Hormonal Therapy
Do hormones help before a prostatectomy?
Question: I have an enlarged prostate as well as localized prostate cancer. Someone in my prostate cancer support group mentioned that hormonal therapy would be helpful to take before my radical prostatectomy. Is it useful to take hormonal therapy before surgery?
Answer: Thus far, there has been evidence that the tumor may be down-staged if hormonal therapy is given before surgery. However, time to PSA progression has not been changed with hormonal therapy before radical prostatectomy versus prostatectomy alone. Therefore, most urologists do not recommend taking hormonal therapy before this surgery.
How about hormones with radiation therapy?
Question: I am a man newly diagnosed with a Gleason 4 + 3 = 7 prostate cancer, a PSA of 12, and a large nodule that may be outside the prostate gland. I have decided to go on intensity modulated radiation therapy (IMRT). Is it useful to use hormonal therapy in addition to radiation therapy for the primary treatment of prostate cancer?
Answer: There are several studies showing an increase in progression-free survival time and some studies have shown survival time and rate improvements when combining these two treatments.
Does the use of hormonal therapy with salvage radiation therapy help?
Question: My original prostate cancer was a Gleason 4 + 4 = 8 adenocarcinoma with PSA of 9.1. I have a recurrence only in the area of my prostate according to my scans. My urologist is recommending hormones and radiation. What should I do?
Answer: There are some studies with only a small number of patients that show that short-term hormonal therapy improves PSA freedom from recurrence and overall survival time. We need more studies to verify this finding. Currently one should seriously be considered for androgen deprivation therapy if they have high-risk features, such as a PSA greater than 10 nanograms per milliliter at the time of surgery, seminal vesicle involvement, or a Gleason score equal to or greater than 7.20.
What are the side effects of androgen deprivation therapy?
Question: I was recently told that my prostate cancer has spread to my bones. My physician wants to start me on hormonal therapy. What can I expect from this treatment?
Answer: There are both immediate and long-term effects. The immediate ones include flushes and sweats, mood changes including depression, fatigue, and loss of sex drive. The longer-term side effects include enlarged breasts, weight gain, osteoporosis, lack of the ability to concentrate, and anemia. There have been recent studies that have also associated hormonal therapy with an increased risk of myocardial infarction, diabetes mellitus, and hyperlipidemia.
What is the advantage of an intermittent androgen blockade versus continuous androgen deprivation therapy?
Question: I am 76 years old and have a rising PSA after radiation was given to me 3 years ago. I had been on antiandrogen treatment for 2 years, but am getting very weak on it. Is there a benefit to go on and off this treatment?
Answer: A number of the side effects of hormonal therapy diminish during the period off treatment, including the flushes and sweats, mental changes, sexual side effects, weight changes, and bone effects.
Question: I am 65 years old and had positive lymph nodes 3 years ago at the time of my surgery. Now my PSA is rising. Am I a good candidate for intermittent androgen blockade?
Answer: There are ongoing studies to evaluate intermittent therapy in men treated with hormones. Although early studies suggest that intermittent therapy is at least as effective as continuous therapy in controlling cancer, large phase III studies are needed to confirm these observations. Two large studies, one from Canada and one from the Southwest Oncology Group, are ongoing.
Who are the good candidates for intermittent androgen blockade?
Question: I am 72 years old and have a rising PSA after radiation was given to me 2 years ago. Am I a good candidate for intermittent hormonal blockade?
Answer: Patients who have a lot of disabling or uncomfortable side effects from continuous hormonal therapy and who have a low metastatic load—that is, not a lot of cancer—are reasonable patients for this technique. Patients who have PSA rising only after radiation or radical prostatectomy, or who have either failed, refused, or are not candidates for a salvage procedure are possibly good patients for this approach.
Several recent randomized trials have demonstrated similar times to progression and overall survival in men treated with intermittent androgen blockade compared to those treated with continuous blockade, with similar or less toxicity in intermittently treated patients. The completion and analysis of the Southwest Oncology Group (SWOG) intermittent therapy trial will help to provide the definitive answer to the applicability of intermittent androgen blockade.
What can I do to prevent the anemia associated with androgen deprivation therapy?
Question: I am a 65 year-old male who has been on hormonal therapy for prostate cancer for 1 year. My doctor tells me I'm becoming anemic. What do you recommend?
Answer: A balanced diet with appropriate vitamin and iron supplementation is helpful. Red blood cell stimulators, such as Aranesp® (darbepoetin alfa) and Procrit® (epoetin alfa), can be very useful in developing red cell production when necessary.
How can I prevent the weight gain associated with androgen deprivation therapy?
Question: I have been on androgen deprivation therapy for about 18 months and have gained a lot of weight. Is there anything I should be doing?
