Treatment for prostate cancer with lymph node involvement

What is Hormone Therapy?

Hormone therapy is a treatment that lowers a man's testosterone, or hormone, levels. This therapy is also called ADT. Testosterone, an important male sex hormone, is the main fuel for prostate cancer cells, so reducing its levels may slow the growth of those cells. Hormone therapy may help slow prostate cancer growth in men when prostate cancer has metastasized (spread) away from the prostate or returned after other treatments. Some treatments may be used to shrink or control a local tumor that has not spread. There are several types of hormone therapy for prostate cancer treatment, including medications and surgery. Your doctor may prescribe a variety of therapies over time.

Hormone Therapy with Surgery

Surgery to remove the testicles for hormone therapy is called orchiectomy or castration. When the testicles are removed, it stops the body from making the hormones that fuel prostate cancer. It is rarely used as a treatment choice in the United States. Men who choose this therapy want a one-time surgical treatment. They must be willing to have their testicles permanently removed and must be healthy enough to have surgery.

This surgery allows the patient to go home the same day. 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 detached. Then the sac is sewn up.

There are multiple benefits to undergoing orchiectomy to 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.

Side effects to your body include infection and bleeding. Removing the testicles means the body stops making testosterone, so there is also a chance of the side effects listed below for hormone therapy. Other side effects of this surgery may be about body image due to the look of the genital area after surgery. Some men choose to have artificial testicles or saline implants placed in the scrotum to help the scrotum look the same as before surgery. Some men choose another surgery called subcapsular orchiectomy. This removes the glands inside the testicles, but it leaves the testicles themselves, so the scrotum looks normal.

Hormone Therapy with Medications

There are different types of hormone therapy available as injections or as pills that can be taken by mouth. Some of these therapies stop the body from producing luteinizing-hormone-releasing-hormone (LHRH, also called gonadotrophin releasing hormone, or GnRH). LHRH triggers the body to make testosterone. Other therapies stop prostate cells from being affected by testosterone by blocking hormone receptors. Sometimes, after the first shot, a blood test is done. This is done to check testosterone levels. You may also have tests to monitor your bone density during treatment.

With LHRH treatment there is no need for surgery. Candidates for this treatment include men who cannot or do not wish to have surgery to remove their testicles.

There are different types of medical hormone therapy your doctor could prescribe to lower your body's production of testosterone. After your testosterone levels drop to a very low level, you are at "castration level." Once testosterone levels drop, prostate cancer cells may decrease in growth and proliferation.

Types of Medications

Agonists (analogs)

LHRH/GnRH agonists are drugs that lower testosterone levels. They may be used for cancer that has come back, whether or not it has spread.

When first given, agonists cause the body to produce a burst of testosterone (called a "flare"). Agonists are longer acting than natural LHRH. After the initial flare, the drug tricks your brain into thinking it does not need to produce LHRH/GnRH because it has enough. As a result, the testicles are not stimulated to produce testosterone.

LHRH or GnRH agonists are given as shots or as small pellets placed under the skin. Based on the drug used, they could be given from once every one, three or six months.

Antagonists

These drugs also lower testosterone. Instead of flooding the pituitary gland with LHRH, they stop LHRH from binding to receptors. There is no testosterone flare with an LHRH/GnRH antagonist because the body does not get the signal to produce testosterone.

Antagonists may be taken by mouth or injected (shot) under the skin, in the buttocks or abdomen. The shot is given in the health care provider's office. You will likely stay in the office awhile after the shot to ensure 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.

Anti-androgen drugs

Antiandrogen drugs are taken as a pill by mouth. This therapy depends partly on where the cancer has spread and its effects.

This treatment lowers testosterone by inhibiting the androgen receptors in the prostate cancer cells. Normally, testosterone would bind with these receptors to fuel growth of prostate cancer cells. With the receptors blocked, testosterone cannot "feed" the prostate. Using anti-androgens a few weeks before, or during, LHRH therapy may reduce "flare ups." Antiandrogens may also be used after surgery or castration when hormone therapy stops working.

CAB (combined androgen reducing treatment, with anti-androgens)

This method blends castration (by surgery or with the drugs described above) and antiandrogen drugs. The treatment reduces production of testosterone and can help stop it from binding to cancer cells.

Surgery or taking oral drugs may be ways to lower the testosterone made by your testicles. The rest of the testosterone is made by the adrenal glands. Antiandrogen therapy blocks testosterone made by the adrenal glands.

Androgen synthesis inhibitors

These drugs help stop other parts of your body (and the cancer itself) from making more testosterone and its metabolites. Men newly diagnosed with metastatic hormone sensitive prostate cancer (mHSPC) or men with metastatic castration-resistant prostate cancer (mCRPC) may be good candidates for this therapy.

Androgen synthesis inhibitors may be taken by mouth as a pill. This drug helps stop your body from releasing the enzyme needed to make androgens in the adrenal glands, testicles and prostate tissue, resulting in reduced levels of testosterone and other androgens. Because of the way it works, this drug must be taken with an oral steroid.

Hormone Therapy Side Effects

Unfortunately, hormone therapy may not work forever, and it does not cure the cancer. Over time, the cancer may grow in spite of the low hormone level. Other treatments are also needed to manage the cancer.

Hormone therapies have many possible side effects. Learn what they are. Intermittent (not constant) hormone therapy may also be a treatment option. Before starting any type of hormone therapy, talk with your health care provider.

Possible hormone therapy side effects include:

• Lower libido (sexual desire) in most men
• Erectile dysfunction, the inability to have or keep a strong enough erection for sex
• Hot flashes or sudden spread of warmth to the face, neck and upper body, heavy sweating
• Weight gain of 10 to 15 pounds. Dieting, eating fewer processed foods and exercising may reduce weight gain
• Mood swings
• Depression to include feeling loss of hope, loss of interest in enjoyable activities, not being able to concentrate or changes in appetite and sleeping
• Fatigue (feeling tired) that doesn't go away with rest or sleep
• Anemia (low red blood cell count) due to less oxygen getting to tissues and organs, causing tiredness or weakness
• Loss of muscle mass causing weakness or low strength
• Weak bones (loss of bone mineral density) or bones getting thinner, brittle and easier to break
• Memory loss
• High cholesterol, especially LDL ("bad") cholesterol
• Breast nipple tenderness or increased breast tissue growth
• Increased risk of diabetes
• May increase cardiovascular risk

There are many benefits and risks to each type of hormone therapy, so ask questions of your doctor so you understand what is best for you.