changes.
Fifty patients with prostatic adenocarcinoma who opted to undergo orchidectomy were studied prospectively. All patients completed 6 months of follow-up, and 20 of those patients completed 12 months of follow-up. Patients' age, weight, height, body mass index (BMI), physical activity, addiction (smoking, alcohol), dietary calcium intake, and lactose tolerance status were noted. Lumbar spinal (L1–L3) trabecular BMD was measured with quantitative computed tomography (QCT) at baseline and every 6 months for 1 year and was compared with preoperative values. The effects of various patient characteristics on preoperative BMD and changes in BMD also were analyzed.
The mean ± standard deviation (SD) age of the patients was 69.5 ± 8.1 years, BMI was 23.5 ± 3.9 kg/m2, dietary calcium intake was 1066.1 ± 443.3 mg per day. Thirty-eight percent of patients were lactose intolerant. Sixty-two percent of patients were in the light weight-bearing activity group. The mean ± SD preoperative BMD was 119.2 ± 34.9 mg/cc, with T-scores of − 1.77 ± 1.22 and Z-scores of 0.43 ± 1.27. A decrease in BMD during the first 6 months (≈ 13%) was statistically significant (P = 0.0001) and continued further during next 6 months (BMD loss of ≈ 18% at 12 months). Patients with osteoporosis, as defined by T-scores ≤ − 2.5, increased from 24% at baseline to 48% at 6 months. Nonsmokers, nonalcoholics, patients with higher physical activity, and patients with a BMI > 25 kg/m2 had statistically significant higher BMD compared with their counterparts (P < 0.05). Body weight < 60 kg and BMI < 25 kg/m2 were significant risk factors for loss of BMD (P < 0.05). Dietary calcium had a discernible but statistically insignificant effect on BMD (P = 0.16). Lactose intolerance had no significant effect on BMD or bone loss.
Osteoporosis was common in the population affected by prostate carcinoma. Orchidectomy led to accelerated bone loss. Periodic measurement of BMD after ADT would help in the early detection of osteoporosis. Maintenance of high BMI, weight-bearing physical activity, avoidance of alcohol and smoking, and possibly high dietary calcium intake help in maintaining bone mass. Cancer 2005. © 2005 American Cancer Society.
Prostate carcinoma is the leading cancer diagnosis and the second most common cause of cancer-related mortality in the U.S., amounting to approximately 19.4 per 100,000 population in 1997.1 Worldwide, it is the fourth most common male malignancy, and its incidence and mortality are the lowest in developing Asian countries.2
Androgen deprivation offers an efficacious and durable treatment modality to control the growth of prostate carcinoma cells. Most patients with metastatic (lymph node or distant) disease at presentation or who develop metastases after undergoing curative radical treatment initially are treated with androgen-deprivation therapy (ADT).3 The main ADTs include luteinizing hormone-releasing hormone (LHRH) agonists, orchidectomy, nonsteroidal antiandrogens, and estrogens, with reported longevity of up to 10–15 years.4–6 Orchidectomy is likely to continue as an important treatment modality, especially in developing countries, due to low-cost and one-time treatment, leading to better compliance.
