Real-world use of bone-modifying agents (BMA) in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC) in the US.
Authors: Swami Umang , Jo Yeonjung , Hage Chehade Chadi , Ozay Zeynep Irem , Sayegh Nicolas , Gebrael Georges , Ostrowski Micah , Campbell Patrick , HU Siqi , Galarza Fortuna Gliceida M , Mathew Thomas Vinay , Li Haoran , Graf Ryon P , Roy Soumyajit , Maughan Benjamin L. , Guha Avirup , Riaz Irbaz Bin , Antonarakis Emmanuel S. , McKay Rana R. , Agarwal Neeraj 
Published: February 2025

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Background:
Most pts with prostate cancer with bone metastasis experience symptomatic skeletal events (SSEs) [PMID: 23884473], leading to increased morbidity and mortality. BMAs have been approved since 2007 and are recommended in mCRPC to prevent SSEs in pts with bone metastases or a high risk of osteoporotic fracture. Herein, we sought to assess the real-world trends of BMA administration in pts with mCRPC.
Methods:
We used the de-identified nationwide Flatiron Health electronic health record (EHR)-derived database to extract pt-level data. Inclusion criteria: pts with mCRPC with available date of diagnosis of mCRPC and information on receipt of BMA. Pts were categorized into 2 cohorts based on BMA receipt (e.g., bisphosphonates, denosumab, teriparatide, romosozumab) or not. Treatment trends of BMA by year of mCRPC diagnosis were summarized using frequency and percentages. Baseline characteristics at the time of mCRPC diagnosis (age, race-ethnicity, practice type, insurance) were compared between cohorts using the Wilcoxon rank-sum and Chi-squared tests.
Results:
Of 24,105 pts with metastatic prostate cancer in the dataset, 14,112 with mCRPC were eligible and included. 7,990 (56.6%) received BMA while 6,122 (43.4%) did not. In BMA receipt cohort: median age was 75 (IQR 67 – 81), majority were White (61%), treated in community practice (87%) and had commercial health plan (80%). In BMA non receipt cohort: median age was 75 (IQR 68 – 82), majority were White (61%), treated in a community practice (78%), and had commercial health plan (76%). The use of BMA decreased over time from 56% in 2013 to 46% in 2024 (Table). Statistically significant differences existed between cohorts in race-ethnicity, practice type, and insurance (p < 0.001) and will be presented at the meeting.
Conclusions:
Despite recommendations to use BMAs in pts with mCRPC and bone metastasis or high risk of osteoporotic fracture, our findings reveal a low utilization rate of BMAs in mCRPC setting with a notable decline over time. This highlights the need to incorporate the use of BMAs in clinical practice and improve access to these agents.

Trends by year of mCRPC diagnosis in receipt of the first BMA and frequency and percentage of each agent.

Year
2013N = 549
2014N = 1035
2015N = 1223
2016N = 1345
2017N = 1441
2018N = 1346
2019N = 1469
2020N = 1380
2021N = 1352
2022N = 1393
2023N = 1196
2024N = 383

Receipt of BMA, n (%)
316 (56)
674 (65)
792 (65)
837 (62)
886 (61)
766 (57)
816 (56)
766 (56)
692 (51)
713 (51)
556 (46)
176 (46)

Denosumab, n (%)
190 (60.1)
450 (66.8)
557 (70.3)
599 (71.6)
606 (68.4)
533 (70)
526 (64.5)
488 (63.7)
410 (59.2)
414 (58.1)
290 (52.2)
94 (53)

Zoledronic acid, n (%)
120 (38)
220 (32.6)
228 (28.7)
233 (27.8)
270 (30.5)
225 (29)
281 (34.4)
273 (35.6)
277 (40)
295 (41.4)
258 (46.4)
82 (47)

Teriparatide, other bisphosphonates, n (%)
6 (1.9)
4 (0.6)
7 (1)
5 (0.6)
10 (1.1)
8 (1)
9 (1.1)
5 (0.7)
5 (0.7)
4 (0.5)
8 (1.4)
0