Hormonal Therapy For Aggressive Prostate Cancer: How Long Is Enough
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Men weighing treatment options for intermediate- or high-risk cancer that is still localized to the prostate can face a tricky question. A standard approach in these cases is to give radiation to the prostate along with drugs that block testosterone, a hormone that makes the cancer cells grow faster. For how long should this hormone therapy last? Thats not entirely clear. The drugs have side effects, such as fatigue, impotence, and a loss of muscle mass. But radiation doesnt control prostate cancer effectively without them. Doctors therefore aim to give hormone therapy only for as long as it takes to help their patients, without causing any undue harm.
Now, newly published results from a phase 3 clinical trial are providing some needed guidance.
Quantitative Assessment Of The New Models
To evaluate the performance of the New Androgen Model and the New PSA Model as formulated in this paper, we compare fitting and forecasting results to those of the Improved BK model . In this application, we define the error in terms of the mean of squared differences between the observed and predicted values of serum androgen levels at each of N measurement time points:
i o are, respectively, the estimated and the observed values of serum androgen at the ith time point. We carry out fitting on 1.5 cycles for each patient to obtain a set of parameters, within the set of admissible values for the New Androgen and New PSA models, that minimizes Eq. . Next, we use the parameters to forecast the next cycle. Finally, we evaluate the MSE over the forecast period to quantify the models predictive ability.
While Youre Taking Hormonal Therapy
- Tell your doctor or nurse if youre taking any medications, including patches and creams, or if youve changed medications. Some medications may change the way hormonal therapy works. Tell your doctor if youre taking:
- Medications that require a prescription
- Medications that dont require a prescription
- Any herbal remedies, vitamins, or dietary supplements
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If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
What Is Intermittent Adt
Researchers have investigated whether a technique called intermittent androgen deprivation can delay the development of hormone resistance. With intermittent androgen deprivation, hormone therapy is given in cycles with breaks between drug administrations, rather than continuously. An additional potential benefit of this approach is that the temporary break from the side effects of hormone therapy may improve a mans quality of life.
Randomized clinical trials have shown similar overall survival with continuous ADT or intermittent ADT among men with metastatic or recurrent prostate cancer, with a reduction in some side effects for intermittent ADT .
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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
Read more about diet and physical activity.
When Is Hormone Therapy Used
Hormone therapy is almost never used for people with Stage I or Stage II prostate cancer.
It is mainly used for:
- Advanced cancer that has spread beyond the prostate gland
- Cancer that has failed to respond to surgery or radiation
- Cancer that has recurred
It may also be used:
- Before radiation or surgery to help shrink tumors
- Along with radiation therapy for cancer that is likely to recur
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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 .
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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Who Gets Prostate Cancer And What Are The Symptoms
Approximately one in nine men will be diagnosed with prostate cancer during their lifetime, according to the American Cancer Society.1 The average age at diagnosis is around 66 years. Common symptoms of prostate cancer can include frequent urination, blood in the urine, sudden onset of erectile dysfunction and discomfort when sitting due to an enlarged prostate gland. Risk factors for prostate cancer include being 65 years or older, having a family history of prostate cancer and certain genetic factors.
This is a cancer that, for some, is slow-growing and doesnt need immediate treatment. It may lay dormant for years. For others, a combination of surgery, radiation, or hormone-blocking therapies may be necessary.
Treating Prostate Cancer with Hormone Therapy
Men with prostate cancer often receive hormone-blocking therapy as part of their treatment plan. Approximately 75 percent of men undergoing this treatment will experience hot flashes. Hot flashes are one of the most common side effects of hormonal therapy, which lowers testosterone and androgens.
Hot flashes and night sweats can be very disruptive to a persons quality of life affecting sleep, sexual function, weight, and mood. Recently, the Oncology Nursing Society released new guidelines to help patients mitigate these issues.2
New Guidelines for Treatment For Hot Flashes Caused by Hormone Therapy
Life After Prostate Cancer
Hormone Therapy For Breast Cancer
If you have breast cancer, your doctor might prescribe medications that stop estrogen or progesterone from attaching to cancer cells. They include:
Fulvestrant . For the first month, you get fulvestrant as a shot every 2 weeks. Then you get a dose every month. It treats advanced breast cancer in women who are past menopause.
Tamoxifen. Your usually take it every day as a pill. Doctors most often prescribe it to women whove been treated for early-stage breast cancer, to lower the chances of cancer coming back. In this situation, you might take it for 5-10 years. You can use tamoxifen before or after menopause.