ADT is associated with side effects due to marked reduction in serum testosterone levels. These changes, collectively termed “andropause,” include decreased libido, fatigue, decreased potency and fragility due to loss of muscle strength (sarcopenia), anemia, hot flashes, gynecomastia, depression, decrease in cognitive function, and, finally, osteoporosis.7
The reported prevalence of osteopenia in patients with prostate carcinoma is 31–38%, and the reported prevalence of osteoporosis is 25–63%.8, 9 The accelerated bone loss, which has been found to increase beyond a period of 36 months after ADT, poses a major hazard in the form of fractures (especially of the spine, hip, and wrist) for men who survive the tumors for several years and in men in whom bone mineral content was depleted by other factors before castration.10 Many studies indicate a need for bone mineral density (BMD) determination at the onset of androgen ablation and at periodic intervals thereafter to begin appropriate therapy.11, 12
A working group of the World Health Organization has defined osteoporosis in Caucasian women based on BMD compared with the reference value in young adults (as the standard deviation [SD]).13 Up to 1 SD below the reference value is considered the normal BMD, between 1.0 and 2.5 SD is considered osteopenia, and ≥ 2.5 SD is considered osteoporosis. An association of fragility fractures with BMD in the osteoporotic range is considered severe osteoporosis. Due to the unavailability of separate, validated definitions, the same definitions also are applied to men. However, using these definitions, quantitative computed tomography (QCT) tends to overestimate, and dual-energy X-ray absorptiometry (DXA) tends to underestimate, the prevalence of osteoporosis in men.14 Nevertheless, because QCT measures trabecular bone density directly, it remains an accurate tool for the purpose despite this limitation.
Female osteoporosis has been studied extensively and characterized due to its high prevalence.15; whereas male osteoporosis, especially that associated with ADT, has gained focus only recently, and there is a paucity of literature on the factors that modify rate of bone loss in this population. Physical stature, physical activity, dietary calcium and vitamin D intake, habits of smoking and alcohol, and lactose intolerance are certain factors with effects on bone mass that have been studied in older men and women and that were been identified as significant in some studies. We conducted the current study to estimate bone loss after orchidectomy and to study the effects of various modifying factors on BMD in patients with prostate carcinoma.
MATERIALS AND METHODS
We prospectively studied 50 men with histologically proven prostate adenocarcinoma who opted to undergo orchidectomy. The study protocol was approved by the institutional ethics committee. Informed consent was obtained from all patients before enrollment in the study. The mean ± SD patient age at the time of presentation was 69.5 years ± 8.1 years. The mean ± SD prostate-specific antigen level at presentation was 53.9 ng/mL ± 51.3 ng/mL. Follow-up ranged from 6 months to 12 months. Height, weight, body mass index (BMI), smoking status, and alcohol use were noted. All patients underwent technetium 99m-methylene diphosphonate bone scintigraphy to rule out metastasis at the lumbar vertebral level followed by measurement of trabecular BMD at lumbar segments 1–3 (L1–L3) using QCT. BMD was measured every 6 months during follow-up after excluding bony metastasis in the lumbar spine.
BMD was measured using a General Electric Light Speed Plus CT scanner (General Electric, Milwaukee, WI) at 160 mA and 120 KV with the QCT-5000™ bone densitometry system software. The L1–L3 lumbar vertebrae were chosen, because they provide a large area for measurement of pure trabecular bone and usually are spared in the degenerative changes common at L4–L5 level. A tripartite phantom that contained solutions of dibasic potassium phosphate (mineral equivalent), ethanol (fat), and glycerol and water (soft tissue) was used during each examination. The QCT-5000 software analyzes each axial image in the sequence and computes the BMD in mg/cc (of calcium hydroxyapatite equivalent) for each vertebra and the mean of all three vertebrae, based on the simultaneous calibration provided by the phantom. It also computes the T-score and the Z-score, which are defined as the SD from the standard young adult mean BMD and the age-matched mean BMD, respectively. Therefore, all manual calculations are avoided, increasing the accuracy and precision of the procedure. A composite male reference data base (provided by General Electric), which was compiled from various studies among different ethnicities, was used for comparison. The SD of BMD in these studies was 29.7 mg/cc, and the standard error of the composite curve was 8.0 mg/cc. The precision of QCT was within 3% and was checked every 2 weeks using quality-assurance QA analysis.
