Sumati Gupta

Background

The bone health of patients with locally advanced and metastatic prostate cancer is at risk both from treatment-related loss of bone density and skeletal-related events from metastasis to bones. Evidence-based guidelines recommend the use of denosumab or zoledronic acid at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer with bone metastases, and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture. For the concerns of jaw osteonecrosis, a dental evaluation is recommended before starting bone modifying agents. The literature review suggests that there is a limited evidence-based practice for bone health with prostate cancer in the real world. Both underdosing and overdosing on bone remodeling therapies place additional risk on bone health. An incomplete dental workup before starting bone modifying agents increases the risk of osteonecrosis of the jaw.

Methods

To minimize the deviation from evidencebased guidelines at VA Salt Lake City Health Care, and to provide appropriate bone health care to our patients, we created an algorithm-based clinical practice tool. This order set was incorporated into the electronic medical record system to be used while ordering a bone remodeling agent for prostate cancer. The tool prompts the clinicians to follow the appropriate algorithm in a stepwise manner to ensure a pretreatment dental evaluation and use of the correct dosage of drugs.

Results

We analyzed the data from Sept 2019 to April 2022 following the incorporation of this tool. 0/35 (0%) patients were placed on inappropriate bone modifying agent dosing and dental health was addressed on every patient before initiating treatment. We noted a significant change in the clinician’s practice while prescribing denosumab/zoledronate before and after implementation of this tool (24/41 vs 0/35, P < .00001); and an improvement in pretreatment dental checkups before and after implementation of the tool was noted to be 12/41 vs 0/35 (P < .00001).

Conclusions

We found that incorporating an evidence-based algorithm in the order set while prescribing bone remodeling agents led to a significant improvement in our institutional clinical practice to provide high-quality evidence-based care to our patients with prostate cancer.

Background

The bone health of patients with locally advanced and metastatic prostate cancer is at risk both from treatment-related loss of bone density and skeletal-related events from metastasis to bones. Evidence-based guidelines recommend the use of denosumab or zoledronic acid at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer with bone metastases, and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture. For the concerns of jaw osteonecrosis, a dental evaluation is recommended before starting bone modifying agents. The literature review suggests that there is a limited evidence-based practice for bone health with prostate cancer in the real world. Both underdosing and overdosing on bone remodeling therapies place additional risk on bone health. An incomplete dental workup before starting bone modifying agents increases the risk of osteonecrosis of the jaw.

Methods

To minimize the deviation from evidencebased guidelines at VA Salt Lake City Health Care, and to provide appropriate bone health care to our patients, we created an algorithm-based clinical practice tool. This order set was incorporated into the electronic medical record system to be used while ordering a bone remodeling agent for prostate cancer. The tool prompts the clinicians to follow the appropriate algorithm in a stepwise manner to ensure a pretreatment dental evaluation and use of the correct dosage of drugs.

Results

We analyzed the data from Sept 2019 to April 2022 following the incorporation of this tool. 0/35 (0%) patients were placed on inappropriate bone modifying agent dosing and dental health was addressed on every patient before initiating treatment. We noted a significant change in the clinician’s practice while prescribing denosumab/zoledronate before and after implementation of this tool (24/41 vs 0/35, P < .00001); and an improvement in pretreatment dental checkups before and after implementation of the tool was noted to be 12/41 vs 0/35 (P < .00001).

Conclusions

We found that incorporating an evidence-based algorithm in the order set while prescribing bone remodeling agents led to a significant improvement in our institutional clinical practice to provide high-quality evidence-based care to our patients with prostate cancer.

Background

The bone health of patients with locally advanced and metastatic prostate cancer is at risk both from treatment-related loss of bone density and skeletal-related events from metastasis to bones. Evidence-based guidelines recommend the use of denosumab or zoledronic acid at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer with bone metastases, and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture. For the concerns of jaw osteonecrosis, a dental evaluation is recommended before starting bone modifying agents. The literature review suggests that there is a limited evidence-based practice for bone health with prostate cancer in the real world. Both underdosing and overdosing on bone remodeling therapies place additional risk on bone health. An incomplete dental workup before starting bone modifying agents increases the risk of osteonecrosis of the jaw.

Methods

To minimize the deviation from evidencebased guidelines at VA Salt Lake City Health Care, and to provide appropriate bone health care to our patients, we created an algorithm-based clinical practice tool. This order set was incorporated into the electronic medical record system to be used while ordering a bone remodeling agent for prostate cancer. The tool prompts the clinicians to follow the appropriate algorithm in a stepwise manner to ensure a pretreatment dental evaluation and use of the correct dosage of drugs.

Results

We analyzed the data from Sept 2019 to April 2022 following the incorporation of this tool. 0/35 (0%) patients were placed on inappropriate bone modifying agent dosing and dental health was addressed on every patient before initiating treatment. We noted a significant change in the clinician’s practice while prescribing denosumab/zoledronate before and after implementation of this tool (24/41 vs 0/35, P < .00001); and an improvement in pretreatment dental checkups before and after implementation of the tool was noted to be 12/41 vs 0/35 (P < .00001).

Conclusions

We found that incorporating an evidence-based algorithm in the order set while prescribing bone remodeling agents led to a significant improvement in our institutional clinical practice to provide high-quality evidence-based care to our patients with prostate cancer.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.

PURPOSE/BACKGROUND: Long term androgen deprivation therapy (ADT) forms the backbone of treatment of locally advanced and metastatic prostate cancer. Bone modifying agents, such as bisphosphonates and denosumab, may be indicated in osteoporosis dosing in the castration-sensitive setting, and more intense dosing for bone metastases in the castration-resistant setting only. Dental evaluation and care prior to bone modifying agent use in osteoporosis or bone metastases has safety benefit. Historical lack of clinical practice guidelines for bone health in men with prostate cancer have limited evidence-based practice. A retrospective review of patients on active bone remodeling therapies for prostate cancer, Revealed that several patients with castration-sensitive disease received treatment at dosing supported only in the setting of castration resistance with bone metastases. Some patients had not completed dental evaluation prior to initiation of bone modifying agents.

METHODS: Following evidence-based expert consensus recommendations from multiple sources regarding bone health in prostate cancer, we created an algorithm- based clinical practice tool. This decision tool is activated within the electronic medical record order set when starting therapy with a bone remodeling agent in patients with prostate cancer. The tool supports treatment with appropriate dosing for the indication, and ensures pretreatment supportive care, such as dental evaluation, is performed.

DATA ANALYSIS/RESULTS: Since implementation of the algorithm-based decision tool, 0/10 (0%) patients were placed on inappropriate bone modifying agent dosing and dental care was addressed on every patient 10/10 (100%) initiating treatment. When evaluating the effect of the decision tool on the desired outcomes, we note that the fraction of patients getting overly intensive treatment before and after implementation of the tool was 24/41 vs 0/10 (p = 0.0008); lack of pretreatment dental assessment before and after implementation of the tool was noted to be 12/41 vs 0/10): ( =0.09). Fisher’s Exact Test was used for both comparisons.

IMPLICATIONS: Through implementation of an evidence- based algorithm and clinical practice tool while prescribing bone remodeling agents to patients with prostate cancer, we were able to improve our institutional practice to a high quality evidenced-based approach to prostate cancer bone health care.