What is hormone therapy?
Hormone therapy is any treatment that lowers the man's androgen (male sex hormone) levels. For prostate cancer, it is any method to block testosterone. Because testosterone is the main fuel for prostate cancer cells, blocking it may slow the cancer.
There are several types of hormone therapy. Some treat prostate cancer that has spread beyond the prostate or is advanced.
Some health care providers may use other types of hormone therapy for earlier stage prostate cancer. Hormone therapy can shrink a local tumor to allow more effective radiation treatment. This helps with more aggressive localized cancer. Types of hormone therapy include:
- Surgery to remove the testicles (Orchiectomy)
- LHRH or GnRH agonists
- LHRH or GnRH antagonists
- Estrogen therapy
Who are good candidates for hormone therapy?
Men whose prostate cancer has metastasized (spread) outside the prostate are good candidates for hormone therapy. It is also used when prostate cancer has come back after surgery or radiation treatments.
What are the benefits, risks and side effects of hormone therapy?
Because hormone therapy can be used as cancer advances, this therapy is useful for cancer that has returned. But hormone therapy usually works for only a few years. Over time, the cancer can grow in spite of the low hormone level. Hormone therapy does not cure the cancer. It has side effects. And other treatments are often needed to manage the cancer.
Before starting any type of hormone therapy, talk with your health care provider. Learn about the effects of testosterone loss. Low dose or intermittent (not constant) hormone therapy may lessen side effects.
Possible side effects include:
Lower libido (sexual desire) in 90% of men
Erectile dysfunction (inability to have or keep a strong enough erection for sex)
Hot flashes (sudden spread of warmth to the face, neck and upper body, heavy sweating). Hot flashes are not a health risk. Medicines can control them.
Weight gain of 10 to 15 pounds. Diet, lower carbohydrate intake and exercise can help.
Depression caused by the treatment, reaction to side effects, or other cancer-related issues. Symptoms include loss of hope and loss of interest in usually enjoyable activities. Other symptoms include not being able to concentrate and changes in appetite and sleeping.
Fatigue (tiredness) that doesn't go away with rest or sleep, caused by lower testosterone
Anemia (low red blood cell count). Less oxygen gets to tissues and organs, causing tiredness or weakness. It can be treated with medicines, vitamins and minerals.
Loss of muscle mass. This may cause weakness or low strength. Progressive weight-bearing exercise help improve strength.
Osteoporosis (loss of bone mineral density). This means bones become thinner, brittle and break easier. It can be treated with medicines, calcium and vitamin D. Progressive weight-bearing exercise help strengthen bones.
High cholesterol, especially LDL ("bad") cholesterol
Breast nipple tenderness
Increased risk of diabetes, 40% higher compared to men not on ADT
Heart disease. Some studies show men on ADT are at higher risk for heart problems. Others have not shown this. The effect of ADT on the heart is still unknown.
What is orchiectomy?
Orchiectomy is surgery to remove the testicles. It is also called castration. The testicles make most of the body's testosterone. Orchiectomy is a type of hormone therapy because removing the testicles stops the body from making the male hormone, testosterone.
Orchiectomy is fairly simple surgery. It is usually done as an outpatient. The surgeon makes a small cut in the scrotum (sac that holds the testicles). The testicles are detached from blood vessels and removed. The vas deferens (tube that carries sperm to the prostate before ejaculation) is removed. Then the sac is sewn up.
What are the benefits, risks and side effects of orchiectomy?
There are multiple benefits to undergoing orchiectomy treat advanced prostate cancer. It is not expensive. It is simple and has few risks. It only needs to be performed once. It is effective right away. Testosterone levels drop dramatically. There is often fast relief from cancer symptoms.
The main risks are infection and bleeding. Death is a risk of all surgery with general anesthesia. But death is extremely rare with castration. Many men are very uncomfortable with this surgery because it is not reversible. Concerns about body image or self-image may lead men to choose another treatment.
Removing the testicles means the body stops making testosterone. This causes the side effects listed above for hormone therapy. Castration may also have a psychological effect. The look of the genital area and lack of testicles may affect self-image. Some men choose to have artificial testicles or saline implants placed in the scrotum. This makes the scrotum look the same as before surgery.
Another surgery choice is subcapsular orchiectomy. This removes the glands around the testicles. But it leaves the testicles themselves. The scrotum looks normal.
Who are good candidates for orchiectomy?
Men who choose this therapy want a one-time surgical treatment. They must be healthy enough to have surgery. And they must be willing to have their testicles permanently removed.
LHRH or GnRH agonists and antagonists
These are the first and second treatment choices for localized cancer and cancer that has come back.
LHRH or GnRH agonists
This hormone therapy is usually the first treatment for localized cancer. It is also used for cancer that has come back, whether or not it has spread. Possible agonists used include:
- Lupron (Leuprolide)
- Zoladex (Goserelin)
- Trelstar (Triptorelin)
- Vantas (Histrelin)
LHRH or GnRH agonists are man-made, powerful versions of natural LHRH hormone. Your body makes natural LHRH in your hypothalamus. LHRH causes your body to make luteinizing hormone (LH). LH then causes your body to make testosterone.
