Bisphosphonates for advanced prostate cancer
Bisphosphonates are drugs that can help manage bone problems when prostate cancer has spread to the bones. Prostate cancer that has spread to the bones and other parts of the body is called advanced prostate cancer.
Use this as a general guide and ask your doctor or nurse for more information. You can also call our Specialist Nurses on our confidential helpline.
Updated February 2013
To be reviewed February 2015
- Who can have bisphosphonates?
- What other treatments are available for bone pain?
- How do bisphosphonates work?
- What are the advantages and disadvantages?
- What does treatment involve?
- What are the side effects?
- Where can I get support?
- Questions to ask your doctor or nurse
- More information
You may be offered bisphosphonates if your prostate cancer has spread to your bones1,2. This is called advanced or metastatic prostate cancer. Prostate cancer that has spread to the bones is not the same as bone cancer, which starts in the bones.
If cancer spreads to your bones, it may damage and weaken them. This can cause bone pain and increase your risk of broken bones.
Bisphosphonates are used to help relieve and prevent bone pain in men with advanced prostate cancer. In some hospitals, bisphosphonates might also be used to manage bone thinning which can be caused by hormone therapy, or to help to prevent and slow down further bone damage4. For more information about bone thinning in prostate cancer, read our pages about Hormone therapy.
Bisphosphonates can also be used to treat a condition called hypercalcaemia which is high levels of calcium in the blood. This is rarely a problem in men with prostate cancer3, but you can read more about it in our booklet, Advanced prostate cancer: Managing symptoms and getting support.
In Scotland, bisphosphonates are not widely available, although they may be available in some areas. If you live in Scotland, talk to your doctor or nurse about what treatments you can have to manage your bone pain or any other problems you are having with your bones.
If you've had problems with your kidneys, teeth or jaws in the past, you may not be able to have bisphosphonates (see section: What does treatment involve?). And bisphosphonates may not be suitable for men who have heart problems. Talk to your doctor or nurse about whether bisphosphonates are suitable for you.
Zoledronic acid (Zometa®) is the bisphosphonate usually used to treat bone pain in men with advanced prostate cancer. Most men don't have problems taking zoledronic acid, but if you do, you might be given other bisphosphonates instead.
There are other treatments that can help with bone pain.
These can be used alone or in combination with other treatments.
Hormone therapy or chemotherapy
These treat the cancer itself, wherever it is in the body, including the bones. Treating the cancer may help with bone pain.
This shrinks the cancer cells and slows down the growth of the cancer. This can relieve pain and help to strengthen your bones.
Surgery to strengthen the bone
This helps to stabilise the bone, making it stronger and less painful.
Denosumab (Xgeva®) is a new drug for treating bone problems in some cancers. It is similar to bisphosphonates5. Denosumb is not yet widely available for men with prostate cancer in the UK, especially outside of England. If you live in England and your doctor thinks denosumab is suitable for you, they may be able to get it for you.
For more information about other ways of treating bone pain in prostate cancer, read out Tool Kit fact sheets:
- Pain and advanced prostate cancer
- Hormone therapy
- Radiotherapy for advanced prostate cancer
- Second-line hormone therapy and further treatment options
Your bones are made of living tissue and are constantly changing. In healthy bones, cells are always breaking down and rebuilding bone tissue - this is called the bone cycle. There are two different types of special bone cells to do this job:
- cells that break down bone, called osteoclasts
- cells that build bone, called osteoblasts
In strong and healthy bones, bone is broken down at the same rate as new bone is formed.
When prostate cancer spreads to the bone, it upsets the careful balance between the breakdown of old bone and the building of new bone6. Two things can happen:
- Bone gets broken down faster than it gets built so too much bone tissue is destroyed. This can make the bones thinner and weaker.
- Bone gets built faster than it gets broken down so too much bone tissue is formed. This is common in men with prostate cancer6,7. If this happens, the bone becomes thicker, but it is not as strong as bone that is formed normally. This is because the new bone tissue can be uneven and disorganised.
Damage to the bones makes them weaker and can cause bone pain and increase the risk of broken bones.
Bisphosphonates prevent the breakdown of bone by osteoclasts. They also encourage bone building by osteoblasts in places where too much bone has been broken down7-9. This can help to relieve pain.
