In
prostate cancer, the development of skeletal
metastases is associated with a significant increase in morbidity, mainly because of severe bone
pain, which eventually becomes refractory to conventional
analgesia.
Androgen ablation is the treatment of choice, but the majority of patients relapse within 2 to 3 years from initiation of treatment. After failure of
hormone therapy, external-beam irradiation
therapy is effective in the palliation of
pain, but
radionuclides represent an attractive and cost-effective alternative.
Strontium 89 is currently the most commonly used
radionuclide in the palliative management of
prostate cancer metastatic to the skeleton. The rationale for the use of
bisphosphonates in metastatic
prostate cancer is not immediately obvious, given the predominantly osteoblastic nature of the metastatic process. The clinical use of these agents rests on a number of basic and clinical observations that provide ample evidence that, in
prostate cancer, the metastatic process is associated with increased
bone resorption. Evidence regarding the beneficial effects of
bisphosphonates in reducing morbidity from metastatic
prostate cancer is reasonably solid, although the choice of optimal
bisphosphonate, mode of administration, dose, and
duration of treatment must be determined in large, controlled studies before their widespread clinical use can be advocated. Available therapeutic modalities that use either
radionuclides or
bisphosphonates can effectively and safely be used in the palliative management of metastatic
prostate cancer. Neither
radionuclides nor
bisphosphonates have been shown to prolong survival, but the potential of both agents to beneficially alter the metastatic process in
prostate cancer is intriguing.