What Are The Different Types Of Radiation Treatments
Radiation therapy uses concentrated doses of radiation to kill cancer cells and reduce the size of tumors. Depending on the type of cancer present in the body, one of two types of radiation therapy may be used.
External beam radiation therapy uses a large machine to send radiation into the specific area containing cancer. The radiation machine never touches the body, but it does move around to deliver radiation into precise parts of the body. External beam radiation is the most common type of treatment for many cancers.
Internal radiation therapy, on the other hand, uses a solid or liquid radiation source to physically deliver radiation inside the body. If a solid source of radiation is used, it only targets a specific part of the body for localized treatment, especially for cancers of the head, neck, breast, cervix, prostate, and eye. If a liquid source of radiation is used, its considered a systemic therapy that travels through the blood into tissues throughout the entire body.
Radiation therapy is often used in conjunction with other treatments or surgeries to target cancer in the most strategic way possible. Its often used to make surgery easier by shrinking the size of the tumor beforehand. Radiation therapy is even used during surgery to go straight into cancer cells without passing through the skin.
Life Expectancy And Localized Prostate Cancer
So how do these treatments affect life expectancy? In one study, researchers in Switzerland examined the treatment and outcomes of 844 men diagnosed with localized prostate cancer. They compared men who had been treated with prostatectomy, radiotherapy and watchful waiting and found that at five years from diagnosis, the type of treatment made little difference to survival. When the researchers went to 10 years from diagnosis, they did find a difference in survival based on treatment, but it was fairly small.
After 10 years, 83 percent of the men who had gotten a prostatectomy were still living, compared to 75 percent who had undergone radiotherapy and 72 percent who took a watchful waiting approach.
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Table : Survival Benefits Of Early Treatment
An analysis of 98 men with prostate cancer that had spread to the lymph nodes, who were randomly assigned to receive immediate hormone therapy or to forgo it until the disease spread further to bones or lungs, found that early treatment saved lives.
Deaths from prostate cancer 21 Source: Lancet Oncology 2006 7:4729. PMID: 16750497.
Other studies have shown that starting hormone therapy early on increases survival times, delays cancer progression, and results in better quality of life. However, in a review of four studies involving 2,167 men with metastatic prostate cancer, the Cochrane Collaboration concluded that early hormone therapy had offered only a small overall survival advantage over deferred treatment, and cautioned that more research on the issue needs to be done.
Although debate on this issue continues, in most cases I advise my patients with metastatic disease to begin hormone treatment early on. This is particularly important for someone with spine metastases, because a bone fracture or extension of the cancer into the spinal cord area could lead to impaired mobility and even paralysis. Fortunately, this is a rare event.
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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.
Stage Iv Prostate Cancer Prognosis
Prostate cancers detected at the distant stage have an average five-year survival rate of 28 percent, which is much lower than local and regional cancers of the prostate. This average survival rate represents stage IV prostate cancers that have metastasized beyond nearby areas to lymph nodes, organs or bones in other parts of the body.
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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 dont get too tired.
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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
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Drugs That Stop Androgens From Working
For most prostate cancer cells to grow, androgens have to attach to a protein in the prostate cancer cell called an androgen receptor. Anti-androgens are drugs that also connect to these receptors, keeping the androgens from causing tumor growth. Anti-androgens are also sometimes called androgen receptor antagonists.
Drugs of this type include:
They are taken daily as pills.
In the United States, anti-androgens are not often used by themselves:
- An anti-androgen may be added to treatment if orchiectomy or an LHRH agonist or antagonist is no longer working by itself.
- An anti-androgen is also sometimes given for a few weeks when an LHRH agonist is first started. This can help prevent a tumor flare.
- An anti-androgen can also be combined with orchiectomy or an LHRH agonist as first-line hormone therapy. This is called combined androgen blockade . There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH agonist alone. If there is a benefit, it appears to be small.
- In some men, if an anti-androgen is no longer working, simply stopping the anti-androgen can cause the cancer to stop growing for a short time. This is called the anti-androgen withdrawal effect, although it is not clear why it happens.
Enzalutamide , apalutamide and darolutamide are newer types of anti-androgens. They can sometimes be helpful even when older anti-androgens are not.
These drugs are taken as pills each day.
How Long Do You Take Hormonal Therapy For
For early prostate cancer this depends on the prostate cancer risk group. If the cancer is:
- intermediate-risk you may have hormonal therapy for a few months after radiotherapy
- high-risk you may be advised to have hormonal therapy for up to 2 to 3 years after radiotherapy.
