The Effect Of Testosterone Replacement Therapy On Psa
Currently available data suggests that even hypogonadal men without prostate cancer will exhibit detectable increases in PSA during testosterone therapy. Patients with large PSA changes should be evaluated for the development of prostate cancer. Current practice guidelines suggest that hypogonadal patients with normal PSA levels should have their PSA rechecked at three months, one year, and every 6 to 12 months thereafter while on testosterone replacement. If the PSA is less than 4.0 ng/ml but rises by 1.5 ng/ml or more in a year, or 0.75 ng/ml per year over two years, further evaluation for prostate cancer including biopsy should be discussed. The role of PSA velocity as an indication for prostate biopsy is still controversial. Data from the Prostate Cancer Prevention Trial indicated an increased sensitivity when PSA velocity was used as an indication for biopsy. However, using a PSA velocity as an indication reduces sensitivity and increases the number of unnecessary biopsies. Finally, biopsies should be offered to any patient with a PSA level above 4.0 ng/ml.
An Excerpt From Testosterone For Life
The oldest and most strongly held prohibition against testosterone therapy is its use in men previously diagnosed with prostate cancer. The fear has been that even in men who have been successfully treated for prostate cancer, raising testosterone levels will potentially make dormant, or sleeping, cancer cells wake up and start growing at a rapid rate. Thus, the FDA requires all testosterone products to include the warning that T therapy is contraindicated in men with a prior history of prostate cancer.
However, attitudes about this are changing and changing rapidly over just the last few years. The reasons for this are several, including the ongoing re-evaluation of the old belief that raising the concentration of testosterone is to prostate cancer like pouring gasoline on a fire or feeding a hungry tumor. In addition, there is growing recognition that T therapy can provide important benefits to a mans quality of life, so the delicate medical balancing act between potential risk and possible benefit is shifting.
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A number of physicians have told me that they have treated occasional patients with testosterone despite the fact that theyd been treated for prostate cancer in the past. The first people to publish their experience with doing this were Drs. Joel Kaufman and James Graydon, whose article appeared in the Journal of Urology in 2004.
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What Are Male Sex Hormones
Hormones are substances that are made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs.
Androgens are a class of hormones that control the development and maintenance of male characteristics. The most abundant androgens in men are testosterone and dihydrotestosterone .
Androgens are required for normal growth and function of the prostate, a gland in the male reproductive system that helps make . Androgens are also necessary for prostate cancers to grow. Androgens promote the growth of both normal and cancerous prostate cells by binding to and activating the androgen receptor, a protein that is expressed in prostate cells . Once activated, the androgen receptor stimulates the expression of specific genes that cause prostate cells to grow .
Almost all testosterone is produced in the testicles a small amount is produced by the adrenal glands. Although prostate cells do not normally make testosterone, some prostate cancer cells acquire the ability to do so .
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Drugs That Stop Androgens From Working
Anti-androgens
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.
Newer anti-androgens
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.
What Are The Side Effects Of Hormone Therapy
Like all treatments, hormone therapy can cause side effects. These are usually caused by low testosterone levels.
Hormone therapy affects men in different ways and you may not get all of the possible side effects. Some men only get a few side effects or dont get any at all. This doesnt mean that the treatment isnt working.
Some men find their side effects improve or get easier to manage the longer theyre on hormone therapy. But if side effects dont improve, there are usually ways to manage them.
Side effects will usually last for as long as youre on hormone therapy. If you stop using it, the side effects should improve as your testosterone levels start to rise again.
Your side effects wont stop straight away it may take several months or years. For some men, the side effects may never go away completely.
The risk of getting each side effect depends on your type of hormone therapy and how long you take it for. If you have hormone therapy alongside another treatment, you may get side effects from that treatment as well.
Surgery to remove the testicles cant be reversed, so the side effects will be permanent. But there are treatments to help manage them.
Discuss the possible side effects with your doctor or nurse before you start or change your hormone therapy, or call our Specialist Nurses. If you know what side effects you might get, it can be easier to manage them.
Read more about prostate cancer and your sex life.
