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Patterns of Bone Mineral Density Testing in Men Receiving Androgen Deprivation for Prostate Cancer

ABSTRACT

BACKGROUND

Practice guidelines recommend bone mineral density (BMD) monitoring for men on androgen deprivation therapy (ADT) for prostate cancer, but single center studies suggest this is underutilized.

OBJECTIVE

We examined determinants of BMD testing in men receiving ADT in a large population-based cohort of men with prostate cancer.

DESIGN

Retrospective cohort study.

PARTICIPANTS

We used the Surveillance, Epidemiology and End-Results (SEER)-Medicare database to identify 84,036 men with prostate cancer initiating ADT from 1996 through 2008.

MAIN MEASURES

Rates of BMD testing within the period 12 months prior to 3 months after initiation of ADT were assessed and compared to matched controls without cancer and to men with prostate cancer not receiving ADT. A logistic regression model was performed predicting use of BMD testing, adjusted for patient demographics, indications for ADT use, year of diagnosis and specialty of the physician involved in the care of the patient.

KEY RESULTS

Rates of BMD testing increased steadily over time in men receiving ADT, diverging from the control groups such that by 2008, 11.5 % of men were receiving BMD testing versus 4.4 % in men with prostate cancer not on ADT and 3.8 % in the non-cancer controls. In the logistic regression model, year of diagnosis, race/ethnicity, indications for ADT use and geographic region were significant predictors of BMD testing. Patients with only a urologist involved in their care were significantly less likely to receive BMD testing as compared to those with both a urologist and a primary care physician (PCP) (odds ratio 0.71, 95 % confidence interval 0.64–0.80).

CONCLUSIONS

There has been a sharp increase in rates of BMD testing among men receiving ADT for prostate cancer over time, beyond rates noted in contemporaneous controls. Absolute rates of BMD testing remain low, however, but are higher in men who have a PCP involved in their care.

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REFERENCES

  1. Shahinian VB, Kuo YF, Gilbert SM. Reimbursement policy and androgen-deprivation therapy for prostate cancer. N Engl J Med. 2010;363:1822–1832.

    PubMed  Article  CAS  Google Scholar 

  2. Crawford ED, Eisenberger MA, McLeod DG, Spaulding JT, Benson R, Dorr FA, et al. A controlled trial of leuprolide with and without flutamide in prostatic carcinoma. N Engl J Med. 1989;321(7):419–24.

    PubMed  Article  CAS  Google Scholar 

  3. D’Amico AV, Manola J, Loffredo M, Renshaw AA, DellaCroce A, Kantoff PW. 6-month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer: a randomized controlled trial. JAMA. 2004;292:821–827.

    PubMed  Article  Google Scholar 

  4. Bolla M, de Reijke TM, Van Tienhoven G, Van den Bergh AC, Oddens J, Poortmans PM, et al. Duration of androgen suppression in the treatment of prostate cancer. N Engl J Med. 2009;360:2516–2527.

    PubMed  Article  CAS  Google Scholar 

  5. Daniell HW, Dunn SR, Ferguson DW, et al. Progressive osteoporosis during androgen deprivation therapy for prostate cancer. J Urol. 2000;163:181.

    PubMed  Article  CAS  Google Scholar 

  6. Wei JT, Gross M, Jaffe CA, et al. Androgen deprivation therapy for prostate cancer results in significant loss of bone density. Urology. 1999;54:607.

    PubMed  Article  CAS  Google Scholar 

  7. Diamond T, Campbell J, Bryant C, et al. The effect of combined androgen blockade on bone turnover and bone mineral densities in men treated for prostate carcinoma. Cancer. 1998;83:1561.

    PubMed  Article  CAS  Google Scholar 

  8. Smith M, McGovern FJ, Zietman AL, et al. Pamidronate to prevent bone loss during androgen-deprivation therapy for prostate cancer. N Engl J Med. 2001;345:948.

    PubMed  Article  CAS  Google Scholar 

  9. Ross RW, Small EJ. Osteoporosis in men treated with androgen deprivation therapy for prostate cancer. J Urol. 2002;167:1952–1956.

    PubMed  Article  CAS  Google Scholar 

  10. Smith MR. Osteoporosis during androgen deprivation therapy for prostate cancer. Urology. 2002;60(3 Suppl 1):79–85.

    PubMed  Article  Google Scholar 

  11. Berruti A, Tucci M, Terrone C, Gorzegno G, Scarpa RM, Angeli A, et al. Background to and management of treatment-related bone loss in prostate cancer. Drugs Aging. 2002;19:899–910.

    PubMed  Article  Google Scholar 

  12. Scardino P. Update: NCCN prostate cancer clinical practice guidelines. J Natl Compr Canc Netw. 2005;3(Suppl 1):S29–33.

    PubMed  Google Scholar 

  13. Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of fracture after androgen deprivation for prostate cancer. N Engl J Med. 2005;352:154–164.

