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.
Hormone Therapy For The Treatment Of Prostate Cancer Patients
Hormone therapy, also known as androgen deprivation therapy or androgen suppression therapy, is one of the treatment options for patients with prostate cancer. The goal is to reduce levels of male hormones, called androgens, in the body, or to stop them from affecting prostate cancer cells, explains the American Cancer Society. It is particularly indicated in patients whose cancer has spread too far to be cured by surgery or radiation, or when patients cant undergo these treatments for some reason, in patients whose cancer is resistant to or returns after previous treatments, as well as in combination or before radiation therapy to increase the probabilities of success.
The main androgens are testosterone and dihydrotestosterone . Most of the bodys androgens come from the testicles, but the adrenal glands also make a small amount. Androgens stimulate prostate cancer cells to grow. 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.
There are different approaches included in the class of hormone therapy such as orchiectomy , luteinizing hormone-releasing hormone analogs, Degarelix , Abiraterone , which are used to decrease the androgen levels. Anti-androgens like flutamide , bicalutamide , nilutamide , Enzalutamide , Estrogens , and Ketoconazole are used to block the function of androgens.
Your Cancer Care Team
People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.
The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.
Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.
When deciding what treatment is best for you, your doctors will consider:
- the type and size of the cancer
- what grade it is
- whether the cancer has spread to other parts of your body
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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.
Intermittent Hormonal Therapy Proves To Be Viable In Prostate Cancer
With no significant difference between intermittent and continuous androgen-deprivation therapy, patients with prostate cancer may experience an improvement in their quality of life with the former.
Androgen-deprivation therapy may be an effective treatment in prostate cancer, though its side effects may result in a loss of quality of life for patients. Allowing low-risk patients to take breaks between treatmentsa practice known as intermittent hormonal therapy, or a hormone holidaymay combat these challenges without impacting survival.
“Intermittent hormonal therapy has been growing in popularity over the years. Patients who receive hormone therapy often have side effects, and giving them so-called ‘hormone holidays’ may improve quality of life. Over the years, there has really been a lot of trials and experimental work that laid the groundwork for this going back 20 years,” said Leonard G. Gomella, MD, in an interview with Targeted Oncology.
“Very recently, several big clinical trials have basically shown that, in general, patients who receive intermittent hormonal therapy have the same cancer-specific and overall survival as patients who receive continuous hormonal therapy. Patients can take a ‘hormone holiday’ and perhaps improve their quality of life and, along the way, also save some money.”
“That is now going to become the standard of care for patients with metastatic disease. We may need to investigate that.”
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What Is Hormone Therapy
The idea that hormones have an effect on prostate cancer is not new. The scientist Charles Huggins first established this over 60 years ago in work that led to his winning the Nobel Prize. Huggins found that removing one of the main sources of male hormones from the body — the testicles — could slow the growth of the disease.
“This procedure worked dramatically,” says Holden, who is also director of the Prostate Cancer Center at Cedar Sinai Medical Center in Los Angeles. “Before, these men were confined to bed and wracked with pain. Almost immediately afterwards, they improved.”
Huggins found that some types of prostate cancer cells need certain male hormones — called androgens — to grow. Androgens are responsible for male sexual characteristics, like facial hair, increased muscle mass, and a deep voice. Testosterone is one kind of androgen. About 90% to 95% of all androgens are made in the testicles, while the rest are made in the adrenal glands located on top of the kidneys.
How Are Treatments Administered
GnRH agonists are either injected or placed as small implants under the skin. Anti-androgens are taken as a pill once per day. Degarelix is given as an injection. A chemotherapy drug called docetaxel is sometimes used in combination with these hormone therapies.
Zytiga is taken by mouth once per day in combination with a steroid called prednisone.
Surgery to remove the testicles can be done as an outpatient procedure. You should be able to go home a few hours after an orchiectomy.
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What To Expect During Hormone Therapy
As you go through hormone deprivation therapy, youâll have follow-up visits with your cancer doctor. Theyâll ask about side effects and check your PSA levels.
Doctors donât know how long hormone therapy works to keep prostate cancer in check. So, while you take it, your doctor will regularly draw blood to check your PSA levels. Undetectable or low PSA levels usually mean that the treatment is working. If your PSA levels go up, itâs a sign that the cancer has started growing again. If this happens, your cancer is considered castrate-resistant, and hormone deprivation therapy is no longer an effective treatment.
Youâll also get other blood tests to see if the cancer is affecting other parts of your body like your liver, kidneys, or bones. Scans will show how well your cancer is responding to hormone therapy.
To lessen the side effects of hormone therapy drugs, researchers suggest that you take them for just a set amount of time or until your PSA drops to a low level. If the cancer comes back or gets worse, you may need to start treatment again.
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Newer Hormonal Therapy Drugs For Advanced Prostate Cancer
These drugs are usually used when other hormonal therapies are no longer helping to control the cancer. This is when the prostate cancer cells need much lower levels of testosterone to grow. Sometimes you may have these drugs earlier on, when you are first diagnosed.