All patients underwent preoperative assessment of dietary calcium intake, lactose intolerance, and physical activity. Dietary calcium intake was estimated on the basis of an interview-based, structured, 3-day diet questionnaire. All questionnaires were administered by one qualified dietician to minimize interviewer bias. Standard tables provided by the Indian National Institute of Nutrition were used to calculate calcium in the diet. Lactose tolerance was evaluated by a 25-g lactose hydrogen breath test16 using a Microlyzer™ self-correcting model (Quintron, Milwaukee, WI). A rise in breath hydrogen by ≥ 20 ppm over the fasting value was considered indicative of lactose intolerance. The test was done either preoperatively or 2–3 weeks after patients underwent orchidectomy to avoid a delay in instituting treatment and, at the same time, allowing the patient time to stop antibiotics and return to a normal diet. Physical activity was assessed by asking relevant questions regarding daily activities over a 1-week period of the patient's usual schedule. Physical activity was classified into 5 grades based on the type of activity performed, for instance, lying down, sedentary (e.g., sitting in an office, walking < 30 minutes only once per week), regular purposeful walking (for 45–60 minutes at least 3 times per week) or the equivalent, moderately heavy work (e.g., carrying weight up to 5 kg, climbing up to 50 stairs per day, jogging, etc.), and heavy weight lifting or the equivalent. With increasing grade of physical activity, there was an increasing level of weight-bearing activity. This assessment also was performed by one investigator to minimize interviewer bias.
All patients underwent bilateral, total orchidectomy under local or regional anesthesia using the standard technique. The patients were seen on follow-up at 6 weeks, 3 months, 6 months, and 12 months after orchidectomy for routine check-ups and evaluation of response to treatment. After orchidectomy, the patients were encouraged to maintain a healthy diet and activity schedule. Patients who developed symptoms of osteoporosis were given appropriate treatment in consultation with the Department of Endocrinology.
All data were entered onto a Microsoft-Excel worksheet and were analyzed using SPSS 10.0(2) computer software for Windows (SPSS Inc., Chicago, IL). Normalcy of data was tested and confirmed using normal quantile plots for all variables. The results for all variables are presented as the mean ± SD. The effect of orchidectomy on BMD was analyzed by using Student t tests for paired data. The effects of dietary calcium intake, lactose intolerance, physical activity, height, weight, BMI, smoking, and alcohol were analyzed individually by applying an independent-sample Student t test with the variables divided into two groups and a one-way analysis of variance (ANOVA) when there were more than two variables. In addition, bivariate analyses were performed to assess the interactions between continuous variables. Complex interplay among more than two variables was studied using multivariate linear regression analysis. Correlation coefficients were tested for significance using Student t tests. Correlation coefficients were compared using multiple regression analyses. P values ≤ 0.05 were considered statistically significant.
Baseline patient characteristics are described in Table 1. The mean preoperative BMD (average of L1–L3) was 119.3 mg/cc ±34.9 mg/cc. Before they underwent orchidectomy, 15 of 50 patients (30%) patients had normal BMD, and 12 of 50 patients (24%) had BMD in the osteoporotic range. Within the first 6 months after orchidectomy, the proportion of patients with osteoporosis increased to 48% (24 of 50 patients).
|Factor||Mean ± SD|
|Age (yrs)||69.5 ± 8.1|
|Weight (kg)||64.5 ± 12.3|
|Height (cm)||165.5 ± 6.4|
|BMI (kg/m2)||23.5 ± 3.9|
|Baseline PSA (ng/mL)||53.9 ± 51.3|
|Dietary calcium (mg/day)||1066.1 ± 443.3|
|Baseline BMD (mg/cc)||119.3 ± 34.9|
|Baseline T-score (no. of SD)||−1.77 ± 1.21|
|Baseline Z-score (no. of SD)||0.43 ± 1.27|
|Lactose intolerant||19 (38.0)|
|Physical activity: No. of patients (%)|
|Grade 1||0 (0.0)|
|Grade 2||12 (24.0)|
|Grade 3||31 (62.0)|
|Grade 4||7 (14.0)|
|Grade 5||0 (0.0)|
|Smoker: No. of patients (%)||18 (36.0)|
|Alcoholic: No. of patients (%)||15 (30.0)|
Patients who had higher activity levels showed significantly greater dietary calcium intake compared with patients who had lower activity levels (P = 0.02). The mean daily calcium intake in those in the Grade 2, Grade 3, and Grade 4 physical activity groups were 826.9 mg, 1047.7 mg, and 1422.6 mg, respectively. None of the patients were on calcium supplements. Similarly, activity also had a favorable impact on BMD (P = 0.05), with a mean BMD in the Grade 2, Grade 3, and Grade 4 physical activity groups of 99.4 mg/cc, 117.7 mg/cc, and 130.1 mg/cc, respectively.
