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.
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.
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Hormone Therapy Can Cause Side Effects
Because hormone therapy blocks your bodys ability to produce hormones or interferes with how hormones behave, it can cause unwanted side effects. The side effects you have will depend on the type of hormone therapy you receive and how your body responds to it. People respond differently to the same treatment, so not everyone gets the same side effects. Some side effects also differ if you are a man or a woman.
Some common side effects for men who receive hormone therapy for prostate cancer include:
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Advising The Patient About Hormonal Therapy
Finally, Mark Moyad, MD, Director of Complementary and Preventive Medicine, University of Michigan, Department of Urology and Oncology, delivered an excellent discussion of the 10 steps he takes in advising patients about initiation of androgen deprivation therapy. Step 1 is to introduce patients to the common and less common side effects of androgen deprivation therapy . Step 2 is to introduce the patient to moderate, practical, and realistic dietary and lifestyle changes that promote general health during the androgen deprivation therapy. Dr. Moyad stated that recommendations for cardiovascular well-being extrapolate well to provide benefit to patients receiving androgen deprivation therapy. Step 3 is to emphasize that when it comes to over-the-counter supplements and other alternative approaches, less is more. He emphasized that some of these agents might have adverse effects on surgery or radiation therapy and that patients should discontinue these agents at least 1 week before definitive treatment. Step 4 is to remind patients that there might be dyslipidemia associated with androgen deprivation therapy patients should be told, know your lipid levels as well as your PSA.
What Are The Advantages Of Orchiectomy
First, it is a single, simple, surgical procedure with a very low risk of problems and 100 percent efficacy.
Second, it can be carried out in ways which are not physically evident. In other words, it is possible to carry out what is known as a subcapsular orchiectomy, in which the cores of the two testes are removed while the capsules remain in the scrotum. This means that the man still appears to be an intact male.
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Problems Getting An Erection
Hormone therapy lowers the amount of testosterone in the body and this affects your ability to have and maintain an erection. This may get better within 3 to 12 months after the treatment ends.
For some men, erection problems are permanent. It depends on the drug you are having and how long you have been taking it.
Your doctor or clinical nurse specialist will be able to offer you advice.
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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About Dr Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
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Prostate Cancer Treatment Can Affect The Penis Length
Treating prostate cancer can reduce the length of penis!
This a worrisome consideration in many men who have or are undergoing the prostate cancer treatment. It is no wonder that a lot of men attribute their penis size/ length with the quality of their sexual relationships. Needless to say that these men are more likely to develop sexual dysfunction due to psychosocial factors in such settings. According to the results of a new study, patients attributed the shrinkage in penis size with the quality of their intimate relationships and shared that they would have chosen another treatment plan if they knew about this therapy-related side effect.
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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.
Good Prostate Cancer Care
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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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 .
Hot Flushes And Sweating
Hot flushes and sweating can be troublesome. They may last for 2 to 30 minutes and you may have a few a month or more often. They are the same as the hot flushes women have when going through menopause.
Lowered testosterone levels cause hot flushes. They are most likely to happen when taking LHRH agonists, also called LH blockers , because these drugs cut testosterone production off altogether.
Getting overheated, drinking tea or coffee, and smoking can all make flushes worse.
They may gradually get better as you get used to the treatment. But, in some men the flushes keep on happening as long as you take the drug.
Talk to your doctor or clinical nurse specialist if you have problems coping with hot flushes and sweating. There are treatments that may help.
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Hormonal Therapy And Its Complications
Several different hormonal approaches are used in the management of various stages of prostate cancer.
These approaches include the following:
- Aminoglutethimide.
Abiraterone acetate
Abiraterone acetate has been shown to improve OS when added to ADT in men with advanced prostate cancer who have castration-sensitive disease. Abiraterone acetate is generally well-tolerated however, it is associated with an increase in the mineralocorticoid effects of grade 3 or 4 hypertension and hypokalemia compared with ADT alone. It may also be associated with a small increase in respiratory disorders.
Bilateral orchiectomy
Benefits of bilateral orchiectomy include the following:
- Ease of the procedure.
- Immediacy in lowering testosterone levels.
- Low cost relative to the other forms of ADT.
Disadvantages of bilateral orchiectomy include the following:
- Psychological effects.
- Osteoporosis.
Bilateral orchiectomy has also been associated with an elevated risk of coronary heart disease and myocardial infarction.
