Friday, August 19, 2022

Hormone Therapy For Prostate Cancer Before Radiotherapy

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External Beam Radiation Therapy

Gleason 4 4=8 & Hormone Therapy | Ask a Prostate Cancer Expert, Mark Scholz, MD

After completing external beam radiation therapy , urinary and bowel side effects may persist for two to six weeks, but they will improve over time. You may need to continue some medications.

Some patients report continued, though lessening fatigue for several weeks after treatment. Other minor problems may include dry itchy skin, a sensation of heaviness in the perineum, anal and rectal irritation, and flare-up of hemorrhoids. However, patients are usually well enough to continue with normal daily activities.

Possible Risks And Side Effects Of Brachytherapy

Radiation precautions: If you get permanent brachytherapy, the seeds will give off small amounts of radiation for several weeks or months. Even though the radiation doesnt travel far, your doctor may advise you to stay away from pregnant women and small children during this time. If you plan on traveling, you might want to get a doctors note regarding your treatment, as low levels of radiation can sometimes be picked up by detection systems at airports.

There’s also a small risk that some of the seeds might move . You may be asked to strain your urine for the first week or so to catch any seeds that might come out. You may be asked to take other precautions as well, such as wearing a condom during sex. Be sure to follow any instructions your doctor gives you. There have also been reports of the seeds moving through the bloodstream to other parts of the body, such as the lungs. As far as doctors can tell, this is uncommon and doesnt seem to cause any ill effects.

These precautions arent needed after HDR brachytherapy, because the radiation doesnt stay in the body after treatment.

Bowel problems: Brachytherapy can sometimes irritate the rectum and cause a condition called radiation proctitis. Bowel problems such as rectal pain, burning, and/or diarrhea can occur, but serious long-term problems are uncommon.

Intensity Modulated Radiation Therapy

IMRT, an advanced form of 3D-CRT therapy, is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity of the beams can be adjusted to limit the doses of radiation reaching nearby normal tissues. This lets doctors deliver an even higher radiation dose to the cancer.

Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy , lets the doctor take pictures of the prostate just before giving the radiation to make minor adjustments in aiming. This appears to help deliver the radiation even more precisely and results in fewer side effects.

A variation of IMRT is called volumetric modulated arc therapy . It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasnt yet been shown to be more effective than regular IMRT.

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External Beam Radiotherapy Androgen Deprivation Therapy

External beam radiotherapy is the only curative therapeutic option, which in randomized trials showed superior efficacy compared with sole androgen deprivation therapy. More than 2300 patients who had been randomized to ADT or a combination of irradiation and ADT were found to have significantly superior results with additional radiotherapy :

Study Population And Characteristics

Prostate cancer treatment

During the study period, 373 patients diagnosed with IR prostate cancer were treated in the Radiation Oncology Department of the CSMC 196 patients were treated with RT with concomitant short-term ADT, and 177 patients with RT alone. Table shows population and treatment-related characteristics of patients treated with RT and short-term ADT and RT alone. Patients in both arms were similar in terms of mean age at time of therapy, Gleason score at biopsy, fiducials implants, RT treatment modality , and the Charlson comorbidity score. The mean follow-up time was 55.9±37.2months and did not significantly differed between the two treatment groups. However, compared to patients treated with RT alone, patients treated with a combination of RT+ ADT had significantly more unfavorable risk factors including: higher PSA levels before RT treatment, more intermediate-risk risk factors, and a higher percent of positive cores on biopsy. Moreover, patients receiving RT and ADT had higher T-stage, however the difference did not reach statistical significance . The vast majority of patients in both groups did not receive pelvic lymph node RT , and a higher fraction of patients receiving RT and ADT were administered pelvic lymph node RT.

Table 1 Patient characteristics and treatment

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Side Effects Of Androgen Deprivation Therapy

Since androgen deprivation treatment with LHRH analogues can also increase the risk of metabolic syndrome or diabetes mellitus, regular control of laboratory variables is required . Because of the two risks mentioned, the US Food and Drug Administration published a warning in 2010. This wasamong othersbased on a recommendation of the American Heart Association, the American Cancer Society, and the American Urological Association, and the support of the American Society for Radiation Oncology .

Side Effects Of Hormone Treatment

The loss of testosterone that hormone therapy causes leads to side effects in nearly all men. These can include:

  • Trouble getting an erection
  • Less interest in sex
  • Shrinkage of your testicles and penis
  • Breast growth and tenderness
  • Hot flashes
  • Thinking changes and memory loss
  • Weight gain
  • Thinning of bones
  • Depression and mood swings

Other side effects depend on the type of hormone therapy you get. For instance, anti-androgens tend to have less effect on your sex life. But they can cause diarrhea, tiredness, and liver problems.

Most side effects go away over time after treatment ends. That’s not the case with testicle-removal surgery, though. Its side effects are permanent.

