Osteoporosis Basics for Men

BY MARK SCHOLZ, MD

Osteoporosis is the medical term for “weakened bones” resulting from the slow leaching of calcium over time. Osteoporosis is incorrectly thought to happen only in females. However, one-third of hip fractures occur in men and are associated with higher mortality rates in men with prostate cancer. Calcium loss is a silent process until a fracture suddenly occurs. Common fracture sites are spine, rib, wrist, and hip. Compression fractures of the spine can be quite painful and result in loss of height with forward curvature of the spine.  

Cause of Osteoporosis
Just as there is a link between lack of estrogen and osteoporosis in women, studies show that there is also a relationship between a lack of testosterone and osteoporosis in men. Other causes of osteoporosis are thyroid or parathyroid hyperactivity, excessive alcohol, cortisone, lack of exercise, low vitamin D and low calcium intake. Osteoporotic fractures also occur more frequently in men taking testosterone inactivating pharmaceuticals (TIP).

Detecting Osteoporosis
Osteoporosis, when it is diagnosed at an early stage, is easier to treat. Unfortunately, the most common scanning technique for diagnosing osteoporosis, the DEXA scan—grossly underestimates the degree of bone mineral loss from the spine in men. Why? Because almost all men over fifty have calcium deposition in the ligaments surrounding the spine. When the DEXA is used to measure bone density, the excess calcium in the ligaments causes an incorrectly “normal” bone density reading.

Fortunately there is a better technique called QCT that measures bone mineral density in the center of the vertebral column. Awareness of the DEXA scans' limitations in men is under appreciated by many physicians even though these limitations have been well documented in a study from Massachusetts General Hospital. In this study 41 men underwent both DEXA and QCT scanning. QCT detected osteoporosis in 26 of the men (63%) but DEXA only diagnosed it in two (5%).

Preventing Osteoporosis
Osteoporosis treatment begins with an exercise program. Supplementation with calcium and vitamin D should also be considered routine. We recommend 500 mg of calcium at bedtime and a starting dose of 1,000 units of Vitamin D. Blood levels of vitamin D should be checked and oral intake of vitamin D adjusted accordingly.  Studies show that using TIP intermittently (compared to continuous TIP) results in less bone loss. Treatment with bisphosphonates or denosumab (see below) can prevent TIP-induced bone loss.

Osteoporosis Medications
Osteoporosis can be reversed with bisphosphonates or denosumab. Normal bone metabolism is a balance between the rate of bone breakdown and the formation of new bone. Osteoporosis occurs when the formation of new bone lags behind the rate of bone breakdown. Bisphosphonates and denosumab function by slowing the rate of bone breakdown, allowing the osteoblasts, the cells that form new bone, to increase the net amount of bone matrix.

Oral Medications: Boniva, Actonel and Fosamax
Bisphosphonates come in both oral and intravenous forms. Absorption into the blood of oral forms is enhanced when they are administered with an empty stomach. The most common side effect from oral bisphosphonates is stomach or esophageal irritation which can be minimized by maintaining an erect position for an hour after taking the drug.

Intravenous Bisphosphonates: Zometa (zolendric acid)
Intravenous administration of Zometa has the advantage of bypassing the stomach thus avoiding concerns about stomach irritation. Also with the intravenous approach 100% of the drug gets into the system as compared to the oral preparations that are only 1-2% absorbed. The most common side effect from Zometa is a brief flu-like muscle soreness lasting a day or so. These symptoms do not usually recur on subsequent infusions. For the treatment of osteoporosis the infusions are repeated every three to six months.

Denosumab Injections: Prolia and Xgeva
Like Zometa, denosumab inhibits the osteoclasts, but by a different mechanism.  Denosumab is marketed in two strengths for injection. A half-dose shot called Prolia is administered every 6 months for osteoporosis.  A full dose shot called Xgeva is given monthly for cancer metastasis to the bone.

Medication Induced Jaw Problems: Osteonecrosis
Zometa and denosumab and to a much lesser degree, oral bisphosphonates can rarely induce damage to the jaw, a condition termed osteonecrosis.  The risk of developing osteonecrosis is much higher when a tooth is extracted. When osteonecrosis occurs, the gum tissue recedes leaving exposed bone which is susceptible to recurrent infections. The risk of osteonecrosis becomes higher as the lifelong cumulative medication dosage increases. In my experience, osteonecrosis almost always reverses, albeit slowly, after the medication is stopped.

