Hormone therapy (or treatment) alone is the standard (or primary) treatment for men with advanced prostate cancer and works well for most men often keeping their cancer in check for several, and in some cases, many years. Recent studies suggest that starting hormone treatment early may be more effective than delaying the start of hormone treatment. This is something you can talk over with your oncologist.
Hormones control the activity and growth of all normal cells and so are naturally present in the body. Men produce a hormone in their testes, called testosterone. Testosterone is responsible for many male characteristics. In order to grow, prostate cancer needs this testosterone. So, by reducing the amount of testosterone, cancer cells wherever they may be in the body, shrink or don’t grow as fast. So the aim of hormone therapy is to remove as much of this testosterone as possible.
What the medical words mean, abbreviations that you might hear and medical staff that you might meet. When you have been diagnosed with any disease or condition, unavoidably, there will be medical words and abbreviations that doctors, nurses and other medical staff may use that you may have never heard of and will perhaps not know what they mean and prostate disease and prostate cancer are no different.
A helpful list of terms you might here is provided here in alphabetical order.
For more information please see Spotlight on Hormone therapy
What are the types of hormone therapy to reduce testosterone levels?
LHRH agonists (luteinising hormone –releasing hormone agonists)
GnRH antagonists (gonadotrophin-releasing hormone antagonists)
Both of these medications stop the testes from making testosterone and are given by an injection. Depending on the medication, injection sites may be beneath the skin in the tummy or in the muscle of the buttock.
|Medication||Type||Brand name||What it does||How it’s given|
|Stops testes making testosterone.
Because of the way LHRH agonists work, there may be a temporary rise or flare in testosterone levels before it reduces.
Anti-androgens (see overleaf) will usually be given initially.
|Zoladex, Prostap and Decapeptyl may be given monthly or 3 monthly.
Decapeptyl may also be given 6 monthly.
This can be particularly useful for men newly diagnosed with advanced prostate cancer and who have a lot of pain or are at risk of spinal cord compression.
|Firmagon®||Very quickly switches off the testes making testosterone. Because of the way it works, it does not cause a rise or flare in testosterone levels so anti-androgens will not be necessary||Monthly injection. This will normally be started in hospital and then given by your GP. However, because of prescribing changes (2014), your GP may now start your first dose of Firmagon.|
These work in a different way from LHRH agonists and GnRH antagonists. These block the cancer cells’ ability to use testosterone.
|Medication||Type||Brand name||What it does||How it’s given|
|Block the action of testosterone and the ability of the cancer cell to use it.||As a tablet.|
|Cyproterone acetate||Cyprostat®||Block cancer cells ability to use testosterone and reduces amount produced in adrenal glands||
As a tablet.
Your doctor may suggest one of the drug treatments above on its own in the first instance. If you have already been treated with one type of hormone treatment your doctor may advise you to change to a different type.
Dual androgen blockade
This is usually used if you have been on a single hormone treatment and it stops working. The doctor may recommend you take LHRH agonists and anti-androgens together.
Surgical treatment or orchidectomy
This means that all the testes or the parts of the testes which make testosterone are taken away during an operation. This type of treatment is permanent and can’t be reversed. Although this used to be the standard treatment, it is much less common now because LHRH agonists give similar results. Reducing testosterone through medication rather than through surgery may be preferable for some men.
Prescribing hormone therapy
In some situations, doctors may prescribe hormone therapy for you to take all the time. This is continuous hormone therapy.
In other situations, doctors may prefer to give 9 – 12 months of treatment until the PSA level is low and will then discuss stopping the hormone therapy until the PSA level starts to rise again as testosterone levels rise. This is intermittent hormone therapy.
As with any drugs, there are potential side-effects. Some men say they hardly notice any side-effects but for others the side-effects have a big impact on their quality of life. Unfortunately, there is no way of telling which of the side-effects you might get or how much they might affect you.
Sweats and hot flushes
These are often one of the first side-effects you may have and are one of the most common complaints from men on hormone therapy. A hot flush is a sudden, strong feeling of heat in your face, neck, chest or back and can last for just a few minutes or can go on for up to a few hours with some men find night sweats to be a problem too. Let the CNS or oncologist know as there are treatments that can help.
Loss of libido
Another common side-effect is losing interest in having sexual intercourse. Rather than avoiding the issue, talk to your spouse or partner about your worries and anxieties and perhaps mention this to the CNS or oncologist.
Erectile dysfunction (ED)
Because hormone treatment works by switching off or blocking testosterone, a common side-effect is not being able to get or keep an erection firm enough to have sexual intercourse. This is sometimes called impotence. Although you may feel upset by ED and perhaps a bit embarrassed talking about something as personal as ED, doctors and CNS’s are used to hearing about this and helping men with these difficulties. There are a number of treatments that may help.
Treatments might include medication as a tablet, by injection, using a cream, using an applicator or using a vacuum pump. For further information about erectile dysfunction see Prostate conditions and erectile dysfunction
Breast swelling and tenderness (also called gynaecomastia)
Hormone therapy can cause one or both breasts to swell, become tender and may also cause nipple tenderness or sensitivity. For some men this can mean just a slight tenderness but for others it can be quite painful. There are treatments available such as a small, one off dose of radiation which helps pain but not swelling, some medications such as Tamoxifen available to help (the medication prescribed varies from hospital to hospital) alternatively any painful swollen areas may be removed by surgery.
