Real-World Trends in Bone Health Agent Use for Metastatic Prostate Cancer - Umang Swami
February 27, 2025
Umang Swami joins Alicia Morgans to discuss real-world bone health agent utilization in metastatic castration-resistant prostate cancer. Analyzing the Flatiron Health database of 14,000 mCRPC patients from 250 centers nationwide, Dr. Swami reveals a concerning trend: after increasing from 56% to 65% between 2013-2015, bone hardener utilization has declined to approximately 46% in recent years. This drop is worrisome because these agents prevent skeletal-related events that increase mortality and reduce patient independence. Significant differences exist between users and non-users regarding practice setting and geographical distribution. While acknowledging limitations of real-world data including potential 'missingness,' Dr. Swami emphasizes the importance of addressing this practice gap and recommends clinicians review their mCRPC patients' charts to ensure appropriate bone health management is scheduled.
Biographies:
Umang Swami, MD, Assistant Professor in the Division of Oncology, Department of Internal Medicine at Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, MA
Biographies:
Umang Swami, MD, Assistant Professor in the Division of Oncology, Department of Internal Medicine at Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, MA
Read the Full Video Transcript
Alicia Morgans: Hi. I'm so excited to be here today with Doctor Umang Swami, who is joining me from the University of Utah Huntsman Cancer Institute at GU ASCO 2025, where he presented some really fascinating data on the real-world use of bone health agents. Thank you so much for being here with me today.
Umang Swami: Thanks, Doctor Morgans, and thanks for having me here today.
Alicia Morgans: Wonderful. So can you tell me a little bit about why this is even an important question? Why do we care about bone health in mCRPC?
Umang Swami: Yes. So in 2007, bone modifying agents, or bone hardeners, were approved. And for patients with metastatic castration-resistant prostate cancer, multiple studies—randomized Phase III studies—have shown that these agents are associated with improved skeletal-related events and are associated with less chances of fracture. So they are recommended by all major guidelines.
However, their real-world utilization patterns and percentages are not available. So we decided to look at this in a large real-world data set. And that prompted us to conduct this study.
For this study, we looked at the Flatiron Health electronic health record data set. It's a nationwide US-based data set which uses technology-enabled abstraction of patient-level data from 250 centers and around 800 US clinical sites. And for this study, we used the eligibility criteria that patients should have a date of diagnosis of metastatic castration-resistant prostate cancer.
And then we looked at whether they received bone modifying agents—which may be Zometa, or zoledronic acid, or denosumab, or some other agents which are approved for this purpose, such as teriparatide. And our data cut-off was May 31, 2024. So, overall, we had 24,000 patients in this data set, of which around 14,000 patients were diagnosed with mCRPC. And we had required information in the data set, and they were included.
So when we analyzed these data sets and we looked at the trend, we found that there were around 8,000 patients who received bone hardeners and around 6,000 patients who didn't receive these agents. And there were significant differences with regards to practice—whether community and academic—geographical distribution, and other baseline characteristics between both of these subgroups. And then when we looked at the overall trend across the years, it looked like in 2013, around 56% of patients received bone hardeners, which increased to around 65% in 2014 and '15.
However, then, gradually, we are seeing a decrease in trend of use of these agents. And it has dropped down to around 46% over the last couple of years, which is really concerning because patients with metastatic castration-resistant prostate cancer can really benefit from these agents, because it will prevent them from getting fractures or other skeletal-related events. So the main conclusion of our study is that we should pay attention to this practice gap which is now emerging. And we should try to mitigate this less use of bone hardeners in our patient population.
Alicia Morgans: It's such an important analysis to do, because, as you said, these bone health agents are really indicated for up to monthly use in patients with mCRPC. In this setting, we don't have to get a DEXA scan. We don't have to confirm that patients are at high risk for fragility fractures because of those studies that you mentioned that really suggest that it's a skeletal-related event outcome that we're trying to prevent, not just a fragility fracture.