What might be an advantage for one man might be a disadvantage for another. Talk to your doctor or nurse about your own situation.
- Bisphosphonates help to relieve bone pain and stop it getting worse. They can also help to prevent any new bone pain10.
- You may find it easier to move around if you have less bone pain.
- Bisphosphonates may help to reduce your risk of broken bones.
- Bisphosphonates lower the amount of calcium in your blood and treat the symptoms of hypercalcaemia.
- Like all treatments, bisphosphonates can cause side effects (see section: What are the side effects)
- If you are having zoledronic acid you will have to travel to the hospital every three or four weeks for treatment (see section: What does treatment involve?).
- Bisphosphonates can take up to three months to start helping with bone pain.
- You may need to have regular dental check-ups.
You will have some tests to check your kidneys. This is because bisphosphonate drugs may affect how well they work. The kidneys get rid of any waste products in your blood so it's important to make sure they are working properly before you begin treatment.
You will have a blood test before each infusion to check that your kidneys are working properly11 Make sure you drink plenty of fluids before treatment. This is to lower your risk of getting kidney problems.
You might need to have a full dental check up before you start treatment12,13. If you need dental treatment, you may not be able to have bisphosphonates until after you have had it. This is to lower the risk of developing a condition called osteonecrosis of the jaw see section: What are the side effects).
Your doctor or nurse will do regular blood tests to check that you have enough calcium, magnesium and phosphate in your blood. These are minerals that the body uses to build new bone. If the tests show that your levels are low, you may need to take supplements11. Your doctor or nurse will give you more information about this.
Speak to your doctor or nurse about any medical or dental problems you have had in the past. Let them know about any medicines you are taking at the moment.
A bisphosphonate called zoledronic acid (Zometa®) is usually used to treat men with prostate cancer. You will have your treatment at the hospital every three or four weeks. Zoledronic acid is a fluid which is given through a drip into a vein. The treatment takes fifteen minutes.
It may feel uncomfortable at the time but it should not hurt. You might feel dizzy or unwell for a few hours after your treatment so it's a good idea to go to the hospital with a friend or family member in case you need help driving or getting home.
How long will I take them for?
If you are having bisphosphonates to help relieve bone pain or to treat bone thinning, you can take them for as long as they are working for you. If you are having them to treat hypercalcaemia, you will usually stop treatment once your calcium levels are back to normal.
Alcohol and bisphosphonates
Drinking alcohol is not known to affect how well zoledronic acid works16. But you should aim to stay within the recommended limits of alcohol for your general health.
Like all medicines, bisphosphonates can cause side effects. Your doctor or nurse will discuss these with you before you begin your treatment.
Side effects vary from person to person. The side effects of zoledronic acid are usually mild and don't last more than a few days. Some of the possible side effects are listed below11,17. If you are taking a different bisphosphonate, speak to your doctor or nurse about their possible side effects. You may not get all or many of these, and there are ways to manage them.
Common side effects
You may get a high temperature, headache, chills and muscle and joint pain. This should go away after the first or second treatment. Tell your doctor or nurse if you have this. They may recommend pain-relieving drugs such as paracetamol to help manage this.
Feeling sick (nausea) and being sick (vomiting)
You may feel or be sick after having bisphosphonates. This shouldn't last for more than a few days. If it does carry on, your doctor or nurse can give you anti-sickness medicines which will help.
Loss of appetite
You may feel less hungry after having treatment. This should improve in a few days, but it is important to drink plenty and eat healthily while you are having bisphosphonates.
Eating healthily and drinking plenty of fluids can lower your risk of getting kidney problems or any other health problems. Tell your doctor or nurse if your appetite does not come back. They can suggest ways of dealing with this.
Some men may experience a slight increase in joint, muscle or more bone pain when taking bisphosphonates. This can begin days or months after starting treatment11,17,18.
Pain-relieving drugs can help until the pain settles down, but you can stop treatment if it continues for more than a few days. Let your doctor or nurse know if you have any more pain.
Low blood calcium and phosphate levels
Bisphosphonates can cause the levels of minerals such as calcium and phosphate in your blood to become too low (hypocalcaemia and hypophosphataemia). Your doctor or nurse will check this regularly and prescribe supplements if you need them.
