Treatment of Prostate Cancer with Bone Metastases to Pelvis and Ribs

Systemic Therapy Approach

The European Association of Urology recommends continuous androgen deprivation therapy (ADT) as the foundation of treatment for metastatic hormone-naïve prostate cancer, with the addition of docetaxel chemotherapy if the patient is fit enough 1, 2
The European Society for Medical Oncology suggests that continuous ADT is the cornerstone first-line treatment for metastatic hormone-naïve prostate cancer, achieved through either bilateral orchiectomy or LHRH agonist/antagonist 1, 2, 4
When initiating LHRH agonists, a short-course antiandrogen (e.g., bicalutamide) should be administered to prevent disease flare from the initial testosterone surge, as recommended by the European Association of Urology 5, 4

The European Society for Medical Oncology recommends either denosumab 120 mg subcutaneously every 4 weeks or zoledronic acid 4 mg intravenously every 3-4 weeks to prevent skeletal-related events in patients with bone metastases from castration-resistant prostate cancer (CRPC) at high risk for skeletal-related events (SREs) 1, 6, 7, 2
Denosumab demonstrated superiority over zoledronic acid in delaying time to SREs (HR 0.82, P=0.0002), though neither agent improves overall survival, according to the European Association of Urology 8, 6, 7

The European Society for Medical Oncology recommends a single 8 Gy fraction of external beam radiation for palliation of painful bone metastases in the pelvis or ribs 1, 2, 3
Single-fraction 8 Gy provides equivalent pain relief to 10 fractions of 3 Gy (30 Gy total) but is more convenient and cost-effective, as suggested by the European Association of Urology 5, 3

The European Association of Urology recommends abiraterone acetate or enzalutamide as first-line options for asymptomatic/mildly symptomatic chemotherapy-naïve metastatic CRPC 1, 2
Docetaxel 75 mg/m² every 3 weeks is recommended for symptomatic metastatic CRPC, according to the European Society for Medical Oncology 1, 6, 7, 2

The European Association of Urology recommends MRI of the spine to detect subclinical cord compression in men with CRPC with vertebral metastases 1, 2
Urgent MRI is very strongly recommended for any patient with vertebral metastases who develops neurological symptoms, as suggested by the European Society for Medical Oncology 1, 2
Monitor for osteoporosis using bone densitometry in men on long-term ADT, and screen for metabolic syndrome complications including cardiovascular risk factors, according to the European Association of Urology 1, 2