Bone Health Programs in Urology Practices Deliver Continuity of Care

Raoul S. Concepcion, MD, FACS

Spurred both by the desire to provide the full spectrum of care to prostate cancer patients and by the emergence of treatments to address bone health in these patients, urologists across the country have begun to integrate bone health clinics into their practices. These clinics assess and treat the bone health of patients with prostate cancer at all stages of disease, allowing for better continuity and coordination of care.

Bone Health in Men

The treatment of prostate cancer within urology clinics is a recent development that has occurred over the last two years, according to Raoul S. Concepcion, MD, director of Clinical Research at Urology Associates in Nashville, Tennessee. And with that development, urology practices are finding that they are also faced with the need to address the skeletal effects of prostate cancer, which leaves men at risk for bone loss and fractures.About 12 million men are at risk for osteoporosis, and another 2 million already have this bone degenerative disease because of the increased incidence of prostate cancer.

Metastasis to the bone is typical in prostate cancer; the median time to bone metastasis is approximately 25 months for patients with nonmetastatic castration-resistant prostate cancer.¹ Bone metastasis causes osteoporosis, osteopenia, escalating bone pain, and bone marrow compromise.

In addition, treatment of prostate cancer can have adverse skeletal effects: androgen-deprivation therapy (ADT) increases the risk of bone loss and osteoporosis. After just one year of ADT, prostate cancer patients can have significant changes in their bone mineral density (BMD). A review of approximately 50,000 men with prostate cancer revealed that a significantly higher proportion of men who received ADT had a fracture compared with men who did not undergo ADT over a four-year period (19% vs 13%, respectively; P < .001).² The chance of fracture increased with longer duration of ADT.

Preventing and Addressing Skeletal Effects

These effects are especially worrisome because patients may stay on ADT for several years. Furthermore, with better screening methods and more awareness, earlier detection of prostate cancer is leading to longer medication use—and more bone loss. These patients are at much higher risk for spontaneous fractures, even without a significant injury or impact. Hip fractures are a particular concern, since about 30% of men die within the first year of breaking a hip.Several treatments are now available to delay time to a first skeletal- related event, including zoledronic acid (Zometa, Novartis) and denosumab (Xgeva, Amgen). In fact, the current large-scale trend to integrate bone health clinics into urology practices was stimulated by the approval of denosumab, Concepcion believes. The drug was approved in 2010 to prevent skeletal-related events in patients with bone metastases.

“Many of us had interest in bone clinics prior to 2010,” Concepcion said. The reason is that one of the standards of care for prostate cancer, luteinizing hormone-releasing hormone (LHRH) therapy, results in significant bone density loss and complications. “Urologists started saying, ‘We have created this issue, and we actually have to start managing this issue,’” Concepcion said.

The urology-bone clinic integration makes it easier for patients to have a BMD assessment prior to starting ADT—a current recommendation in prostate cancer guidelines. All prostate cancer patients need to have their BMD monitored and understand the preventive options available, according to a Canadian study.³

Mark G. Delworth, MD

Bone Health Clinics in Practice

The ability to monitor bone health and administer bonespecific treatments makes bone clinics within a urology practice a great asset: With a bone clinic embedded into the community urology practice, the prostate cancer patient’s spectrum of bone disease—from initial treatment-related fractures, to new bone metastases, to further skeletal complications that come with advanced, refractory disease—can be assessed and treated along with the cancer. The long-term care and follow-up that prostate cancer patients require are also made easier when a bone clinic is part of the urology practice.At the Cincinnati-based Urology Group, construction of a $20 million facility for advanced surgery care, slated to open later this summer, includes a bone health program to meet the needs of patients in the community. The Urology Group is one of the largest single-specialty groups of urologists in the central United States, with 34 physicians across 19 locations. The presentation of osteoporosis and osteopenia among their prostate cancer patients was the main driver for the program, according to Mark G. Delworth, MD, a urologic oncologist in the practice. “The impetus [for our bone health program] is to prevent further development of osteoporosis in the patient,” Delworth said.

Urology San Antonio, in Texas, also saw the bone health of prostate cancer patients as an unmet need—and met it by adding its own bone health clinic. Urologists at the clinic became aware of the bone health effects of ADT on the more than 700 prostate cancer patients it was seeing regularly, said Daniel R. Saltzstein, MD, the group’s medical director of Clinical Research. The center felt obliged to treat not just the cancer, but the bone health of the patients, said Saltzstein, who is now the director of the clinic’s Advanced Prostate Cancer and Bone Health Clinic.

Daniel R. Saltzstein, MD

Urology San Antonio centralized its bone health efforts at a single location, which allowed for a standardization of all bone health protocols and treatments. A physician assistant, directly supervised by Saltzstein, manages the clinic. Urology patients have access to the clinic on a once-weekly basis for their needs. One administrator is dedicated to conducting billing and insurance precertification for the clinic.“Our patients truly appreciate the continuity of care in the urologist’s office that this clinic provides,” Saltzstein said. “They like the fact that we’re not just addressing their problems with prostate cancer, but their other health issues as well.”

Saltzstein consults for other urology groups, helping them integrate a bone health service into their practice. A bone clinic “cheerleader” within a practice is essential for success, he says. A physician assistant to manage the clinic and set up protocols is the second step. “Having a physician assistant manage it and help set up protocols to deliver a quality standard of care has been a great help.”

For practices investigating the addition of a bone health program to their services, Delworth believes they may be in for a surprise. “I think [a urology practice] is going to be shocked by the prevalence of bone disease that’s out there,” he said. “We’ve known about bone disease and osteoporosis in women—that’s been identified for quite a period of time—but I don’t think people realize the propensity of [bone disease] in the male population.”

One issue for smaller or multidisciplinary practices is volume of patients. Each center has to understand its own goals and whether the urology center wants to fully manage prostate cancer without sending patients to a medical oncologist.

Although care of prostate cancer and now bone health are both relatively new to urology practices, many believe the trend will continue. And the next step in this evolution of care? Concepcion believes the extension of bone clinics into men’s health clinics and therapeutic clinics for advanced prostate cancer will be the next logical avenue for expansion of the urology clinic.

References

1. Smith MR, Cook R, Lee KA, Nelson JB. Disease and host characteristics as predictors of time to first bone metastasis and death in men with progressive castration-resistant nonmetastatic prostate cancer. Cancer. 2010;117:2077-2085.
2. 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.
3. Egerdie B, Saad F. Bone health in the prostate cancer patient receiving androgen deprivation therapy: a review of present and future management options. Can Urol Assoc J. 2010; 4:129-135.