Answer: A careful approach to dietary caloric content is very important. A dietitian can be very helpful in this regard. A well-planned and disciplined exercise regimen will help control this frequent side effect of hormonal therapy.
How can I help control the flushes and sweats associated with androgen deprivation therapy?
Question: I've been on hormonal therapy for nearly 2 months and find the flushes and sweats unbearable. What can I do to diminish or get rid of them?
Answer: Sleeping in a cool room and maintaining a stable temperature environment can be helpful. There also are a number of medications that have been shown to be helpful.
We are not sure why a number of antidepressants significantly decrease these side effects, but we know they work in a large population of patients. These agents also help with the depression and mood changes that can occur with this treatment.
Hormonal treatments, such as progestational agents and estrogens, have also been useful in this regard. Recently a drug called Neurontin® (gabapentin) has been shown to decrease this side effect by up to 50 percent. It is important that your doctor is intimately involved in decisions on which agents to use because of the side effect profile of these drugs.
Is androgen deprivation therapy useful when receiving external beam radiation therapy?
Question: I'm 65 years old and have been told that I have a T3 (cancer beyond the capsule) prostate cancer. Will hormonal therapy be of benefit if I take radiation treatments?
Answer: There are studies that show the addition of hormonal therapy to radiation therapy has, especially in high-risk patients, improved local and metastatic progression-free survival, disease-free survival, and overall survival.
When and how long should androgen deprivation therapy be given with radiation therapy?
Question: I'm 65 years old and have been told that I have a T3 (cancer beyond the capsule) prostate cancer. When should I begin and how long will I be on hormonal therapy?
Answer: There are a number of studies addressing this issue. Currently, the answer to this question is still evolving. Generally, we try to access the risk of relapse to assign a period of time to be on androgen deprivation therapy.
For example, one study showed that lifetime androgen deprivation therapy immediately after radiation therapy in patients with lymph node involvement or advanced local disease had superior local, biochemical (PSA), and distant disease control rates as well as disease-specific survival and overall survival when compared with those treated with hormones when they relapse.
Each patient must be assessed individually by his multidisciplinary team to assign an effective evidenced-based time for androgen deprivation treatment.
If lymph node involvement in the pelvis is discovered during a radical prostatectomy, should the patient be placed on immediate androgen deprivation therapy?
Question: I was recently found to have two lymph nodes involved when my doctor attempted a radical prostatectomy. He aborted the procedure and wanted to place me on hormones. Should I do this right away?
Answer: There are a number of studies that show an advantage to early hormonal treatment. One study in particular addressed this question. Fifty percent of the patients were placed on immediate hormone deprivation therapy and the other 50 percent were placed on delayed hormone therapy. Delayed hormone therapy was given upon progression of their disease. The early treatment group had a significantly improved disease-specific survival and overall survival advantage.
If patients cannot tolerate LHRH-A treatment, are there alternative treatments available?
Question: I'm 64 and have been on Lupron® (leuprolide) for 6 months. I am depressed and hate the way it makes me feel. Are there alternative treatments for me?
Answer: Antiandrogen therapy, alone or with a 5 alpha-reductase inhibitor—Proscar® (finasteride) or Avodart® (dutasteride)—has been shown to be helpful in a number of groups to delay the rate of progression of disease. This treatment remains experimental and needs to be discussed with your physician.
When should androgen deprivation therapy be instituted in patients failing primary treatment (radical prostatectomy, radiation therapy, seeds, etc.)?
Question: I'm a 70-year-old man who has been told by my doctor that my PSA is now rising 3 years after my radiation for prostate cancer. Should I begin hormonal treatments sooner or later?
Answer: This is a very difficult question to answer because there is some conflicting data. However, the preponderance of information that we have to date appears to indicate a longer tumor-free interval for patients who are put on early, rather than late, androgen deprivation therapy.
We await further studies before we can make definitive recommendations. However, it does appear that a subset of patients who have more aggressive tumors—that is, PSA equal to or greater than 7 and PSA doubling time less than 9 months—may have a greater benefit from the initiation of early androgen deprivation treatment.
What is the best form of androgen deprivation therapy?
Question: I'm 67 and have five bone lesions appearing on my bone scan. What is the best form of hormonal treatment for me to take now?
Answer: This has been a long disputed question. The preponderance of evidence appears to confirm the following:
1. Use of an antiandrogen before or at the time of LHRH-A treatment helps prevent the testosterone surge that occurs with LHRH-A alone. This is especially important in patients who have urinary obstructive symptoms or metastatic disease, so that urinary obstruction and events such as spinal cord compression can be prevented.