Weight gain
Strength and muscle loss
Bone thinning
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How Does Hormone Therapy Work Against Prostate Cancer
Early in their development, prostate cancers need androgens to grow. Hormone therapies, which are treatments that decrease androgen levels or block androgen action, can inhibit the growth of such prostate cancers, which are therefore called castration sensitive, androgen dependent, or androgen sensitive.
Most prostate cancers eventually stop responding to hormone therapy and become castration resistant. That is, they continue to grow even when androgen levels in the body are extremely low or undetectable. In the past, these tumors were also called hormone resistant, androgen independent, or hormone refractory however, these terms are rarely used now because the tumors are not truly independent of androgens for their growth. In fact, some newer hormone therapies have become available that can be used to treat tumors that have become castration resistant.
Treating Prostate Cancer With Hormone Therapy
Hormone therapy, also known as androgen deprivation therapy , has long been the backbone of treatment for metastatic prostate cancer.
The male sex hormone testosterone is known to stimulate the growth of prostate cancer cells.
Hormone therapy, depending on the form, reduces this effect by either decreasing the bodys production of testosterone or blocking testosterone from binding to cancer cells.
There are several scenarios in which hormone therapy is typically used:
- When prostate cancer has spread too far to be cured by surgery or radiation, or has recurred after surgical or radiation treatment
- As an initial treatment for patients who are at higher risk of recurrence after treatment, such as those with a high PSA level or a high Gleason score
- For patients who have a high PSA level following surgery or radiation, even if they have no evidence of disease. Not all doctors, however, agree with this approach
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Testosterone Supplementation After Prostate Cancer
Two experts examine the pros and cons of this controversial practice
At some point in their 40s, mens testosterone production begins to slow. By some estimates, levels of this hormone drop by about 1% a year. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone. These include reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, lower muscle mass and bone density, and anemia. When severe, these signs and symptoms characterize a condition called hypogonadism.
Researchers estimate that hypogonadism affects two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment, according to the FDA. Deciding which patients should receive testosterone supplementation has proved tricky, however. For example, little consensus exists on what constitutes low testosterone. In addition, some men may have low blood levels of testosterone but not experience any symptoms. And few large, randomized studies on the long-term risks or benefits of testosterone supplementation have been completed.
Promising Prostate Cancer Drug Hints At Improved Immunotherapy
Immunotherapy is a promising cancer treatment, but getting it to work against solid tumors is proving difficult. A new study has not only identified a drug thats effective against solid tumors, but may have uncovered a reason that immunotherapy often fails.
The human immune system is a powerful weapon, but cancer does a good job of hiding from it and creating an environment around itself that keeps immune cells out. Immunotherapy is an emerging treatment that allows scientists to supercharge the immune system against cancer, and while its had some success against things like melanoma and leukemia, the technique hasnt translated well to solid tumors.
But new research into a drug that helps treat prostate cancer might have uncovered a mechanism for immunotherapys patchy record, and point to a way to fix it. Scientists at Washington University in St. Louis started out by testing a drug compound called -9b, which in previous studies had proven promising against cancer. Since the drug is known to block a gene called ACK1, the team engineered mice to completely lack this gene and investigated how well they responded to cancer.
The research was published in the journal Nature Communications.
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What Are The Advantages And Disadvantages Of Hormone Therapy
What may be important to one person might be less important to someone else. So speak to your doctor or nurse about your own situation.
- Its an effective way to control prostate cancer, even if it has spread to other parts of your body.
- It can be used alongside other treatments to make them more effective.
- It can help to reduce some of the symptoms of advanced prostate cancer, such as urinary symptoms and bone pain.
- It can cause side effects that might have a big impact on your daily life.
- It cant cure your cancer when its used by itself, but it can help to keep the cancer under control, sometimes for many years.
How Will I Know If My Treatment Is Working
You will have regular appointments to check how well your treatment is working and monitor any side effects. These will involve regular prostate specific antigen blood tests to measure the amount of PSA in your blood.
PSA is a protein produced by cells in your prostate and also by prostate cancer cells, even if they have spread to other parts of your body. The PSA test is a good way to check how well your treatment is working.
