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Hormonal therapy is used in several ways to treat prostate cancer:
1. The most common use of hormonal therapy is for metastatic prostate cancer (prostate cancer that has spread outside of the prostate gland to lymph nodes, bone, or other sites).
2. Hormonal therapy may also be used in combination with radiation therapy for aggressive (high-risk) forms of prostate cancer.
3. After failure of surgery or radiation therapy, hormonal therapy can be used to keep the prostate cancer under control.
4. Hormonal therapy may also be the primary treatment for older patients newly diagnosed with prostate cancer who are not candidates for or choose not to have surgery or radiation therapy. This treatment can control the cancer growth for many years.
5. Occasionally, hormone therapy may be used to shrink the size of the prostate gland prior to brachytherapy treatment (insertion of radioactive seeds into the prostate gland).
Contents of Page
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What is Hormonal Therapy and How Does It Work?
What Are The Types of Hormonal Therapy?
What Are Continuous and Intermittent Hormonal Therapies?
What Are the Common Side Effects of Hormonal Therapy?
When Can I Expect These Side Effects to Occur?
How Can I Manage the Side Effects of Hormonal Therapy?
In Summary
References
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What is Hormonal Therapy and How Does It Work?
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Most prostate cancers need the male hormone testosterone to grow. Testosterone is the hormone that one typically associates with "masculine" characteristics, such as a lower voice, stronger muscles, specific patterns of facial and body hair, and male "sex drive" or libido.
The hormonal medications used to treat prostate cancer work by interrupting the secretion of testosterone by the testicles, or blocking the action of testosterone on normal prostate and prostate cancer cells. These medications work in several ways and cause prostate cancer growth to be slowed down.
LHRH agonists and antagonists (see medications below) interrupt signals to the pituitary gland in the brain, thus causing the testicles to stop producing testosterone. Antiandrogens block the action of testosterone on normal and prostate cancer cells.
There are many terms that are used to connote hormonal therapy:
Generic Names for Hormonal Therapy:
ADT: Androgen Deprivation Therapy
AAT: Androgen Ablation Therapy
Specific Types of Hormonal Therapy (explained below):
CAB: Combined Androgen Blockade
IADT: Intermittent Androgen Deprivation Therapy
CADT: Continuous Androgen Deprivation Therapy
The person undergoing hormonal therapy accomplishes this decrease in testosterone by taking pills orally, or receiving intermittent injections into subcutaneous tissue or muscle.
Decrease or almost total elimination of testosterone can also be done surgically by removal of the testicles (called bilateral orchiectomy).
Sometimes, after quite a while, prostate cancers will grow even in the absence of testosterone. These cancers are called "hormone-insensitive prostate cancers," or "androgen-independent prostate cancers."
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What Are The Types of Hormonal Therapy?
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Hormonal therapy is the use of single medications or the use of combinations of medications for varying periods of time.
These medications have many common side effects. Many of the side effects occur "early on" (within the first 2 months of therapy), and many occur later (after 6 months of therapy). The common side effects and their time delineation will be described by your physician.
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What Are Continuous and Intermittent Hormonal Therapies?
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The term "CAB" refers to using a combination of hormonal therapy medicines (at least two of them) that block the secretion of testosterone by the testes, and stop the action of any remaining androgens on prostate cells and prostate cancer cells. CAB can be used when a patient has an aggressive cancer, or when a patient has a recurrence after surgery or radiation therapy.
"IADT, "or intermittent androgen deprivation therapy, refers to the use of hormonal therapy for a given time (usually until the PSA stabilizes at a low level). By stopping the hormone therapy the patient has a reversal of the side effects and an increased quality of life. The hormones are then started again if the PSA rises to a certain agreed upon level. The hormones can often bring down the PSA again. There is controversy in the medical community regarding this topic - if and when to use IADT, as well as the timing of when to stop and restart hormones.
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What Are the Common Side Effects of Hormonal Therapy?