So this includes things like radiation and surgery to the bone—things that are really important to patients. And SREs increase mortality and certainly can limit patients in terms of their ability to be independent and to really function in their lives. So it's so important, and I appreciate that your group has done this work, to understand that there is actually a drop-off in our utilization.
As you look at the differences in the baseline characteristics of your patients—and you mentioned some of them—are there any factors, any things that you think may be associated with some patients really not getting as many treatments or as regular a treatment with bone health agents as we would expect? And anything that we as a field can look to and say, here's something that we can do in terms of identifying patients—low-hanging fruit, perhaps—that we can really use as a first step to intervene and improve here?
Umang Swami: So that's an excellent question. And we are doing a deep dive in our data set, and we will try to address these important questions in the manuscript with regards to how we can make things better and where the gaps are and why these gaps are emerging.
One particular reason may be that in the older time period we had these agents, which sometimes were used as treatment of prostate cancer. It's also possible that now physicians are not that much aware or paying attention to use of these agents. But I think we will need some more time to look at these data sets to understand why this is happening and how we can make it better.
Alicia Morgans: Absolutely. It's really important as a first step to hold up the mirror to our practices and publish data like the data that you investigated. Because without understanding where we stand, it's really hard to move forward in the future. As you think about your analysis and the ways that we can integrate it—and, of course, we also have to think about limitations of a real-world data set—what should we keep in mind as we consider this information?
Umang Swami: So, yeah, so this is a real-world data set. And, as with any real-world data set, there may be missingness. So theoretically, it's possible that some patients may be receiving these agents at some other place, and they are not being captured in the data set as an administered medication. It's also possible that some of these patients may have some contraindication due to which they are not able to receive this medication.
They may be having some osteonecrosis, or maybe having a history of allergy, or some other things. There may be some insurance issues and maybe some other factors which may be playing a role. So these are some of the limitations, as we see in all real-world data sets.
Alicia Morgans: Absolutely. So when you consider this study and you consider your findings, what should clinicians take away as a bottom line or a message from this work as they go into clinic tomorrow?
Umang Swami: So I suggest having a look at your patient's chart to make sure, if they are having a metastatic castration-resistant prostate cancer, then they are on a schedule to receive bone hardening agents. And that will probably help them a long way.
Alicia Morgans: Absolutely. So taking those steps to understand what we ourselves are doing is absolutely a first step. And I really look forward to you and your team helping us find ways to do this on a larger scale, even, as we continue to learn from the work that you've done. Thank you so much for your time and your expertise.
Umang Swami: Thanks, Doctor Morgans, and thanks to UroToday for this interview.
Alicia Morgans: Hi. I'm so excited to be here today with Doctor Umang Swami, who is joining me from the University of Utah Huntsman Cancer Institute at GU ASCO 2025, where he presented some really fascinating data on the real-world use of bone health agents. Thank you so much for being here with me today.
Umang Swami: Thanks, Doctor Morgans, and thanks for having me here today.
Alicia Morgans: Wonderful. So can you tell me a little bit about why this is even an important question? Why do we care about bone health in mCRPC?
Umang Swami: Yes. So in 2007, bone modifying agents, or bone hardeners, were approved. And for patients with metastatic castration-resistant prostate cancer, multiple studies—randomized Phase III studies—have shown that these agents are associated with improved skeletal-related events and are associated with less chances of fracture. So they are recommended by all major guidelines.
However, their real-world utilization patterns and percentages are not available. So we decided to look at this in a large real-world data set. And that prompted us to conduct this study.
For this study, we looked at the Flatiron Health electronic health record data set. It's a nationwide US-based data set which uses technology-enabled abstraction of patient-level data from 250 centers and around 800 US clinical sites. And for this study, we used the eligibility criteria that patients should have a date of diagnosis of metastatic castration-resistant prostate cancer.
And then we looked at whether they received bone modifying agents—which may be Zometa, or zoledronic acid, or denosumab, or some other agents which are approved for this purpose, such as teriparatide. And our data cut-off was May 31, 2024. So, overall, we had 24,000 patients in this data set, of which around 14,000 patients were diagnosed with mCRPC. And we had required information in the data set, and they were included.
