Fracture risk and survival outcomes of radium-223 therapy for bone metastases in mCRPC and the modulatory role of bone-protective therapy: a systematic review and meta-analysis
Abstract
Background: Metastatic castration-resistant prostate cancer (mCRPC) frequently involves the skeleton. While Radium-223 (Ra-223) alleviates symptomatic bone lesions, its effect on overall survival (OS) and fracture risk is debated. Bone-protective agents (BPAs) may play a critical modulatory role. This study systematically examined how Ra-223 influences OS and fracture risk and the effect of concomitant BPA use.
Methods: As per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, Embase, the Cochrane Library, and Web of Science were retrieved for randomized controlled trials (RCTs) and cohort studies through July 14, 2025. The primary outcomes were OS and fracture incidence in this PROSPERO-registered review (Registration No.: CRD420251102769). Hazard ratios (HRs) with 95% confidence intervals (CIs) were preferentially extracted; relative risks (RRs) were used when necessary. Heterogeneity was assessed using the I² statistic to guide the choice of random-effects versus random-effects models. Leave-one-out sensitivity analyses were conducted, and study quality was appraised using the NIH tool for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies.
Results: Nine studies were included, including six RCTs and three cohort studies. The pooled OS analysis (five studies, n=3,671) showed no significant benefit (HR = 0.82, 95% CI: 0.60-1.11; I²=79.8%). Excluding one study on an abiraterone background revealed a survival advantage…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 3,671 participants or records.
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