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
Intermittent Hormonal Therapy For Locally Advanced Prostate Cancer
Intermittent hormonal therapy is where you stop taking the drugs and after a while start taking them again. This may be an option for locally-advanced prostate cancer. It gives you a break from the side effects of hormonal therapy.
Intermittent hormonal therapy is not suitable for everyone and should only be done on your doctors advice. Your doctor can explain more about this. They usually measure your PSA level using the PSA test every 3 months. If it goes up to a certain level or you get symptoms, your doctor will advise you to start hormonal therapy again.
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.
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External Beam Radiation Therapy
In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.
You will usually go for treatment 5 days a week in an outpatient center for at least several weeks, depending on why the radiation is being given. Each treatment is much like getting an x-ray. The radiation is stronger than that used for an x-ray, but the procedure typically is painless. Each treatment lasts only a few minutes, although the setup time getting you into place for treatment takes longer.
Newer EBRT techniques focus the radiation more precisely on the tumor. This lets doctors give higher doses of radiation to the tumor while reducing the radiation exposure to nearby healthy tissues.
Hormone Therapy Helps Some Prostate Cancer Survivors Live Longer
A study published in the New England Journal of Medicine in January 2017 indicates that men whose prostates are removed to treat prostate cancer are likely to survive longer if they take drugs to block the male hormone testosterone in addition to undergoing radiation therapy.
Unfortunately, its not that simple.
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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.
How Are Hormone Therapy Medicines Used
Hormone therapy medicines may be used alone, with another type of hormone therapy, or with another type of prostate cancer treatment.
Monotherapy is when only one type of hormone therapy medicine is used to lower the amount of testosterone in your body. Monotherapy can be effective in shrinking a prostate cancer tumor, slowing the spread of your prostate cancer, and relieving pain caused by your prostate cancer. Monotherapy may be used with neoadjuvant therapy or adjuvant therapy. Please read When is Hormone Therapy Used for Prostate Cancer? to learn more about neoadjuvant and adjuvant therapy.
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Treatment To Lower Testicular Androgen Levels
Androgen deprivation therapy, also called ADT, uses surgery or medicines to lower the levels of androgens made in the testicles.
Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens are made. This causes most prostate cancers to stop growing or shrink for a time.
This is done as an outpatient procedure. It is probably the least expensive and simplest form of hormone therapy. But unlike some of the other treatments, it is permanent, and many men have trouble accepting the removal of their testicles. Because of this, they may choose treatment with drugs that lower hormone levels instead.
Some men having this surgery are concerned about how it will look afterward. If wanted, artificial testicles that look much like normal ones can be inserted into the scrotum.
Luteinizing hormone-releasing hormone agonists are drugs that lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called medical castration because they lower androgen levels just as well as orchiectomy.
With these drugs, the testicles stay in place, but they will shrink over time, and they may even become too small to feel.
- Leuprolide mesylate
Possible side effects
Many side effects of hormone therapy can be prevented or treated. For example:
How Might Hormone Therapy Make Me Feel
Hormone therapy itself can affect your mood. You may find that you feel more emotional than usual or just different to how you felt before. Some men find that they cry a lot. You may also get mood swings, such as getting tearful and then angry. Just knowing that these feelings are caused by hormone therapy can help.
Everyones different some men are surprised by the side effects and how upsetting they find them. Others have fewer symptoms or are not as worried by them.
Some of the other side effects of hormone therapy are hard to come to terms with. Physical changes, such as putting on weight, or changes to your sex life, might make you feel very different about yourself. Some men say they feel less masculine because of their diagnosis and treatment.
If youre starting hormone therapy very soon after being diagnosed with prostate cancer, you might still feel upset, shocked, frightened or angry about having cancer. These feelings are normal, and it’s okay to feel this way.
Things in your day-to-day life can change because of the hormone therapy. Your relationships with your partner, family and friends might change. Or you might be too tired to do some of the things you used to do.
