Surgery To Remove The Testicles
Surgery to remove your testicles isnt a common way of lowering the amount of testosterone you make.
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 dont want to have injections or tablets.
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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- Both normal and cancerous cells in the prostate gland rely on male hormones such as testosterone.
- The aim of ADT is to control cancer growth by reducing the level of male hormones. Potential side effects include impotence, reduced sex drive, fatigue and an increased risk of osteoporosis.
- Men should take calcium and vitamin D while undergoing ADT to reduce the risk of osteoporosis.
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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.
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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Staging Of Prostate Cancer
Doctors will use the results of your prostate examination, biopsy and scans to identify the stage of your prostate cancer .
The stage of the cancer will determine which types of treatments will be necessary.
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.
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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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.
When Hormone Therapy Stops Working
After some months or years, 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 you’re having anti androgens and your PSA level has started to rise again your doctor might ask 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. This includes chemotherapy and steroids.
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What Is Advanced Prostate Cancer
When prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer.
Prostate cancer is often grouped into four stages.
- Stages I & II: The tumor has not spread beyond the prostate. This is often called early stage or localized prostate cancer.
- Stage III: Cancer has spread outside the prostate, but only to nearby tissues. This is often called locally advanced prostate cancer.
- Stage IV: Cancer has spread outside the prostate to other parts such as the lymph nodes, bones, liver or lungs. This stage is often called advanced prostate cancer.
When an early stage prostate cancer is found, it may be treated or placed on surveillance . If prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer. Stage IV prostate cancer is not curable, but there are many ways to control it. Treatment can stop advanced prostate cancer from growing and causing symptoms.
There are several types of advanced prostate cancer, including:
Biochemical Recurrence
If your Prostate Specific Antigen level has risen after the first treatment but you have no other signs of cancer, you have biochemical recurrence.
Castration-Resistant Prostate Cancer
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Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someones risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
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Hormone Therapies & Other Systemic Therapies For Prostate Cancer
At Perlmutter Cancer Center, medical oncologists may prescribe systemic medical therapies, such as hormone therapy, immunotherapy, or chemotherapy when prostate cancer has spread or returned after surgery or radiation therapy. Systemic therapy may also be used to boost the effects of radiation therapy.
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 its 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 youve 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?
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Hormone Therapy For Prostate Cancer
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Hormone therapy is also called androgen suppression therapy. The goal of this treatment is to reduce levels of male hormones, called androgens, in the body, or to stop them from fueling prostate cancer cell growth.
Androgens stimulate prostate cancer cells to grow. The main androgens in the body are testosterone and dihydrotestosterone . Most androgens are made by the testicles, but the adrenal glands as well as the prostate cancer cells themselves, can also make androgens.
Lowering androgen levels or stopping them from getting into prostate cancer cells often makes prostate cancers shrink or grow more slowly for a time. But hormone therapy alone does not cure prostate cancer.
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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What The Researchers Did
Dr. Crawfords team reviewed clinical data from nearly 23,000 men who were given ADT injections between 2007 and 2016. Each mans treatment varied by how their ADT was formulated. Some types of ADT are given once a month, and others are given at three-, four-, or six-month intervals. The researchers wanted to know how many men were late on their ADT treatments, and how that would affect the amounts of testosterone in their blood.
During this research, the investigators defined month in two ways: either as one lasting 28 days, which is how months were defined during the clinical trials that set dosing schedules for ADT, or as a calendar month lasting 31 days. ADT was deemed late if it was given after day 28 by the first definition or after day 32 by the second definition.
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What Other Drugs Will Affect Eligard
Eligard can cause a serious heart problem. Your risk may be higher if you also use certain other medicines for infections, asthma, heart problems, high blood pressure, depression, mental illness, cancer, malaria, or HIV.
Other drugs may interact with leuprolide, including prescription and over-the-counter medicines, vitamins, and herbal products. Tell your doctor about all your current medicines and any medicine you start or stop using.
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How Prostate Cancer Is Treated
In cancer care, different types of doctorsincluding medical oncologists, surgeons, and radiation oncologistsoften work together to create an overall treatment plan that may combine different types of treatments to treat the cancer. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as palliative care experts, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, and others.
The common types of treatments used for prostate cancer are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patients preferences and overall health.
Cancer treatment can affect older adults in different ways. More information on the specific effects of surgery, chemotherapy, and radiation therapy on older patients can be found another section of this website.
Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer:
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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Early History Of Hormonal Therapy For Prostate Cancer
The use of androgen deprivation as therapy for advanced prostate cancer began in 1941, when Huggins and Hodges first treated men with prostate cancer with either orchiectomy or estrogen.1 They monitored changes in prostate size and observed that improvements in acid and alkaline phosphatases were associated with cancer-related symptom relief. Largely due to the absence of other therapies, hormonal manipulation became a mainstay of treatment for symptomatic metastatic disease. Although it was originally hoped that suppression of testicular androgens would be curative, this proved not to be the case.
Although the testes are the primary source of testosterone, the adrenal glands also produce androgens. As a result, many patients with castrate levels of testosterone continue to have measurable levels of dihydrotestosterone in the prostate, thereby allowing continued stimulation of prostate cancer cells.2 The importance of adrenal androgens in prostate cancer was observed by Huggins and Hodges in their pioneering study, as many patients continued to have measurable levels of serum acid phosphatase, a surrogate marker of the disease, following medical or surgical castration. The authors considered this a clear indication that androgen production by the adrenal glands was ongoing.1
Options In Hormone Therapy
Testosterone levels in the body can be reduced either surgically or with drugs. The surgical option is castration, achieved by removing the testicles during a bilateral orchiectomy. Once the only option, it has since been supplanted by drugs that lower testosterone levels to amounts achieved by surgery.
For men, normal testosterone levels range from 300 to 1,000 ng/dl. The FDA requires that any new drug used in hormone therapy for prostate cancer lower testosterone levels to 50 ng/dl or less. In my practice, I usually try to lower levels even further, to 20 ng/dl.
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The Future Of Hormone Therapy For Prostate Cancer
Some experts aren’t sure how much further we can improve hormone therapy for prostate cancer.
“I’m not saying that we’ve reached the end of what we can do with hormonal therapy,” Thrasher tells WebMD, “but there are only so many ways to shut down the hormonal effects. The cancer will still eventually escape.”
Brooks argues that, overall, prostate cancer is only moderately affected by hormones. “You can only do so much manipulating the levels of hormones,” says Brooks. “We have to find better ways to fight the basis of the cancer cells.”
Thrasher and Brooks have more hope that the next breakthroughs will come with different approaches, like chemotherapy or vaccines.
But Holden remains optimistic about the future of hormone therapy for prostate cancer.
“Cancer cells eventually figure out how to survive, how to overcome a specific hormone therapy,” he says. “But if we have enough types of drugs and can keep changing the hormone therapy, we might be able to keep the cancer cells in a state of confusion. We could change therapies before they have a chance to adapt.”
“It’s like an endless chess game,” he says. “You may not ever win, but you might be able to prolong the game indefinitely. I think that hormone therapy still has a lot of promise. We just need to develop better anti-androgens, and more varieties of them.”
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