Hormonal therapy for locally-advanced prostate cancer
Hormonal therapy may be given to men with locally advanced prostate cancer before radiotherapy. This is known as neo-adjuvant therapy, which can help make radiotherapy treatment more effective.
Hormonal therapy is also sometimes given after radiotherapy (adjuvant therapy), where the aim is to reduce the chance of the cancer coming back.
Hormonal therapy can also be given as a treatment on its own, and some studies have shown that it can improve survival.
Hormones control the growth and activity of normal cells. In order to grow, prostate cancer depends on the hormone testosterone, which is produced by the testicles. Hormonal therapies reduce the amount of testosterone in the body. They can be given as injections or tablets.
Occasionally, an operation called a subcapsular orchidectomy is done to remove the part of the testicles that produces testosterone.
Some drugs ‘switch off’ the production of male hormones by the testicles by reducing the levels of a hormone produced by the pituitary gland. These drugs are called pituitary down-regulators or gonadotrophin-releasing hormone antagonists (GnRH antagonists). They include:
They are usually given as a pellet injected under the skin of the abdomen (goserelin), or as a liquid injected under the skin or into a muscle (leuprorelin or triptorelin). Injections are given either monthly or every three months.
Other hormonal therapy drugs work by attaching themselves to proteins (receptors) on the surface of the cancer cells. This blocks the testosterone from going into the cancer cells. These drugs are called anti-androgens and are often given as tablets. Commonly used anti-androgens are:
Anti-androgen tablets are usually given for two weeks before the first injection of a pituitary down-regulator. This prevents ‘tumour flare’, which is when symptoms get worse after the first dose of treatment.
Research trials are being carried out to find out whether it’s better to start the hormonal therapy before or after radiotherapy (if you are having both), and to find out how long to give the treatment for (it can range from two months to two years).
Side effects of hormonal therapy drugs
Unfortunately, most hormonal therapies usually cause erection difficulties (impotence) and loss of sexual desire for as long as the treatment is given. If the treatment is stopped, the problem may disappear. Some types of anti-androgens are less likely to cause impotence than others.
Hormonal therapy can cause bone thinning (osteoporosis), which can sometimes lead to tiny cracks in the bone (fractures). The risk of bone thinning increases if you are taking hormonal therapy for long periods. You may have to have a special type of x-ray called a DEXA scan (dual-energy x-ray absorptiometry scan). This scan allows doctors to check the bones for any areas of weakness or fractures. You might also be given bone-strengthening drugs called bisphosphonates, which can help if you experience problems. Our section on bone health has more information.
Most men who have hormonal therapy experience hot flushes and sweating. Your doctor can prescribe medicines to help relieve this side effect while you’re having treatment. The flushes and sweats will stop if treatment is stopped.
Hormonal treatment can also make you put on weight and feel constantly tired, both physically and mentally. Some drugs (most commonly flutamide and bicalutamide) may also cause breast swelling and tenderness.
Different drugs have different side effects, so it’s important to discuss the possible effects with your doctor or specialist nurse before you start treatment. By being aware of the effects that may occur, you may find them easier to cope with.
Advantages and disadvantages
Hormonal therapy can slow or stop the growth of cancer cells for many years. It doesn’t involve surgery or radiation, so there’s little risk of bowel or bladder problems.
Hormonal therapy won’t get rid of all the cancer cells if it’s the only treatment given. It can cause a range of side effects that include breast swelling, hot flushes, erection problems (impotence) and a lowered sex drive.
Removal of part of the testicles (subcapsular orchidectomy)
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There are many different hormonal therapy drugs available today, so a subcapsular orchidectomy is not commonly used. But it can be effective in certain situations. It’s mostly used in men who can’t have the other types of hormonal therapy mentioned above. It can be effective in controlling prostate cancer and reducing symptoms .
A subcapsular orchidectomy is a simple operation. A small cut is made in the scrotum (the sac that holds the testicles), and the part of the testicles that produces testosterone is removed. After the operation the scrotum will appear smaller than it was before.
You can have the operation as a day patient under a local or general anaesthetic. Sometimes, both testicles are completely removed (bilateral orchidectomy).
Some men find the idea of this operation distressing. You may find it helpful to talk through the procedure with your cancer specialist, who can give you more information about what this operation involves.
After the operation, you’re likely to experience some pain, and some swelling and bruising of the scrotum. You will be given painkillers to ease any pain. You’ll also start to have side effects similar to those of hormonal therapy drugs, which include hot flushes and impotence.
Advantages and disadvantages
A subcapsular orchidectomy is a simple operation that avoids the use of drugs and some of the associated side effects such as breast swelling and tenderness. Subcapsular orchidectomy and other hormonal treatments are equally effective.
Some men find the idea of this operation difficult to cope with. As with any operation, there are risks associated with surgery. Your specialist will give you more information about these risks and the side effects you’re likely to have.