Some men experience low moods, anxiety or depression. This could be directly caused by the hormone therapy itself, or because you’ve been diagnosed with prostate cancer. It could also be due to the impact that treatment is having on you and your family.
What can help?
Talking about it
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Will Side Effects Limit What I Can Do
What you are able to do will depend on which side effects you have and how bad they are. Many men are able to work, cook meals, and enjoy their usual daily activities when they have hormone therapy for their prostate cancer. Other men find that they need more rest than before they started hormone therapy so they cant do as much. You should try to keep doing the things you enjoy as long as you don’t get too tired.
Your Cancer Care Team
People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.
The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.
Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.
When deciding what treatment is best for you, your doctors will consider:
- the type and size of the cancer
- what grade it is
- whether the cancer has spread to other parts of your body
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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
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 .
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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.
Treating Advanced Prostate Cancer
If the cancer has reached an advanced stage, it’s no longer possible to cure it. But it may be possible to slow its progression, prolong your life and relieve symptoms.
Treatment options include:
- hormone treatment
If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.
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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:
What Kinds Of Medical Information Should I Keep
It is important for you to keep a copy of your prostate cancer treatment records. You may not always see the same doctor for your follow-up care, so having this information to share with another doctor can be very helpful. The following is a list of medical information you may want to keep.
Remember, you have the right to copies of all your medical paperwork and the actual slides, x-rays and any other information about your health care and treatment. A good idea would be to create two copies of your medical information and keep them in folders. Keep one folder at home and take the other one with you to your doctors appointments. Whenever you see a new doctor, it is important for you to let them know about your prostate cancer and any treatment that you have had.
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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.
Can Hormone Therapy Cure My Prostate Cancer
No, hormone therapy cannot cure your prostate cancer. The goal of hormone therapy is to stop or slow the growth of the prostate cancer cells in your body. Hormone therapy can shrink prostate cancer tumors and may stop or limit the spread of your prostate cancer. Hormone therapy is used to control your prostate cancer.
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Intermittent Or Continuous Therapy
Once prescribed, hormone therapy used to continue for life, but scientists are now reevaluating that strategy and investigating whether hormone therapy can be taken intermittently, with so-called holidays from treatment. The thinking is that this may not only help restore quality of life as, for example, returning libido and sexual health but also delay the hormone resistance that eventually develops in men taking hormone therapy.
Clinical trials evaluating whether intermittent therapy is as effective or more effective than continuous therapy are now under way, so it is too early to say for sure.
Figure : How Hormone Therapy Affects The Androgen Cascade
The male sex hormones are known as androgens. Probably the best known hormone in this family is testosterone. Most androgens are produced in the testicles.
Androgens fuel the growth of prostate cells, including prostate cancer cells. Hormone therapy also known as androgen-deprivation therapy seeks to cut off the fuel supply. But different therapies work in different ways.
A. The hypothalamus releases pulses of LHRH, which signals the pituitary gland to release the hormones FSH and LH.
B. LH travels through the bloodstream. When it reaches the testicles, it binds to specialized cells that secrete testosterone into the bloodstream.
C. In the prostate, the enzyme 5-alpha-reductase converts testosterone and other types of androgens into dihydrotestosterone , which stimulates the growth of prostate cells and fuels the growth of cancer, if it is present.
Centrally acting agents
LHRH agonists flood the pituitary gland with messages to crank out LH. This causes a temporary surge of testosterone until receptors in the pituitary are overloaded. Then testosterone levels drop sharply.
The GnRH antagonist jams receptors in the pituitary gland so that it cannot respond to the pulses of LHRH sent by the hypothalamus. This prevents the LH signal from being sent and no testosterone is made in the testicles.
DES inhibits secretion of LHRH from the hypothalamus.
Peripherally acting therapies
Orchiectomy removes the testicles, preventing testosterone production.
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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.