Lactose intolerance was found in 19 of 50 patients, comprising 38.0% of the total. Although only 2 of 13 patients (15.4%) age < 65 years were lactose intolerant, as many as 18 of 37 patients (48.6%) were intolerant in the older group, and this difference was statistically significant (P < 0.01).
Lactose-tolerant patients had a higher mean dietary calcium intake (1048.7 mg per day) than patients who were lactose intolerant (913.8 mg per day). However, the difference was not statistically significant (P = 0.396). The mean BMD in the lactose-tolerant and intolerant groups were similar (123.4 mg/cc and 119.7 mg/cc, respectively; P = 0.7), as was the prevalence of osteoporosis (23.8% vs. 25%, respectively; P = 0.29). Lactose intolerance did not have an affect on the loss of BMD (P = 0.84).
All 50 patients completed 6 months of follow-up. BMD decreased significantly, from a preoperative mean of 119.3 mg/cc ± 34.9 mg/cc to 103.5 mg/cc ± 35.1 mg/cc at the 6-month follow-up visit (loss of ≈ 13%; P = 0.0001) (Table 2, Fig, 1A). Twenty patients who completed 1 year of follow-up showed continued, significant declines in BMD. Their mean preoperative BMD was 123.6 mg/cc, which declined to 107.7 mg/cc in 6 months and to 100.9 mg/cc in 12 months (loss of ≈ 18% over 12 months) (Table 3, Fig. 1B).
|Vertebral level||Bone mineral density in mg/cc (mean ± SD)||P valuea|
|Preoperative||At 6 mos||Difference|
|L1||123.1 ± 37.8||107.3 ± 37.2||15.8 ± 9.9||0.0001|
|L2||119.6 ± 37.2||103.5 ± 39.3||16.2 ± 10.3||0.0001|
|L3||115.2 ± 31.7||98.31 ± 29.1||16.8 ± 12.4||0.0001|
|Average||119.2 ± 34.9||103.5 ± 35.1||15.7 ± 8.6||0.0001|
|T-score||−1.77 ± 1.21||−2.34 ± 1.20||0.57 ± 0.31||0.0001|
|Z-score||0.43 ± 1.27||−0.18 ± 1.25||0.62 ± 0.40||0.0001|
|Vertebral level||Bone mineral density in mg/cc (mean ± SD)||P valuea|
|At 6 mos||At 12 mos||Difference|
|L1||114.66 ± 45.05||102.48 ± 42.73||12.17 ± 8.25||0.0001|
|L2||108.83 ± 44.62||100.00 ± 43.94||8.83 ± 8.00||0.003|
|L3||99.49 ± 28.96||100.34 ± 37.96||−0.85 ± 15.70||0.855|
|Average||107.71 ± 38.93||100.95 ± 40.00||6.76 ± 8.84||0.023|
|T-score||−2.20 ± 1.36||−2.43 ± 1.38||−0.23 ± 0.31||0.023|
|Z-score||−0.08 ± 1.65||−0.29 ± 1.70||−0.21 ± 0.27||0.023|
Among the variables studied (i.e., age, weight, BMI, dietary calcium intake, physical activity, lactose tolerance, smoking, and alcohol intake), a BMI < 25 kg/m2 (P = 0.021), physical activity (P = 0.05), smoking (P = 0.026), and alcohol (P = 0.025) were found to have a statistically significant impact on BMD (Figs. 2, 3). Most smokers coabused alcohol, and vice versa. Linear regression analysis revealed that the deleterious effect of alcohol and smoking was due to the combined abuse of both and were not independent of one another. Similarly, the protective effect of physical activity was not identified as independent of dietary intake of calcium.