 

Bone Metastases

Zometa and denosumab are also FDA approved to treat cancer that has metastasized to bone. Their anticancer effect is believed to occur because by inhibiting bone breakdown, cancer cell access to the growth factors and cytokines that are normally locked up in the bone matrix is blocked. So these medications that inhibit bone turnover by stopping osteoclast activity not only help osteoporosis but also help to prevent bone metastases from progressing.

Final thoughts

Eventually some degree of osteoporosis occurs in most men as they age.  Regular exercise, calcium and vitamin D help delay bone loss.  Bone density screening in men should probably begin when they are in their 60s, so the condition can be detected early.  Bone density augmentation with denosumab or bisphosphonates seems to be more effective when osteoporosis is not too severe at the start of therapy.   

 

 

Preventing Hormone Therapy Side Effects

BY MARK SCHOLZ, MD

Side effects vary from patient to patient and are influenced by types of testosterone inactivation pharmaceuticals (TIP) used, and by the duration of treatment. However, a number of interventions are available that can substantially reduce these adverse side effects.

Loss of Libido
Libido is an emotional attraction to the opposite sex (in most cases). Libido is not the same thing as potency, which is defined as the ability to get an erection. TIP causes loss of libido about 90% of the time.  Libido returns when TIP is stopped though some men say libido after TIP is chronically diminished. Loss of libido and the cessation of sexual activity has wide ranging ramifications far beyond the intended scope of this blog. Specialists in sexual counseling are available and can be of great assistance.

Erectile Atrophy
Whether or not couples continue to have sexual intercourse after treatment, we counsel men to induce daily erections to counteract the risk of penis shrinkage. Cialis or Viagra should be taken daily.  If this fails to restore the normal pattern of nighttime erections then either a vacuum pump or injection therapy should be considered.  

Muscle Atrophy
Muscle mass can be maintained with a strength training program. Walking, aerobics, and stretching are healthy but accomplish little toward building muscle mass. Strength training that is effective requires a program similar to that undertaken by body builders.  Ideally, strength training requires a minimum of two, one-hour sessions weekly during which all the major muscle groups are exercised: Pectorals, Deltoids, Biceps, Triceps, Latissimus dorsi, Upper and lower back muscles, Abdominals, Gluteus, Quadriceps, Hamstrings, and Calf muscles. Three sets of 10-12 repetitions should be undertaken with weight selected to result in muscle failure toward the end of the third set.

Fatigue and Lassitude

Tiredness and weakness from TIP are a direct result of muscle loss and reversible with strength training. Strength training is very effective for counteracting fatigue. Men who begin strength training when they initiate TIP will not only forestall tiredness, they can actually increase their strength.

Osteoporosis
TIP causes accelerated calcium loss from the bones, termed osteoporosis. Untreated bone loss can result in hip and spine fractures. Osteoporosis can be prevented with medications such as Prolia, Xgeva, Zometa, Boniva, Actonel and Fosamax which should be initiated when TIP is started.  See the booklet titled Osteoporosis available** soon at www.prostateoncology.com for further details.  

Hot Flashes
Hot flashes occur in about two-thirds of men on TIP. When severe, a progesterone injection (depo provera) can dramatically reduce hot flashes. Other prescription medications, which are effective about half the time, are low dose Effexor, a medication approved for the treatment of depression, and Neurontin, a medication approved to prevent seizures. Transdermal estrogen patches are very effective but sometimes cause breast enlargement or nipple tenderness.

Weight Gain
TIP slows metabolism causing weight gain. Keeping a stable weight is easier than trying to lose weight. It is wise to evaluate your diet at the time of starting TIP to see if fat and sugar intake can be reduced. See the brochure about diet from the PCRI for more details.

Breast Growth
Breast growth (even without estrogen patches) occurs frequently in men treated with Casodex monotherapy and less frequently, about one-third of the time, in men treated with other forms of TIP. If there is any evidence for breast growth or nipple tenderness, therapy with an estrogen blocking pill called Femara should be started immediately.  Alternatively, a short course of radiation to the nipples can be administered prior to starting TIP.  

