Hormonal therapy for prostate cancer
Hormonal therapies lower testosterone levels or stop testosterone reaching the prostate cancer cells. Hormonal therapy may be given on its own, or in combination with other treatments.
Hormonal therapy for prostate cancer is a treatment to lower the levels of the hormone testosterone in the body. Prostate cancer needs testosterone to grow. Testosterone is mainly made by the testicles. Hormonal therapies reduce the amount of testosterone in the body, or stop it reaching the prostate cancer cells.
Testosterone is important for:
- sex drive (libido)
- getting an erection
- facial and body hair
- muscle development and bone strength.
Hormonal therapies are drugs that can be given as injections or as tablets.
Hormonal therapy is often used to treat early and locally advanced prostate cancer. If you have low-risk early prostate cancer you do not usually need hormonal therapy.
Doctors often advise having hormonal therapy with radiotherapy (including brachytherapy for prostate cancer), to make your treatment more effective. You may have hormonal therapy before, during and after radiotherapy. It can be given:
- a few months before radiotherapy, to shrink the cancer (neo-adjuvant treatment)
- after radiotherapy, to reduce the chance of the cancer coming back (adjuvant treatment).
Your doctor will talk to you about how long you take hormonal therapy for. They will also explain the possible side effects.
How long do you take hormonal therapy for?
For early prostate cancer this depends on the prostate cancer risk group. If the cancer is:
- intermediate-risk you may have hormonal therapy for a few months after radiotherapy
- high-risk you may be advised to have hormonal therapy for up to 2 to 3 years after radiotherapy.
For locally advanced prostate cancer you usually have hormonal therapy for 2 to 3 years after radiotherapy.
Doctors do not usually advise having hormonal therapy instead of a prostatectomy or radiotherapy. Hormonal therapy alone cannot cure early or locally-advanced prostate cancer.
Depending on your general health and preferences, you may decide to have hormonal therapy on its own. For example, if you:
- are not well enough to have a prostatectomy or radiotherapy
- do not want to have a prostatectomy or radiotherapy
- are monitoring prostate cancer, for example having watchful waiting and the cancer starts to grow.
Hormonal therapy can slow down or stop the cancer cells growing for many years. It can also improve any symptoms. Not having surgery or radiotherapy means you avoid the side effects of these treatments. But hormonal therapy also causes side effects. It is important to talk to your doctor or nurse before you decide.
Intermittent hormonal therapy for locally advanced prostate cancer
Intermittent hormonal therapy is where you stop taking the drugs and after a while start taking them again. This may be an option for locally-advanced prostate cancer. It gives you a break from the side effects of hormonal therapy.
Intermittent hormonal therapy is not suitable for everyone and should only be done on your doctor’s advice. Your doctor can explain more about this. They usually measure your PSA level using the PSA test every 3 months. If it goes up to a certain level or you get symptoms, your doctor will advise you to start hormonal therapy again.
There are different types of hormonal therapy. Your doctor or nurse will explain the treatment that is most suitable for you.
The pituitary gland in the brain makes make a hormone called luteinising hormone (LH). This hormone tells the testicles to make testosterone.
LHRH agonists interfere with this action and stop the testicles making testosterone. You have them as an implant injection or an injection under the skin.
The commonly used LHRH agonists are:
- goserelin (Zoladex®, Zoladex LA®)
You have goserelin as an injection of a small pellet (implant) under the skin of your tummy (abdomen). The drug is released slowly as the pellet dissolves. You have it every 4 weeks, or as a longer-acting injection every 12 weeks.
- leuprorelin and triptorelin (Decapeptyl®, Gonapeptyl®)
You have leuprorelin and triptorelin as an injection under the skin or into a muscle. Leuprorelin can be given either once a month or every 3 months. Triptorelin can be given once a month, or every 3 months or 6 months.
A nurse or doctor at your GP practice or hospital can give you these drugs.
The first time you have one of these drugs, it can cause a temporary increase in testosterone. This can make any symptoms worse for a short time. This is sometimes called tumour flare. To prevent this, your doctor usually asks you to take an anti-androgen drug, such as bicalutamide (Casodex®). You take it for a short time before and after starting the LHRH agonist.
These drugs stop testosterone from reaching the cancer cells. You take them as tablets.
You may have anti-androgen drugs with radiotherapy, instead of an LHRH agonist. Or you may have an anti-androgen before and after the first injection of a LHRH agonist. This is to prevent any symptoms getting temporarily worse (tumour flare).
Anti-androgen drugs for prostate cancer include:
Reducing the level of testosterone can cause different side effects. There are different ways hormonal side effects can be managed or treated. Your doctor or nurse will explain this to you. Some side effects are only likely to affect you when you have hormonal therapy for over 6 months.
Different hormonal therapies have different side effects. Ask your doctor or nurse to explain the side effects before treatment.
Common side effects of hormonal therapy
Common side effects include:
Erection difficulties and reduced sex drive
Erection difficulties is called erectile dysfunction (ED). This usually improves after you stop hormonal therapy,
depending on how long you take it for. But it may take a few months.
If you have ED, there are drugs and treatments that may help. Even with a low sex drive, some ED treatments may work for you.
Hot flushes and sweats
These may reduce as your body adjusts to hormonal treatment. They usually gradually improve after treatment finishes. Talk to your doctor or nurse if you are having problems. They can give you advice about managing hot flushes and may be able to prescribe medicines to help.
Tiredness and difficulty sleeping
Feeling tired is a very common side effect of hormonal therapy. Regular physical activity can help reduce tiredness. Hot flushes may make sleeping difficult, so managing these may help you to sleep better.
Memory and concentration problems
Other side effects of hormonal therapy
If you have hormonal therapy for 6 months or more, you may have other side effects. The benefits of hormonal therapy generally outweigh these possible risks. Your doctor or nurse will talk to you about this.
Other possible side effects include:
Weight gain and loss of muscle strength
Breast swelling or tenderness
This is more common if you have flutamide or and bicalutamide over a longer period. Some people have low-dose radiotherapy to their chest before treatment to prevent breast swelling. If you are taking bicalutamide, another option is to take a hormonal drug called tamoxifen to reduce breast swelling.
Bone thinning (osteoporosis)
The risk of this is increased with long-term hormonal treatment. You may have a bone density scan to check your bones before you start treatment. Regular weight-bearing exercises such as walking, dancing, hiking, or gentle weight-lifting can help keep your bones healthy. Your doctor may give you advice on diet and exercise. They may advise you to take calcium and vitamin D tablets. Depending on your bone health, they may talk to you about taking bone-strengthening drugs called bisphosphonates, or a drug called denosumab (Prolia®).
Increased risk of heart disease and diabetes
Below is a sample of the sources used in our prostate cancer information. If you would like more information about the sources we use, please contact us at firstname.lastname@example.org
C. Parker, E. Castro, K. Fizazi, et al. Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 2020, Volume 31, Issue 9, p1119-1134. Available from www.esmo.org/guidelines/genitourinary-cancers/prostate-cancer
National Institute for Health and Care Excellence (2019) Prostate cancer: diagnosis and management (NICE guideline NG131). Last updated December 2021 to include Risk stratification for localised or locally advanced prostate cancer. Available at www.nice.org.uk/guidance/ng131
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editors, Dr Jim Barber, Consultant Clinical Oncologist and Dr Lisa Pickering, Consultant Medical Oncologist.
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