OF PROSTATE CANCER WITH HORMONE THERAPY?
prostate gland is an organ that makes nutrient fluid (seminal
fluid) to nourish the sperm. The prostate increases in size with
age. As the prostate gland grows, it can cause urinary symptoms
of decreased stream, hesitancy, frequency, urgency to void, and
frequent urination at night. Islands of the prostate gland can
also form cancer cells. The prostate tissue is very sensitive
to the male hormone testosterone, causing normal prostate cells
and prostate cancer cells to grow.
observation led urologists to the use of hormone reduction to
treat prostate cancer in the 1940s and except for newer drugs,
the principle of hormone reduction still stands today. Today the
most common ways of effecting male hormone reduction is surgical
removal of the testicles (orchiectomy), or shots every 1 to 4
months of Lupron (TAP Pharmaceutical) or Zoladex
cause the testicles to stop producing the male hormone, testosterone.
In patients, where the prostate cancer has spread outside of the
gland into other parts of the body such as lymph nodes, bone,
lung, or liver, hormone treatments are frequently recommended.
When spread of the cancer has occurred, the disease can not usually
be cured with surgical removal or with radiation treatments. This
is because the cancer is almost always more widespread and all
of the cancer cell can not be treated or removed. Since hormone
therapy treats the entire body, cancer cells too small to see
can be treated, no matter where they are.
patients with localized prostate cancer are treated with hormones
circumstance is where patients, for varied reasons, cannot undergo
surgery or radiation immediately and the hormone treatment allows
us to delay treatment.
situation is when doctors may wish to shrink the prostate cancer
to allow surgery or radiation to possibly be more effective.
This is especially true for patients with large glands that
may be opting for brachytherapy, or seed implantation. The prostate
needs to be less than 50 grams in most cases, and the hormones
will shrink the prostate. This process takes about 3-6 months
in most cases.
therapy is where Lupron or Zoladex
is given to help improve the results of standard radiation therapy
TO DECREASE THE MALE HORMONE, TESTOSTERONE:
is Hormone Therapy used?
- The testicles manufacture almost all of the male
hormones. Therefore, removal of both testicles lowers the hormone
levels sufficiently to often achieve an excellent response against
the prostate cancer. The procedure requires a brief anesthetic
(general, spinal or local) and usually requires less than 30
minutes to perform. In most instances, the patient goes home
from the hospital on the same day. There is some discomfort
that is usually treated with a mild pain medication and a few
days of restricted activity. A small chance of infection exists,
along with the risks associated with the anesthesia.
side effects of removal of the testicles are mild in most
cases. The most problematic are 'hot flashes'. Because of
the abruptness of the hormone changes, some men will have
'hot flashes', which consist of brief episodes of feeling
of warmth, sweating and redness, especially of the face. Rarely,
these can come so often that we need to offer medication to
try to reduce their effects. Usually the flashes decrease
Injections (Lupron or Zoladex)
- These are long-acting medications that are injected into the
buttocks or subcutaneously under the skin, These medicines are
able to stop the testicle from producing testosterone. The action
of the drug is actually on the pituitary gland in the brain,
which makes, LH (Leutenizing Hormone), a special hormone that
stimulates the testicles to release testosterone. Without LH,
the testicle does not make any significant amount of testosterone.
The effect is the same as orchiectomy. Testosterone production
by the testicles is stopped.
The injections have no direct
effect on the cancer, only an effect on the testicles. The
lack of male hormone circulating in the blood kills the prostate
cancer cells. The major advantage is no need for surgical
removal of the testicles. Most patients prefer the injections
instead of having their testicles removed.
The disadvantages are the
need for an injection every 1 to 4 months, but most men are
willing to exchange the effort to spare their testicles. There
is a high to cost of the medication; however, this treatment
is standard and is covered by almost every insurance company,
HMO, and by Medicare. Allergic reactions have been reported
and can result in a rare case of arthritis.
Hormone Therapy is currently being investigated. Intermittent
hormone therapy is a treatment regimen where hormone therapy
is started and when the cancer shrinks to a certain level as
measured by the PSA, we stop the hormone therapy.
Treatment is re-started when the cancer grows again (as measured
by PSA). The advantage of intermittent hormone therapy is a
reduction in the side effects of the hormone therapy during
the periods that the patient is off treatment and reduced overall
costs. Early studies have suggested that success in treating
the cancer is not hurt by using intermittent therapy. Intermittent
therapy is still investigational.
Hormones - Until the mid-1980s, female hormones in
pill form, particularly Stilbesterol, were
used to treat prostate cancer. Female hormones act on the male
pituitary gland in the brain to reduce the release of a special
pituitary hormone that stimulates the testicles to release testosterone.
Female hormones had the advantage of requiring only a daily
pill to take, but has the disadvantage of increased risks of
heart attack and stroke and also caused painful breast enlargement
in many men. We still use female hormones to reduce the effects
of hot flashes in some men, and occasionally in men whose tumors
have started to grow again despite the hormone treatments.
Hormone Therapy - Many studies have suggested that
the addition of another type of medicine called anti-androgens,
may help potentiate the effectiveness of either hormone injections
or removal of the testicles. The most common ones used are called
or bicalutamide (Casodex). These drugs, taken
in pill form, further reduce the hormone levels by blocking
the action of remaining male hormones (mostly made in the adrenal
glands). Some controversy still exists as to the effectiveness
of this additional treatment and the cost is about $300 per
month. Many insurance companies pay for this medicine, while
other companies, including Medicare
do not cover this prescription.
certain percentage of men will have some reaction to the medication,
particularly diarrhea (more common in flutamide than bicalutamide).
The symptoms resolve in time or the dosage can be reduced.
At this time, doctors may suggest that flutamide or bicalutamide
be used if the cost of the medicine will not be a burden and
the side effects are minimal. The usefulness of these medications
is still not a certainty to all investigators. So that if
you do not use antiandrogens, you shouldn't feel that you
are getting inferior or substandard treatment.
cancer has spread to other areas of the body away from
the prostate, such as bone, lung, liver, lymph nodes (otherwise
known as metastasis or metastatic cancer). The exact time to
start treatment varies with each patient. In some patients treatment
is started when the diagnosis of metastatic disease is made,
in others, we may wait for symptoms, such as pain, before starting
treatment. The major advantages of delaying treatment are the
lack of side effects from the hormone therapy and the reduced
cost. Overall survival time may be improved by starting earlier.
preparation for radical surgery or radiation therapy to cure
the cancer. Some studies have shown that hormone therapy
can be used to make radical prostate surgery or radiation therapy
more successful. The treated cancer shrinks before and during
hormone therapy, thereby possibly increasing chances for successful
curative therapy. The hormone therapy is stopped after surgery
or radiation. This is investigational for now.
How long is hormone therapy
For patients with metastatic cancer, the therapy is used indefinitely
as long as the therapy is successful in controlling or stopping
the growth of cancer.
preparation for radical surgery, external beam X-radiation,
and brachytherapy (seed implantation), the therapy is usually
given for three to four months. Surgery is then performed
and the medication is stopped.
treatments for prostate cancer have been used successfully for
over 50 years. The overall success rate or chances of the cancer
shrinking is greater than 70%. In those that respond, the length
of time that the tumor remains under control is variable, but
can be many, many years. Doctors will continue to follow your
cancer with examinations, blood tests (particularly PSA) and other
scans, depending on your circumstances.
by Stephen M. Auerbach, MD
Board Certified Urologist
Medical Director for California Professional Research
HHH education information staff member , HisandHersHealth.com