Bisphosphonates can change how well your kidneys work. You will have regular tests to check this. These changes may not be serious, and your kidneys will return to normal if you stop taking bisphosphonates.
Red or sore eyes (conjunctivitis)
Your eyes may feel itchy, sore or dry. Your doctor or nurse can prescribe eye drops to help with this.
Less common side effects
Rash or itching
You may notice a rash on your skin or feel quite itchy. This can be uncomfortable but should not last for more than a few days. Tell your doctor or nurse about this so they can prescribe medicine to help.
Stomach or bowel problems
You may feel stomach pain or notice changes in your bowel habits. For example, you may have loose and watery stools (diarrhoea). Or you may find it harder to pass stools and completely empty your bowels (constipation). This should not last more than a few days. Tell your doctor or nurse if you have any problems so they can be treated.
Risk of heart problems
Bisphosphonates may slightly increase your risk of heart problems, including a fast and irregular heartbeat and stroke19. Talk to your doctor about this if you are worried about it, or if you have a history of heart problems.
Jaw problems (osteonecrosis of the jaw)
Osteonecrosis of the jaw is a rare side effect. It happens when the healthy bone in the jaw becomes damaged and dies. Gum disease, problems with dentures and some dental treatments can increase your risk of getting osteonecrosis of the jaw12. Smoking may also increase your risk of this condition13. If you would like to stop smoking, ask your doctor or nurse for advice about this.
Keeping your teeth and mouth clean may help to lower your risk of getting osteonecrosis of the jaw. Ask your dentist if you have any questions about this.
Talk to your doctor or nurse about any dental problems you have before starting treatment. You should mention any loose teeth, gum problems (pain, swelling or infections) and numbness or heaviness in the jaw. It is important to tell your doctor if you have any of these symptoms during or after your treatment. Tell your doctor or nurse if you need any dental treatment while you are having bisphosphonates.
Visit your dentist before starting bisphosphonates and let them know that you will be having this treatment. It is a good idea to have regular checkups at the dentist while you are having bisphosphonates13.
Treatment for osteonecrosis of the jaw includes pain-relieving drugs and antibiotics. If you are diagnosed with osteonecrosis of the jaw, you may be referred to a specialist for further treatment and support.
Although osteonecrosis of the jaw has been linked to bisphosphonates, the risk of developing it is very low.
Reporting unusual side effects: The Yellow Card Scheme
If you think you are experiencing a side effect from a drug that is not mentioned in the information leaflet that comes with it, then you can report it using the Yellow Card Scheme. This is run by the Medicines Healthcare products Regulatory Agency (MHRA). The MHRA is a government agency which controls prescription drugs in the UK. They will investigate and if they find a problem with a medication then the MHRA will take action to protect the public.
There are three ways you can report a side effect:
There is support available if you want it.
Friends and family
Some men get all the back-up they need from their family and friends. Get things off your chest by talking to a partner, friends or family. And explaining how you feel can help those close to you understand and give you support.
Your doctor or nurse
Talk to your specialist nurse, doctor or other health professionals involved in your care. They should be able to answer any questions or concerns you might have, as well as providing support.
You and those close to you can also speak to one of our Specialist Nurses on our helpline. This can give you a better understanding of your treatment options and the emotional effects of cancer.
Counsellors are trained to listen and can help you to find your own answers. Your GP may be able to refer you to a counsellor or you can see a private counsellor. There are different types of counselling available. To find out more contact the British Association for Counselling and Psychotherapy (see section: More Information)
Talking to someone affected by prostate cancer
Talking to someone with similar experiences often helps. The support volunteers in our peer support service are all men and women personally affected by prostate cancer, either as a man with prostate cancer or a family member. They are trained to listen and offer support over the telephone. Call our Specialist Nurses to arrange to speak to a volunteer. Or you can sign up to the Prostate Cancer UK online community, where you can talk to other people affected by prostate cancer.
There are also prostate cancer support groups across the country, where you and your family can meet other people affected by prostate cancer. You can find details on our website or ask your nurse.
Find out more in our booklet, Advanced prostate cancer: Managing symptoms and getting support.
- Would you recommend bisphosphonate treatment for me?
- What are the main benefits of bisphosphonates?
- What are the main side effects of bisphosphonates?
- Who do I contact if I have side effects?