With LHRH therapy, you are given man-made LHRH. Your body then makes more LH. Testosterone levels rise. Your prostate and prostate cancer cells grow, causing bone pain. This is called a "flare up." It lasts 7-10 days. Your body then stops making any new natural LHRH. That causes your body to stop making new LH and testosterone.
Your testosterone levels drop by 90-95%. This is called the "castrate level." It's the same as if your testicles were gone. Once testosterone levels drop, prostate cells and cancer cells stop growing. This is because testosterone is not fueling their growth.
LHRH or GnRH antagonists
This is the second line of treatment for localized cancer or cancer that has come back. LHRH or GnRH antagonists interfere with brain signals. This blocks the release of natural LH. When LH isn't released, your body stops making testosterone. The drug used is Firmagon (degarelix).
Antagonists usually do not produce the hormonal "flare up" seen often with agonists. There is no short-term testosterone boost when you begin this therapy.
Antagonists are injected (shot) in the buttocks every month. It is done in the health care provider's office. You will stay in the office awhile after the shot. This is to make sure there is no allergic reaction. After the first shot, a blood test makes sure testosterone levels have dropped. You may also have tests to monitor bone density.
What are the benefits, risks and side effects of LHRH or GnRH treatment?
With LHRH treatment you must go to your health care provider every month or two for injections. Your health care provider will also need to check side effects and PSA levels. The PSA test will tell if the cancer has slowed.
With LHRH treatment there is no need for an orchiectomy (surgery). Side effects may be reversible. This depends on the length of time you are on treatment.
The main disadvantage to LHRH treatment is the cost. The injections together are more expensive than a one-time surgery. The cost may be a burden if health insurance does not cover the treatment.
Side effects include the "flare up" from the agonist treatment, bone pain and possible irreversible loss of the body's ability to make testosterone.
Who are good candidates for LHRH treatment?
Men who cannot or do not wish to have surgical removal of the testicles are good candidates for these treatments.
Combined androgen blockade (CAB)/anti-androgen therapy
This treatment is only used when first line LHRH agonist and LHRH antagonist treatment did not work. Or the drugs are not working by themselves. It is used for castration resistant prostate cancer that is non-metastatic (is not spreading).
What is combined androgen blockade (CAB)/anti-androgen therapy?
This treatment combines castration and anti-androgen therapy. Castration is either by surgery or by using hormones to stop your body from making testosterone.
The treatment stops testosterone by blocking the androgen receptors in the prostate cells. Normally, testosterone would bind with these receptors. This fuels growth of prostate cancer cells. With the receptors blocked, testosterone cannot "feed" the prostate. Anti-androgen therapy does not lower testosterone. So it may have fewer or milder side effects than surgery and medical hormone treatment.
These are the three most common anti-androgen drugs used as second line treatment for non-metastatic prostate cancer growth:
The drug is taken as a tablet or pill. A single dose usually has 50 mg to 150 mg. You should take the drug around the same time every day. This keeps a steady level of the drug in your body. If you forget to take a dose you should not take a double dose. Taking a dose the same time each day also lowers side effects like nausea or vomiting.
What are the benefits, risks and side effects of CAB/anti-androgen therapy?
Using anti-androgens a few weeks before LHRH therapy reduces painful and potentially dangerous "flare ups." Anti-androgens are also used after surgery or castration when hormone therapy stops working. A few studies show anti-androgens alone may not work as well as medical or surgical castration alone. Other studies found no difference in survival rates of people who used only one form of treatment.
Who are good candidates for CAB/anti-androgen therapy?
You and your doctor will weigh the benefits and risks of this therapy against other treatments. Whether this therapy is a good choice for you depends partly on where the cancer has spread and its effects.
What is estrogen hormone therapy?
Estrogens are female sex hormones. They can be used to block testosterone production in the testicles.
What are the risks, benefits and side effects of estrogen hormones?
Estrogen hormone therapy has side effects similar to androgen hormone therapy. But the use of estrogens may cause female sex characteristics to develop. This may include breast tenderness and swelling and other changes.
Who are good candidates for estrogen hormone therapy?
Because of the side effects of estrogen hormone therapy, it is not often used today.
New hormone therapies for mCRPC, advanced prostate cancer that has metastasized (spread)
Scientists have made new discoveries in how to treat metastatic CRPC (mCRPC). There are new treatments for mCRPC. And changes are being made to make existing treatments work better.
If you are diagnosed with mCRPC, your health care provider may prescribe one of these treatments to help you. Treatments may help you delay symptoms and live longer:
Androgen synthesis inhibitors
Abiraterone acetate (Zytiga®) is a drug you take as a pill. It stops your body and the cancer from making steroids (including testosterone). Because of the way it works, this drug must be taken with an oral steroid called Prednisone. Abiraterone may be used before or after chemotherapy in men with mCRPC.
Androgen receptor binding inhibitors
Enzalutamide (Xtandi®) is a drug that blocks testosterone from binding to the prostate cancer cells. Because it works differently than Abiraterone , you do not need to take a steroid with this drug. It is taken as a pill. Enzalutamide (Xtandi®) may be used in men with mCRPC before or after chemotherapy.
Updated August 2018