April 2, 2007
To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) asks its medical experts to develop evidence-based recommendations for specific areas of cancer care. In 2004, ASCO published a clinical practice guideline about hormone therapy for advanced prostate cancer. This guideline was updated in 2007 to reflect developments in the treatment of advanced prostate cancer. This patient guide is based on ASCO's recommendations.
- Some types of hormone therapy can help slow the growth of prostate cancer.
- Before beginning treatment, discuss the risks and benefits of hormone therapy with your doctor.
- Talk with your doctor about potential short- and long-term side effects of your treatment.
Advanced prostate cancer includes cancer that has spread, cancer that has returned after treatment, and cancer that continues to grow or spread despite treatment or while under surveillance. Because androgens (male sex hormones), such as testosterone, help the growth of prostate cancer, lowering the levels of androgens helps slow the growth of prostate cancer. Androgen deprivation therapy (ADT) is a hormone therapy that slows the growth of prostate cancer by lowering the levels of androgens or blocking the androgens from getting to the prostate cancer cell.
ADT includes the following treatments:
- Bilateral orchiectomy is the surgical removal of the testicles, the main source of testosterone production. Although this treatment is surgery, it is considered hormone therapy because it effectively removes most of the testosterone from the body. This treatment is also called surgical castration.
- Luteinizing hormone-releasing hormone (LHRH) agonists are drugs that lower the body's production of testosterone by stopping the testicles from making testosterone. These drugs are usually given as injections. This treatment is sometimes called medical castration.
- Anti-androgen drugs prevent the body from using testosterone. These drugs are in the form of a pill.
- Combined androgen blockade (CAB) is a treatment strategy to eliminate any remaining androgens in the body. It is a combination of an anti-androgen drug and either surgery or an LHRH agonist drug. Surgical or medical castration eliminates about 90% to 95% of the body's testosterone, and adding the anti-androgen eliminates the remaining 5% to 10% of the body's testosterone.
Some common side effects of hormone therapy may include:
- Psychological effects resulting from testicle removal
- Loss of sex drive
- Impotence (inability to have erections)
- Hot flashes
- Mood changes
- Muscle shrinkage
- Enlarged and/or tender breasts
- Osteopenia and osteoporosis (loss of bone mass, which may result in a broken bone)
- Weight gain
Some uncommon or rare side effects of hormone therapy include:
- Rise in cholesterol
- Heart disease
- Liver damage (rare)
Many of these side effects are treatable, and most side effects go away once treatment is finished, except those resulting from an orchiectomy, which are permanent. Men who have received an LHRH agonist drug for more than two years frequently experience persistent side effects for more than one year after the drug is discontinued, and some men never fully recover. In addition, recent research suggests that LHRH agonist therapy may also increase a man's risk of heart disease, heart attack, and death from cardiac arrest (sudden loss of heart function).
To help doctors determine when to use hormone therapy for men with advanced prostate cancer that responds to treatment with anti-androgens, ASCO recommends the following:
- For most men, the initial recommended treatment is the removal of testosterone through a bilateral orchiectomy or with an LHRH agonist drug. Each procedure has a specific set of physical and psychological side effects, and it is important to talk with your doctor to understand the risks and benefits of each treatment.
- An alternative to surgical or medical castration is a nonsteroidal anti-androgen drug. Bicalutamide (Casodex), flutamide (Eulexin) and nilutamide (Nilandron) are examples of anti-androgens. This treatment is as effective as a bilateral orchiectomy or an LHRH agonist drug, but it has different side effects (most notably, less effect on a man's sex drive).
- For men with prostate cancer that continues to grow and spread, CAB treatment lowers the risk of death by more than either method listed above. However, there may also be an increase in potentially serious side effects. It is important to talk with your doctor about risks and benefits of this treatment, especially in the context of your own health history.
- The timing of starting ADT should be discussed with your doctor. Research shows that starting treatment right away may not always be better. Most doctors recommend beginning treatment when a man shows symptoms of recurrent or progressive cancer. Men who are not treated right away should meet with their doctors every three to six months to monitor the cancer.
- Intermittent hormone therapy is given for a specific time, stopped temporarily, and restarted again once the PSA hits a certain predetermined level. At this time, the use of intermittent hormone therapy is still considered experimental. Although a man's quality of life will likely be better during the “off therapy” periods (the time when the hormones are temporarily stopped), it is not known whether intermittent hormone therapy controls the cancer as long as continuous hormone therapy.
What This Means for Patient
Hormone therapy for prostate cancer comes in several forms: surgical removal of the testicles, LHRH agonist drugs, anti-androgen drugs, and a combination of these treatments. Men with advanced prostate cancer should discuss with their doctors the risks and benefits of all the treatment options and when to begin treatment. This discussion should address the current state of the cancer (such as whether PSA levels are rising or steady and whether the cancer has spread to the bones), your health history, and other medical conditions, such as diabetes. You may also want to discuss any concerns you may have about how your sexual and physical functioning might be affected by hormone therapy. For some men, the side effects of prostate cancer treatment are a bigger risk to their health than the prostate cancer itself, so it is important to talk with your doctor about the long-term side effects of a particular treatment.
Questions to Ask the Doctor
To learn more about hormone therapy for advanced prostate cancer, consider asking your doctor the following questions:
- What are my options for treatment?
- What are the possible side effects of these treatment options?
- How will treatment affect my sexual and emotional well-being?
- How will treatment affect my fertility?
- Which treatment do you recommend, given my health history?
- What type of follow-up care is necessary after treatment?
- Do I need to begin treatment right away?
- If my treatment is delayed, how will the cancer be monitored?
- Am I eligible for a clinical trial?
- Who should I talk with if I have questions about health insurance and the cost of follow-up care?
Read the entire clinical practice guideline at www.asco.org/guidelines/asprostate .
About ASCO's Guidelines
To help doctors give their patients the best possible care, ASCO asks its medical experts to develop evidence-based recommendations for specific areas of cancer care, called clinical practice guidelines. Due to the rapid flow of scientific information in oncology, new evidence may have emerged since the time a guideline or assessment was submitted for publication. As a result, guidelines and guideline summaries, like this one, may not reflect the most recent evidence. Because the treatment options for every patient are different, guidelines are voluntary and are not meant to replace your physician's independent judgment. The decisions you and your doctor make will be based on your individual circumstances. These recommendations may not apply in the context of clinical trials.
The information in this guide is not intended as medical or legal advice, or as a substitute for consultation with a physician or other licensed health care provider. Patients with health care-related questions should call or see their physician or other health care provider promptly, and should not disregard professional medical advice, or delay seeking it, because of information encountered in this guide. The mention of any product, service, or treatment in this guide should not be construed as an ASCO endorsement. ASCO is not responsible for any injury or damage to persons or property arising out of or related to any use of this patient guide, or to any errors or omissions.
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