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.
These drugs are taken as pills each day.
When Hormone Therapy Is Indicated
HT can be administered before, during or after a localized treatment, such as radical prostatectomy, radiation, high-intensity focused ultrasound or cryotherapy. When given before a localized treatment, it is called neoadjuvant therapy. When given after localized treatment without evidence of prostate cancer recurrence, it is called adjuvant therapy. When HT is prescribed after localized treatment for a prostate cancer recurrence, it is called salvage therapy. If a patient’s PSA starts rising after a radical prostatectomy, HT is typically given in combination with radiation therapy. Treatment recommendations are based on each patient’s specific circumstances.
Sometimes we give neoadjuvant HT while the patient is deciding on his primary treatment or to reduce the tumor’s size before starting primary treatment. Neoadjuvant HT will usually slow or stop cancer growth for a period of time.
Many radiation oncologists use HT along with radiation treatment in the belief that HT weakens cancer cells so that they’re more susceptible to destruction by the radiation. Clinical studies have suggested a synergy between radiation therapy and hormone therapy meaning they work better together. Clinical trials have shown improved outcomes for patients who receive combined therapy.
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
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What Have I Learned By Reading This
You learned about:
- Why prostate cancer treatment can cause erectile dysfunction
- What can be done about erectile dysfunction
- How erectile dysfunction may affect your sex life
- What your partner can expect
If you have any questions, please talk to your doctor or health care team. It is important that you understand what is going on with your prostate cancer treatment. This knowledge will help you take better care of yourself and feel more in control. It will also help you manage any side effects you may have from your treatment.
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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How Testosterone Helps Prostate Cancer Grow
Testosterone travels through the bloodstream and eventually reaches prostate cancer cells, where it helps the cancer grow. Up to a point, the more testosterone the cancer cells have, the more the cancer can grow and eventually spread to other parts of the body. Hormone therapy is designed to prevent testosterone from fueling the growth of these cancer cells.
Intermittent Hormonal Therapy For Locally Advanced Prostate Cancer
Intermittent hormonal therapy is where you stop taking the drugs and after a while start taking them again. This may be an option for locally-advanced prostate cancer. It gives you a break from the side effects of hormonal therapy.
Intermittent hormonal therapy is not suitable for everyone and should only be done on your doctors advice. Your doctor can explain more about this. They usually measure your PSA level using the PSA test every 3 months. If it goes up to a certain level or you get symptoms, your doctor will advise you to start hormonal therapy again.
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What Is A Radical Prostatectomy
Surgery to remove the prostate is called a radical prostatectomy. Before the operation, the surgeon will explain what will happen and tell you about the possible side effects. They may also tell you about other treatments that may help in your situation, such as radiotherapy.
The aim of the surgery is to remove all of the cancer cells. It is usually only done when the cancer is contained within the prostate and has not spread to the surrounding area.
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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Mental And Emotional Health
A cancer diagnosis and cancer treatment may affect how you feel mentally and emotionally. Hormone therapy can cause:
- Mood swings
- A drop in mental sharpness
If you have any of these side effects, your doctor may recommend medication, counseling, or both.
Research shows that hormone therapy for prostate cancer may lead to problems with short-term memory, language, thinking, and concentration. But these problems are usually mild. Researchers are still studying the effect of hormone therapy on the brain.
When you stop taking hormone therapy, emotional and mental side effects usually disappear. But if youâve taken the drugs for many years, they may not fully go away.
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 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.
Hormone Therapy For Prostate Cancer
Hormone therapy is often used to treat prostate cancer. Hormone therapy for prostate cancer works by reducing the amount of androgens or blocking androgens from being used.
Androgens, such as testosterone, help prostate cancer cells to grow. Androgens control the development of male physical traits, such as a deep voice and the growth of hair on the body and face. Androgens are made mainly by the testicles.
Drugs or surgery can be used to block the production or effects of androgens like testosterone. Hormone therapy alone can’t cure prostate cancer, but it can shrink tumours, slow the growth of cancer cells and help you live longer.
You may have hormone therapy to:
- treat cancer that has spread outside of the prostate
- treat prostate cancer that comes back after treatment
- treat prostate cancer along with radiation therapy for cancer that has a higher risk of coming back
- shrink a tumour before other treatments , such as surgery or radiation therapy
Your healthcare team will consider your personal needs to plan your hormone therapy. You may start hormone therapy soon after you are diagnosed. Or you may not start treatment until the symptoms of prostate cancer get worse. You may be on hormone therapy longer than others. You may start and stop hormone therapy , while others will take it continuously for a long time.
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Risk Of Heart Problems
Hormone therapy for prostate cancer might increase the risk of heart problems if you have certain medical conditions.