Estrogen therapy
Estrogens at a dose of 3 mg qd ofdiethylstilbestrol will achieve castrate levels of testosterone. Likeorchiectomy, estrogens may cause loss of libido and impotence. Estrogens also cause gynecomastia, and prophylactic low-dose radiation therapy to the breasts is given to prevent this complication.
Luteinizing hormone-releasing hormone agonist therapy
Evidence :
4/5kill tumor cellstumorscancerAbirateronetumor cellscellgiven here
Does ADT kill prostate cancer cells?
Breast Cancer Test Receives Lcd
GenomeDx describes Decipher as a unique genomic test intended for men who have had prostate surgery and are considered by guidelines to be at high risk for their cancer returning. It is designed for men with specific risk factors for cancer recurrence, including positive surgical margins, stage T3 disease , or rising PSA after an initial drop-off.3On October 15, 2014, BioTheranostics announced that it had received a positive local coverage determination from Palmetto GBA for its Breast Cancer Index, or BCI, test, a gene expression test that assesses risk during the following periods:
- In the first 5 years after diagnosis
- Late recurrence beyond 5 years after diagnosis
- Overall 10-year risk
In a statement, BioTheranostics said that the draft Medicare language calls for covering BCI to predict risk of late distant recurrence in women with early stage, estrogen receptor-positive breast cancer who are considering extended therapy but are concerned about continuing anti-hormonal therapy because of documented toxicity or possible significant patient-specific side effects.
References
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Complications Of Hormonal Therapy
E. David Crawford, MD, Professor of Surgery and Radiation Oncology, Head of the Section of Urologic Oncology at the University of Colorado, and Chairman of the 16th International Prostate Cancer Update, provided an excellent overview of complications of hormonal therapy and their treatment. He began this discussion by outlining not only the benefits but also the complications of androgen deprivation, the latter including osteoporosis, hot flushes, gastrointestinal side effects, anemia, gynecomastia, sarcopenia, central nervous system effects, change in body weight, sexual dysfunction, loss of bone density, and increased risk of bone fracture and hot flushes .
Evidence For Combining Hormone Therapy And Radiation Treatment
Bolla M, Collette L, Blank L, et al. Long-Term Results with Immediate Androgen Suppression and External Irradiation in Patients with Locally Advanced Prostate Cancer : A Phase III Randomised Trial. Lancet 2002 360:1036. PMID: 12126818.
Bolla M, Gonzalez D, Warde P, et al. Improved Survival in Patients with Locally Advanced Prostate Cancer Treated with Radiotherapy and Goserelin. New England Journal of Medicine 1997 337:295300. PMID: 9233866.
DAmico AV, Schultz D, Loffredo M, et al. Biochemical Outcome Following External Beam Radiation Therapy With or Without Androgen Suppression Therapy for Clinically Localized Prostate Cancer. Journal of the American Medical Association 2000 284:12803. PMID: 10979115.
DAmico AV, Manola J, Loffredo M, et al. Six-Month Androgen Suppression Plus Radiation Therapy Versus Radiation Therapy Alone for Patients with Clinically Localized Prostate Cancer: A Randomized Controlled Trial. Journal of the American Medical Association 2004 292:8217. PMID: 15315996.
Denham JW, Steigler A, Lamb DS, et al. Short-Term Androgen Deprivation and Radiotherapy for Locally Advanced Prostate Cancer: Results from the Trans-Tasman Radiation Oncology Group 96.01 Randomised Controlled Trial. Lancet Oncology 2005 6:84150. PMID: 16257791.
Nesslinger NJ, Sahota RA, Stone B, et al. Standard Treatments Induce Antigen-Specific Immune Responses in Prostate Cancer. Clinical Cancer Research 2007 13:1493502. PMID: 17332294.
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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.
Combined Androgen Blockade: Pro And Con
Pro:
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.
Con:
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.
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How Long Does Hormone Therapy Work To Stop Cancer Progression
On average, hormone therapy can stop cancer progression for 1-2 years before the prostate cancer becomes resistant. Hormone therapy can stop working over time as the prostate cancer begins to grow again .
When this occurs, doctors may offer other therapies. Since they cant predict how long hormone therapy will work, they may perform regular blood tests to check PSA and testosterone levels. If PSA levels start to increase and testosterone levels are low, these may be signs that the cancer has started to grow again.
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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