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Introduction
When is hormone treatment used?
What does hormone treatment involve?
What are the current medications available in Australia?
What are the side effects of hormone treatment?
A word about hormonal therapy
Hormone resistance: what if the treatment stops working?
What about additional therapies?
Who is taking care of me?
Other Resources
Introduction
Mr PHIP no. 3 in this series talked about the importance of stage, or how far the cancer has spread, when deciding the best type of treatment. Mr PHIP no. 4, talked about recurrence of cancer after surgery or radiotherapy, and how this is monitored. Hormonal therapy is the major treatment option for cancer which has already spread beyond the prostate region, or has recurred following initial treatment by surgery or radiotherapy. It is also sometimes used in combination with radiotherapy for the initial treatment of prostate cancer. This information sheet describes what hormonal therapy is, its effects and the long term outcome.
Hormone treatment controls cancer growth by reducing the effects of male hormones. |
Male hormones (also called androgens) are important for prostate growth. Indeed the normal development of the prostate to its adult form is very dependent on testosterone, the principal male hormone released from the testicles. Men rely on normal levels of male hormones to have adult sexual function and fertility. The level of male hormone in the body is precisely controlled by several factors, the main one being the normal secretion of stimulatory hormones from the pituitary gland which is in turn stimulated by hormones from the hypothalamus. These two structures are at the base of the brain.
Both normal and cancer cells in the prostate are stimulated to grow by male hormones. Prostate cancer cells that have left the prostate and are growing in other areas of the body (metastases) are also stimulated to grow by male hormones. Consequently one relatively common treatment for prostate cancer which has spread outside the prostate region (see Mr PHIP no. 3 and 4) is to lower the levels of male hormones in the body and thereby stop the growth of cancer cells. This happens irrespective of whether the cells are in the prostate or in other areas of the body. Indeed, prostate cancer cells typically respond to the withdrawal of male hormones by dying.
Unfortunately, not all prostate cancer cells die, and with time, often several years later, the cancer starts growing again. Nevertheless, good cancer control and a symptom-free lifestyle can be achieved for many years by men on hormone therapy. This information sheet is designed to assist those with prostate cancer for whom hormone treatment is an option.
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When is hormone treatment used?
This is not a simple question to answer, for many factors need to be considered prior to choosing this treatment option. In general, hormonal therapy is used when there is evidence that the cancer is no longer confined to the prostate.
Hormone treatment is commonly used for men in whom radical treatments have not succeeded in curing the disease, ie following radical surgery or radiotherapy. Often our best indicator of recurrent prostate cancer growth is from a rising PSA level (PSA is a blood test which, after surgery or radiotherapy, indicates the amount of cancer activity still remaining in the body - see Mr PHIP no.2 and 4). Exactly when to start hormone treatment in response to a rising PSA level varies. It is based to some extent on the speed of tumour growth and the sites of the tumour.
Hormone treatment is also the principal therapy for metastatic prostate cancer - when the prostate cancer cells have escaped from the prostate to grow in other sites of the body. In this case, the treatment may be started soon after this diagnosis is made, although on occasions a delay in starting does not pose serious risk to the patient.
Hormone therapy may also be used to shrink the tumour prior to or in conjunction with other treatments. There is evidence that this is beneficial with radiotherapy when the tumour is bulky, however, its use in conjunction with surgery is not thought to be useful. Once the radiotherapy treatment has been completed, the hormone treatment may continue for 6 to 24 months. Tumour control is followed over time with PSA testing, typically every 3 - 6 months.
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What does hormone treatment involve?
Essentially, there are two ways of reducing male hormones:
- by surgery where the testicles are removed (orchidectomy)
- by medication, either in the form of regular injections and / or tablets.
Both are effective. (Refer to Table 1 and Figure 1).
Since the testicles provide over 95% of the male hormones it is obvious that surgey to remove them will reduce the blood levels of male hormones. This occurs very quickly after the operation. An advantage of this form of hormone treatment is that the inconvenience and cost of regular medications is avoided. The operation is usually performed as day surgery. The scrotum (pouch of skin that holds the testes) remains intact and the testes are removed through a small incision. The operation provides continuous hormone therapy.
Medications are available as an alternative to orchidectomy. They include drugs which are injected and others given as tablets. The injectable drugs (called Leutenising Hormone Releasing Hormone agonists or LHRH agoists) act on the brain to reduce the production of male hormones in the testicles. They currently last from 1- 6 months per injection. This means that regular monthly or 6-monthly injections are required to control the cancer cell growth. Should these be stopped, the cancer growth will occur when male hormone levels begin to rise (after several months).
