How to maintain it and what to do.

“The 5-year survival rate for people with prostate cancer in the United States is 98%. The 10-year survival rate is also 98%.”.

Osteoporosis and osteopenia are common in men with prostate cancer, even before initiating ADT (androgen deprivation therapy), particularly in the elderly population. Several studies have identified factors that can help decrease bone loss even in the absence of cancer. Factors that help maintain optimal bone health include maintaining a normal BMI, consistent weight-bearing exercises, reducing or avoiding alcohol, not smoking, and eating a diet that is rich in calcium.

The National Comprehensive Cancer Network (NCCN) recommends a daily target of 1000 to 1200 mg calcium and 400 to 1000 IU vitamin D ideally from food and appropriate supplements.

The key to protecting and improving bone health in prostate cancer is to be aware of your baseline bone health status, start protecting your bones early in the treatment process, assess fracture risk regularly, and use the results to monitor and maintain a bone health plan. Here’s how you can systematically do this:

Before starting ADT, get your serum calcium and vitamin D levels at baseline measured, and then consider supplementation.

Studies using DEXA scans indicate that supplementation helps attenuate loss of bone density during ADT, particularly during the first year of treatment. Dark and leafy greens, such as kale, collard greens, and bok choy, have calcium. They also have bone-strengthening vitamin K. Sweet potatoes have magnesium and potassium, which are also needed for bone health. Fatty fish, like salmon, has vitamin D, which helps your bones absorb calcium, and the omega-3 fatty acids are also good for bones.

If you have been newly diagnosed with prostate cancer, consider some form of baseline fracture risk assessment using tools such as the FRAX® algorithm.

A DEXA scan alone may not be sufficient to assess fracture risk. The FRAX® algorithm estimates the 10-year probability of major osteoporotic fracture (clinical spine, forearm, hip, or shoulder) and of hip fracture based on independent risk factors such as age, body weight, smoking history, glucocorticoid exposure, and family history of hip fracture.

Osteonecrosis of the jaw is a low but important risk of prostate cancer treatment, so dental concerns should be addressed prior to treatment initiation.

Oral numbness is an early warning sign of jaw osteoporosis, and patients who develop this symptom should promptly contact their cancer care team.

Exercise has benefits for the maintenance of bone health during aging.

In terms of musculoskeletal health outcomes, a number of interventions have shown that progressive resistance training (PRT) can increase muscle strength, muscle endurance, and balance in men treated with ADT. Another important consequence of exposure to ADT is sarcopenia, a degenerative loss of muscle mass that is in turn associated with frailty and increased fall risk. Muscle-strengthening exercise and maintaining healthy nutrition with adequate protein intake have been evaluated and shown to potentially help decrease the risk of sarcopenia and its consequences in patients on ADT.

Smoking in any amount has a detrimental effect on bone density.

Smoking has been shown to reduce blood supply to the bones, slow the production of bone-forming cells, and negatively affect the absorption of calcium. Both drinking alcohol and smoking cigarettes increase your risk of falling, which can lead to fractures.

Alcohol intake of greater than 1-2 ounces per day (or about 1-2 typical drinks) has been shown to increase bone loss.

When you drink 2 to 3 ounces of alcohol every day, it affects the ability of the stomach to absorb calcium adequately. Alcohol also interferes with the ability of the pancreas (mitochondrial dysfunction) to absorb calcium and vitamin D. It is a proven fact that alcohol is significantly detrimental to liver function. The liver is important for vitamin D activation, which in turn affects calcium absorption and overall bone health.

If you have or are at risk for osteoporosis, it is important to prevent falls.

Here are some tips for keeping yourself safe in your home:

• Place items you use most often within easy reach so you don’t have to bend and stoop.
• Put skid-proof backing on carpets and area rugs, or tack them to the floor.
• Remove loose cords and wires from the floor.
• Place a non-skid rubber mat in the shower or tub.
• Keep a flashlight by your bed so you don’t trip if the power goes out.
• Mark the bottom and top steps of your staircase with brightly colored tape.
• Choose the right footwear. To fully support your feet, wear non-skid, rubber-soled, low-heeled shoes. Don’t walk on stairs or floors in socks or in shoes and slippers with smooth soles.

Prescription medications such as denosumab, zoledronic acid, or alendronate may be recommended if your risk for fracture is high.

Bisphosphonates (zoledronic acid and alendronate) increase bone mineral density during ADT. Denosumab increases bone mineral density and decreases fracture risk in patients with non-metastatic prostate cancer undergoing ADT. Your cancer care team will advise you if these medications are appropriate for you.

Taking charge of your bone health can go a long way toward maintaining your quality of life at home and outside as you go through treatment and survivorship.