Your doctor can treat many of the side effects. And there are things you can do to help prevent some of them. You might take statins to help control your blood cholesterol, or calcium supplements to help with bone problems.

Talk to your treatment team so you know what to expect when you’re on hormone therapy. Tell them about any changes you notice. Treating side effects right away can keep them from getting worse.

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Are There Any Surgical Techniques That Have Been Developed To Improve Erectile Function Outcomes

At this time, there are several different surgical approaches to carry out the surgery, including retropubic or perineal approaches as well as laparoscopic procedures with freehand or robotic instrumentation. Much debate but no consensus exists about the advantages and disadvantages of the different approaches. Further study is needed before obtaining meaningful determinations of the success with different new approaches.

What Is Stereotactic Body Radiation Therapy And What Advantages Does It Offer

Intermittent Hormone Therapy for Prostate Cancer 101 | Ask a Prostate Expert, Mark Scholz, MD

Traditionally, we deliver external beam radiation in 45 to 48 sessions over a span of ten weeks, using very sophisticated computer-based planning and enhanced imaging techniques and tumor tracking during the treatment. This is called image-guided IMRT and it is the current standard of care.

But there is increasing interest in giving this radiation in shorter courses of treatment. Many of the people we care for have a type of radiation therapy called MSK PreciseTM. MSK Precise is a form of SBRT that can be given in five sessions instead of the usual 45 to 50. MSK has been doing this for the past nine years, and the results in the several hundred people whove been treated have been excellent so far. The treatment is very well tolerated, with outcomes that are at least equivalent to and possibly better than the standard ten weeks of treatment. Because of its superior precision, MSK Precise has less side effects than more conventional radiation techniques, with extremely low rates of incontinence and rectal problems. The sexual side effects are low and similar to what is experienced with conventional external radiation techniques. And of course, its much more convenient for patients.

For patients with more-advanced tumors, we are completing a phase II trial in which were combining sophisticated brachytherapy approaches with MSK Precise. This kind of combination of dose-intense or escalated radiation may end up being a very effective regimen.

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What Is Hormone Therapy

Hormones occur naturally in your body. They control the growth and activity of normal cells. Testosterone is a male hormone mainly made by the testicles.

Prostate cancer usually depends on testosterone to grow. Hormone therapy blocks or lowers the amount of testosterone in the body.

Hormone therapy on its own doesn’t cure prostate cancer. But it can lower the risk of an early prostate cancer coming back when you have it with other treatments. Or it can shrink an advanced prostate cancer or slow its growth.

Addition Of Hormone Therapy To Radiotherapy Benefits Men With Localized Prostate Cancer

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The addition of androgen deprivation therapy to radiotherapy improved survival outcomes among patients with localized prostate cancer, according to study results published in TheLancet Oncology.

Additionally, prolonging the adjuvant component of ADT provided significant benefit regardless of radiotherapy dose among those with intermediate-risk and high-risk disease, researchers noted.

Lancet Oncol

Rationale

Prostate cancer is an extremely common cancer worldwide that has been studied in multiple randomized trials. Yet, to date there has been no prior effort to pool data from multiple global trials to quantify the benefits we see from common treatment intensification strategies,Amar U. Kishan, MD, associate professor and vice-chair of clinical and translational research, and chief of the genitourinary oncology service for the department of radiation oncology at David Geffen School of Medicine at UCLA and UCLA Jonsson Comprehensive Cancer Center, told Healio.

These benefits include the addition of ADT to radiotherapy, prolonging the duration of ADT that follows radiotherapy , and extending the duration of ADT that may precede radiotherapy , Kishan added.

Methodology

Metastasis-free survival served as the studys primary outcome. Median follow-up was 11.4 years.

Key findings

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What Should Patients Know About Msks Approach To Treating Prostate Cancer

At MSK, we manage prostate cancer in a very comprehensive way, tailored to each patients disease. There is no one specific therapy that is best for everyone.

Our initial assessment includes a carefully evaluated biopsy and a very detailed MRI to show the location of the disease, the integrity or soundness of the capsule surrounding the prostate, and the amount of disease. We will often obtain next-generation imaging and do genomic testing. Then, based on that information and with input from the urologist, the radiation oncologist, and the medical oncologist we can provide a comprehensive recommendation.

The radiotherapy we do here at MSK is state-of-the-art and unparalleled. We are one of the few centers in the world to do MRI-based treatment planning and one of the few centers in the US to offer MRI-guided treatment. When we give brachytherapy, we use computer software that provides us with real-time information about the quality and accuracy of the seed implant during the procedure. It requires a great deal of collaboration with our medical physics team to try to get the most accurate positioning of the prostate during the actual three or four minutes of the treatment.

We make adjustments while the patient is still under anesthesia, so that when the procedure is completed, we have been able to achieve ideal placement of the radiation seeds. This translates into improved outcomes.

