Therapies That Interfere With Androgen Function
Taken daily as pills, antiandrogens bind to the androgen receptor proteins in the prostate cells, preventing the androgens from functioning. In addition to preventing a flare reaction, antiandrogens may be added to your treatment plan if an orchiectomy, LHRH agonist or LHRH antagonist is no longer working by itself. Commonly prescribed antiandrogens include flutamide and bicalutamide .
Enzalutamide is a newer type of antiandrogen that blocks the signal that the receptor normally sends to the cells control center to trigger growth and division. This antiandrogen may be used to treat castration-resistant prostate cancer.
Hormonal Therapy For Endometrial Cancer
Cancer of the uterus or its lining, the endometrium, may respond to hormone therapy with progestins. Other types of hormone therapy for endometrial cancer include:
- Aromatase inhibitors
When and why theyre used: Hormone therapy is typically reserved for advanced uterine or endometrial cancer, or for cancer that has returned after treatment. Its often combined with chemotherapy.
Risks: Side effects are similar to those seen with hormone treatment for other types of cancer.
Expert cancer care
How Long Do You Take Hormonal Therapy For
For early prostate cancer this depends on the prostate cancer risk group. If the cancer is:
- intermediate-risk you may have hormonal therapy for a few months after radiotherapy
- high-risk you may be advised to have hormonal therapy for up to 2 to 3 years after radiotherapy.
For locally advanced prostate cancer you usually have hormonal therapy for 2 to 3 years after radiotherapy.
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What Is Hormonal Therapy For Prostate Cancer
Hormonal therapy for prostate cancer is a treatment to lower the levels of the hormone testosterone in the body. Prostate cancer needs testosterone to grow. Testosterone is mainly made by the testicles. Hormonal therapies reduce the amount of testosterone in the body, or stop it reaching the prostate cancer cells.
Testosterone is important for:
- muscle development and bone strength.
Hormonal therapies are drugs that can be given as injections or as tablets.
What Are The Side Effects Of Hormone Therapy For Prostate Cancer
Because androgens affect many other organs besides the prostate, ADT can have a wide range of side effects , including:
- loss of interest in sex
Studer UE, Whelan P, Albrecht W, et al. Immediate or deferred androgen deprivation for patients with prostate cancer not suitable for local treatment with curative intent: European Organisation for Research and Treatment of Cancer Trial 30891. Journal of Clinical Oncology 2006 24:18681876.
Zelefsky MJ, Eastham JA, Sartor AO. Castration-Resistant Prostate Cancer. In: Vincent T. DeVita J, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology, 9e. Philadelphia, PA: Lippincott Williams & Wilkins 2011.
Smith MR, Saad F, Chowdhury S, et al. Apalutamide and overall survival in prostate cancer. European Urology 2021 79:150158.
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Selective Estrogen Receptor Modulators
Selective estrogen receptor modulators including tamoxifen , raloxifene and toremifene selectively block estrogen from certain tissues, namely the breast, while increasing its availability in other areas such as the bones.
When and why theyre used: Doctors may recommend SERMs after surgery for early ER-positive breast cancer in men or women, to reduce the chances that it recurs. Theyre also approved to treat advanced breast cancer, and may be used to prevent breast cancer in high-risk individuals. Toremifene is only approved for advanced stage breast cancer that has spread.
Risks: In addition to more common side effects of hormone therapy such as hot flashes, tamoxifen risks may include blood clots, stroke, bone loss, mood changes, depression and loss of sex drive. Men who take tamoxifen may experience headaches, nausea, vomiting, rashes, impotence and loss of sex drive. Raloxifene may increase a patients chances of having a stroke or developing potentially fatal blood clots in the lungs or legs. Fortunately, these side effects are considered relatively rare. Have your doctor explain the potential side effects associated with each SERM when discussing the pros and cons of these medications with you.
Hormonal Therapy On Its Own
Doctors do not usually advise having hormonal therapy instead of a prostatectomy or radiotherapy. Hormonal therapy alone cannot cure early or locally-advanced prostate cancer.
Depending on your general health and preferences, you may decide to have hormonal therapy on its own. For example, if you:
- are not well enough to have a prostatectomy or radiotherapy
- do not want to have a prostatectomy or radiotherapy
- are monitoring prostate cancer, for example having watchful waiting and the cancer starts to grow.
Hormonal therapy can slow down or stop the cancer cells growing for many years. It can also improve any symptoms. Not having surgery or radiotherapy means you avoid the side effects of these treatments. But hormonal therapy also causes side effects. It is important to talk to your doctor or nurse before you decide.
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How Do Doctors Tell If Hormone Therapy Stops Working
Rising PSA levels and low testosterone levels can indicate CRPC. Doctors may also use imaging tests to determine whether the cancer is growing.
- Complete androgen blockade: Androgen receptor blockers, such as enzalutamide, flutamide, or bicalutamide.
- Abiraterone: A type of anti-androgen medication.
- Immunotherapy: This uses sipuleucel-T, a vaccine that helps the immune system fight prostate cancer.