Fatigue or tiredness
You may find that you get very tired quite easily, even doing your normal day-to-day activities because of the drop in your testosterone level. Fatigue is often the one symptom that many men consider to be their worst problem. During hormone treatment, exercise or activity has been shown to be an effective self-help for fatigue.
Changes to your body shape
You may find that you gain some weight and some men notice this especially around their middle. At the same time you might notice that you lose some muscle tissue. Having a healthy well-balanced diet combined with some regular, resistance exercise may help deal with these difficulties. Taking some regular exercise, such as brisk walking, can also help with any feelings of tiredness (fatigue) that you may have. Some men also notice that their penis and testes become smaller.
Because bones need testosterone to keep them healthy and strong, over time hormone therapy can cause bones to thin and become weak or brittle so they may break more easily. Men at particular risk are those who are on long-term steroids or drink excessive amounts of alcohol.
It is understandable that men who are having treatment for prostate cancer (and their families) are going through a very difficult time. You may feel angry, depressed and worried about what the future holds. Hormone therapy can also make you much more emotional and you may get upset more easily and feel quite tearful. If this is the case it may be possible to change your treatment or get some additional help for instance by going along to a support group to chat with other men and their families who have been in a similar situation.
Men who have hormone therapy for just short periods may not notice any difference to body hair. However, long-term hormone therapy may lead to a loss of hair on your arms, legs, underarms and genital area and you may not need to shave facial hair as often.
When your testosterone level drops, your blood pressure and cholesterol level may increase and some studies suggest that this may put the man at greater risk of developing heart problems. The longer you are on hormone therapy the greater the risk becomes. The team looking after you will respond to any concerns that might arise.
It may be helpful to think about some healthy lifestyle changes such as stopping smoking, not drinking more alcohol than the healthy guideline limits, having a well- balanced diet and taking exercise.
How do I know if hormone therapy is working?
The doctor or CNS will continue to check your PSA level which often falls quickly and then stays at a lower level for as long as the treatment is working effectively.
Your doctor may want you to have a bone scan to check whether the cancer has spread to the bones. A bone scan may be done if new symptoms develop or if a new treatment such as radiotherapy is planned.
CT scan or MRI scan
Both of these scans are used to get detailed pictures of your prostate and surrounding areas to check the spread of the cancer outside the prostate.
Hormone resistant prostate cancer
Once hormone therapy has been started it is usually ongoing. However, overtime, prostate cancer may start to grow again even if the testosterone levels are low. The usual sign is a rising PSA level. This is called castrate-resistant prostate cancer or hormone resistant prostate cancer.
The treatments available at this stage will therefore be dependent on any previous treatments and on individual circumstances.
|Hormone treatment you had first (first line treatment)||Hormone treatment to try next (second line treatment)||How it works|
|LHRH agonists||Add or change anti-androgens||Block the action of any remaining testosterone|
|Dual androgen blockade||Stop anti-androgens completely||Anti-androgens can change from ‘switching off’ testosterone receptors to switching them ‘on’. Sometimes by withdrawing the anti-androgen this can slow down the growth of the cancer|
|Orchidectomy (surgical removal of testes)||Anti- androgen tablets||Block the action of any remaining testosterone|
Sometimes an addition of a small dose of steroid such as dexamethasone to the injections can bring about a fall in PSA. Normally side-effects are minimal as only a small dose is used but the man may experience indigestion and weight gain.
Novel hormonal therapies
Enzalutamide and Abiraterone
Enzalutamide and Abiratreone are now available in Scotland for men with advanced prostate cancer where the cancer has spread and become resistant to standard hormone therapy (the monthly/3 monthly injections). These may now be prescribed, depending on clinical need, before the man starts chemotherapy or after a course of chemotherapy.
These are newer types of hormone therapy and work in a different way from other hormone therapies. They are usually given when hormone therapies alone, such as LHRH injections, are not working any longer.
It is likely that one but not both drugs would be recommended as the use of Enzalutamide after Abiraterone or vice versa has not been well studied. Because Enzalutamide and Abiraterone work differently one of these will be given in combination with the LHRH injections detailed earlier.
Both of these seem to have much the same benefits; generally, an increased feeling of well-being, a better chance of living longer, pain may be reduced, possible delay in the tumour(s) growing and a possible improvement in quality of life. Your oncologist or CNS will most likely go over with you the reasons for suggesting one of these drugs.
|Medication||Type||Brand name||What it does||How it’s given|
|Anti-androgen (nonsteroidal)||Enzalutamide||Xtandi®||Blocks the action of testosterone||It is taken as a tablet.|
|Anti-androgen(steroidal)||Abiraterone||Zytiga®||Blocks cancer cells ability to use testosterone and reduces amount produced in adrenal glands||It is taken as a tablet, after meals and tablets should be spread evenly throughout the day if taking more than one tablet|
The option of when to consider Enzalutamide or Abiraterone will be discussed by the oncology team.