Hormonal Treatments For Prostate Cancer Are Often Given Late
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Men with advanced prostate cancer are typically treated with drugs that cause testosterone levels to plummet. Testosterone is a hormone that fuels growing prostate tumors, so ideally this type of treatment, which is called androgen deprivation therapy , or hormonal therapy, will stall the disease in its tracks.
For that to happen, ADT has to be administered correctly. But according to a new study, men frequently dont get ADT at the proper dosing intervals. Too many of them get the treatments later then they should, causing testosterone levels to rise unacceptably. Rapid increases in testosterone following delays in dosing could have implications for cancer progression, cautions Dr. David Crawford, a urologist at the University of California San Diego, who led the study.
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When Hormone Therapy Is Recommended
Hormone therapy is typically given to patients with intermediate- or high-risk prostate cancer. It may be used in the following ways:
- In combination with radiation, mostly for patients with high Gleason scores or other high-risk factors.
- After radiation or surgery when PSA rises, indicating a recurrence.
- As therapy for patients unsuitable for radiation or surgery.
- As therapy for metastatic prostate cancer . It may be given instead of or in combination with chemotherapy.
HT is usually not prescribed for:
- Patients choosing a localized treatment for low-risk prostate cancer
- Low-risk patients preferring to monitor their cancer on an active surveillance program
HT may be an option for patients who are not candidates for surgery, radiation or other localized treatment because of age, pre-existing health conditions or concerns about potential side effects of localized treatments.
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
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How Hormone Therapy Is Used Against Cancer
Hormone therapy is used for two main reasons.
- Treat cancer. Hormone therapy can stop or slow cancer’s growth and reduce the chance it will return.
- Ease cancer symptoms. Hormone therapy may be used to reduce or prevent symptoms in men with prostate cancer who are not able to have surgery or radiation therapy.
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.
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.
What Is Lupron Depot
Lupron Depot overstimulates the bodys own production of certain hormones, which causes that production to shut down temporarily. This medicine reduces the amount of testosterone in men or estrogen in women.
Lupron Depot is used in men to treat the symptoms of prostate cancer .
Lupron Depot-Ped is used to treat precocious puberty in both male and female children at least 2 years old.
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Hormone Therapy Available At Willamette Valley Cancer Institute
Some cancers grow because of hormones present in the body. Usually, there is too much of a hormone that is fueling the cancers growth. A cancer treatment that slows or stops the growth of cancers that use hormones to grow is called hormone therapy. Prostate and breast cancers are commonly treated with hormone therapies.
Hormone therapy, also called hormonal therapy or endocrine therapy, is commonly used in addition to other cancer treatments. The types of treatment you are prescribed are based on the type of cancer, if it has spread, and how far, if it uses hormones to grow, and if you have other health problems.
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
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Maximum Treatment Minimum Side Effects
California Protons, located in San Diego, is the only center in the state using clinically proven, revolutionary technology to deliver proton therapy radiation with unmatched precision and the utmost care. Its one of the safest and most effective prostate cancer treatments in the world, which can result in high cure rates, reduced side effects and improved outcomes.
Different Approaches To Starting Hormone Therapy
Experts debate how early treatment with hormone therapy should be started. Some argue that the benefits of hormone therapy for prostate cancer should be offered to men earlier in the course of the disease. Others assert that there’s little evidence that getting treatment early is better than getting it later.
“Unfortunately, there are still some doctors who are offering hormonal therapy earlier in the course of the disease than is commonly recommended,” Brooks says. Given that the side effects can be serious, Brooks argues that starting treatment with hormone therapy so early may not be a good idea.
However, Holden argues that early treatment may be helpful. “I think one of the reasons that the death rate from prostate cancer is going down is that we’re using hormone therapy early,” he tells WebMD. “We haven’t proved that early treatment improves overall survival yet, but I think we will.”
Researchers are also looking at “intermittent therapy,” starting and stopping hormone treatment for months at a time. The big advantage is that men could go off therapy temporarily and thus be free of the side effects. Early study results have been promising.
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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 .
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.
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Side Effects Of Androgen Deprivation Therapy
Since androgen deprivation treatment with LHRH analogues can also increase the risk of metabolic syndrome or diabetes mellitus, regular control of laboratory variables is required . Because of the two risks mentioned, the US Food and Drug Administration published a warning in 2010. This wasamong othersbased on a recommendation of the American Heart Association, the American Cancer Society, and the American Urological Association, and the support of the American Society for Radiation Oncology .
