Table 4.

Experts’ advices on monitoring modalities by setting

Non-metastatic disease	Metastatic disease
Early management of bone health is mandatory from the start of hormonal therapy and at least throughout its course, regardless of the blockade scheme	Monitor metastases by scintigraphy, NMR or any other evaluation at physician’s discretion and pay closer attention to bone health
Assess the risk of fracture	Assess the risk of fracture
FRAX score only discouraged; it should integrate the following	Same as for non-metastatic disease
Independent factors: BMD Familiarity for fragility fractures Corticosteroid therapy (>5 mg/prednisone equivalent in the past for >3 months consecutively or ongoing) Metabolic bone diseases or fragilising disease/treatment Disability or high risk of fall Age Anamnesis for low-energy trauma fractures
When feasible, perform the following evaluations at baseline and every 12–18 months afterwards	When feasible, perform the following evaluations at baseline and every 12–18 months afterwards
Bone turnover markers (bone ALP) Vitamin D, serum calcium and PTH DEXA scan (for BMD and if available vertebral morphometry (MXA)) Height, weight and BMI If feasible, evaluate body composition (by DEXA, bioelectrical impedance or plicometry) besides BMI	Same as for non-metastatic disease However, when assessing vitamin D, serum calcium and PTH, pay closer attention to the serum levels of these prognostic markers since ongoing administration of BPs or DNB therapies (at the dose for SRE prevention) may cause hypocalcemia
Do not overlook pain	Do not overlook pain
In case of back pain or height loss, perform a spine radiography	Same as for non-metastatic disease
In the adjuvant setting of M0 HSPC, reassess the fracture risk at the end of hormonal therapy: if the patient experienced no fracture during treatment, no particular monitoring will be necessary; otherwise, monitoring should be continued; if the patient presents any additional risk factor (eg, new fracture), monitoring and therapy must be carried on
In case of M0 CRPC, it is strongly advised to continue with the same monitoring scheme adopted in case of M0 HS disease, but with closer attention to bone health

Unless specified, advices are valid for both settings. For detailed explanation, see the text.

HSPC hormone-sensitive prostate cancer; ALP, alkaline phosphatase; BMD, bone mineral density; BMI, body mass index; BP, bisphosphonate; CRPC, castration-resistant prostate cancer; CTX, C-terminal cross-linked telopeptide of type I collagen; DEXA, dual-energy X-ray absorptiometry; DNB, denosumab; M0, non-metastatic; MXA, morphometric X-ray absorptiometry; NMR, nuclear magnetic resonance; P1NP, procollagen type 1 N-terminal propeptide; PTH, parathyroid hormone; SRE, skeletal-related event.