    PubMed  Article  CAS  Google Scholar 

  14. Smith MR, Lee WC, Brandman J, Wang Q, Botteman M, Pashos CL. Gonadotropin-releasing hormone agonists and fracture risk: a claims-based cohort study of men with nonmetastatic prostate cancer. J Clin Oncol. 2005;23:7897–7903.

    PubMed  Article  CAS  Google Scholar 

  15. http://www.nccn.org. NCCN clinical practice guidelines in oncology version 1.2013 prostate cancer. Last accessed March 4th, 2013.

  16. Tanvetyanon T. Physician practices of bone density testing and drug prescribing to prevent or treat osteoporosis during androgen deprivation therapy. Cancer. 2005;103:237–241.

    PubMed  Article  Google Scholar 

  17. Wilcox A, Carnes ML, Moon TD, Tobias R, Baade H, Stamos E, Elliott ME. Androgen deprivation in veterans with prostate cancer: implications for skeletal health. Ann Pharmacother. 2006;40:2107–2114.

    PubMed  Article  Google Scholar 

  18. Yee EFT, White RE, Murata GH, Handanos C, Hoffman RM. Osteoporosis management in prostate cancer patients treated with androgen deprivation therapy. J Gen Int Med. 2007;22:1305–1310.

    Article  Google Scholar 

  19. Alibhai SMH, Yun L, Cheung AM, Paszat L. Screening for osteoporosis in men receiving androgen deprivation therapy. JAMA. 2012;307:255–256.

    PubMed  Article  CAS  Google Scholar 

  20. Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-medicare data: content, research applications, and generalizability to the United States elderly population. Med Care. 2002;40(suppl IV):3–18.

    Google Scholar 

  21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    PubMed  Article  CAS  Google Scholar 

  22. Klabunde C, Potosky A, Legler J, Warren J. Development of a comorbidity index using physician claims data. J Clin Epidemiol. 2000;53:1258–67.

    PubMed  Article  CAS  Google Scholar 

  23. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–1465.

    PubMed  Article  CAS  Google Scholar 

  24. Smith MR, Egerdie B, Toriz NH, et al. Denusomab in men receiving androgen-deprivation therapy for prostate cancer. N Engl J Med. 2009;361:745–755.

    PubMed  Article  CAS  Google Scholar 

  25. Smith MR, Morton RA, Barnette KG, et al. Toremifene to reduce fracture risk in men receiving androgen deprivation therapy for prostate cancer. J Urol. 2010;184:1316–1321.

    PubMed  Article  CAS  Google Scholar 

  26. Ito K, Elkin EB, Girotra M, Morris MJ. Cost-effectiveness of fracture prevention in men who receive androgen deprivation therapy for localized prostate cancer. Ann Intern Med. 2010;152:621–629.

    PubMed  Article  Google Scholar 

  27. Shahinian VB. Prostate cancer: reducing fracture risk in men on androgen deprivation therapy. Nat Rev Urol. 2011;8:9–10.

    PubMed  Article  CAS  Google Scholar 

  28. King AB, Fiorentino DM. Medicare payment cuts for osteoporosis testing reduced use despite tests’ benefit in reducing fractures. Health Aff. 2011;30:2362–2370.

    Article  Google Scholar 

  29. Curtis JR, Laster AJ, Becker DJ, et al. Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries. J Clin Densitom. 2008;11:568–574.

    PubMed  Article  Google Scholar 

  30. Shahinian VB, Kuo YF, Freeman JL, Orihuela E, Goodwin JS. Increasing use of gonadotropin-releasing hormone agonists for the treatment of localized prostate carcinoma. Cancer. 2005;103:1615–1621.

    PubMed  Article  CAS  Google Scholar 

  31. Earle CC, Burstein HJ, Winer EP, Weeks JC. Quality of non-breast cancer health maintenance among elderly breast cancer survivors. J Clin Oncol. 2003;21:1447–1451.

    PubMed  Article  Google Scholar 

  32. Earle CC, Breville BA. Under use of necessary care among cancer survivors. Cancer. 2004;101:1712–1719.

    PubMed  Article  Google Scholar 

  33. Earle CC. Failing to plan is planning to fail: improving the quality of care with survivorship care plans. J Clin Oncol. 2006;24:5112–5116.

    PubMed  Article  Google Scholar 

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Acknowledgments

Funding

This work was supported by grants from the National Cancer Institute (CA140272) and the American Cancer Society (118244-RSGI-10-076-01-CPHPS).

The sponsors had no role in the design or conduct of the study, in the interpretation of data, or in the preparation of the manuscript.

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

Conflict of Interest

Dr. Shahinian is a paid consultant for Amgen, Inc.

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Corresponding author

Correspondence to Vahakn B. Shahinian MD, MS.

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Shahinian, V.B., Kuo, YF. Patterns of Bone Mineral Density Testing in Men Receiving Androgen Deprivation for Prostate Cancer. J GEN INTERN MED 28, 1440–1446 (2013). https://doi.org/10.1007/s11606-013-2477-2

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  • DOI: https://doi.org/10.1007/s11606-013-2477-2

KEY WORDS

  • prostate cancer
  • osteoporosis
  • androgen deprivation therapy
  • bone mineral density