Addition Of Hormone Therapy To Radiotherapy Benefits Men With Localized Prostate Cancer
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The addition of androgen deprivation therapy to radiotherapy improved survival outcomes among patients with localized prostate cancer, according to study results published in TheLancet Oncology.
Additionally, prolonging the adjuvant component of ADT provided significant benefit regardless of radiotherapy dose among those with intermediate-risk and high-risk disease, researchers noted.
Prostate cancer is an extremely common cancer worldwide that has been studied in multiple randomized trials. Yet, to date there has been no prior effort to pool data from multiple global trials to quantify the benefits we see from common treatment intensification strategies,Amar U. Kishan, MD, associate professor and vice-chair of clinical and translational research, and chief of the genitourinary oncology service for the department of radiation oncology at David Geffen School of Medicine at UCLA and UCLA Jonsson Comprehensive Cancer Center, told Healio.
These benefits include the addition of ADT to radiotherapy, prolonging the duration of ADT that follows radiotherapy , and extending the duration of ADT that may precede radiotherapy , Kishan added.
Metastasis-free survival served as the studys primary outcome. Median follow-up was 11.4 years.
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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.
Hormone Therapy With Radiotherapy
You have this if:
- your cancer hasnt spread to other parts of the body but is at a high risk of coming back, eg the cancer has grown through the covering of your prostate
- you have a very high prostatic specific antigen level
- you have a high Gleason score
You might have hormone therapy before, during and after radiotherapy. Doctors usually recommend that you have the treatment for between 3 months and 3 years. How long depends on the risk of your cancer coming back and how many side effects you get.
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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.
How The Study Was Performed
During the study, scientists randomized 1,071 men with intermediate- or high-risk localized prostate cancer into four groups. One group received radiation and six months of an anti-testosterone drug called leuporelin, and the second group received radiation plus 18 months of leuporelin therapy. Two other groups were treated with the same regimens of either radiation plus six or 18 months of leuporelin therapy, along with another drug called zoledronic acid, which helps to limit skeletal pain and related complications should cancer spread to the bones. Study enrollment occurred between 2003 and 2007 at 23 treatment centers across New Zealand and Australia.
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Are There Side Effects Of The Combination Approach
There is a slightly higher chance that patients who receive the combined therapy will have rectal irritation or urinary side effects. This is common with prostate cancer radiation therapy because the radiation can damage cells in the tissues surrounding the prostate. But at MSK, we routinely use sophisticated computer-based planning techniques that help us reduce the dose given to normal tissues such as the rectum, bladder, and urethra, lessening the chances of side effects and complications. We have also found that, when treating with the combined approach, using the high-dose-rate brachytherapy compared to low-dose-rate brachytherapy may have less in the way of side effects.
In addition, at MSK, we routinely use a rectal spacer gel, which we inject between the prostate and the rectum while the patient is under mild anesthesia, to create a buffer between these two tissues. By creating this space, we can further reduce the dose of radiation the rectum is exposed to. This leads to fewer side effects for the patient. The rectal spacer gel is biodegradable and dissolves on its own within the body after a few months.
What To Expect During Treatment
Doctors often use hormone therapies, such as Lupron, in combination with radiation therapy or other treatments. They may also use it following surgery.
Healthcare professionals administer Lupron as a depot, which is a small implant that they inject under the persons skin. The individual can often choose an injection site that is suitable for them. Common injection sites include:
The treatment regimen for Lupron will depend on the individuals circumstances, and a person can work with their doctor to determine the best dosage. Some typical dosages include:
- 7.5 mg one injection every 4 weeks
- 22.5 mg one injection every 12 weeks
- 30 mg one injection every 16 weeks
- 45 mg one injection every 24 weeks
When a person first starts treatment with Lupron, they may have a testosterone flare. Later on, they may experience side effects due to having very low testosterone levels in their body. After treatment stops, testosterone levels begin to return to normal.
When a person first takes Lupron, their testosterone levels may rise, or flare, before dropping to very low levels. For some people, particularly those with advanced prostate cancer, a testosterone flare can temporarily cause their symptoms to worsen.
The symptoms of a testosterone flare can include:
- blockage of the ureters, the tubes that carry urine from the kidneys to the bladder
- spinal cord compression
- issues with urination
Possible side effects of hormone therapies, such as Lupron, can
- radiation therapy
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