PROSTATE TREATMENT

Prostate Hormone therapy most commonly is used to treat cancer that has spread (metastasized) outside the pelvic area.

Two types of hormone therapy can be used: (1) surgical removal of the testicles, the organs that produce male hormones, or (2) drugs that prevent the production or block the action of testosterone and other male hormones, called androgens. Hormone therapy cannot cure prostate cancer. Instead, it slows the cancer’s growth and reduces the size of the tumor(s).

Hormone therapy may be combined with radiation therapy or surgery in advanced stages of cancer when the disease has spread locally beyond the prostate. This therapy may help to extend life and relieve symptoms. When the cancer has spread beyond the prostate, complete surgical removal of the prostate is not common.

In patients with early-stage cancer, hormone therapy may be used in combination with radiation therapy. A short course of hormone therapy can also be used prior to surgery to reduce the size of the prostate and may make it easier to remove.

The primary strategy of hormone therapy is to decrease the production of testosterone by the testicles. Regardless of the method of hormone therapy, this decrease in testosterone can result in certain side effects such as hot flashes, a loss of sexual desire, and impotence.

The specific methods used to reduce testosterone production or block the actions of testosterone and other male hormones are described below:

Surgical Removal of the Testicles

An orchiectomy is an operation to remove the testicles, which produce 95 percent of the body’s testosterone.

Since the testicles are the major source of androgen in the body, this procedure is classified as hormone therapy rather than surgical treatment. The goal of an orchiectomy is to shrink the prostate cancer and/or prevent future growth of the tumor by removing the source it depends on (testosterone).

Advantages:

Orchiectomy is an effective procedure that is relatively simple. The patient is usually given a local anesthetic and allowed to go home the same day as the surgery.

Disadvantages:

Many patients prefer a nonsurgical option if the success rates are similar. Depending on the kind of anesthesia used, there may be special risks in certain types of patients.

Orchiectomy is not reversible, and in some cases, may require hospitalization. Patients will often experience side effects that result from the lack of male hormone in the body. Many men will notice decreased sexual desire following the procedure, and some will observe breast tenderness and/or growth over time. Other men may temporarily have hot flashes, similar to those experienced by women during menopause. Finally, there is a risk of impotence with orchiectomy procedures.

Estrogen Therapy

Another form of hormone therapy involves administering a female hormone such as estrogen. Female hormones reduce the production of testosterone by the testicles.

The most commonly used estrogen in prostate cancer is diethylstilbestrol or DES. Hormone therapy with estrogen has limited use and is generally considered only for patients who cannot have surgery or to relieve pain in patients with prostate cancer that is progressing. Estrogens were once considered standard treatment for prostate cancer, but this is not the case today. Other drugs with fewer side effects have replaced DES.

Advantages:

Estrogen therapy is simple and only involves taking a pill. Estrogen therapy preserves the testicles, and its effects are usually reversible.

Disadvantages:

Estrogen therapy produces various side effects of its own. Estrogens can cause water retention, breast growth and tenderness, and symptoms such as stomach upset, nausea, and vomiting. In addition, even low doses of estrogen may significantly increase the risk of heart and blood vessel problems.

LHRH Analog Therapy

LHRH analog therapy consists of administering a drug called a luteinizing hormone-releasing hormone (LHRH) analog, which leads to a drop in testosterone.

Taking an LHRH analog works as well as removal of the testicles but does not involve surgery. Some of these agents can be given in combination with an antiandrogen. In addition, LHRH analogs commonly are used to help relieve the symptoms associated with advanced prostate cancer. When used this way, this class of drugs may offer an alternative for the patient who either cannot, or chooses not to, have an orchiectomy or take estrogen therapy.

Advantages:

Administering LHRH analog therapy is simple; it involves an injection that is usually given at specified intervals of about one month or more depending on the dosage of hormone used. Treatment with LHRH analogs is as effective as orchiectomy, but it does not require surgical removal of the testicles. It also avoids some of the side effects of estrogen therapy.

Disadvantages:

Because LHRH analogs are usually given as long-acting injections, patients must follow the instructions for the dosage regimen and must remember to visit their physician on a regular basis. Some men may experience hot flashes, general body pain, and breast growth. Additional side effects may include a decrease in sexual desire and/or ability to have erections. In a small percentage of patients, LHRH analog therapy may cause a brief worsening of cancer symptoms, such as bone pain, for a few weeks before the testosterone level begins to fall. This pain may be eased with a pain reliever (such as aspirin or acetaminophen) or an antiandrogen drug. Finally, if an LHRH analog is used in combination with radiation therapy, or an antiandrogen, it can be difficult to know for sure which component of therapy, if any, is responsible for the side effects that a man may be experiencing. Sometimes a worsening of the actual disease may be confused for a side effect of a particular drug regimen.

Antiandrogen Therapy

Another type of hormone therapy used in prostate cancer is the administration of drugs that are called antiandrogens. An antiandrogen is a drug that blocks the action of male hormones. There are two different types of antiandrogens — steroidal antiandrogens and nonsteroidal antiandrogens. Only the nonsteroidal antiandrogens are approved for use in the treatment of prostate cancer in the United States at this time.

Nonsteroidal antiandrogens are used in combination with an LHRH analog or orchiectomy in the treatment of advanced prostate cancer. When an antiandrogen drug is used in conjunction with an LHRH analog, this combination therapy is commonly known as maximal androgen blockade (MAB), total androgen blockade (TAB), or combined androgen blockade (CAB). Because there is still a small amount of androgen present in the body after an orchiectomy, antiandrogens also may be used in men who have already had this surgery.

Advantages:

Clinical trials suggest that some men treated with MAB therapy may live longer than men treated with LHRH analog therapy alone. This regimen of hormone therapy is convenient for the patient.

Disadvantages:

After taking an antiandrogen for a certain period of time, patients and their physicians may find that the prostate cancer is progressing despite treatment. When this occurs, the cancer is said to have become resistant to treatment. The patient may have to stop taking the antiandrogen for a while to help make the cancer respond to hormone therapy again. Other side effects from this type of hormone therapy will depend on which antiandrogen is used. Since antiandrogens are used in combination with LHRH analogs or just after an orchiectomy, it may be difficult to determine which component of the treatment is responsible for side effects.

Some of the more common adverse effects of an antiandrogens are sensitivity of the eyes to light (either natural or artificial), mild to moderate nausea, hot flashes, gynecomastia (growth of the breasts in males), nausea, vomiting, diarrhea, and an increase in liver enzymes. Patients must always consult their physician and/or health care practitioner before intentionally stopping or interrupting treatment with any of the antiandrogen medications.