Treatment To Lower Androgen Levels From Other Parts Of The Body
LHRH agonists and antagonists can stop the testicles from making androgens, but cells in other parts of the body, such as the adrenal glands, and prostate cancer cells themselves, can still make male hormones, which can fuel cancer growth. Some drugs can block the formation of androgens made by these cells.
Abiraterone blocks an enzyme called CYP17, which helps stop these cells from making androgens.
Abiraterone can be used in men with advanced prostate cancer that is either:
This drug is taken as pills every day. It doesnt stop the testicles from making testosterone, so men who havent had an orchiectomy need to continue treatment with an LHRH agonist or antagonist. Because abiraterone also lowers the level of some other hormones in the body, prednisone needs to be taken during treatment as well to avoid certain side effects.
Ketoconazole , first used for treating fungal infections, also blocks production of androgens made in the adrenal glands, much like abiraterone. It’s most often used to treat men just diagnosed with advanced prostate cancer who have a lot of cancer in the body, as it offers a quick way to lower testosterone levels. It can also be tried if other forms of hormone therapy are no longer working.
Ketoconazole also can block the production of cortisol, an important steroid hormone in the body, so men treated with this drug often need to take a corticosteroid .
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.
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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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.
Prostate Cancer Survival By Age
Five-year survival for prostate cancer shows an unusual pattern with age: survival gradually increases from 91% in men aged 15-49 and peaks at 94% in 60-69 year olds survival falls thereafter, reaching its lowest point of 66% in 80-99 year olds patients diagnosed with prostate cancer in England during 2009-2013. The higher survival in men in their sixties is likely to be associated with higher rates of PSA testing in this age group.
Prostate Cancer , Five-Year Net Survival by Age, Men, England, 2009-2013
Hormone Therapy: Immediate Versus Delayed
Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate Versus Deferred Treatment for Advanced Prostatic Cancer. British Journal of Urology 1997 79:23546. PMID: 9052476.
Messing EM, Manola J, Sarosdy M, et al. Immediate Hormonal Therapy Compared with Observation after Radical Prostatectomy and Pelvic Lymphadenectomy in Men with Node-Positive Prostate Cancer. New England Journal of Medicine 1999 341:17818. PMID: 10588962.
Messing EM, Manola J, Yao J, et al. Immediate Versus Deferred Androgen Deprivation Treatment in Patients with Node-Positive Prostate Cancer after Radical Prostatectomy and Pelvic Lymphadenectomy. Lancet Oncology 2006 7:4729. PMID: 16750497.
Nair B, Wilt T, MacDonald R, Rutks I. Early Versus Deferred Androgen Suppression in the Treatment of Advanced Prostatic Cancer. Cochrane Database of Systematic Reviews 2002 CD003506. PMID: 11869665.
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.
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Lhrh Agonists And Antagonists
LHRH agonist and antagonist medications stop your body from producing testosterone.
These medications are injected under your skin or into a muscle monthly, every three months or every six months. Or they can be placed as an implant under your skin that slowly releases medication over a longer period of time.
These medications include:
Testosterone levels may increase briefly for a few weeks after you receive an LHRH agonist. Degarelix is an exception that doesnt cause a testosterone flare.
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:
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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.
Side Effects Of Hormone Therapy
Most side effects experienced by patients receiving HT are caused by low testosterone. The three most reported side effects are fatigue, hot flashes and sexual changes, including decreased libido and reduced erectile function.
Many of these side effects develop over time. Patients treated for eight months or less time are less likely to experience many of them, although some, such as hot flashes and sexual side effects, usually manifest within the first four to six weeks. Most of these side effects are reversible, diminishing or disappearing when the therapy is stopped and testosterone levels recover.
Not all patients experience all side effects, and there is much variability in their severity.
Here are the side effects patients most often report, along with suggestions for minimizing them:
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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.
Results Of Treating Prostate Cancer With Radiation Therapy
American Cancer Society. Radiation therapy for prostate cancer. January 2013.
Radiation therapy is best used as an early treatment for a lower-grade cancer that is confined within the prostate gland. The survival rates are similar to the results of radical prostatectomy. Radiation therapy treatments can also be used along with hormone therapy as a first step in treating prostate cancer that has spread outside of the prostate gland to nearby tissues. External beam radiation therapy can be focused on the prostate gland therefore, reducing the radiation exposure to the surrounding healthy tissues. This may increase survival rates over other forms of prostate cancer treatments.
National Cancer Institute at the National Institutes of Health. September 2012
Clinical trials show that external-beam radiation therapy does not seem to improve the survival rate of prostate cancer, but it does help to stop the progression of the disease. One such trial showed an increased progression-free survival at 4 years for patients with a 15% estimated risk of lymph node involvement who received whole-pelvic radiation therapy as compared with prostate-only radiation therapy With this in mind, radiation therapy treatments should be delayed 4 to 6 weeks after a TURP procedure in order to reduce incidence of stricture.