Anemia
Blood is a mixture of red cells and "serum" (water). When the proportion of red cell is diminished it is termed anemia. Severe anemia can cause shortness of breath. Milder degrees cause fatigue. Anemia reverses when TIP is stopped. If anemia is severe, it can be corrected with a medication called Aranesp. Iron is not beneficial.

Arthritis
Joint pains particularly in the hands but sometimes in other joints are common and often improve with glucosamine, Motrin or Celebrex.

Liver Changes
Casodex and Flutamide occasionally cause serious liver problems. This is detected by blood tests that need to be done routinely after starting TIP. The problem is easily reversible if detected early and the medication is stopped.  

Mood Swings
Men on TIP occasionally mention increased intensity in their emotions. Some find this effect unpleasant whereas others enjoy it. For men with the former attitude, low doses of medications such as Zoloft or Paxil can reverse the unpleasant feelings.

Final Thoughts
My general impression after many years treating men with TIP is that treatment is quite tolerable if side effects are expertly managed. Preventative measures such as weight lifting and diet are critically important. Checking blood tests for anemia and liver function is essential. Side effects like joint pains, hot flashes, depression, emotional swings, breast enlargement and impotence can be greatly reduced with judicious medical care.

**email us to receive Osteoporsis booklet -- mail@prostateoncology.com

The Quest for the Prodigal Hard-On

BY RALPH BLUM

There is no doubt that all the main prostate cancer treatments—surgery, radiation or hormone therapy—are likely to affect erections. And although many men who are diagnosed with prostate cancer are older, and may therefore already be subject to the ordinary fatigue and malfunction of nature’s ultimate erector set, the degree to which sexual function returns—or fails to return—after treatment is still a matter of major concern for a number of us.

 

There is no set formula or predictable schedule for recovery of sexual function after prostate cancer treatment. If you choose surgery, your chance of recovering potency is partly dependent on the experience and skill of your surgeon. The minuscule nerves that control erections are located dangerously close to the prostate, and damage to or actual removal of those nerves during surgery causes permanent erectile dysfunction. Viagra or Cialis only works if the nerves can be spared. And even with successful nerve-sparing surgery it can take up to 12 months for the restoration of the natural ability to have an erection.

 

The radiation options—seed implants or IMRT—are associated with a significantly better chances for maintaining erectile dysfunction. But the reality is that radiation therapy still can cause erectile dysfunction because of the inflammation or scarring that occurs around the nerves.

 

Hormone therapy, another treatment alternative, causes total dissolution of sex drive, and you don’t even care that it’s gone! Fatigue, joint pain, depression and hot flashes are not exactly a turn-on either. And yet even without a libido, an erection can be achieved through the manipulation of modern pharmacology—that is if you can dredge up enough desire to give it a try for your partner’s sake—but even with a pharmacological assist, personal satisfaction is often seriously diminished.

 

There is, moreover, a “use it or lose it” caveat: many doctors who specialize in erectile dysfunction encourage sexual activity as soon as possible after treatment (or in the case of hormone therapy during treatment) on the grounds that the nerves and muscles that control erections can atrophy if they are not used for a long period of time.

 

If prostate cancer has already affected your ability to achieve erection, there are various options that might help—penile injections, a vacuum pump device, implantable pellets, or penile implants. I will present the pros and cons of these methods for inducing an erection in my next Blog. In the meantime, keep in mind that there are ways you can express your love for your partner and attain sexual gratification that don’t include penetration. Ways that include intimacy and tenderness, lest we forget.

Surgery vs. Seeds vs. IMRT

BY MARK SCHOLZ, MD

 

Many men with Intermediate-Risk prostate cancer consider treatment with radiation or surgery. Treatment selection is influenced by age and preexisting status, especially as regards baseline sexual and urinary function. These days “surgery” usually means robotic surgery rather than the older, “open” procedure. Brachytherapy (radioactive seeds), and intensity modulated radiation (IMRT) are the most widely used types of radiation.

 

Cure Rates

All treatment options result in similar cure rates assuming the best physicians and technology are used. If any single treatment can be considered to have a slight advantage, it is brachytherapy. Seed implants deliver a somewhat higher dose of radiation, possibly with slightly better accuracy. All types of radiation have a slight cure-rate advantage over surgery because radiation treats a small margin around the gland. Surgery, especially when extra-capsular disease is present, may leave cancer behind, an unfortuante situation called “a positive margin.”

