Calcium and Vitamin D supplements

Like all (or most) prostate cancer docs, I have routinely recommended calcium and vitamin D supplements for men going on androgen deprivation therapy (ADT, “hormone treatment”). The reason for this is that many studies show that men, just like their wives/girlfriends, start losing calcium from their bones as soon as testosterone levels drop – the equivalent of menopause and loss of estrogen in women. Of course, medical history is filled with examples of well-meaning interventions for patients that actually don’t work, even though they seem logical. One of the more commonly cited examples is the Vineberg procedure, in which cardiac surgeons re-routed arteries from the chest wall into the left ventricle in patients with coronary artery disease. Makes a lot of sense – the heart muscle isn’t getting enough blood, resulting in angina, so “fix it”. The problem is that it was never properly studied, and when it was, it didn’t work any better than sham operations in reducing angina. There may have been some benefit, but by the time proper studies were done, bypass grafts had overtaken the approach, and now this has been replaced in many cases by stents.

So back to the Vitamin D and Calcium story. An article appearing this week has suggested that our recommendations for calcium and vitamin D supplements are similarly poorly studied. They make sense, but the author appropriately raises questions as to what we actually know verses what seems logical in this paper in “The Oncologist”:

“CONCLUSIONS: Calcium and vitamin D supplements are widely prescribed to men with prostate cancer undergoing ADT. Whether supplementation of men undergoing ADT with calcium and/or vitamin D results in a higher BMD than in those with no supplementation has not been tested. Available clinical trial data regarding supplemental calcium at 500–1,000 mg/day and vitamin D at 200 –500 IU/day indicate that these regimens are inadequate to prevent BMD loss. Calcium supplements have been implicated in greater risks for cardiovascular disease and advanced prostate cancer. Thus, clinical trials to determine the risk–benefit ratio of calcium and vitamin D supplementation in men undergoing ADT for prostate cancer are urgently needed. Key safety endpoints in such trials should include markers of prostate cancer growth, for example, PSA and PSA velocity, as well as surrogate markers of cardiovascular disease.”

For now, I don’t think I will change my recommendations, and like the articles on coffee drinking, or alcohol intake on heart disease and everything else that goes wrong as we age, there will no doubt be lots of counterpoints. The “vitamin D believers” all will tell us that we need to be taking even more vitamin D and the evidence that vitamin D might slow the development of prostate cancer is reasonably solid. In any case, if you have significant heart disease, this article might be something to discuss with your cardiologist, if not your oncologist.

5 Comments

Filed under General Prostate Cancer Issues

5 responses to “Calcium and Vitamin D supplements

  1. Bob Lederer

    Thanks for sharing this. I assume this is only referring to oral vitamin and calcium supplementation. For those of us who get Zometa or one of the other Bisphosphonates I assume one cannot draw any conclusion from this article. Do you have thoughts about these?

    • In the article referenced, the authors point out that calcium and vit D supplementation has never been properly studied. Instead, it is the default “control arm” in the studies that led to approval of first the bisphosphonates, and later, denosumab. In those trials, both arms in fact got the calcium and vitamin D. Even a single bisphosphonte injection will prevent calcium loss for up to a year. It make take two injections of denosumab (called “Prolia” in this usage – versus “xgeva” when used monthly). As to the monthly use for slowing prostate cancer, both zoledronic acid (Zometa) and denosumab (Xgeva) have shown efficacy when given monthly in reducing “skeletal events”. However for both, there is a risk that increases over time/dose of osteonecrosis of the jaw which is a nasty lesion. Because of this, some of us prescribe these two in an every three month regimen, even though this has never been studied. Such use strikes a balance (maybe) and definitely reduces the cost of therapy.

  2. Arlen Heller

    Dr. Glode, the following article re aspirin and prostate cancer appeared in the NY Times today. I would appreciate your thoughts. Thank You Arlen
    http://www.nytimes.com/2012/08/28/health/research/regular-aspirin-use-may-aid-prostate-cancer-recovery-study-finds.html?_r=2

    • I will try to look this up and eventually report on it. For now, I think it is worth thinking about. The Journal of Clinical Oncology publishes among the best of articles, so the article has been fully vetted. Several of the authors are good friends. Here is the quote from the publicly available abstract:
      Patients and Methods This study comprised 5,955 men in the Cancer of the Prostate Strategic Urologic Research Endeavor database with localized adenocarcinoma of the prostate treated with radical prostatectomy (RP) or radiotherapy (RT). Of them, 2,175 (37%) were receiving ACs (warfarin, clopidogrel, enoxaparin, and/or aspirin). The risk of prostate cancer–specific mortality (PCSM) was compared between the AC and non-AC groups.

      Results After a median follow-up of 70 months, risk of PCSM was significantly lower in the AC group compared with the non-AC group (3% v 8% at 10 years; P < .01). The risks of disease recurrence and bone metastasis were also significantly lower. In a subgroup analysis by clinical risk category, the reduction in PCSM was most prominent in patients with high-risk disease (4% v 19% at 10 years; P < .01). The benefit from AC was present across treatment modalities (RT or RP). Analysis by type of AC medication suggested that the PCSM reduction was primarily associated with aspirin. Multivariable analysis indicated that aspirin use was independently associated with a lower risk of PCSM (adjusted hazard ratio, 0.43; 95% CI, 0.21 to 0.87; P = .02)."

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