Newer hormonal therapy drugs include:
These newer hormonal therapy drugs may be given before you need chemotherapy. This is if you have no symptoms or mild symptoms, or if chemotherapy is no longer helping to control the cancer.
Or they may sometimes be given as the first hormonal therapy you have. This may be with hormonal injections or implants, or on their own.
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Hormonal Therapy And Radiation
A retrospective review by DAmico and colleagues demonstrated the benefit of neoadjuvant hormone therapy for locally advanced CaP. Estimates of 5-year PSA outcome after radiation therapy with or without NHT were not statistically different among low-risk patients , whereas intermediate- and high-risk patients treated with radiation therapy plus ADT had significantly better outcomes than those treated with radiation therapy alone . Subsequently, several prospective randomized trials were published confirming the benefit of NHT to radiation.
Two additional RTOG trials also investigated the use of long-term ADT in patients with locally advanced CaP. RTOG 85-31 was designed to evaluate lifelong adjuvant androgen ablation combined with radiation therapy for clinical T3 or N positive disease versus radiation therapy and delayed androgen ablation . Hormonal therapy was begun in the last week of radiotherapy and continued indefinitely. Adjuvant therapy improved all clinical endpoints, including improving 10-year overall survival from 39% to 49%. While there was no survival advantage seen in patients with lower-grade tumors, a significant advantage was seen for patients with higher-grade cancers .
Hormone Therapy For Prostate Cancer: What You Should Know
Your treatment team will determine whether you might benefit from hormone therapy based on factors such as the stage of disease and where its located on your prostate. Here are some details:
- What is hormone therapy for prostate cancer? Male hormones are called androgens. These hormones, such as testosterone, can aid the growth of prostate cancer cells. Hormone therapy uses man-made hormones or other medications to prevent cancer cells from getting or using the hormones they need to grow and spread.
- How we use hormone therapy for prostate cancer: Your care team will personalize your treatment recommendations to your specific circumstances. In general, your doctor may recommend using hormone therapy
- At the same time as radiation therapy, if doctors consider the cancer more aggressive or more likely to spread
- Before radiation therapy, to shrink the cancer
- If cancer comes back after a successful treatment
- If surgery or radiation are not recommended
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Combined Hormonal Therapy For Advanced Prostate Cancer
If the cancer starts growing during treatment with an injection or implant, your doctor may advise taking an anti-androgen tablet as well.
Having the two drugs together can help to slow the cancer from growing or spreading. You will not usually have combined hormonal therapy as your first treatment. This is because you may have more side effects if you are taking two drugs. Your doctor or specialist nurse can explain more about this.
There are different types of hormonal therapy that may be used. Your doctor or nurse will explain the drug that is most suitable for your situation.
What Have I Learned By Reading This
You learned about:
- Why you may need hormone therapy
- How hormone therapy works
- Ways to get hormone therapy
- What to expect when you have hormone therapy
- What side effects you may have from hormone therapy
If you have any questions, please talk to your doctor or healthcare team. It is important that you understand what is going on with your treatment. This knowledge will help you take better care of yourself and feel more in control so that you can get the most from your treatment..
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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 .
How Can You Tell That Hormone Therapy Is Not Working
Prostate-Specific Antigen blood tests are conducted regularly to determine the effectiveness of hormone therapy. High levels of PSA in the blood are an indication that your cells have become resistant to the therapy.
At this point, your doctor will inquire if youve been experiencing any other symptoms like urinary and bowel problems and pain. If the PSA levels are rising slowly and you arent experiencing any symptoms your doctor will recommend frequent checkups.
If the tests reveal that the PSA levels are quickly rising, they will be followed by MRI and CT scans to check the prostate cancer progression and identify potential treatments that could help manage it.
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Hormone Therapy With Radiation
Hormone therapy is often given together with radiation therapy for localized disease .
Hormone therapy usually consists of a shot that lowers your testosterone, given every 1 to 6 months, depending on the formulation. Sometimes, it is prescribed as a daily pill that blocks testosterone from reaching the cancer cells. Clinical trials show a benefit in patients who receive hormonal treatment in combination with external beam radiation. Hormone therapy has been shown to improve cure rates of prostate cancer for men receiving radiation therapy and is part of the standard of care for men with certain types of intermediate-risk prostate cancer and nearly all high-risk prostate cancer. It is often given for intermediate-risk cancer for 4 to 6 months , and for 2 to 3 years in men with high-risk localized prostate cancer, although some doctors may recommend as little as 18 months of hormone therapy.
Hormone therapy should not be given to men with low-risk prostate cancer and is not a standalone treatment for localized prostate cancer in any risk category.
Want more information about a prostate cancer diagnosis and treatment options? Download or order a print copy of the Prostate Cancer Patient Guide.
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 it’s 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 you’ve 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?
Talking about it
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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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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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