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was measured by forearm dualenergy X-ray absorptiometry (DEXA) before ADT and repeated annually. Patients with osteoporosis (T-score ≤− 2.5) were commenced on bicalutamide; patients with osteopenia (T-score between − 1.0 and − 2.5) and normal BMD (T-score > − 1.0) were commenced on an LHRH agonist. Patients with osteopenia and osteoporosis received calcium and vitamin D supplements. RESULTSOver 7 years, 1690 DEXA scans were performed. In all, 41% of patients with newly diagnosed prostate cancer were osteoporotic, 39% were osteopenic and 20% had normal BMD. In the normal group, treated with an LHRH agonist, there were significant decreases in BMD (1 year 1.2%; 2 year 3.7%; 3 year 6.5%; 4 year 8.9%; 5 year 9.9%; 6 year 12.7%), which also occurred in the patients with osteopenia with 60% developing osteoporosis after 2 years (1 year 1.8%; 2 year 5.1%; 3 year 8.0%; 4 year 8.2%; 5 year 11.5%; 6 year 14.1%). By contrast, the osteoporotic group maintained BMD (1 year 0.5%; 2 year 0%; 3 year + 1.2%; 4 year 0.5%; 5 year 1.7%; 6 year 2.2%). CONCLUSIONPatients treated with an LHRH agonist have significant and sustained decreases in BMD, whereas bicalutamide maintains BMD. We advocate routine assessment of BMD before ADT, with surveillance thereafter. KEYWORDSprostate cancer, androgen antagonists, bone density, osteoporosis Study Type -Prognosis (inception cohort) Level of Evidence 1b OBJECTIVETo study the long-term effects of androgendeprivation therapy (ADT) using luteinizing hormone-releasing hormone (LHRH) agonists or antiandrogen therapy with bicalutamide on bone mineral density (BMD) of selected groups of patients with newly diagnosed advanced prostate cancer, stratified by BMD at presentation and to predict alterations in fracture risk. PATIENTS AND METHODSIn all, 618 men with a mean (sd, range) age of 73 (7.1, 49-94) years, initiating ADT for prostate cancer were prospectively recruited

densitometry values were compared with those from 106 age-matched controls (mean age 74.3 years, range 66-90). RESULTSOf the 174 patients, 73 (42%) were osteoporotic (t score £ -2.5) and 65 (37%) were osteopenic (t score -1 to -2.4). This compares with a 27% incidence of osteoporosis in the control group ( P = 0.022). There were also no significant correlations between prostate specific antigen levels, Gleason score, tumour stage, biochemical markers and the presence or absence of osteoporosis risk factors. CONCLUSIONPatients with advanced prostate cancer requiring ADT have a high incidence of osteoporosis before treatment. In addition, osteoporosis in these men cannot be predicted from clinical or biochemical values. Therefore, bone densitometry should be used in all patients with advanced cancer requiring ADT, as the results have implications for the choice of cancer therapy and the prophylaxis for osteoporosis.

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This is the largest multicentre RAPN study in the UK. Initial results show that RAPN is safe and can be performed with minimal morbidity. Early oncological outcomes and renal function preservation data are encouraging.