This may be because some of the side effects of hormone therapy, such as weight gain, can make heart disease worse.
Gynecomastia in Patients with Prostate Cancer: A Systematic Review
A Fagerlund and others
Treatment Of Osteoporosis in Men
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Cardiovascular effects of hormone therapy for prostate cancer
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Cognitive Effects of Androgen Deprivation Therapy in Men With Advanced Prostate Cancer
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Things You Should Expect After Prostate Surgery
Prostate removal is a major type of surgery and requires time for the body to recover. Even though robotic prostatectomy using the Da Vinci robot has less severe effects on the body and the patient can leave the hospital the same day, men should expect some changes in order to know how to deal with them. The surgery is performed through small incisions that are barely sensitive at the incision sites and the scar tissue is almost unnoticeable. Typically, the recovery is fast, most men are able to go home the next day and resume driving and working in two to three weeks after the surgery.
In the immediate hours after surgery:
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Advantages And Disadvantages Of Surgery
What may be important for one person might be less important for someone else. The advantages and disadvantages of surgery may depend on your age, general health and the stage of your cancer.
- If the cancer is completely contained inside the prostate, surgery will remove all of the cancer.
- The prostate is looked at under a microscope to give a clearer picture of how aggressive your cancer is, whether it has spread outside your prostate and if you need further treatment.
- Your health professionals can get a good idea of whether your cancer was completely removed during surgery. Your PSA level should drop so low that its not possible to detect it at six to eight weeks after surgery.
- If there are signs that your cancer has come back or wasnt all removed, you may be able to have further treatment.
- Some men find it reassuring to know that their prostate has been physically removed, although you will still need to have follow-up tests to make sure no cancer cells have spread outside the prostate.
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Types Of Prostate Surgery
There are several ways of removing the prostate keyhole surgery either by hand or robot-assisted, and open surgery.
Although robot-assisted keyhole surgery is the newest technique, the most recent research suggests all three techniques are as good as each other for treating prostate cancer, as long as the surgeon is experienced. They also have similar rates of side effects.
The advantages of keyhole surgery, both by hand and robot-assisted, are that you are likely to lose less blood, have less pain, spend less time in hospital, and heal more quickly than with open surgery.
Keyhole surgery .
- Robot-assisted keyhole surgery Your surgeon makes five or six small cuts in your lower abdomen and a slightly bigger cut near your belly button, and removes the prostate using special surgical tools. These include a thin, lighted tube with a small camera on the tip. The image will appear on a screen so the surgeon can see what theyre doing. Your surgeon controls the tools from a console in the operating room via four or five robotic arms. Although its called robot-assisted, its still a surgeon who does the operation. You may hear the equipment called the da VinciÂ® Robot.
- Keyhole surgery by hand As with robot-assisted keyhole surgery, the surgeon will make four or five small cuts in your abdomen. But they will hold the surgical tools in their hands, rather than using robotic arms.
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Hormonal Therapy On Its Own
Doctors do not usually advise having hormonal therapy instead of a prostatectomy or radiotherapy. Hormonal therapy alone cannot cure early or locally-advanced prostate cancer.
Depending on your general health and preferences, you may decide to have hormonal therapy on its own. For example, if you:
- are not well enough to have a prostatectomy or radiotherapy
- do not want to have a prostatectomy or radiotherapy
- are monitoring prostate cancer, for example having watchful waiting and the cancer starts to grow.
Hormonal therapy can slow down or stop the cancer cells growing for many years. It can also improve any symptoms. Not having surgery or radiotherapy means you avoid the side effects of these treatments. But hormonal therapy also causes side effects. It is important to talk to your doctor or nurse before you decide.
How Hormone Therapy Works
Hormone therapy can be obtained via surgery, injections, or pills. The surgery takes out the hormone-producing organs, predominantly the testes in men and ovaries in women.
Male hormones act like a source of fuel for cancer. Without an adequate hormone supply, the tumor wont thrive. Hormone treatment is meant to slowly yet surely starve the tumor from its much-needed hormone supply. It basically provides an androgen blockage.
Androgen deprivation puts a lid on testosterone release, thus preventing testosterone from acting on the prostate cancer cells. Androgen deprivation can be used in advanced prostate cancer to reduce the tumor.
When used in locally advanced prostate cancer, the therapy can make external beam radiation therapy more effective in curbing the risk of prostate cancer recurrence.
In certain individuals, the cancer cells respond well to the drop in testosterone level. But, for others, the block of testosterone is not enough. These cancer cells can thrive independently of testosterone. Therefore, the therapy wont affect them.
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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.
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.