So when we analyzed these data sets and we looked at the trend, we found that there were around 8,000 patients who received bone hardeners and around 6,000 patients who didn't receive these agents. And there were significant differences with regards to practice—whether community and academic—geographical distribution, and other baseline characteristics between both of these subgroups. And then when we looked at the overall trend across the years, it looked like in 2013, around 56% of patients received bone hardeners, which increased to around 65% in 2014 and '15.
However, then, gradually, we are seeing a decrease in trend of use of these agents. And it has dropped down to around 46% over the last couple of years, which is really concerning because patients with metastatic castration-resistant prostate cancer can really benefit from these agents, because it will prevent them from getting fractures or other skeletal-related events. So the main conclusion of our study is that we should pay attention to this practice gap which is now emerging. And we should try to mitigate this less use of bone hardeners in our patient population.
Alicia Morgans: It's such an important analysis to do, because, as you said, these bone health agents are really indicated for up to monthly use in patients with mCRPC. In this setting, we don't have to get a DEXA scan. We don't have to confirm that patients are at high risk for fragility fractures because of those studies that you mentioned that really suggest that it's a skeletal-related event outcome that we're trying to prevent, not just a fragility fracture.
So this includes things like radiation and surgery to the bone—things that are really important to patients. And SREs increase mortality and certainly can limit patients in terms of their ability to be independent and to really function in their lives. So it's so important, and I appreciate that your group has done this work, to understand that there is actually a drop-off in our utilization.
As you look at the differences in the baseline characteristics of your patients—and you mentioned some of them—are there any factors, any things that you think may be associated with some patients really not getting as many treatments or as regular a treatment with bone health agents as we would expect? And anything that we as a field can look to and say, here's something that we can do in terms of identifying patients—low-hanging fruit, perhaps—that we can really use as a first step to intervene and improve here?
Umang Swami: So that's an excellent question. And we are doing a deep dive in our data set, and we will try to address these important questions in the manuscript with regards to how we can make things better and where the gaps are and why these gaps are emerging.
One particular reason may be that in the older time period we had these agents, which sometimes were used as treatment of prostate cancer. It's also possible that now physicians are not that much aware or paying attention to use of these agents. But I think we will need some more time to look at these data sets to understand why this is happening and how we can make it better.
Alicia Morgans: Absolutely. It's really important as a first step to hold up the mirror to our practices and publish data like the data that you investigated. Because without understanding where we stand, it's really hard to move forward in the future. As you think about your analysis and the ways that we can integrate it—and, of course, we also have to think about limitations of a real-world data set—what should we keep in mind as we consider this information?
Umang Swami: So, yeah, so this is a real-world data set. And, as with any real-world data set, there may be missingness. So theoretically, it's possible that some patients may be receiving these agents at some other place, and they are not being captured in the data set as an administered medication. It's also possible that some of these patients may have some contraindication due to which they are not able to receive this medication.
They may be having some osteonecrosis, or maybe having a history of allergy, or some other things. There may be some insurance issues and maybe some other factors which may be playing a role. So these are some of the limitations, as we see in all real-world data sets.
Alicia Morgans: Absolutely. So when you consider this study and you consider your findings, what should clinicians take away as a bottom line or a message from this work as they go into clinic tomorrow?
Umang Swami: So I suggest having a look at your patient's chart to make sure, if they are having a metastatic castration-resistant prostate cancer, then they are on a schedule to receive bone hardening agents. And that will probably help them a long way.
Alicia Morgans: Absolutely. So taking those steps to understand what we ourselves are doing is absolutely a first step. And I really look forward to you and your team helping us find ways to do this on a larger scale, even, as we continue to learn from the work that you've done. Thank you so much for your time and your expertise.
Umang Swami: Thanks, Doctor Morgans, and thanks to UroToday for this interview.