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Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?LH-RH agonists, by suppressing testosterone and oestrogen, cause rapid bone demineralization and reduce both muscle strength and health related quality of life (HRQOL) in prostate cancer. A significant proportion of patients about to commence ADT are already osteoporotic, placing them at fracture risk. Bicalutamide monotherapy elevates testosterone and oestrogen levels, is licensed in locally advanced disease, but significantly underutilised in this setting.Whereas previous studies have assessed BMD and HRQOL in men across a range of BMDs, this study specifically evaluated osteoporotic men who are often older, with reduced muscle strength and with potentially the most to gain from bicalutamide monotherapy. BMD, muscle strength and HRQOL were each maintained across a 12-month period, suggesting that this treatment option should be considered more often by physicians and patients counseled appropriately.•To evaluate changes in bone mineral density (BMD), body composition, muscle strength and health-related quality of life (HRQL) during bicalutamide (150 mg) monotherapy in osteoporotic patients with non-metastatic locally advanced prostate cancer. Osteoporosis is prevalent in men presenting with prostate cancer and also a common side effect of treatment with luteinizing hormone-releasing hormone agonists, which are associated with decreased BMD and loss of lean body mass and suppress testosterone, unlike bicalutamide, which results in an increase in serum testosterone and oestrogen levels.•Forty-two men with non-metastatic locally advanced prostate cancer and osteoporosis (T-score ≤−2.5) were treated with bicalutamide (150 mg) monotherapy. BMD was measured at baseline and 1 year. HRQL was assessed 3-monthly using the RAND 36-Item Health Survey and University of California Los Angeles Prostate Cancer Index questionnaires. Bone turnover markers, liver function tests, prostate-specific antigen, testosterone, oestradiol and haemoglobin were measured at baseline, at 3 weeks and 3-monthly thereafter. Arm anthropometry and dynamometry assessed fat mass, skeletal muscle mass and quadriceps strength.•BMD was maintained (+2.1% lumbar spine, +1.2% total hip and +1.1% forearm). Prostate-specific antigen decreased by 88% at 3 months. Testosterone and oestradiol had increased at 1 year by 58% and 42%, respectively. No increase in bone turnover markers was seen over 1 year. Quadriceps muscle strength was maintained. General and prostate cancer-specific HRQL were maintained throughout the study, with no significant reductions in physical or sexual function. Adverse events included breast pain and gynaecomastia.•Bicalutamide preserves BMD, muscle strength and HRQL in osteoporotic men with non-metastatic locally advanced prostate cancer. It provides an alternative to medical castration for well informed men at high fracture risk and those wishing to retain physical and sexual activity, with luteinizing hormone-releasing hormone agonists being reserved for those failing to respond or relapsing.