Clinical decision tool rules out inappropriate BMA therapies in prostate cancer

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SAN DIEGO — An algorithm-based decision tool has eliminated inappropriate prescribing of bone modifying agents (BMAs) in patients with advanced prostate cancer, according to a VA-based study.

Prior to tool implementation, inappropriate BMA prescribing was seen in over 50% of men with metastatic susceptible and resistant prostate cancer (mCSPC) without bone metastases at the George E Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, explained Kamal Kant Sahu, MD, of the Huntsman Cancer Institute, also in Salt Lake City.

After implementing the tool, inappropriate prescribing was reduced to zero, he reported in a poster presentation at the Association of VA Hematology/Oncology meeting.

The “simple implementation of the tool” enabled all patients to receive the necessary dental screening prior to BMA therapy and overall improved prostate cancer bone health care, a he declared.

Long-term androgen deprivation therapy (ADT) remains the backbone of treatment for locally advanced and metastatic PC. But a well-known consequence of ADT treatment is the potential for bone health complications, due to decreased bone mass density and increased risk of osteoporosis and bone fracture.

Evidence-based guidelines recommend using denosumab (Prolia, Xgeva) or zoledronic acid (Reclast) at doses indicated for bone metastases in castration-resistant prostate cancer (CRPC). ) with bone metastases, and at doses indicated for osteoporosis in the hormone-sensitive environment in patients at significant risk of fragility fracture, Sahu explained. “But there are incidents where BMAs are under-prescribed and over-prescribed,” he noted.

For example, in a 2022 Journal of the National Cancer Institute study, researchers found that among 2,627 patients with stage IV prostate adenocarcinoma who had received ADT or anti-androgen therapy and had no evidence of high risk of fracture due to osteoporosis, 24% had received BMAs inappropriately.

Sahu pointed out that underprescribing BMAs increases the risk of osteoporosis and bone fracture, while overprescribing leads to unnecessary costs and the risk of toxicity, such as osteonecrosis of the jaw.

A review of records at Salt Lake City VA Medical Center indicated that a similar situation existed there, “with several patients receiving BMAs that were not supported by evidence,” according to Sahu. Specifically, among 41 patients with mCSPC without bone metastases, 58% were treated with a supported dose of BMA for CRPC with bone metastases.

Additionally, although patients are recommended to undergo a full dental examination and the start of BMA treatment is delayed until the necessary preventive dental work is completed, almost a third of the patients in the examination records had not been assessed prior to the start of BMA therapy.

“So this is a real problem that we are facing,” Sahu said.

Sahu’s group created an algorithm-based clinical practice tool designed to provide appropriate bone health care by increasing adherence to evidence-based guidelines at the VA center. The tool prompts clinicians to follow the appropriate algorithm in a step-by-step fashion to ensure pre-treatment dental assessment and use of the correct drug dosage.

Implementing the tool “resulted in a significant difference in clinicians’ practice when prescribing denosumab and zoledronate,” Sahu reported.

Compared to the 58% of patients treated inappropriately before the implementation of the tool, none of the 35 patients assessed after the implementation were treated inappropriately. And while 12 of the 41 patients (29%) did not receive recommended dental assessments in the pre-implementation period, all 35 patients in the post-implementation period received dental assessments.

“Implementing an algorithm-based decision tool in the medical records system can help guide providers to indications for BMAs, account for side effects, and provide more standardized care,” concluded Sahu and his colleagues.

  • Mike Bassett is a writer who focuses on oncology and hematology. He is based in Massachusetts.

Disclosures

Sahu did not disclose any relationship with the industry.

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