- Chemotherapy: Doctors usually use the drug docetaxel for CRPC or cabazitaxel.
- Targeted therapy: Rucaparib camsylate and olaparib are two types of targeted therapy drugs that may help treat CRPC that has mutations.
- Radium-223 dichloride: Radium-223 dichloride is a type of radiotherapy drug that works inside the body to kill cancer cells with radiation.
- Radiation therapy: Doctors may combine external radiation therapy with hormone therapy to destroy cancer cells and relieve pain or urinary problems.
- Clinical trials: Clinical trials may offer new treatment options for people with prostate cancer that is resistant to standard treatments.
Doctors will continue to prescribe ADT as part of the treatment. This keeps testosterone levels low, as an increase in testosterone could contribute to tumor growth.
, in recent years, there have been improvements in treatment for CRPC, particularly metastatic CRPC, with many promising new treatments.
How Will I Know That My Hormone Therapy Is Working
Doctors cannot predict how long hormone therapy will be effective in suppressing the growth of any individual mans prostate cancer. Therefore, men who take hormone therapy for more than a few months are regularly tested to determine the level of PSA in their blood. An increase in PSA level may indicate that a mans cancer has started growing again. A PSA level that continues to increase while hormone therapy is successfully keeping androgen levels extremely low is an indicator that a mans prostate cancer has become resistant to the hormone therapy that is currently being used.
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What Types Of Hormone Therapy Are There
There are three main ways to have hormone therapy for prostate cancer. These are:
- injections or implants
- surgery to remove the testicles .
The type of hormone therapy you have will depend on whether your cancer has spread, any other treatments youre having, and your own personal choice. You may have more than one type of hormone therapy at the same time.
Questions To Ask Your Doctor Or Nurse
- What is the aim of treatment?
- What type of hormone therapy are you recommending for me and why?
- How often will I have my injections or implants?
- How will my treatment be monitored?
- How long will it be before we know if the hormone therapy is working?
- What are the possible side effects, and how long will they last?
- What will happen if I decide to stop my treatment?
- Are there any clinical trials that I could take part in?
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Secondary Treatment Following Relapse
Hormone therapy may also be used as a secondary or salvage treatment when PSA levels rise following initial prostate cancer treatment, indicating the cancer has returned. This situation is known as biochemical recurrence. The salient points to keep in mind are that hormone therapy is most often used as a salvage treatment when PSA doubling time is less than six months, indicating that the cancer is aggressive or may have already metastasized.
When Is Hormone Therapy Used
Hormone therapy may be used:
- If the cancer has spread too far to be cured by surgery or radiation, or if you cant have these treatments for some other reason
- If the cancer remains or comes back after treatment with surgery or radiation therapy
- Along with radiation therapy as the initial treatment, if you are at higher risk of the cancer coming back after treatment
- Before radiation to try to shrink the cancer to make treatment more effective
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Combined Androgen Blockade: Pro And Con
Crawford ED, Eisenberger MA, McLeod DG, et al. A Controlled Trial of Leuprolide With and Without Flutamide in Prostatic Carcinoma. New England Journal of Medicine 1989 321:41924. PMID: 2503724.
Eisenberger MA, Blumenstein BA, Crawford ED, et al. Bilateral Orchiectomy With or Without Flutamide for Metastatic Prostate Cancer. New England Journal of Medicine 1998 339:103642. PMID: 9761805.
Two large meta-analyses that reviewed many studies comparing combined androgen blockade to monotherapy concluded that the combination offered only a small survival advantage and even that finding was inconsistent between the two analyses. One analysis, which reviewed 27 randomized studies involving 8,275 men, estimated that combined androgen blockade improved five-year survival by only 2% to 3%, at most. However, an advantage of only 2% to 3%, when applied to thousands of men undergoing treatment, translates into hundreds of lives extended obviously an important benefit to the men who gain months and even years of life as a result. That is why I use combined therapy for all of my patients who undergo hormone treatments.
Checking Your Hormone Therapy Is Working
You have regular blood tests to check the level of a protein called prostate specific antigen . PSA is a protein made by both normal and cancerous prostate cells. It is in the blood in small amounts in all men, unless you have had the prostate gland completely removed.
While the hormone therapy is working, the level of PSA should stay stable or may go down. But if prostate cancer starts to grow and develop, the level of PSA may go up. This is hormone resistant prostate cancer or castrate resistant prostate cancer. Then your doctor may need to change your treatment. They will discuss this with you
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Biochemical Recurrence And Hormone Therapy
Hormone therapy is the standard of care for patients with metastatic prostate cancer, but for patients whose only sign of cancer recurrence is a rising PSA level , the benefits are less clear.
Some doctors think that hormone therapy works better if its started as soon as possible, even if a man is not having any symptoms. Other doctors feel that, because of the side effects of hormone therapy and the chance that the cancer could become resistant to the therapy, treatment shouldnt be started until symptoms develop. This issue is being actively studied.
