Adjuvant Hormonal Therapy

Hormone therapy is used to treat prostate cancer by reducing the levels of male hormones, known as androgens, in the body. Most prostate cancers need testosterone, one of the primary male hormones, to grow. By lowering androgen levels, doctors can often shrink prostate cancers or slow their growth. However, it should be noted that hormone therapy does not cure prostate cancer; but it can shrink a tumor’s size.

About one-third of men with prostate cancer undergo hormone therapy, often in addition to other treatments such as surgery or radiation, especially if those treatments prove ineffective or the cancer returns after such treatments. It may also be an option if a patient cannot undergo surgery or radiation or if the cancer has spread. It has been found that hormone therapy is most effective in treating men with locally advanced, high-grade tumors in conjunction with radiation therapy.

Types of hormone therapy
Orchiectomy: Also known as an orchidectomy, this type of hormone therapy involves the removal of the testicles. The testicles are removed because this is where most of the androgens, chiefly testosterone, are produced. However, men can choose to have saline-filled sacs inserted into the scrotal sac, which allow for a natural look and feel. Done on an outpatient basis, orchiectomies rapidly reduce the androgen levels causing the cancer to shrink.

Many men who undergo the surgery experience side effects, but most are treatable. The most common side effects include impotence and a reduced or absent libido. Other side effects include hot flashes, breast tenderness or enlargement, osteoporosis, anemia, weight gain, fatigue, loss of muscle mass, a decrease in their HDL cholesterol, and depression.

Luteinizing hormone-releasing hormone (LHRH) analogs: LHRH analogs, also known as LHRH agonists, lower testosterone levels by blocking the production of androgens, mostly testosterone, by the testicles. LHRH analogs are periodically injected or implanted under the skin. LHRH analogs include Leupolide (Lupron, Viadur, Eligard), goserelin (Zoladex), and triptorelin (Trelstar). Side effects are similar to those listed with orchiectomy. LHRH treatments briefly stimulate androgen production before suppressing testosterone levels, so they should be used cautiously with symptomatic advanced or metastatic cancer. Some patients may be treated with intermittent therapy, where LHRH is given for 6 months or so, then withheld for 6-12 months until the PSA rises again. Also, LHRH injections are more costly to the patient over time compared to the one-time orchiectomy.

Anti-androgens. These types of drugs are given to men with prostate cancer to more completely block the action of androgens on prostate tissue. Their use may be necessary because treatment with LHRH or orchiectomy may not be sufficient to stop the adrenal glands from producing a small amount of testosterone. Combining an orchiectomy or LHRH analog with anti-androgens is known as a combined androgen blockade (CAB). Anti-androgens include flutamide (Eulexin), nilutamide (Nilandron), and bicalutamide (Casodex). Side effects may include nausea, fatigue, liver problems, diarrhea, and breast tenderness or enlargement.

Advantages of hormone therapy

• The disease disappears in approximately 5 percent of patients
• May benefit patients with locally advanced cancer when combined with external beam radiation therapy
• May benefit patients whose cancer has spread regionally when used with surgery
• May benefit patients with rising PSA levels that occur after surgery
• Shrinks large prostates before brachytherapy treatments

Disadvantages of hormone therapy

• Possible side effects including hot flashes, fatigue, breast swelling or tenderness, osteoporosis, anemia, weight gain, loss of muscle mass, and depression. None are dangerous, but these do impact quality of life.
• LHRH injections more costly over time than orchiectomy, but they can be used as intermittent (reversible) therapy for selected situations