This content does not have an English version. This content does not have an Arabic version. Sections for Hormone therapy for prostate cancer About. Overview Prostate cancer Open pop-up dialog box Close.
Prostate cancer Prostate cancer occurs in the prostate gland, which is located just below the bladder in males and surrounds the top portion of the tube that drains urine from the bladder urethra. Request an Appointment at Mayo Clinic. Share on: Facebook Twitter. Show references Wein AJ, et al. Diagnosis and staging of prostate cancer. In: Campbell-Walsh Urology. Philadelphia, Pa.
Accessed Feb. Dawson NA. Overview of the treatment of disseminated castration-resistant prostate cancer. Niederhuber JE, et al. Prostate cancer. In: Abeloff's Clinical Oncology. Lee RJ, et al. If wanted, artificial testicles that look much like normal ones can be inserted into the scrotum. Treatment with these drugs is sometimes called medical castration because they lower androgen levels just as well as orchiectomy.
With these drugs, the testicles stay in place, but they will shrink over time, and they may even become too small to feel. LHRH agonists are injected or placed as small implants under the skin. Depending on the drug used, they are given anywhere from once a month up to once every 6 months. When LHRH agonists are first given, testosterone levels go up briefly before falling to very low levels. This effect, called tumor flare , results from the complex way in which these drugs work.
Men whose cancer has spread to the bones may have bone pain. Men whose prostate gland has not been removed may have trouble urinating. If the cancer has spread to the spine, even a short-term increase in tumor growth as a result of the flare could press on the spinal cord and cause pain or paralysis. A flare can be avoided by giving drugs called anti-androgens discussed below for a few weeks when starting treatment with LHRH agonists.
LHRH antagonists can be used to treat advanced prostate cancer. Treatment with these drugs can also be considered a form of medical castration. Orchiectomy and LHRH agonists and antagonists can all cause similar side effects from lower levels of hormones such as testosterone. These side effects can include:.
Some research has suggested that the risk of high blood pressure, diabetes, strokes, heart attacks, and even death from heart disease is higher in men treated with hormone therapy, although not all studies have found this. Still, hormone therapy does seem to lead to memory problems in some men. These problems are rarely severe, and most often affect only some types of memory. More studies are being done to look at this issue.
LHRH agonists and antagonists can stop the testicles from making androgens, but cells in other parts of the body, such as the adrenal glands, and prostate cancer cells themselves, can still make male hormones, which can fuel cancer growth. Currently available treatments can do so in several ways:. Treatments that reduce androgen production by the testicles are the most commonly used hormone therapies for prostate cancer and the first type of hormone therapy that most men with prostate cancer receive.
This form of hormone therapy also called androgen deprivation therapy , or ADT includes:. Normally, when androgen levels in the body are low, the hypothalamus releases LHRH.
This stimulates the pituitary gland to produce luteinizing hormone, which in turn stimulates the testicles to produce androgens. However, the continued presence of high levels of LHRH agonists actually causes the pituitary gland to stop producing luteinizing hormone. As a result, the testicles are not stimulated to produce androgens. Treatment with an LHRH agonist is called medical castration or chemical castration.
But, unlike surgical castration orchiectomy , the effects of these drugs on androgen production are reversible. Once treatment is stopped, androgen production usually resumes. LHRH agonists are given by injection or are implanted under the skin. When patients receive an LHRH agonist for the first time, they may experience a phenomenon called " testosterone flare. The flare may worsen clinical symptoms such as bone pain, ureter or bladder outlet obstruction , and spinal cord compression.
The increase in testosterone is usually countered by giving another type of hormone therapy, called antiandrogen therapy , along with the LHRH agonist for the first few weeks of treatment. Two LHRH antagonists are approved to treat advanced prostate cancer in the United States: degarelix Firmagon is given by injection, and relugolix Orgovyx is a pill that is taken by mouth.
Treatments that block the action of androgens in the body also called antiandrogen therapies are typically used when ADT stops working.
Such treatments include:. Three androgen synthesis inhibitors are approved in the United States: abiraterone Yonsa, Zytiga , ketoconazole , and aminoglutethimide. All are given as pills to be swallowed. Hormone therapy may be used in several ways to treat hormone-sensitive prostate cancer, including:. Early-stage prostate cancer with an intermediate or high risk of recurrence. Factors that are used to determine the risk of prostate cancer recurrence include the grade of the tumor as measured by the Gleason score , the extent to which the tumor has spread into surrounding tissue, and whether tumor cells are found in nearby lymph nodes during surgery.
The use of hormone therapy alone or in combination with chemotherapy before prostatectomy has not been shown to be of benefit and is not a standard treatment. More intensive androgen blockade prior to prostatectomy is being studied in clinical trials. Hormone therapy used alone is the standard treatment for men who have a prostate cancer recurrence as documented by CT , MRI , or bone scan after treatment with radiation therapy or prostatectomy.