For locally advanced prostate cancer you usually have hormonal therapy for 2 to 3 years after radiotherapy.
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Mechanisms Of Androgen Receptor Signaling
Figure 2 The structure of the androgen receptor gene and protein. The AR gene is situated on position q11-12 of chromosome X and contains 8 exons. The protein reference sequence NM_000044.3 is comprised of 920 amino acids and is composed of different domains which are depicted. In addition, posttranslational modifications known to influence AR function are shown. AR, androgen receptor bp, base pair NTD, N-terminal domain DBD, DNA binding domain LBD, ligand binding domain AF, activation function TAU, transcription activation unit NLS, nuclear localisation signal NES, nuclear export signal.
Figure 3 Genomic androgen receptor signaling pathway. Androgens, such as testosterone and dihydrotestosterone, enter the cell and are converted in the more active metabolite by the steroid-5-reductase. Upon ligand binding heat stress protein chaperones are released and AR undergoes conformational change and dimerization. In the nucleus the AR together with co-regulators activates the transcription of androgen regulated genes. T, testosterone AR, androgen receptor DHT, 5-dihydrotestosterone HSP, heat shock TF, transcription factor ARE, Androgen Response Element.
What Are Estrogen And Progesterone Receptors
Normal breast cells and some breast cancer cells contain receptors that attach to estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells. An important step in evaluating a breast cancer is to test the cancer removed during the biopsy to see if it has estrogen and progesterone receptors.
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How Often Should I Receive Lupron Depot
Lupron Depot is given as an intramuscular injection into the muscle in your upper arm, buttock or thigh. Lupron Depot is available as single dose kits that contain a prefilled injection syringe of:
Depot formulations continuously release medicine into your body over a certain period of time after injection. This means you may not need to get a shot every day, or even every month. Your healthcare provider will give you Lupron Depot injection, and together you can decide which treatment dose and schedule might work best for you.
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.
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Survival Rates For Prostate Cancer
Survival rates can give you an idea of what percentage of people with the same type and stage of cancer are still alive a certain amount of time after they were diagnosed. These rates cant tell you how long you will live, but they may help give you a better understanding of how likely it is that your treatment will be successful.
Keep in mind that survival rates are estimates and are often based on previous outcomes of large numbers of people who had a specific cancer, but they cant predict what will happen in any particular persons case. These statistics can be confusing and may lead you to have more questions. Talk with your doctor about how these numbers may apply to you, as he or she is familiar with your situation.
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.
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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.
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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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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.
Who Gets Prostate Cancer And What Are The Symptoms
Approximately one in nine men will be diagnosed with prostate cancer during their lifetime, according to the American Cancer Society.1 The average age at diagnosis is around 66 years. Common symptoms of prostate cancer can include frequent urination, blood in the urine, sudden onset of erectile dysfunction and discomfort when sitting due to an enlarged prostate gland. Risk factors for prostate cancer include being 65 years or older, having a family history of prostate cancer and certain genetic factors.
This is a cancer that, for some, is slow-growing and doesnt need immediate treatment. It may lay dormant for years. For others, a combination of surgery, radiation, or hormone-blocking therapies may be necessary.
Treating Prostate Cancer with Hormone Therapy
Men with prostate cancer often receive hormone-blocking therapy as part of their treatment plan. Approximately 75 percent of men undergoing this treatment will experience hot flashes. Hot flashes are one of the most common side effects of hormonal therapy, which lowers testosterone and androgens.
Hot flashes and night sweats can be very disruptive to a persons quality of life affecting sleep, sexual function, weight, and mood. Recently, the Oncology Nursing Society released new guidelines to help patients mitigate these issues.2
New Guidelines for Treatment For Hot Flashes Caused by Hormone Therapy
Life After Prostate Cancer
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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.
How To Tell If Hormone Therapy Is Working
If you are taking hormone therapy for prostate cancer, you will have regular PSA tests. If hormone therapy is working, your PSA levels will stay the same or may even go down. But, if your PSA levels go up, this may be a sign that the treatment is no longer working. If this happens, your doctor will discuss treatment options with you.
If you are taking hormone therapy for breast cancer, you will have regular check-ups. Checkups usually include an exam of the neck, underarm, chest, and breast areas. You will have regular mammograms, though you probably wont need a mammogram of a reconstructed breast. Your doctor may also order other imaging procedures or lab tests.
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