Bone health management, including regular assessment with dual-energy X-ray absorptiometry and Trabecular Bone Score and use of bone health agents, should be integrated as standard clinical practice across the prostate cancer continuum to improve health outcomes and quality of life.
Key Findings
Background
Bone loss can begin from the initiation of androgen-deprivation therapy (ADT) and represents a significant source of morbidity in prostate cancer patients.
ADT compromises bone integrity from treatment initiation, before bone metastases develop.
The review characterizes this as occurring across 'the prostate cancer continuum,' indicating it is not limited to advanced disease stages.
Both bone loss from treatment and bone metastases can increase morbidity and impair quality of life.
Results
Current guidelines recommend regular bone loss assessment using dual-energy X-ray absorptiometry (DXA) and Trabecular Bone Score (TBS) for all men starting or receiving ADT.
DXA and TBS are identified as recommended predictive tools for bone loss monitoring.
Assessment is recommended for 'all men starting or receiving androgen-deprivation therapy for prostate cancer.'
Regular monitoring is framed as a standard-of-care recommendation rather than a selective intervention.
Results
Bone health agents (BHAs) are recommended for all men with castration-resistant prostate cancer (CRPC) with skeletal metastases to prevent symptomatic skeletal-related events.
BHAs are also recommended for high-risk men receiving ADT to prevent treatment-related bone loss.
Recommended BHA options include bisphosphonates such as zoledronic acid and alendronate.
The receptor activator of nuclear factor kappa-B ligand (RANK-L) inhibitor denosumab is also listed as a recommended BHA option.
The recommendation applies to two distinct patient populations: those with metastatic CRPC and high-risk ADT recipients.
Results
Adverse effects of bone health agents requiring monitoring include osteonecrosis of the jaw and hypocalcemia.
Both osteonecrosis of the jaw and hypocalcemia are specifically named as adverse effects requiring patient monitoring.
Monitoring for these adverse effects is presented as a necessary component of BHA management.
No specific incidence rates for these adverse effects are provided in the abstract.
Results
Certain treatments for metastatic castration-resistant prostate cancer (mCRPC) have associated beneficial bone-related effects, notably abiraterone acetate, enzalutamide, and radium-223.
Three agents are specifically identified as having beneficial bone-related effects: abiraterone acetate, enzalutamide, and radium-223.
These agents are presented as treatment options for mCRPC that complement dedicated bone health agents.
The bone-related benefits of these agents are described as 'notable,' suggesting clinically meaningful effects.
Results
The authors developed a test-and-treatment algorithm for bone health management in men with metastatic prostate cancer.
The algorithm is presented as a practical clinical tool to integrate bone health management into standard practice.
The algorithm addresses both assessment (testing) and intervention (treatment) components.
It is intended to apply specifically to men with metastatic prostate cancer.
Conclusions
Improving treatment-related bone loss and proactively managing bone metastases should be considered standard practice for all men with prostate cancer.
The review frames proactive bone health management as applicable to 'all men with prostate cancer,' not only those with advanced disease.
The stated goals of this standard practice are to 'improve health outcomes and quality of life.'
This is a narrative review synthesizing current evidence and guidelines rather than a primary clinical trial.
What This Means
This research review examines the problem of bone health in men with advanced prostate cancer and outlines strategies to address it. Prostate cancer treatments, particularly androgen-deprivation therapy (ADT, which lowers testosterone levels), can weaken bones starting from when treatment begins. When cancer spreads to the bones, it further raises the risk of serious bone-related complications such as fractures and spinal cord compression. The authors argue that protecting bone health should be a priority throughout the entire course of prostate cancer treatment, not just at advanced stages.
The review identifies specific tools and medications to manage this problem. Doctors are advised to regularly measure bone density using scans (DXA) and a related measurement called Trabecular Bone Score for all men on ADT. For men whose cancer has become resistant to hormone therapy and has spread to bones, medications called bone health agents — including bisphosphonates (such as zoledronic acid and alendronate) and a drug called denosumab — are recommended to reduce the risk of bone complications. Some cancer treatments, including abiraterone acetate, enzalutamide, and radium-223, also appear to have additional beneficial effects on bone health. Side effects of bone health agents, particularly a serious jaw condition (osteonecrosis of the jaw) and low calcium levels, require monitoring.
This research suggests that a proactive, structured approach to bone health — combining regular monitoring with appropriate medications — can meaningfully reduce complications and improve quality of life for men with prostate cancer. The authors provide a practical decision-making algorithm to help doctors integrate bone health assessment and treatment into routine cancer care, emphasizing that this should be considered a standard part of managing prostate cancer rather than an optional add-on.
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R. Mckay, H. Hofflich, Gina Woods, Richard Andres, A. Farooki. (2026). Bone health in advanced prostate cancer: pathophysiology and management strategies.. The Oncologist. https://doi.org/10.1093/oncolo/oyag321