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Hormone Therapy With Radiation

Orchid

Hormone therapy is often given together with radiation therapy for localized disease .

Hormone therapy usually consists of a shot that lowers your testosterone, given every 1 to 6 months, depending on the formulation. Sometimes, it is prescribed as a daily pill that blocks testosterone from reaching the cancer cells. Clinical trials show a benefit in patients who receive hormonal treatment in combination with external beam radiation. Hormone therapy has been shown to improve cure rates of prostate cancer for men receiving radiation therapy and is part of the standard of care for men with certain types of intermediate-risk prostate cancer and nearly all high-risk prostate cancer. It is often given for intermediate-risk cancer for 4 to 6 months , and for 2 to 3 years in men with high-risk localized prostate cancer, although some doctors may recommend as little as 18 months of hormone therapy.

Hormone therapy should not be given to men with low-risk prostate cancer and is not a standalone treatment for localized prostate cancer in any risk category.

Want more information about a prostate cancer diagnosis and treatment options? Download or order a print copy of the Prostate Cancer Patient Guide.

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Are There Side Effects Of The Combination Approach

There is a slightly higher chance that patients who receive the combined therapy will have rectal irritation or urinary side effects. This is common with prostate cancer radiation therapy because the radiation can damage cells in the tissues surrounding the prostate. But at MSK, we routinely use sophisticated computer-based planning techniques that help us reduce the dose given to normal tissues such as the rectum, bladder, and urethra, lessening the chances of side effects and complications. We have also found that, when treating with the combined approach, using the high-dose-rate brachytherapy compared to low-dose-rate brachytherapy may have less in the way of side effects.

In addition, at MSK, we routinely use a rectal spacer gel, which we inject between the prostate and the rectum while the patient is under mild anesthesia, to create a buffer between these two tissues. By creating this space, we can further reduce the dose of radiation the rectum is exposed to. This leads to fewer side effects for the patient. The rectal spacer gel is biodegradable and dissolves on its own within the body after a few months.

Surgery To Remove The Testicles

Surgery to remove your testicles isnt a common way of lowering the amount of testosterone you produce.

You usually only have surgery to remove your testicles if you need your testosterone reduced urgently. For example if your cancer has spread to your bones and is pressing on your spinal cord, your doctors might want to reduce the amount of testosterone quickly.

Your doctors might also suggest surgery as an option if you don’t want to have injections or tablets.

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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, such as urinary incontinence and erectile dysfunction.

In extremely rare cases, problems arising after surgery can be fatal.

It’s 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.

Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

After a radical prostatectomy, you’ll no longer ejaculate during sex. This means you will not be able to have a child through sexual intercourse.

You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .

Good Prostate Cancer Care

Hormone Therapy & Advanced Therapies for Prostate Cancer, Celestia Higano, MD | 2021 Mid-Year Update

Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.

You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.

You should also be told about any clinical trials you may be eligible for.

If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.

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Increased Survival Rate In Prostate Cancer Patients With Addition Of Hormone Therapy Treatments

by University Hospitals Cleveland Medical Center

Prostate cancer is the leading cause of cancer in men worldwide, and radiotherapy is one of the common forms of treatment. In a first-of-its kind meta-analysis, published today in The Lancet Oncology, researchers from University Hospitals and Case Western Reserve University show that there is consistent improvement in overall survival in men with intermediate- and high-risk prostate cancer with the addition of hormone therapy to radiotherapy treatments.

Throughout the past 40 years, randomized trials have been conducted on the impact of adding hormone therapy to prostate cancer treatments. While these trials individually show the benefit of hormone therapy, there are inconsistencies in timing and duration of treatment recommendations.

In this analysis, the team made three key discoveries:

1) Men with intermediate- and high-risk prostate cancer have an increased survival rate from the addition of hormone therapy to radiotherapy. This was seen in both younger and older men, and in men treated with lower and higher doses of radiotherapy.

3) The prolongation of neoadjuvant hormone therapy before radiotherapy did not benefit men in any outcome measured. This is an important finding, because some countries routinely give extended durations of hormone therapy before radiotherapy. The team showed that this method isn’t advantageous over shorter durations.

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What Types Of Hormone Therapy Are Used For Prostate Cancer

Hormone therapy for prostate cancer can block the production or use of androgens . Currently available treatments can do so in several ways:

  • reducing androgen production by the testicles
  • blocking the action of androgens throughout the body
  • block androgen production throughout the body

Treatments that reduce androgen production by the testicles are the most commonly used hormone therapies for prostate cancer and the first type of hormone therapy that most men with prostate cancer receive. This form of hormone therapy includes:

Treatments that block the action of androgens in the body are typically used when ADT stops working. Such treatments include:

Treatments that block the production of androgens throughout the body include:

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