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Sandy Srinivas, MD


Castration-Sensitive Prostate Cancer: The Cost of Overusing Bone-Modifying Agents

By: Jenna Carter, PhD
Posted: Wednesday, May 15, 2024

The use of bone-modifying agents to prevent skeletal-related events may be necessary for patients with castration-resistant prostate cancer; however, early initiation of these treatments in patients who are still castration-sensitive may have no benefit and ultimately contribute to excess costs to Medicare. In an article published in JCO Oncology Practice, Aaron P. Mitchell, MD, MPH, of Memorial Sloan Kettering Cancer Center, New York, and colleagues assessed the use of bone-modifying agents among patients who did not have an indication for osteoporosis fracture prevention. Their findings revealed that the estimated Medicare cost for annual excess use of bone-modifying agents was $44,105,041 in U.S. dollars.

“This study suggests substantial excess costs to Medicare resulting from [bone-modifying agents] overuse for patients with [castration-sensitive prostate cancer]…. These results therefore indicate an opportunity for potential cost-savings without a tradeoff in terms of patient outcomes,” stated the investigators.

Surveillance, Epidemiology, and End Results (SEER) Program–Medicare data from 2011 to 2015 were employed in this study to assess the frequency and number of doses of the bone-modifying agents zoledronic acid and denosumab. Doses were measured between diagnosis and initiation of metastatic castration-resistant prostate cancer therapy. The Medicare fee schedule was used to assess drug prices, and peer-reviewed sources were used to estimate adverse event frequencies and costs.

Findings revealed that the median duration of castration-sensitive prostate cancer was 387 days (interquartile range = 253–573 days); during this time, 42% of patients had received at least one dose of denosumab (mean doses, 7), and 18% had received at least one dose of zoledronic acid (mean doses, 7). A total of 38% of those receiving denosumab and 47% of those receiving zoledronic acid had a history of osteoporosis, osteopenia, spine or hip fracture, or hypercalcemia. Cost analyses revealed that the estimated annual excess bone-modifying agents cost to Medicare was $44,105,041, with a total of $682,865 and $75,585 recorded for adverse event costs for denosumab and zoledronic acid, respectively.

Disclosure: For full disclosures of the study authors, visit

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