Hormone therapy is sometimes recommended for men who have a "biochemical" recurrence —a rise in prostate-specific antigen PSA level following primary local treatment with surgery or radiation—especially if the PSA level doubles in fewer than 3 months. Advanced or metastatic prostate cancer. ADT used alone was for many years the standard treatment for men who are found to have metastatic disease i.
In addition, an NCI-sponsored trial showed that men with hormone-sensitive metastatic prostate cancer lived longer when treated with the chemotherapy drug docetaxel Taxotere at the start of ADT than men treated with ADT alone Men with the most extensive metastatic disease appeared to benefit the most from the early addition of docetaxel.
Although hormone therapy can delay progression of disease and may be able to prolong survival, it can also have substantial side effects. Men should discuss the risks and potential benefits of hormone therapy with their doctor in light of their own medical concerns. Palliation of symptoms. Hormone therapy is sometimes used alone for palliation or prevention of local symptoms in men with localized prostate cancer who are not candidates for surgery or radiation therapy Therefore, men who take hormone therapy for more than a few months are regularly tested to determine the level of PSA in their blood.
Treatments for castration-resistant prostate cancer include:. Men with castration-resistant prostate cancer who receive these treatments will continue to receive ADT e. Randomized clinical trials in men with metastatic castration-resistant prostate cancer have shown improved survival among men receiving abiraterone or enzalutamide in addition to ADT compared with those receiving ADT alone, whether or not they have previously received chemotherapy 11 , 12 , 15 — Similarly, in randomized clinical trials, men with nonmetastatic castration-resistant prostate cancer who received apalutamide, enzalutamide, or darolutamide in addition to ADT lived longer than those who received ADT alone 21 — Researchers have investigated whether a technique called intermittent androgen deprivation can delay the development of hormone resistance.
With intermittent androgen deprivation, hormone therapy is given in cycles with breaks between drug administrations, rather than continuously. Randomized clinical trials have shown similar overall survival with continuous ADT or intermittent ADT among men with metastatic or recurrent prostate cancer, with a reduction in some side effects for intermittent ADT 24 — Because androgens affect many other organs besides the prostate, ADT can have a wide range of side effects 4 , 27 , including:.
Antiandrogens can cause diarrhea, breast tenderness, nausea, hot flashes, loss of libido, and erectile dysfunction. The antiandrogen flutamide may damage the liver, and enzalutamide and apalutamide may cause fractures. Darolutamide may avoid some central nervous system—related side effects seen with enzalutamide and apalutamide, such as seizures and falls.
Androgen synthesis inhibitors can cause diarrhea, itching and rashes, fatigue, erectile dysfunction with long-term use , and, potentially, liver damage. Estrogens avoid the bone loss seen with other kinds of hormone therapy, but they increase the risk of cardiovascular side effects, including heart attacks and strokes.
Because of these side effects, estrogens are rarely used today as hormone therapy for prostate cancer. Although the addition of ADT to radiation therapy has been shown to increase survival for men with high-risk prostate cancer , it worsens some adverse effects of radiotherapy, particularly sexual side effects and vitality Many of the side effects of ongoing hormone therapy also become stronger the longer a man takes hormone therapy Men who lose bone mass during long-term hormone therapy may be prescribed drugs to slow or reverse this loss.
The drugs zoledronic acid Zometa and alendronate Fosamax both of which belong to a class of drugs called bisphosphonates can be used to increase bone mineral density in men who are undergoing hormone therapy 29 , 30 , as can a newer drug, denosumab Prolia , which increases bone mass through a different mechanism However, drugs to treat bone loss are associated with a rare but serious side effect called osteonecrosis of the jaw Exercise may help reduce some of the side effects of hormone therapy, including bone loss, muscle loss, weight gain, fatigue, and insulin resistance 20 , Degarelix treatment was associated with a more rapid decline of serum testosterone, and was not associated with an initial surge of serum testosterone seen during the first few days of treatment with leuprolide.
They discuss the role of this new form of medical gonadal suppression for the treatment of prostate cancer. Androgen-deprivation therapy ADT is an effective treatment for patients with prostate cancer. Most patients with metastatic prostate cancer treated with ADT demonstrate major declines of the serum levels of prostate-specific antigen PSA , and objective tumor responses, evident clinically or by imaging tests. In patients with metastatic disease, ADT reduces bone pain and other serious and debilitating disease-related complications ie, pathologic fractures, spinal cord compression, and urethral obstruction.
Suppression of gonadal testosterone by medical LHRH agonists or surgical castration is considered the central mechanism of ADT for prostate cancer.
With continuous exposure, gonadal luteinizing hormone receptors are downregulated, and testosterone levels decline to the castration range after 1 month.
Initial studies of LHRH agonists reported that a number of patients with bone metastasis and bone pain at baseline had transient worsening of their symptoms ie, flare phenomenon during the initial few weeks of treatment. Symptomatic management was the recommended approach, and most patients eventually improved without the need for major changes in therapy. However, a clear-cut association has not been shown between the development of spinal cord compression or bladder outlet obstruction and the initial rise in serum testosterone during LHRH agonist therapy.
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