About Hormonal Therapy For Prostate Cancer
Testosterone is a male hormone. Its made when hormones from your pituitary gland cause your testes to make sperm. Testosterone can cause prostate cancer cells to grow.
Hormonal therapy prevents prostate cancer cells from growing by:
- Blocking the action of testosterone and other male hormones.
Your doctor may recommend hormonal therapy in order to:
- Make it easier for radiation to kill prostate cancer cells.
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How Might I Feel During Hormone Therapy
Nearly all men being treated for prostate cancer say that they feel emotionally upset at different times during their hormone therapy. It’s not unusual to feel anxious, depressed, afraid, angry, frustrated, alone, or helpless. Hormone therapy may affect your emotions because it lowers the amount of testosterone in your body.
Some men find it helps to learn about their disease and treatment because it makes them less afraid of their treatment. Find out as much as you want to know. Do not be afraid to ask questions. Your emotional health is as important as your physical health.
Talking with an understanding friend, relative, minister or another patient may be helpful. Your doctors office may be able to give you a list of local prostate cancer support groups. There will be men in the support groups who have had hormone therapy. You may also contact the American Cancer Society at 1-800-227-2345 or the National Cancer Institutes Cancer Information Line at 1-800-422-6237 to find out about cancer resources in your local community.
Many people don’t understand prostate cancer or its treatment. They may stay away from you because they’re not sure what to say or how to help. Try to be open when you talk to other people about your illness, treatment, needs, and feelings. People will often be willing to lend their support. If you get tired easily, limit your activities and do only the things that mean the most to you.
What Is Hormone Therapy
The idea that hormones have an effect on prostate cancer is not new. The scientist Charles Huggins first established this over 60 years ago in work that led to his winning the Nobel Prize. Huggins found that removing one of the main sources of male hormones from the body — the testicles — could slow the growth of the disease.
“This procedure worked dramatically,” says Holden, who is also director of the Prostate Cancer Center at Cedar Sinai Medical Center in Los Angeles. “Before, these men were confined to bed and wracked with pain. Almost immediately afterwards, they improved.”
Huggins found that some types of prostate cancer cells need certain male hormones — called androgens — to grow. Androgens are responsible for male sexual characteristics, like facial hair, increased muscle mass, and a deep voice. Testosterone is one kind of androgen. About 90% to 95% of all androgens are made in the testicles, while the rest are made in the adrenal glands located on top of the kidneys.
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Early Versus Delayed Treatment
For men who need hormone therapy, such as men whose PSA levels are rising after surgery or radiation or men with advanced prostate cancer who dont yet have symptoms, its not always clear when it is best to start hormone treatment. Some doctors think that hormone therapy works better if its started as soon as possible, even if a man feels well and is not having any symptoms. Some studies have shown that hormone treatment may slow the disease down and perhaps even help men live longer.
But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the side effects of hormone therapy and the chance that the cancer could become resistant to therapy sooner, treatment shouldnt be started until a man has symptoms from the cancer. This issue is being studied.
When Hormone Therapy Is Indicated
HT can be administered before, during or after a localized treatment, such as radical prostatectomy, radiation, high-intensity focused ultrasound or cryotherapy. When given before a localized treatment, it is called neoadjuvant therapy. When given after localized treatment without evidence of prostate cancer recurrence, it is called adjuvant therapy. When HT is prescribed after localized treatment for a prostate cancer recurrence, it is called salvage therapy. If a patient’s PSA starts rising after a radical prostatectomy, HT is typically given in combination with radiation therapy. Treatment recommendations are based on each patient’s specific circumstances.
Sometimes we give neoadjuvant HT while the patient is deciding on his primary treatment or to reduce the tumor’s size before starting primary treatment. Neoadjuvant HT will usually slow or stop cancer growth for a period of time.
Many radiation oncologists use HT along with radiation treatment in the belief that HT weakens cancer cells so that they’re more susceptible to destruction by the radiation. Clinical studies have suggested a synergy between radiation therapy and hormone therapy meaning they work better together. Clinical trials have shown improved outcomes for patients who receive combined therapy.
Mental And Emotional Health
A cancer diagnosis and cancer treatment may affect how you feel mentally and emotionally. Hormone therapy can cause:
- A drop in mental sharpness
If you have any of these side effects, your doctor may recommend medication, counseling, or both.
Research shows that hormone therapy for prostate cancer may lead to problems with short-term memory, language, thinking, and concentration. But these problems are usually mild. Researchers are still studying the effect of hormone therapy on the brain.
When you stop taking hormone therapy, emotional and mental side effects usually disappear. But if youâve taken the drugs for many years, they may not fully go away.