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There are many potential side effects of ADT (androgen deprivation therapy):
Most Common Side Effects:- Loss of libido
- Erectile dysfunction
- Hot flashes
Side Effects That You Feel:- Fatigue
- Lack of energy / initiative
- Aches & pains
- Depression
- Emotional lability
- Cognitive changes
| Side Effects That You Can See- Weight gain
- Gynecomastia (enlarged breasts)
- Loss of muscle mass
- Loss of strength
- Decreased size of testicles
- Hair changes (loss of body hair, increased density of scalp hair)
Side Effects That You Can't See
- Loss of bone density
- Anemia (lowered red blood cell count)
- Alteration of serum lipids
- Worsening of hypertension, diabetes, heart disease
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Adapted with permission from Higano, Celestia. "Hormone Therapy: A Survivor's Guide." Article in ASCO 2006 Prostate Cancer Symposium Program/Proceeding. February 2006. p. 65.
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When Can I Expect These Side Effects to Occur?
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Commonly Reported Acute & Chronic Androgen Deprivation Syndrome Symptoms
Acute (symptoms in < 2 months)- Hot Flushes
- Loss of libido and possible Impotence
- Aches & pains in joints
- Loss of energy & "feeling weak
- Short-term memory
- Mood "swings"
- Emotional changes (tearfulness, etc.)
- Anemia unrelated to blood loss, iron deficiency
- Loss of blood sugar control in patients with diabetes mellitus (sugar diabetes)
- Increase in urinary symptoms (urination or difficulty starting the urinary stream)
| Chronic (symptoms in > 6 months)- Muscle atrophy in chest, arms, & legs
- Atrophy of testicles
- Decreased muscle strength & endurance
- Weight gain due to increased body fat
- Gynecomastia (breast enlargement)
- Osteoporosis, progressive on CHB
- Chronic fatigue-like syndrome
- Difficulty controlling blood pressure, often or bone marrow involvement requiring initiation of changes in drug therapy
- Alzheimer's-like symptoms (severe short-term memory difficulties, inability to concentrate)
- Increased serum cholesterol (LDL, or "bad" cholesterol) and/or & triglyceride levels
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From Strum, Stephen B., MD. The Androgen Deprivation Syndrome. Reprinted from PCRI Insights, January 1999, vol. 2., no., 1.
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How Can I Manage the Side Effects of Hormonal Therapy?
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The following table can help you manage the side effects of hormonal therapy:
Hot Flashes
Hot flashes - noted as a sudden feeling of flushing (especially in the face), a feeling of heat, and/or sweating - can be seen in up to 75% or more of patients taking LHRH analog hormonal therapy. The severity of these episodes varies from man to man, and often they are bothersome but passing. Occasionally, they are very annoying to men, and the following may be helpful:
Complementary remedies & lifestyle: - Use of soy (see Nutrition Section)
- Use of acupuncture
- Vitamin E
- Avoid caffeine, alcohol, hot liquids
Megace, 20 mg twice a day: Possible side effects include episodes of chills, appetite stimulation, weight gain, blood clots, and symptoms of carpal tunnel syndrome.
Clinidine (Catapres): Transdermal patch 0.1mg, weekly. Possible side effects include lowered blood pressure and allergic reaction to the patch.
Venlafaxine (Effexor): SSRI Antidepressant- Can have dry mouth, nausea, constipation
- Works well in about 2 out of 3 men
- Must be discontinued slowly
Decreased Sex Desire/ Erectile Dysfunction:
This side effect can be decreased libido, as well as difficulty to have or maintain an erection. The condition is reversible once hormonal therapy is stopped. Often, a gentleman can have an erection and orgasm once stimulated, but the "idea" for sex does not come spontaneously.
There are many interventions that can be done if you would like to pursue having sex during this time. Please discuss these issues with your urologist as he/she is the best person to help you. Additionally, a licensed sex counselor who is familiar with issues surrounding prostate cancer can be very helpful.
There are many other components to sexuality that include intimacy and communication. This is a time to be gentle with yourself and with your partner - life changes take a while to adapt to, and it is important to know that you do not have to do it alone. A consultation with a licensed counselor for short-term therapy or longer-term intervention could be very valuable. See the section below (Depression, Emotional Lability, Cognitive Problems) for more information regarding finding a therapist.
Fatigue
Fatigue can be due to and associated with weight gain, muscle wasting, and and/or anemia. The following may be helpful:- Watch cholesterol numbers: Seek assistance from your health care provider in monitoring your cholesterol; diet and exercise changes, consider statin therapy as needed
- Start exercise program: Especially aerobic and resistance training
- Anemia: Experienced by about 60% of patients. Monitor blood counts. Your doctor may prescribe use erythropoietin if needed.