2. There is a small advantage for combination hormonal therapy with an antiandrogen, such as Casodex® (bicalutamide) or Eulexin® (flutamide), versus an LHRH-A only in a large study examining several trials.
3. There is very little data comparing single agent (that is, LHRH-A) versus combination hormonal therapy (LHRH-A plus an antiandrogen) in the subgroup of patients without gross metastatic prostate cancer. (This is not your case, however.)
In summary, the form of androgen deprivation therapy that is selected must be tailored to the particular patient, the status of his prostate cancer, his overall medical condition, and the comfort of he and his doctor with each type of treatment.
In patients who have metastatic prostate cancer, should androgen deprivation therapy be started before symptoms begin?
Question: I have asymptomatic metastatic prostate cancer in several bones according to the bone scan. However, I feel fine. Should I start hormonal therapy now?
Answer: The preponderance of evidence favors the early use of androgen deprivation treatment. It appears to delay symptoms, such as urinary obstruction and spinal cord compression, and improves overall survival time. This is especially true in patients with high-risk features.
Is Nizoral® (ketoconazole) useful in the treatment of hormone-refractory prostate cancer?
Question: I have just been told that my prostate cancer is now hormone-refractory and my oncologist suggested that I go on a drug called ketoconazole and hydrocortisone. Do you think it might help me?
Answer: Yes. A number of studies have found this secondary hormonal (it is an antifungal drug with both direct tumor cell killing and androgen depleting effects) therapy gives a favorable response rate between 30 percent and 63 percent. One study showed that those patients who had a greater than 50 percent decrease in PSA while receiving ketoconazole experience a longer survival time (41 months versus 13 months) than those who did not.
Why is it important to be on hydrocortisone when taking ketoconazole?
Question: I have just been told that my prostate cancer has become hormone-refractory and my oncologist suggested that I go on a drug called Nizoral® (ketoconazole) and hydrocortisone. What is the hydrocortisone for?
Answer: Ketoconazole shuts down the production of steroids from the adrenal gland. Because we all need a certain amount of cortisone (a steroid) to live, it needs to be replaced (usually in the form of hydrocortisone).
What is the effective dose of Nizoral® (ketoconazole)?
Question: I have just been told that my prostate cancer has become hormone-refractory and my oncologist suggested that I go on a drug called ketoconazole and hydrocortisone. What are the correct doses?
Answer: The starting dose of ketoconazole is 200 milligrams (one tablet) three times daily on an empty stomach. Some doctors believe that it is more effective when taken with vitamin C (or anything acidic, such as coffee or cola), and that if it is tolerated, the dose should be increased slowly to 400 milligrams (two tablets) three times daily, along with 20 milligrams of hydrocortisone orally twice daily. It can, however, work at the lower dosage if not tolerated when the dose is increased.
What dose of hydrocortisone should be taken with Nizoral® (ketoconazole)?
Answer: Usually between 30 milligrams (20 milligrams in the morning and 10 milligrams in the evening) and 40 milligrams (20 milligrams in the morning and 20 milligrams in the evening), but this can be individualized based upon other medical conditions.
What are the side effects of Nizoral® (ketoconazole)?
Question: I was recently put on ketoconazole and hydrocortisone for HRPC (hormone-refractory prostate cancer). What side effects can I expect?
Answer: If the dose is started as 200 milligrams (one tablet) three times daily and then slowly increased by one tablet per day every 3 days until two tablets three times per day is reached, a lot of the side effects can be avoided. These include nausea, vomiting, diarrhea, lethargy, tiredness, and abnormal liver test results. A rash can also be seen sometimes. This can occur with or without itching.
Are there drugs that Nizoral® (ketoconazole) interacts with?
Question: I was recently put on ketoconazole and hydrocortisone for HRPC (hormone-refractory prostate cancer). Do I need to be careful if I'm on other medications?
Answer: Yes. Check with your pharmacist because they have computers to look at interactions with any drugs you are taking. There are two very important ones that anyone taking ketoconazole should be aware of. It can prolong the effect of Coumadin® (warfarin), and therefore frequent pro-time/international normalized ratios (INRs) need to be checked when starting and stopping ketoconazole. There is also a very dangerous interaction when one is on Zocor® (simvastatin). This combination can cause muscle death and kidney failure.
How does a doctor decide if a patient goes on a second hormonal manipulation versus chemotherapy?
Question: I'm 71 years old and have become resistant to hormonal treatment. Should I go on secondary hormones or go on chemotherapy?
Answer: Until we find out through randomized controlled trials the answer to this question, most of us will place patients on chemotherapy when their hormone-refractory prostate cancer is symptomatic and/or rapidly progressing. If the patient is felt to have time to try secondary and tertiary hormonal manipulations, these are frequently used first.
This content was last modified on
August 07, 2007
.