- Are there any trials of bone drugs which I can take part in at my own hospital or somewhere else?
British Association for Counselling and Psychotherapy
Phone: 01455 883300
Information about counselling and details of therapists in your area.
British Dental Health Foundation
Helpline: 0845 063 1188
Information about the mouth and teeth. Call the helpline with questions about dental health.
Nurse helpline: 0808 800 4040
Cancer Research UK's patient information website.
Adviceline: 0808 808 7777
Information and advice for carers, and details of local support group
Watch, listen to and read personal experiences of men with prostate cancer and other medical conditions.
King's College London Dental Institute
Phone: 020 7188 7188
The unit of Social and Behavioural Sciences can provide support to men who have been diagnosed with osteonecrosis of the jaw.
Macmillan Cancer Support
Freephone: 0808 808 0000
Practical, financial and emotional support for people with cancer, their family and friends.
Phone: 0300 123 1801
A network of drop-in centres for cancer information and support. Includes an online support group.
Helpline: 0300 123 0789 Offers information and support for people with pain and those who care for them.
Helpline: 0800 00 22 00
A UK charity that helps smokers to stop. Includes a helpline and community programmes in eight languages.
UK Prostate Link
Helps you find and compare reliable information about prostate cancer.
This publication was written and edited by:
Prostate Cancer UK's Information Team
It was reviewed by:
- Lawrence Drudge-Coates, Urological Oncology Clinical Nurse Specialist and Honorary Lecturer, King's College Hospital NHS Foundation Trust, London
- Rob Jones, Senior Lecturer and Honorary Consultant in Medical Oncology, Beatson West of Scotland Cancer Centre, Glasgow
- Philip Reynolds, Advanced Urological Practitioner, Cancer Outpatients Clinic, Guy's and St. Thomas' Hospital, London
- Bruce Turner, Uro-oncology Nurse Practitioner, Homerton University Hospital and Bart's Health, London
- Deborah Victor, Urological Oncology Clinical Nurse Specialist, Royal Cornwall Hospitals Trust, Truro
- Cathryn Woodward, Consultant Clinical Oncologist, West Suffolk Foundation Trust Hospital, Bury St Edmunds
- Prostate Cancer UK Specialist Nurses
- Prostate Cancer UK Volunteers
- NICE. CG58 Prostate cancer: NICE guidance [Internet]. [cited 2013 Jan 9]. Available from: http://publications.nice.org.uk/prostate-cancer-cg58
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- Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, Lacombe L, et al. Long-term efficacy of zoledronic acid for the prevention of skeletal complications in patients with metastatic hormone-refractory prostate cancer. J. Natl. Cancer Inst. 2004 Jun 2;96(11):879-82.
- Zometa 4mg/5ml Concentrate for Solution for Infusion - Summary of Product Characteristics (SPC) - (eMC) [Internet]. [cited 2013 Jan 9]. Available from: http://www.medicines.org.uk/EMC/medicine/14062/SPC/Zometa+4mg+5ml+Concentrate+for+Solution+for+Infusion/
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- Medicines and Healthcare products Regulatory Agency (MHRA) www mhra gov uk. Drug Safety Update: Volume 3, Issue 4, November 2009 [Internet]. [cited 2013 Jan 9]. Available from: http://www.mhra.gov.uk/Publications/Safetyguidance/DrugSafetyUpdate/CON062553
- Alendronic Acid 10 mg Tablets - Summary of Product Characteristics (SPC) - (eMC) [Internet]. [cited 2013 Jan 14]. Available from: http://www.medicines.org.uk/EMC/medicine/25809/SPC/Alendronic+Acid+10+mg+Tablets/
- Zoledronic acid monohydrate - Hypercalcaemia (in cancer) medicines and drugs - NHS Choices [Internet]. [cited 2013 Jan 9]. Available from: http://www.nhs.uk/medicine-guides/pages/MedicineOverview.aspx?condition=Hypercalcaemia%20(in%20cancer)&medicine=Zoledronic%20acid%20monohydrate
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- Wilkinson GS, Baillargeon J, Kuo Y-F, Freeman JL, Goodwin JS. Atrial fibrillation and stroke associated with intravenous bisphosphonate therapy in older patients with cancer. J. Clin. Oncol. 2010 Nov 20;28(33):4898-905.