Stevens, G Firth, I. Audit in radiation therapy: long-term survival and cost of treatment. National Institute of Health. Feb. 1997
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.
What Type Of Hormone Therapy Works Best
Unfortunately, understanding the details of hormone therapy for prostate cancer can be difficult. Which drug or combination of drugs works best? In what order should they be tried? Research hasn’t answered these questions yet.
“Right now, there’s a level of art to figuring out which agents to use,” says Durado Brooks, MD, MPH, director of prostate cancer programs at the American Cancer Society. “We don’t have clear evidence yet.”
LHRH agonists remain the usual first treatment. But in some cases, doctors are trying anti-androgens first. Anti-androgens may be especially appealing to younger men who are still sexually active, since these drugs don’t completely shut down sex drive. When anti-androgens stop working — based on PSA tests — a person then might shift onto an LHRH agonist.
Other doctors prefer to begin therapy with a combination of two or even three drugs, especially for patients with symptoms or advanced disease, says Holden.
Researchers originally hoped that combined androgen blockade would significantly add to the benefits of LHRH agonists. However, the results, to date, have been mixed. Some studies have shown slightly longer survival with combined androgen blockade, but the results haven’t been as dramatic as many experts had hoped. Other studies have shown no benefit. A possible explanation may be the type of anti-androgen used, but further studies are needed to answer this question.
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What Is Hormone Herapy
To help you understand what hormone therapy is and how it may affect your prostate cancer, it is good for you to understand what hormones are and how they work in your body. Hormones control or manage your bodys activities. Hormones are made by glands in your body and are carried by your blood to all areas in your body. Glands are groups of cells in your body that make and release materials needed by your body.
Testosterone is the main male hormone in your body. It makes you grow hair on your face and body and have a mans body shape and controls your desire for sex. Testosterone also controls your prostate gland. Your testicles make most of the testosterone in your body. A small amount of testosterone is also made by your adrenal glands. Your adrenal glands are located on top of each kidney. Your adrenal glands also make other hormones.
Prostate cancer is hormone sensitive or hormone dependent. This means that the testosterone in your body helps your prostate cancer to grow. The goal of hormone therapy is to lower the amount of testosterone in your body to stop or slow the growth of your prostate cancer. You can lower the amount of testosterone in your body by taking medicines or having surgery.
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An enlarged prostate can also be the cause of other problems. If the enlarged prostate is causing symptoms, the best treatment would be a natural remedy. In the meantime, there are treatments for a wide range of conditions that cause a man to experience pain. A common surgical procedure involves an electric loop, laser, or electro-stimulation. The procedure is a safe and effective option for treating enlarged or symptomatic BPH.
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What Kinds Of Medicines Can Be Used To Lower My Testosterone
There are several types of medicines you can take to lower the amount of testosterone in your body. These are temporary ways to lower the amount of testosterone. When you stop taking these medicines, your testosterone level will begin to go up.
LHRH is a normal human hormone that tells your body to make testosterone. An LHRH agonist is a man-made hormone similar to the one made naturally in your body. LHRH agonists work like a light switch to shut off the production of testosterone in your body. When you are given this medicine, your body will stop making the LHRH hormone and your testicles will stop making testosterone. When you are first given this medicine, your body will continue to make testosterone for a couple of weeks. This means that your testosterone level may go up for a week or two and then begin to drop. This type of medicine works as well as having an orchiectomy . These medicines are given either monthly or every three months in a shot . The medicine may also be placed as small implants under your skin. The implant gives you a steady dose of medicine. Depending on the type of implant the medicine may last from one to 12 months.
Anti-androgens act like a brick wall. They block the small amount of testosterone made in your adrenal glands from reaching your prostate cancer cells. This keeps your prostate cancer cells from growing. These medicines are pills that are taken orally one to three times a day.
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Another type of prostate issue is chronic prostatitis, or chronic pelvic pain syndrome. This condition causes pain in the lower back and groin area, and may cause urinary retention. Symptoms include leaking and discomfort. In severe cases, a catheter may be required to relieve the symptoms. If the problem is unresponsive to other treatments, your doctor may suggest a surgical procedure. If these do not work, your symptoms could progress and become chronic.
An acute bacterial infection can cause a burning sensation. Inflammation of the prostate can affect the bladder and result in discomfort and other symptoms. This is the most common urinary tract problem in men under 50, and the third most common in men over 65. The symptoms of acute bacterial prostatitis are similar to those of CPPS. Patients may experience a fever or chills as a result of the infection.
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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.