Tablets (drugs called anti-androgens) are also available to control the cancer cells. In the past, both injectables and tablets were frequently used in combination to control prostate cancer cell growth (called total androgen ablation). However, we are currently not certain of the additional effectiveness of taking a tablet whilst on an injectable drug or in combination with orchidectomy (removal of the testicles). Frequently doctors start with a tablet, then 2-4 weeks later, give an injectable medication. The tablets are often phased out after a few more weeks.
Sometimes hormone therapy may be given in cycles, ie. started and stopped repeatedly. This type of treatment is called intermittent hormonal therapy. Typically, hormone treatment is continued for several months until the PSA has reached a low level, and then discontinued. Once the PSA level in blood rises to a particular level again (and this can take many months), hormone therapy is re-started. The main benefit of this approach is a reduction in side effects of the hormone therapy (see the next section), without reduction in tumour control (as far as we know currently).
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What are the current medications available in Australia?
A list of current medications available in Australia is shown in Table 1 below.
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What are the side effects of hormone treatment?
Many of the side effects of hormone treatment are related to the low levels of male hormone within your body and occur whether you choose surgery or medications. These are summarised in table 2 below. Typically, most men experience poor or absent erections impotence) and also a lack of interest in sexual activity (reduced libido). Your voice will not change; however, some men notice an alteration of their body hair, such that it is a different texture and may grow again on previously quite bald areas. Tiredness is a common complaint, and is related to the main male fuel being suppressed.
Hot flushes are very common in the early stages of treatment but may decline spontaneously after several months of treatment. There are medications available to reduce the intensity of this sometimes disabling symptom if required. Over many months or years there may be a decline in muscle strength and some tenderness or enlargement in the breast area.
Before commencing on hormonal therapy, it is helpful to discuss the possibility of side effects with your wife or partner. Good communication is important in dealing successfully with these changes and maintaining your close relationship.
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A word about hormonal therapy
The very nature of this treatment, the removal of male hormone or its effects means that a man will experience changes in the way he feels, his attitudes, and of course his sex life. While this can be distressing, it does not change who you are. It does not change your identity as a man and your ability to direct your own life. Communication with your partner is particularly important. Some men feel a need for a change in focus in their lives at this stage, however, and they may take up activities which are more meaningful to them. According to these men, the years that follow can be rewarding and productive.
In Mr HIP no. 3 we discussed the importance of talking to those close to you, to others who may have had similar experiences and to your medical team as often as you need to. In Mr PHIP no. 4, we also suggest ways of maintaining a good quality of life. You may wish to read these additional information sheets, there is much that you can do for yourself at this stage, as there is at earlier stages.
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Hormone resistance: what if the treatment stops working?
You may notice changes in evergy levels and sexual interest. |
The ability of hormone treatment to continue controlling your cancer over the years is quite variable. Some men (approximately one in five) have recurrent cancer growth within a year from starting hormone treatment whereas others have little sign of recurrent disease after 10 years of treatment. For men with metastatic disease (cancer is present in areas of the body remote from the prostate), the average time to active cancer growth (hormone resistance) is about 3 years.
When resistance to hormonal therapy occurs (usually indicated by rising PSA in the blood), treatment is frequently tailored to an individual's symptoms. Symptoms typically occur many months to years after a rising PSA. Symptoms can be caused by growth of the cancer in the pelvic region. They may include blood in the urine and reduced ability to pass urine. Symptoms may also be caused by growth of the cancer at distant sites such as the bones. They may include pain in the bones such as pelvis and back.
Treatment Options for Hormone-resistant Cancer:
These Include:
- Radiotherapy, to alleviate pain and control cancer growth at sites away from the prostate. Radiation is usually delivered by "external beam" (meaning from outside the body) in this setting although radio-active agents which are injected are sometimes used.
- Additional hormone treatments, typically tablets. Not many men have a lasting favourable effect from "second-line" hormonal therapy; however, a downward trend to the PSA can occur for some months. Stopping one tablet and using a different one is also sometimes helpful.
- Steroids such as prednisolone to control pain and reduce tumour growth.
- Non-specific pain relief medications, including arthritis-type tablets and morphine.
- Chemotherapy has not been as successful in controlling prostate cancer as it has been for other cancers, but it is an area of active research with a range of newer agents and methodologies gaining support. Docetaxol is a chemotherapy agent used successfully for other cancers that has been shown to extend life and reduce pain from prostate cancer1. Discussion regarding the pros and cons of chemotherapy options is usually undertaken with a medical oncologist. This should occur early on when considering approaches to treating hormone resistant prostate cancer.