 

Quality of Life

Since cure rates are equivalent, the main criteria for selecting treatment are side effects. Table 1 lists the risks faced by a 65-year-old with good erectile function and without preexisting prostate problems. Risks are adjusted up or down based on a man’s age and his sexual and urinary function prior to treatment.
 

Table 1 Long Term Side Effects

Impotence Incontinence Climacturia* Urethritis Stricture** Proctitis Surgery 50% 8% 15% - 5% - Seeds 30% 1% - 10% 2% 1% IMRT 30% 1% - 4% 2% 2% *Climacturia is the ejaculation of urine rather than sperm **Stricture is a urethral scar

Short Term Side Effects
Some of the long-term effects noted in Table 1 also occur short term. All men are impotent after surgery though 50% eventually recover some functionality. Urinary symptoms, termed “urethritis,” occur in two-thirds of men who undergo brachytherapy, usually lasting a couple months. Proctitis symptoms lasting one to two months occur in about half of the men who are treated with IMRT.

Treatment for Long Term Side Effects

Shrinkage and shortening of the penis due to surgery may be partially averted with early use of Viagra, Cialis or Levitra, and when necessary, the injection of prostaglandins. For treating impotence or incontinence, patient satisfaction is about 85% with a surgically implanted penile prosthesis and 60% with a surgically implanted artificial urinary sphincter. Chronic urethritis, a non-healing radiation burn of the urinary passage, manifests as pain, frequent urination, and a compelling urge to urinate right now. Proctitis side effects can be described similarly, but affecting the rectum. Palliative treatments for chronic urethritis and proctitis are only partially effective.

 

Further Aspects of Surgery and Radiation

 

Surgery: The surgical skill of urologists varies and is measured by how frequently cancer is left behind after the surgery, termed a positive margin. The best surgeons average a 10% rate. Studies show that many urologists, even at reputable centers, leave cancer behind up to 50% of the time. Prostate removal gives information about the size and grade of the cancer, helping to improve the accuracy of projections about future relapse. Surgery also simplifies PSA monitoring, since unlike radiation, there is no residual prostate gland producing PSA.

Seeds: Brachytherapy with permanent seeds is an outpatient procedure. Temporary, high-dose-rate (HDR) brachytherapy requires an overnight stay in the hospital. Men with preexisting urinary problems or glands over 60cc are more prone to develop urethritis from brachytherapy. A benign PSA rise after the implant, termed a “PSA Bump,” occurs in 30% of men and can engender considerable anxiety.

IMRT treatment requires two months to deliver. Radiation beaming through surrounding organs may increase the risk of bladder and rectal tumors, though the risk is clearly less than one percent. The biggest risk besides impotence is proctitis. In the future, the injection of hydrogel between the prostate and the rectal wall may eliminate this risk (Hydrogel is pending FDA approval).

Cyberknife and Proton Therapy: Cyberknife is like IMRT but treatment is over one to two weeks rather than two months. Proton therapy is also similar to IMRT except it fires heavier subatomic particles (proton vs. photon). Proctitis rates are reported to be slightly higher with either of these two modalities.

Combination Radiation with Seeds and IMRT: Men with High-Risk disease and even some with Intermediate-Risk are treated with a combination of Seeds and IMRT. The side effects of Seed/IMRT combinations are similar to those of seeds alone.

The Outdated Sequencing Argument
As stated at the outset, cure rates are high with both radiation and surgery. Arguments touting surgery as the “Gold Standard” were true ten years ago when suboptimal radiation resulted in lower cure rates. Regrettably, to this day, many surgeons are still claiming that sequencing surgery before radiation is advantageous. This outdated thinking prioritizes planning for relapse, forgetting about the need to focus on quality of life. The goal is to be cured with the first treatment and be spared the side effects of additional rounds of therapy.

Taking Time to Decide
Prostate cancer is slow moving condition. There is no need rush to a decision. Radiation or surgery cures men with Intermediate-Riskprostate cancer 70-90% of the time. Even if a relapse occurs, salvage therapy usually gives a normal life expectancy. Additional options, besides surgery and radiation, can also be considered for men in the Intermediate-Risk category including active surveillance, focal therapy and intermittent hormone blockade. However, these treatments are outside the medical mainstream and beyond the scope of this short blog.