How Does Hormone Therapy Work Against Prostate Cancer
Early in their development, prostate cancers need androgens to grow. Hormone therapies, which are treatments that decrease androgen levels or block androgen action, can inhibit the growth of such prostate cancers, which are therefore called castration sensitive, androgen dependent, or androgen sensitive.
Most prostate cancers eventually stop responding to hormone therapy and become castration resistant. That is, they continue to grow even when androgen levels in the body are extremely low or undetectable. In the past, these tumors were also called hormone resistant, androgen independent, or hormone refractory however, these terms are rarely used now because the tumors are not truly independent of androgens for their growth. In fact, some newer hormone therapies have become available that can be used to treat tumors that have become castration resistant.
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Hormone Therapy And Prostate Cancer
Prostate cancer is fueled by testosterone, a hormone produced in the testicles. The aim of HT is to interfere with either testosterone production or cancer cells’ ability to use testosterone. Medical evidence tells us that eliminating or substantially reducing testosterone production has a significant impact on controlling progression of the disease and may even halt progression. Testosterone is one of several hormones called androgens that are linked to sexual health and other processes in the body. This is why HT is often referred to as androgen deprivation therapy .
To be clear, this is not the “hormone therapy” of which you often hear. Women get “hormone therapy” to supplement waning estrogen levels, and older men without prostate cancer may get “hormone therapy” that administers additional testosterone. The “hormone therapy” we are talking about for men with prostate cancer is more accurately described as androgyn deprivation therapy . It is given to lower testosterone levels.
Why Is This Medication Prescribed
Degarelix injection is used to treat advanced prostate cancer . Degarelix injection is in a class of medications called gonadotropin-releasing hormone receptor antagonists. It works by decreasing the amount of testosterone produced by the body. This may slow or stop the spread of prostate cancer cells that need testosterone to grow.
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Will I Need To See My Doctor During And After Hormone Therapy
Yes, you will need regular medical checkups while getting hormone therapy. During these checkups your doctor will look at your medical history and give you a physical exam. Your checkup may include blood tests and imaging tests. For example:
Imaging studies are ways used by doctors to take pictures of the inside of your body, such as x-rays or a CT Scan . These check-ups are important because:
Surgically Removing The Prostate Gland
A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.
Like any operation, this surgery carries some risks.
A recent trial showed possible long-term side effects of radical prostatectomy may include an inability to get an erection and urinary incontinence.
Before having any treatment, 67% of men said they could get erections firm enough for intercourse.
When the men who had a radical prostatectomy were asked again after 6 months, this had decreased to 12%. When asked again after 6 years, it had slightly improved to 17%.
For urinary incontinence, 1% of men said they used absorbent pads before having any treatment.
When the men who had a radical prostatectomy were asked again after 6 months, this had increased to 46%. After 6 years, this had improved to 17%.
Out of the men who were actively monitored instead, 4% were using absorbent pads at 6 months and 8% after 6 years.
In extremely rare cases, problems arising after surgery can be fatal.
Its possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.
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How Testosterone Helps Prostate Cancer Grow
Testosterone travels through the bloodstream and eventually reaches prostate cancer cells, where it helps the cancer grow. Up to a point, the more testosterone the cancer cells have, the more the cancer can grow and eventually spread to other parts of the body. Hormone therapy is designed to prevent testosterone from fueling the growth of these cancer cells.
Controversies In Hormone Therapy
The use of hormone therapy requires as much art as science. Physicians do not always agree about when it is best to start treatment, whether it needs to be continuous or can be stopped and started up again periodically, and whether monotherapy or combination therapy is best. Here are the salient issues, what the studies say and what I believe and follow in my own practice.
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Drugs That Stop The Body From Making Androgens
Androgens can be produced in other areas of the body, such as the adrenal glands. Some prostate cancer cells can also make androgens. Three drugs help to stop the body from making androgens from tissue other than the testicles.
Two medicines, ketoconazole and aminoglutethimide , treat other diseases but are sometimes used to treat prostate cancer. The third, abiraterone treats advanced prostate cancer that has spread to other places in the body.
What Is Lupron Depot
Lupron Depot overstimulates the body’s own production of certain hormones, which causes that production to shut down temporarily. This medicine reduces the amount of testosterone in men or estrogen in women.
Lupron Depot is used in men to treat the symptoms of prostate cancer .
Lupron Depot-Ped is used to treat precocious puberty in both male and female children at least 2 years old.
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Heres What The Results Showed
After a median follow-up of just over 10 years, 9.7% of men who were treated with radiation and leuporelin for 18 months had died from prostate cancer, compared to 13.3% of the men treated with radiation and leuporelin for six months. Adding zoledronic acid made no difference in either case.
The authors concluded that hormonal therapy is more effective at preventing prostate cancer death when its given for 18 months rather than six. And similar benefits were noted for other endpoints as well. For instance, prostate tumors were less likely to metastasize, or spread, among men in the longer duration treatment group, and it took longer for their cancers to become resistant to hormone therapy if it was reinitiated later.