Protecting the bones
Hormone therapy is known to weaken bones over time and can increase the risk of a break or fracture. A test of bone strength called a "DEXA scan" is a common investigation for men on hormone therapy. This is a safe and readily available scan, often used to assess the bone strength at the beginning of hormone therapy.
In order to maintain bone strength, it is good advice to have an active exercise program and to keep a balanced diet with adequate calcium intake. Exposure to sunlight stimulates the production of vitamin D, which is also important to good bone health.
Prostate cancer itself may spread to the bones, where metastases can lead to bone pain and fractures. Additional action may be advised by your specialist(s) or GP, such as a type of medication called "Bisphosphonates" eg. Zoledronate, Fosamax, Actonel. Studies show regular use by men with secondary prostate cancer in the bones has led to a reduction in fractures and bone pain2. These drugs help to retain bone mineral but they do have some side effects. The drugs can be taken orally or by intravenous injection. Radiotherapy is also used to effectively control bone pain and metastases.
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What about additional therapies?
There are additional non-medical therapies available to those with the diagnosis of prostate cancer, which we have not covered in this series. Information about these and complementary therapies is available from the cancer organisation in your state and prostate cancer support groups (see the resource list at the end of this sheet). Looking after your health through improving your diet, undertaking active exercise and managing stress is a good way to begin. It is wise to advise your medical team if you are taking additional non-conventional therapies.
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Who is taking care of me?
Different kinds of specialists may need to be involved in your care, and their different roles may not be clear. A Urologist specialises in disorders of the urinary tract and reproductive system, and so he / she will probably be the first specialist you see. If radiation therapy is an option, you will be referred to a radiation oncologist who will discuss with you, plan and deliver this treatment. Sometimes a medical oncologist, who specialises in the treatment of cancer, particularly chemotherapy, may also be involved. A palliative care doctor will focus on sympton control and quality of life. Other practitioners may provide psychosocial and specialist nursing assistance. Ideally care is multi-disciplinary: your specialists discuss and plan your care together, however formal multi-disciplinary care is not widely offered in Australia.
If you are ever unsure about who has overall responsibility for your care, discuss this with your GP - our system of care can be confusing, and your GP can act as your guide as needed.
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Other Resources
Internet:
You are not alone!
This site has a strong patient input and is very supportive. It has stories from family members as well as men themselves.
http://www.yananow.net/
Lions Australian Prostate Cancer Website
Gives support groups, treatment centres, overseas links and other educational resources.
http://www.prostatehealth.org.au
PSA rising
Prostate cancer information and support with sections on eating well, recipes, stories and more.
http://psa-rising.com
Prostate Pointers
This site has email lists where men on different types of treatments and their families can discuss issues.
http://www.prostatepointers.org
National Centre for Alternative and Complementary Medicine
You can search for trials of complementary treatments on PubMed from this site.
http://www.nccam.nih.gov
Phone:
National Cancer Help-line: 13 11 20.
Books:
Your Guide to Prostate Cancer: the disease, treatment options and outcomes
(paperback) 2006. Dr Prem Rashid, Publisher: Uronorth Group, Port Macquarie NSW. Phone 02 6581 3456.
Coping with Prostate Cancer
This useful booklet from the Queensland Cancer Fund gives issues you may face after a diagnosis and strategies for dealing with them. Phone 13 11 20.
www.qldcancer.com.au/Cancer_Info_and_Services/PCS/CancerResources.html
Dr. Patrick Walsh's Guide to SurvivingProstate Cancer
(paperback) by Janet Farrar Worthington, Patrick C. Walsh. Warner Books, NY, 2001.
Dr. Peter Scardino’s Prostate Book: The Complete Guide to Overcoming Prostate Cancer, Prostatitis and BPH
(hardcover) by Peter Scardino, Judith Kelman. Penguin Group NY, 2005.
Footnotes:
- Berry, W.R.,
The evolving role of chemotherapy in androgen independent (hormone-refractory) prostate cancer. Urology, 2005. 65 (6 Suppl): p. 2 - 7.
- Michaelson, MD. and M.R. Smith, Bisphosphonates for treatment and prevention of bone metastases.
J Clin Oncol, 2005. 23 (32): p. 8219 - 24.
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This information sheet is not intended to take the place of medical advice. Information on prostate disease is constantly being updated. We have made every effort to ensure that information was current at the time of production, however your GP or specialist may provide you with new or different information which is more appropriate to your needs.
© Repatriation General Hospital, July 2006
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