Patients with higher dietary calcium intake, lactose-tolerant patients, and patients age < 70 years tended to have higher BMD, but this difference was not statistically significant (P = 0.165, P = 0.343, and P = 0.453, respectively) (Figs. 2, 3). Patients who were shorter than 165 cm and heavier than 60 kg showed no effect of height or weight on BMD (P = 0.85 and P = 0.92, respectively). However, when controlling for weight, height had a significant, negative effect on BMD (correlation coefficient [r] = − 0.352; P = 0.03) (Fig. 2).
Patients with higher preoperative mean BMD tended to have a lower degree of loss of BMD in 6 months, a difference that was statistically significant (r = = 0.334; P = 0.04). Patients with body weight < 60 kg and BMI < 25 kg/m2 had a statistically significant faster loss of BMD (P = 0.021 and P = 0.048, respectively) within 6 months after undergoing orchidectomy. Smoking, alcohol, and dietary calcium intake did not have a significant impact on the rate of loss of BMD (Figs. 4, 5).
Both androgens and estrogens are essential modulators of bone biology in men.11 Orchidectomy, by removing the major source of androgens (and thereby causing marked reductions in the circulating levels of both androgens and estrogens), causes accelerated bone loss. In this situation, a man is even more deprived of circulating sex steroids than postmenopausal women, in whom the ovaries still produce a substantial amount of testosterone. We found statistically significant loss of BMD after orchidectomy (13% at 6 months and 18% at 12 months; P = 0.0001), resulting in an increased incidence of osteoporosis from 24% to 48% 6 months after orchidectomy. Wei et al.8 reported that, before starting ADT, 38% of men with prostate carcinoma had osteopenia, and 25% of men were osteoporotic. At the end of 1 year these proportions increased to 50% and 38%, respectively. This prevalence of osteoporosis is higher than that in the general population (up to 6%),17 and some investigators have reported that it is due to certain environmental and genetic predisposing factors that are common to both prostate carcinoma and osteoporosis.9 Several studies that used maximum androgen blockade or LHRH agonists reported 5.7–6.6% loss of spinal BMD in 6 months and 8.5% loss in 1 year, as measured by QCT18–20 (Table 4). It is noteworthy that these values are nearly double the values measured by DXA. This indicates the more sensitive and accurate nature of QCT, because it directly measures trabecular BMD (the bone compartment that shows differential, early loss of bone), unlike DXA, which measures integral bone density.21, 22 Moreover, unlike DXA, QCT is not affected by osteophytosis or aortic calcification, which often are seen in older individuals.23, 24 In some patients, measurements at the L1 vertebrae may be obscured by lower ribs. However, we did not encounter any such problem in our study.
|Study||No. of patients||Treatment||% change (mos)|
|QCT LS||DXA LS||DXA hip|
|Smith et al., 200118||21||MAB||−8.5 (12)||−3.3||−1.8 (12) (whole hip)|
|Diamond et al., 200119||21||MAB||−5.7 (6)||—||−2.3 (6) (femoral neck)|
|Diamond et al., 199820||12||MAB||−6.6 (6)||—||−6.5 (6) (femoral neck)|
|Daniell et al., 200025||26||Castration or LHRH||—||—||−4.1 (12) (femoral neck)|
|Berruti et al., 200252||35||LHRH||—||−2.9 (12)||−0.64 (12) (not specified)|
|Current study||50||Castration||−13.25 (6), −18.0 (12)||—||—|
Furthermore, to our knowledge, not many studies are available on the effect of orchidectomy on loss of BMD. Daniell et al.25 reported a 4.1% loss of BMD at the hip (DXA) 1 year after patients underwent orchidectomy. At 2 years, 10% BMD loss (range, 2.5–17%) was observed. Clarke et al.26 reported a 20% loss of bony material in iliac crest biopsies from 9 men within 7 months after orchidectomy. Those studies and our results suggest that there may be a higher degree of loss of BMD after orchidectomy than after LHRH agonists or maximum androgen blockade. This may be due to the different secondary endocrine effects of LHRH and orchidectomy, despite similar androgen-suppression effects.27–30 However, in the absence of direct, comparative, randomized trials, this remains speculative.