Osteoporosis
This is a gradual loss in bone mineral density, which occurs normally in aging men and women, but is hastened in men taking hormonal therapy. This is a serious complication in men - fracture rates can occur (5%-28% in the second year of hormonal therapy). The following may be helpful:- Obtain a baseline DEXA Scan: This scan measures bone mineral density and provides valuable information
- Take Vitamin D and Calcium Supplements: Under the supervision of your doctor
- Increase weight bearing exercise: Work with a personal trainer if needed
- Consider taking bisphosphanates: Zolidramate (Xometa) has been shown to reduce rates of fractures among men on hormonal therapy. Talk to your doctor about side effects.
Depression, Emotional Lability, Cognitive Problems
Learning that you have prostate cancer is often quite a shock, since usually there are no symptoms to know that you have something different growing in your body. Gentlemen and their loved ones have described the journey of prostate cancer as "difficult," "a minor nuisance," to a "shattering experience."
Being faced with the diagnosis of prostate cancer is often the first time many men have ever had a physical problem. Please know that you are not alone in any part of managing this diagnosis, and that there is much help, guidance, and loving support available to you every step of the way.- Take good care of yourself and your loved ones: This is a time to take good care of yourself and your loved ones, and give yourself plenty of time to investigate your options, make your decisions, and in general, be very gentle with yourself.
- Join a support group: There are many support groups in your local area-US TOO, American Cancer Society's Man-to-Man group, etc. It can be very helpful to share your experience with someone who has already gone through it.
- Consider counseling: Counseling, either short-term or longer, can be very beneficial in understanding your new and powerful feelings, and making sense of what is often regarded as "a chaotic inner world."
- Consider medications: Sometimes the use of an anti-depressant medication can be very beneficial. Work with a practitioner who is skilled in these matters, and in whom you trust.
- Seek assistance: Ask your primary care physician for a referral to an MFT, LCSW, clinical psychologist, or psychiatrist. You may be able to connect with someone who has a lot of experience in dealing with grief, loss, and illness. Other people who can refer you are your friends (almost everyone knows of a "great therapist" in their area), or your "Employee Assistance Program at work can help you confidentially.
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In Summary
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Hormonal therapy has a very definite place in the treatment of prostate cancer. Knowledge of the different options, how they work, side effects, and what the gentleman and his loved ones can do to manage the treatments and the side effects is useful and valuable. Please consult with your health care practitioners in determining what are the best treatment modalities and interventions for you and your particular situation. We are always pleased to be a resource to you in your healthcare decision process.
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References
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Bostwick, D.G., Crawford,E.d., Higano, C.S., Roach, M., Eds. American Cancer Society's Complete Guide to Prostate Cancer. Atlanta, GA: American Cancer Society. 2005.
Higano, Celestia. "Hormone Therapy: A Survivor's Guide." Article in ASCO 2006 Prostate Cancer Symposium Program/Proceedings. February 2006. p. 65.
Moyad, Mark A. "Promoting General health during androgen deprivation therapy (ADT): A rapid 10-step review for your patients." Urologic Oncology: Seminars and Original Investigations, Vol. 23. 2005. pp. 56-64.
National Cancer Institute. Prostate Cancer (PDQ):
"Treatment Health Professional Version."
Pienta, K.J, and Moyad, M.A. Prostate Cancer from A to Z. Ann Arbor, Michigan: J.W. Edwards, Inc. 2004.
Prostate Cancer Foundation. 2005 Report to the Nation on Prostate Cancer: A Guide for Men and Their Families. Santa Monica, CA: Prostate Cancer Foundation. 2005. (available to order or download at www.prostatecancerfoundation.org)
Prostate Cancer Foundation. 2004 Report to the Nation on Prostate Cancer: Focus on Advanced Disease. Santa Monica, CA: Prostate Cancer Foundation. 2004. (available to order or download at www.prostatecancerfoundation.org)
Strum, Stephen B., MD. "The Androgen Deprivation Syndrome." Reprinted from PCRI Insights, January 1999, Vol. 2., No., 1.
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