Bone Health
There are so many side effects that you are blissfully unaware of when you are diagnosed with stage 4 prostate cancer. When you’ve just been told that you have incurable cancer and face a likely premature death, the reality is that even if you were told about every possible side effect, very little may sink in.
In my view, the three most neglected areas of support where side effects of long-term hormone therapy have the most impact are fatigue, sexual health/sexuality, and bone health. I’m going to focus on the latter in this article, but I think the others are equally important.
Potential side effect: weakened bones
The mainstay of standard treatment for advanced stage prostate cancer has for decades been hormone therapy, in my case delivered by injection into subcutaneous fat (in the stomach for me) every 4 or 12 weeks. This is chemical castration, stopping the production of male hormone, testosterone, that feeds prostate cancer. Newer style treatments, in pill form, androgen receptor drugs, also have impact on male hormones and some men are treated with those drugs.
One of the potential side effects of hormone therapies is that they can lead to reduction in bone density, which in turn can weaken bones and mean that bones break more easily.1 Osteoporosis is the condition we reach as our bones continue to lose density and become susceptible to breaking. This is a common condition in the elderly, but hormone therapies for men with prostate cancer means this state can be reached earlier. Osteopenia is the stage reached where bone density is much reduced but not quite enough to be classed as osteoporosis.1,2
Regrettably, this possible side effect is often not adequately explained to men with prostate cancer, and rarely do I think men are supported to reduce the risk.
How I believe hormone therapy affected my bones
I suffered a serious bone break, approximately 2 years after starting on hormone therapy, that I believe was exacerbated by the treatment.
I was taking part in a local marathon as part of a relay team and tripped, landing on my left wrist but not with enough force that I would expect to have caused the amount of damage that I suffered. I knew immediately that it was broken but still had another 4 miles to complete to pass on the baton. That was not a lot of fun! Three days in the hospital and surgery to plate, pin, and wire my wrist followed.
The hospital subsequently arranged a DEXA scan, which is a form of scan that measures bone density, and the outcome was that I was already in a state of osteopenia.
How I was treated
Simultaneously to this my oncologist had mentioned that it was becoming the norm for men like me to have pre-emptive treatment to head off osteoporosis. The oncologist suggested that I go onto bisphosphonates, a medicine that may help treat osteoporosis and strengthen bones.3
These pills have to be taken while in an upright position for me, as they can cause serious problems if they get stuck on their journey. However, I really couldn’t tolerate the pills, as they gave me horrendous acid reflux. This led to me being given zoledronic acid, another form of bisphosphonates, instead. This was given by infusion at the cancer center every 12 weeks.
The only side effects that I’ve really suffered are feeling a bit like I’ve been hit by a truck for a couple of days after each infusion. However, it’s really important to be aware of possible side effects. One is possible osteonecrosis of the jaw, a rare but serious side effect in which your jawbone can poke through an opening in your gums. Thankfully I was made aware of this and made sure that my dental health was tip-top, and I have made sure to maintain my dental health ever since. It’s also really important to tell your dentist that you are on bisphosphonates!4
Getting ahead of weakened bones
Of course, I’m very grateful that my oncologist decided to offer this treatment. But the harsh reality is that men are not typically offered this level of care, and that needs to change.
One way to try to maintain bone health can be having a good exercise regime. But I think it’s also becoming important to support men proactively with pre-emptive treatments to help stave off the rate of bone degradation. At a minimum calcium and vitamin D supplements may help, but more aggressive treatments like bisphosphonates may be considered.1
What else can be done to improve things? In my opinion every patient diagnosed with cancer should have a written cancer care plan (CCP) agreed with the medical team, as well as a holistic needs assessment (HNA). These can be reviewed at least annually as our circumstances change and should cover every potential aspect of our needs, including bone health. This is starting to happen in the UK with CCPs and HNAs happening in the first year after diagnosis but, regrettably, without regular annual reviews thereafter. We really do need to do better!
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