Apart from the above-mentioned hormonal changes, anemia, sarcopenia, depression, and cognitive decline produced by andropause may have some impact on physical activity and diet pattern, contributing to accelerated bone loss.7 All these factors together have been named “castration syndrome” and have a significant impact on quality of life.31
It is estimated that the optimal dietary calcium for middle aged men (age < 65years) and women (premenopausal) is 1000 mg per day or, for older individuals, 1200–1500 mg per day.32 Our patients had a mean (± SD) daily dietary calcium intake of 1066.1 mg ± 443.3 mg. We did not find any statistically significant correlation between dietary calcium and BMD, although a weakly positive correlation was observed (r = 0.208, P = 0.165). Retrospective and longitudinal studies have provided conflicting evidence about the association of calcium intake, adult bone mass, and the risk of osteoporosis in later life.33, 34 In 1984, the Consensus Development Conference on Osteoporosis first suggested that increased intake of calcium may prevent osteoporosis. Since then, many studies have suggested a slower rate of bone loss and fewer fractures with adequate dietary levels of calcium and vitamin D,35, 36, 37 although some large studies have not found such correlation.38, 39 The reason for these discrepancies may depend on the difference in methods used to evaluate the dietary intake of calcium and the presence of confounding factors during analyses. However, it is prudent to suggest an adequate calcium diet to these patients, reserving calcium supplements for frankly osteoporotic patients.
Our finding of a higher prevalence of lactose intolerance in individuals age > 65 years provides indirect support for the literature view that acquired lactase deficiency develops later in life.40, 41 We did not find that lactose intolerance affected baseline BMD, loss of BMD, or prevalence of osteoporosis, with or without controlling for calcium in statistical analysis. We have not come across any study evaluating the role of lactose intolerance along with dietary calcium in bone loss in this group of patients. However, its role has been studied in other groups, but with conflicting results. In a cohort of 2025 women (ages 48–59 years), Honkanen et al.42 showed a significantly lower calcium intake (558 mg per day vs. 828 mg per day; P < 0.001) and lower BMD (1.097 g/cm2 vs. 1.129 g/cm; P = 0.016) in the lactose-intolerant women. Goulding et al.43 found similar results (P < 0.05), but only in elderly women ages 70–79 years; the younger women did not showing such a correlation. Others have found no correlation between lactose intolerance and dietary calcium intake or bone mass.41, 43, 44
Immobility is a significant risk factor for osteoporosis, with up to 40% loss of BMD reported.45 Many investigators have found that weight-bearing exercises are beneficial in the maintenance of bone mass46, 47 in addition to retarding bone loss48 and reducing the fracture rate.46, 49–51 However, some other investigators have not found any such association.39, 52 We found a statistically significant relation between physical activity and baseline BMD. However, a significant correlation with bone loss was not found. Despite these conflicting results, in the light of the current data, patients should be advised to do regular weight-bearing exercises in the form of regular walking for 1 hour per day at least 3 times per week.53 Other activities, such as cycling, gardening, climbing stairs, jogging, etc., also are encouraged.
Heavy alcohol abuse and smoking are strong risk factors for bone loss and fracture in both men and women.53 A 16-year prospective study of elderly male twins found a 10% decline in BMD among alcoholics and smokers compared with a decline of 5% in other men.45 We also found that smoking and alcohol consumption were associated with low bone mass (P < 0.05). Smoking cessation and avoiding overindulgence in alcohol should be advised to osteopenic patients to decrease bone loss.
