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

Prior to implementing the tool, inappropriate BMA prescribing was found in more than 50% of cases of men with metastatic sensitive-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 the tool was implemented, inappropriate prescribing was reduced to zero, he reported in a poster presentation at the Association of VA Hematology/Oncology meeting.

The "simple tool implementation" ensured that all patients got the necessary dental screening pre-BMA therapy, and overall, improved prostate cancer-related bone healthcare, he stated.

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

Evidence-based guidelines recommend using denosumab (Prolia, Xgeva) or zoledronic acid (Reclast) at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer (CRPC) with bone metastases, and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture, Sahu explained. "But there are incidents of BMAs being underprescribed and overprescribed," he noted.

For example, in a 2022 study, researchers found that among 2,627 patients with stage IV prostate adenocarcinoma who had received ADT or antiandrogen therapy, and had no evidence of a high risk of fracture from osteoporosis, 24% inappropriately received BMAs.

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

A chart review at the Salt Lake City VA Medical Center indicated a similar situation existed there, "with several patients receiving BMAs that were not supported by the evidence," according to Sahu. Specifically, among 41 patients with mCSPC without bone metastasis, 58% were treated with BMA dosage supported in the setting of CRPC with bone metastases.

Furthermore, while it is recommended patients should undergo a comprehensive dental exam, and that initiation of BMA therapy should be delayed until after necessary preventive dental work is completed, almost one-third of the patients in the chart review had not been evaluated prior to the start of BMA therapy.

"So this is a real-world problem we are dealing with," Sahu said.

Sahu's group created an algorithm-based clinical practice tool designed to provide appropriate bone healthcare by increasing adherence to evidence-based guidelines at the VA center. 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.

Implementation of the tool "resulted in a significant difference in clinicians' practice while prescribing denosumab and zoledronate," Sahu reported.

Compared with the 58% of patients inappropriately treated prior to implementation of the tool, none of 35 patients evaluated post-implementation were inappropriately treated. And while 12 of 41 patents (29%) had not received recommended dental evaluations in the pre-implementation period, all 35 patients in the post-implementation period underwent dental evaluations.

"Implementation of an algorithm-based decision tool in the medical record system can help guide providers to indications of BMAs, be mindful of side effects, and provide more standardized care," Sahu and colleagues concluded.

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