What Kind Of Cancers Can Be Treated With Hormone Therapy
Hormone levels can control several types of cancer. Common cancers that are treated with hormone therapy are:
Breast cancer. In many cases, breast cancer depends on the hormones estrogen and/or progesterone to grow. Tumors that have receptors that these hormones can bind to are called “hormone receptor positive.” Blocking the hormones can help prevent a recurrence and death from breast cancer. Learn about estrogen and progesterone receptor testing for breast cancer.
Prostate cancer. The growth of prostate cancer is usually driven by hormones called androgens. The most common androgen is testosterone. Lowering levels of androgens can help slow the growth of cancer.
Thyroid cancer. People with thyroid cancer who are treated with surgery usually need thyroid hormone therapy. In addition to replacing the hormone that is needed by the body, the therapy may slow down the growth of any remaining cancer cells in the body.
Hormone therapy can also be recommended for other cancers that are less common. Examples include:
Adrenal cancer. An adrenal gland tumor may produce excess hormones. The doctor may prescribe various medications to control the levels of these hormones before, during, or after other treatments.
Neuroendocrine tumors. Hormone therapies may slow the growth of a neuroendocrine tumor . They can also be used to control the symptoms created by the hormones a NET can release.
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Intermittent Versus Continuous Hormone Therapy
Most prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression might not be needed, so they advise intermittent treatment. This can allow for a break from side effects like decreased energy, sexual problems, and hot flashes.
In one form of intermittent hormone therapy, treatment is stopped once the PSA drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy uses hormone therapy for fixed periods of time for example, 6 months on followed by 6 months off.
At this time, it isnt clear how this approach compares to continuous hormone therapy. Some studies have found that continuous therapy might help men live longer, but other studies have not found such a difference.
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.
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When Is Hormone Therapy Used For Prostate Cancer
On its own, hormone therapy can be a good way to control the growth of your prostate cancer. It can also be used with another prostate cancer treatment to help it work better. You should keep in mind that the following things will affect when you have hormone therapy and if you have hormone therapy along with another type of prostate cancer treatment:
Your stage, grade, and Gleason score are determined by a pathologist. A pathologist is a specially trained physician who reviews biopsy results in order to find changes in your body caused by cancer. When you had your prostate biopsy, the pathologist looked at the tissue samples taken from your prostate gland and prepared your biopsy report. The report tells you and your doctor the following information:
This information is used to help your doctor chose the most effective type of hormone therapy for you. The types of hormone therapy include:
Neoadjuvant hormone therapy
If you have early stage prostate cancer, you and your doctor may decide on a course of hormone therapy prior to the start of your main prostate cancer treatment. This is called neoadjuvant or pre-therapy. This type of hormone therapy is used to help shrink your prostate cancer tumor. This helps make your main treatment more effective. This is very common with men who get radiation therapy.
Adjuvant hormone therapy
Adjuvant therapy is given to you at the same time you have your main prostate cancer treatment.
Salvage hormone therapy
Why Choose Md Anderson Cancer Center At Cooper For Prostate Cancer Care
As a partner with MD Anderson Cancer Center, one of the nations top cancer care centers, we offer research-backed prostate cancer prevention, detection, and treatment services. Youll benefit from:
- Leading cancer care expertise: Our specialists are experts in cancer care. We offer a range of advanced technologies, therapies, and procedures for cancer diagnosis and treatment.
- Team approach to treatment: At MD Anderson Cancer Center at Cooper, our surgeons, medical oncologists, radiation oncologists, and other skilled professionals work together to find the best treatment plan for you. This coordination leads to more successful treatment outcomes.
- Access to clinical trials: Our specialists participate in a wide range of cancer research studies. That means you might have the opportunity to take part in a promising clinical trial as part of your treatment.
- Full range of support services: A cancer diagnosis affects so much more than your physical health. We offer behavioral therapy, palliative care, social work services, and other resources to help you cope with whatever challenges cancer treatment presents. Learn more about our cancer care support services.
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Orchiectomy Surgical Removal Of The Testicles
Once a common treatment, orchiectomy is rarely used now, thanks to the development of advanced ADT drugs. The procedure removes the testicles the source of most testosterone production. The scrotal sac is left intact, and patients can have testicular prostheses implanted for cosmetic purposes. Orchiectomy is effective in drastically reducing levels of testosterone, but it has several downsides. Removal of the testicles is permanent and irreversible. Loss of the testicles makes it challenging to have intermittent hormone therapy, an advantageous treatment. And there is a psychological effect: Many patients feel distress related to the idea of lost masculinity if they undergo this procedure.
Systemic Therapy For Metastatic Disease
The most common use of hormone therapy today is to treat men whose prostate cancer has metastasized to other parts of the body. If prostate cancer cells escape the prostate, they migrate first to surrounding structures, such as the seminal vesicles and lymph nodes, and later to the bones or, rarely, to other soft tissues.
Hormone therapy is recommended as a palliative treatment, to relieve symptoms such as bone pain. And while hormone therapy is not a cure, in that it cant eliminate prostate cancer completely, it often extends life for many years. By reducing testosterone levels, hormone therapy can shrink a prostate tumor and its metastases and slow further progression of the cancer for so long that sometimes a man with this disease dies of something other than prostate cancer.
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