Lean stature and thin build have been identified as significant risk factors for osteoporosis in both men and women, whereas obesity has a protective role.39, 45, 48 Oefelein et al.54 reviewed data from 181 patients with prostate carcinoma who were treated with ADT and found that slender white men (BMI < 25 kg/m2) were at the greatest risk of osteoporotic fractures. The protective role of obesity can be explained by higher serum estrogen levels in obese men secondary to peripheral aromatization of androgens in adipose tissue.55 Estrogens play an important role in bone metabolism in both men and women. Conversely, some investigators have found no relation or an inverse relation between loss of BMD and obesity.6, 10, 25 This contradicts the known protective effect of obesity on osteoporosis risk and has been explained by the larger postcastration decreases in serum estrogen levels derived from the peripheral conversion of testosterone in fatty tissue.
One limitation of the current study was that it did not incorporate the measurement of markers of bone turn-over. Studies have shown that these markers correlate with BMD56 and predict fracture risk independent of BMD,57 making them important in both diagnosing and monitoring responses to therapy.45
Nevertheless, the current study highlighted the impact of hormone ablation therapy and certain modifying factors on skeletal health, as evidenced by a marked decrease in bone mass. The results of this study may increase the awareness of clinicians and medical researchers regarding the severity of osteoporosis among patients with prostate carcinoma. Because these patients are easy to identify, an early assessment of bone mass and bone turn-over may help in their long-term management to ensure maintenance of skeletal integrity during androgen ablation therapy for prostate carcinoma.
In conclusion, osteoporosis is common in elderly individuals who also are affected by prostate carcinoma. At the time of presentation, we found that 46% of our patients were osteopenic, and 24% were osteoporotic. Orchidectomy leads to accelerated bone loss, which was indicated by a 13% loss of BMD and a doubling of the prevalence of osteoporosis at the 6-month follow-up visit in our patients. Hence, periodic estimation of BMD using QCT would help in the early identification and treatment of osteoporosis in these patients. Identification of risk factors is essential to retard the progression of osteoporosis in this population. Maintenance of body-weight, weight-bearing physical activity, avoidance of smoking and alcohol, and possibly adequate dietary calcium are some measures to maintain bone mass. Furthermore, our observation of a higher rate of loss of BMD after orchidectomy versus LHRH agonists (compared with other studies) needs further evaluation in comparative studies.
- 2Epidemiology. Etiology and prevention of prostate cancer. In: WalshPC, RetickAB, VaughanED, et al., editors. Campbell's urology, 8th edition. Philadelphia: Saunders, 2002: 3003–3024., .
- 15Metabolic bone disease. In: FauciAS, BraunwaldE, IsselbacherKJ, et al., editors. Harrison's principles of internal medicine. 14th edition. Volume 2. New York: McGraw-Hill, 1998: 2247–2253., .
- 19The antiosteoporotic efficacy of intravenous palmidronate in men with prostate carcinoma receiving combined androgen blockade. A double blind, randomized, placebo controlled cross-over study. Cancer. 2001; 92: 1444–1450., , , et al.
- 21Dynamics of bone remodeling. In FrostHM, editor. Bone biodynamics. Boston: Little-Brown, 1964: 315–334..
- 22Quantitative computed tomography of the lumbar spine and not dual X-ray absorptiometry, is an independent predictor of prevalent vertebral fractures in postmenopausal women with osteopenia receiving long-term glucocorticoid and hormone-replacement therapy. Arthritis Rheum. 2002; 46: 1292–1297., , , .
- 55Disorders of testes. In: FauciAS, BraunwaldE, IsselbacherKJ, et al., editors. Harrison's principles of internal medicine. 14th edition. New York: McGraw-Hill, 1998: 2087–2096., .