In earlier clinical research, scientists discovered that hormonal therapy given for three years protects against prostate cancer death more effectively than a six-month treatment regimen. But three years of hormone therapy isnt easily tolerated, and evidence so far shows that 10-year survival rates after either 18 months or three years of hormonal therapy are similar, the authors of the new study claim.
About the Author
Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Drugs That Lower Androgen Levels
The most common treatment is to take drugs that lower the amount of androgens made by the testicles. They are called luteinizing hormone-releasing hormone analogs and anti-androgens . These drugs lower androgen levels just as well as surgery does. This type of treatment is sometimes called “chemical castration.”
Men who receive androgen deprivation therapy should have follow-up exams with the doctor prescribing the drugs:
- Within 3 to 6 months after starting therapy
- At least once a year, to monitor blood pressure and perform blood sugar and cholesterol tests
- To get PSA blood tests to monitor how well the therapy is working
LH-RH analogs are given as a shot anywhere from once a month to every 6 months. These drugs include:
LH-RH antagonists are another class of treatments, including degarelix and relugolix . They reduce androgen levels more quickly and have fewer side effects. LH-RH antagonists are used in men with advanced cancer.
Some doctors recommend stopping and restarting treatment . This approach appears to help reduce hormone therapy side effects. However, it is not clear if intermittent therapy works as well as continuous therapy. Some studies indicate that continuous therapy is more effective or that intermittent therapy should only be used for select types of prostate cancer.
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When To Consider Hormone Therapy
Hormone therapy is a treatment option for men with prostate cancer in any of the following situations:
- when cancer has metastasized beyond the prostate
- when cancer is confined to the prostate, but hormone therapy is used to boost the effectiveness of radiation therapy or to shrink the size of a tumor before brachytherapy
- when PSA begins to rise sometime after initial treatment with surgery or radiation therapy, indicating the cancer may have recurred.
Not all doctors agree on when to use hormone therapy, or how to administer it. Indeed, this is an area that requires a physician to exercise as much art as science in clinical practice. You should also be aware that side effects can be daunting, although most men tolerate treatment reasonably well .
What The Researchers Did
Dr. Crawfords team reviewed clinical data from nearly 23,000 men who were given ADT injections between 2007 and 2016. Each mans treatment varied by how their ADT was formulated. Some types of ADT are given once a month, and others are given at three-, four-, or six-month intervals. The researchers wanted to know how many men were late on their ADT treatments, and how that would affect the amounts of testosterone in their blood.
During this research, the investigators defined month in two ways: either as one lasting 28 days, which is how months were defined during the clinical trials that set dosing schedules for ADT, or as a calendar month lasting 31 days. ADT was deemed late if it was given after day 28 by the first definition or after day 32 by the second definition.
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Table : Boosting The Effectiveness Of Radiation Therapy
A randomized controlled study involving 206 men with early-stage prostate cancer evaluated whether adding six months of hormone therapy to external-beam radiation treatment would boost both overall survival and disease-free survival . The results are given below. The same research group found, in an earlier study, that the addition of hormone therapy was of most benefit to men who were considered at moderate or high risk, based on their clinical profile.
Five-year follow-up 82% Source: Journal of the American Medical Association, 2004 292:8217. PMID: 15315996.
Combined with radiation therapy. A number of studies have shown that men with early-stage prostate cancer are more likely to be cured when hormone therapy is given in conjunction with radiation therapy . Even when the disease is regionally advanced, meaning that it has progressed to tissues immediately surrounding the prostate gland, neoadjuvant hormone therapy reduces risk of progression and relapse .
Risk Of Other Health Problems
Evidence suggests that having hormone therapy might increase the chance of developing heart disease, stroke and type-2 diabetes. There is also some research that suggests having hormone therapy can increase your risk of getting blood clots and anaemia. But more research is needed to help us understand the links between these conditions.
Research shows that hormone therapy can cause:
- an increase in weight, particularly around the waist
- an increase in cholesterol levels
- changes in insulin.
Talk to your hospital doctor and GP about how often you should have general health checks. You may be weighed and have your blood pressure checked regularly. You may also have blood tests to check for diabetes and to measure your cholesterol levels. Your GP may suggest you have these checks about every six months. Or you can ask for them yourself at your GP surgery.
If you already have heart problems or diabetes, talk to your doctor before you start hormone therapy. They will work with you to manage these conditions.
While the risk of getting these conditions may be worrying, its important to remember that hormone therapy helps men to live longer by controlling the cancer.
What can help?
A healthy lifestyle can help reduce your risk of heart disease, stroke and type-2 diabetes. This includes:
- eating a healthy diet
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