How your treatment is monitored will depend on whether youre having hormone therapy as part of treatment that aims to cure your prostate cancer, or having life-long hormone therapy to keep advanced prostate cancer under control.
You can contact your nurse at the hospital, or our Specialist Nurses, between appointments if you have any side effects or symptoms that youd like to talk about.
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Nhs Expedites Rollout Of Bayers Darolutamide For Prostate Cancer
Darolutamide is administered as a tablet along with androgen-deprivation therapy and docetaxel chemotherapy.
The National Health Service in England, UK, has expedited the rollout of Bayers new life-extending drug, darolutamide, to treat the most advanced kinds of prostate cancer that have spread to other body parts.
With the latest development, NHS will become the first healthcare system in Europe to offer this drug to prostate cancer patients.
Nearly 9,000 men with prostate cancer will be eligible to receive this treatment.
Darolutamide is administered as a tablet along with androgen-deprivation therapy and docetaxel chemotherapy.
According to data from the ARASENS clinical trial carried out at nearly 300 sites globally, including various NHS hospitals, subjects who received the combination therapy had a 32.5% reduced chance of mortality versus ADT and docetaxel alone.
Darolutamide acts by hindering androgen receptors in cancer cells, which subsequently obstructs testosterones effect that enables the survival and replication of the cancer cells.
It is branded as Nubeqa and is already offered on the NHS for patients with localised prostate cancer.
This is the fifth cancer therapy to be offered by the NHS in England as part of an early national access agreement.
The agreement was entered after the UK Medicines and Healthcare products Regulatory Agency granted approval for darolutamide under the global collaboration Project Orbis.
Patients On As At Risk For Developing Cap Or Who Have High Risk Cap
Few studies to date have studied TTh in men with active CaP and have reported predominantly positive outcomes in men with CaP, with a common theme of caution. A 2016 review concluded that although the data on using TTh in men on AS are limited, preliminary studies show no, or minimal, increased risk compared to the quality of life improvements seen with treatment of hypogonadism . Conversely, a 2011 study following 25 men with CaP reported highly variable outcomes after starting TTh. The authors urged caution in treating these patients and concluded that an international registry to collect more data would be the only way to address whether TTh was safe in men with CaP . While the preliminary studies of TTh in the setting of AS appear to demonstrate the relatively safety of treating hypogonadism with TTh in this setting, it is important to note that none of these studies were randomized or controlled and that more work must be done before unequivocally determining the safety of such treatment.
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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.
How May Changing Prostate Cancer Screening Guidelines Impact Use Of Adt
PSA is the most utilized biomarker for diagnosing prostate cancer. It is a serine protease inhibitor that was discovered and purified in 1979. Thirteen years later, two large studies reported the utility of using PSA screening for prostate cancer., In one study, approximately 15% of men of 1249 over the age of 50 years were found to have an elevated PSA, defined by a serum level > 4.0 ng/mL. Prostate cancer was diagnosed in slightly more than 30% of men with an elevated PSA. Soon thereafter, PSA screening gained widespread acceptance in the United States. According to Zeliadt and colleagues, it has been estimated that approximately 50% of the male US population between the ages of 55 and 74 years undergo PSA screening over a 6- to 7-month period.
The European Randomized Study of Screening for Prostate Cancer had less contamination than the PLCO study because a smaller proportion of men in the unscreened cohort underwent screening prior to randomization or during the study. The median follow-up was 9 years. Overall, prostate cancer mortality was reduced by 20%. Upon correcting for contamination, PSA screening decreased prostate cancer mortality by 31% in actually screened patients.
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About The Southwest Prostate Cancer Symposium
The Southwest Prostate Cancer Symposium is a multi-day conference that seeks to educate urologists, radiation oncologists, medical oncologists, and other healthcare professionals involved in the treatment of prostate cancer. The topics focus on current technical aspects of diagnosis and treatment of localized and advanced disease, particularly regarding imaging, technology, and training in the related devices. Dr. Morgentaler presented this lecture during the 24th SPCS in 2019. In 2020, the 25th SPCS will also offer training sessions involving imaging, scanning, and prostate cancer treatment related devices on site. Please visit this page in order to register for future SPCS meetings.
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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