Toremifene . You take toremifene every day as a pill to treat metastatic breast cancer. Thats breast cancer that has spread to other parts of your body. You use it only if youve already gone through menopause.
If you’ve gone through menopause, your doctor may prescribe aromatase inhibitors. These stop your body from making estrogen. They include:
Anastrozole . It reduces the risk that cancer will return after youve been treated for early-stage breast cancer. Your doctor can also use it to treat advanced breast cancer.
Exemestane . You also take this to lower the risk of cancer coming back after treatment for early-stage breast cancer. You sometimes get it after taking tamoxifen for 2-3 years. Your doctor may also use it to treat advanced breast cancer if tamoxifen stops working for you.
- Radiation aimed at your ovaries
- Surgery to take out your ovaries
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What Are Prostate Cancer Survival Rates By Stage
Staging evaluation is essential for the planning of treatment for prostate cancer.
- A basic staging evaluation includes the patient examination, blood tests, and the prostate biopsy including ultrasound images of the prostate.
- Further testing and calculations may be performed to best estimate a patients prognosis and help the doctor and patient decide upon treatment options.
Prognosis refers to the likelihood that the cancer can be cured by treatment, and what the patients life expectancy is likely to be as a consequence of having had a prostate cancer diagnosis.
If a cancer is cured, your life expectancy is what it would have been had you never been diagnosed with prostate cancer. If the cancer cannot be cured due to it recurring in distant locations as metastases, or recurs either locally or in an area no longer able to be treated in a curative manner, then estimates can be made of what is likely to be your survival based again on group statistics for people who have been in the same situation.
Nomograms are charts or computer-based tools that use complex math from analysis of many patients treatment results.
The prognosis for prostate cancer varies widely, and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and the cancers responsiveness to treatment, among other factors.
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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What To Expect During Hormone Therapy
As you go through hormone deprivation therapy, youâll have follow-up visits with your cancer doctor. Theyâll ask about side effects and check your PSA levels.
Doctors donât know how long hormone therapy works to keep prostate cancer in check. So, while you take it, your doctor will regularly draw blood to check your PSA levels. Undetectable or low PSA levels usually mean that the treatment is working. If your PSA levels go up, itâs a sign that the cancer has started growing again. If this happens, your cancer is considered castrate-resistant, and hormone deprivation therapy is no longer an effective treatment.
Youâll also get other blood tests to see if the cancer is affecting other parts of your body like your liver, kidneys, or bones. Scans will show how well your cancer is responding to hormone therapy.
To lessen the side effects of hormone therapy drugs, researchers suggest that you take them for just a set amount of time or until your PSA drops to a low level. If the cancer comes back or gets worse, you may need to start treatment again.
Evidence About Hormone Therapy And Prostatectomy
Gleave ME, La Bianca S, Goldenberg SL. Neoadjuvant Hormonal Therapy Prior to Radical Prostatectomy: Promises and Pitfalls. Prostate Cancer and Prostatic Diseases 2000 3:13644. PMID: 12497089.
Hurtado-Coll A, Goldenberg SL, Klotz L, Gleave ME. Preoperative Neoadjuvant Androgen Withdrawal Therapy in Prostate Cancer: The Canadian Experience. Urology 2002 60:4551. PMID: 12231047.
Kumar S, Shelley M, Harrison C, et al. Neo-adjuvant and Adjuvant Hormone Therapy for Localized and Locally Advanced Prostate Cancer. Cochrane Database of Systematic Reviews 2006 CD006019. PMID: 17054269.
Soloway MS, Sharifi R, Wajsman Z, et al. Randomized Prospective Study Comparing Radical Prostatectomy Alone Versus Radical Prostatectomy Preceded by Androgen Blockade in Clinical Stage B2 Prostate Cancer. The Lupron Depot Neoadjuvant Prostate Cancer Study. Journal of Urology 1995 154:4248. PMID: 7541859.
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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.
When Hormone Therapy Stops Working
After some months or years the hormone treatment usually stops working and the cancer starts to grow again. Your doctor might recommend stopping or changing hormone treatment at this stage.
If youre having anti androgens and your PSA level has started to rise again your doctor might get you to stop taking them. In some cases this can cause the cancer to shrink and stop growing for some time. This is called anti androgen withdrawal response .
There are different treatment options for when hormone therapy stops working, such as chemotherapy or steroids.
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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. Its 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 dont understand prostate cancer or its treatment. They may stay away from you because theyre 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.