Addressing the unmet need for BMD screening in prostate cancer patients undergoing ADT requires a multifaceted approach13. Healthcare providers must prioritize bone health assessments and integrate BMD screening into routine clinical practice. This project, utilizing the Auto-recruit path for bone health screening in the outpatient management system, effectively increased the overall screening rate from 9.5% between 2000 and 2018 to 33.6% in 2021–2022. Additionally, patients’ willingness to accept osteoporosis-related prevention and treatment significantly improved after undergoing the screening process. To our knowledge, this study is the first to demonstrate a significant increase in prostate cancer osteoporosis screening rates through a simple program setup, proving that electronic system support can effectively enhance healthcare efficiency.
Despite a significant improvement in the screening rate, the actual rate of 33.6% remains below expectations. Several factors may explain this outcome. First, the system’s mandatory pop-up reminder is designed to comprehensively ensure that all eligible patients are considered. However, the inclusion criteria did not account for factors such as age, race, comorbidities, performance status, or life expectancy, which may make patients unsuitable for screening. These factors could potentially impact the final enrollment results and the overall screening rate. Second, some physicians may have considered BMD screening unnecessary for specific patients, as indicated by the higher age and longer ADT duration among non-participants, which could correlate with a poorer prognosis. Third, 20.4% of non-participants were already receiving BMAs without prior DXA screening, likely impacting the physicians’ decision to forgo additional screening. Furthermore, some non-participants may have undergone DXA screening over 12 months prior, or had bone metastases, where BMAs were prescribed to prevent skeletal-related events rather than to address low BMD.
Bone-modifying agents (BMAs) are effective in preventing fractures and reducing skeletal-related events (SREs) in patients with CRPC with bone metastasis14. In contrast, previous clinical trials have shown that there is no significant survival benefit from using BMAs in patients with metastatic castration-sensitive prostate cancer (mCSPC), which is why routine use of BMAs is not recommended in this population15,16. However, in recent years, this recommendation against BMA use has often been interpreted more broadly as an indication of “unnecessary use.”17 Nonetheless, providing BMAs selectively to patients who truly need it can still yield substantial benefits, as supported by the post hoc analysis of the LATITUDE trial18. A crucial component of this approach is BMD screening and the prevention of osteoporotic complications. Thus, implementing comprehensive BMD screenings for prostate cancer patients on ADT could help identify those at high risk for fractures. These high-risk patients could then receive BMAs, effectively preventing fractures while avoiding unnecessary side effects and reducing medical waste19,20.
ADT can accelerate bone loss, leading to osteoporosis and an increased risk of fractures. A 24-month prospective observational study of prostate cancer patients undergoing ADT found that the prevalence of osteoporosis and osteopenia significantly increased from 10% and 58–22% and 70%, respectively21. In our study, patients who had been on ADT for more than a year showed a significant decrease in their minimal T-scores and a higher proportion meeting the criteria for osteoporosis, echoing these findings. Although older patients on long-term ADT might initially overlook bone health issues, our study revealed that this group showed a significant increase in willingness to accept calcium supplements and bone-modifying agents after BMD screening. This indicates that these patients are not unwilling to take action to protect themselves, but rather they are unaware of their bone health status. Therefore, patient education and awareness initiatives are crucial to empower individuals to advocate for their bone health and pursue appropriate screening and preventive interventions22.
This study has several limitations. First, although it is a prospective cohort study, most patients lacked baseline BMD data prior to initiating ADT, which may affect the accuracy of osteoporosis data analysis. To address this issue, we simultaneously established a bone-health database aimed at facilitating long-term and comprehensive data analysis regarding the impact of ADT on bone health. Second, although the auto-recruit path in the outpatient system was associated with a significant increase in screening rates, other factors—such as heightened clinician awareness, patient education initiatives, and evolving clinical practices over time—may also have contributed to this rise. Our current study design does not allow us to isolate the impact of each of these factors. Future research will focus on examining the effects of different clinical policies over time to better assess the specific contribution of the auto-recruit system. Third, while many patients took preventive and therapeutic measures for bone health after BMD screening, there is still no direct evidence that these measures effectively reduce SREs. Long-term follow-up and comparison of cohort differences are necessary to establish this evidence. Furthermore, in this study, we referred to ‘patient willingness’ regarding the increased uptake of calcium supplementation and BMA use. However, without direct patient-reported outcomes, we lack definitive evidence to attribute the increase solely to patient willingness. Other factors, such as increased clinician awareness or prioritization, may have also played a role. Therefore, it is challenging to fully distinguish the contributions of each factor in this context. Lastly, this study was conducted at a single medical center. Although the implementation relied on simple diagnostic and medication codes, not all healthcare electronic systems may support such configurations, potentially limiting the generalizability of the system. Further validation in diverse healthcare settings is needed to assess its broader applicability.
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