MEN'S HEALTH MATTERS:Hormone treatment is used when surgery and radiotherapy have not succeeded, writes THOMAS LYNCH
Q My 67-year-old father was recently diagnosed with prostate cancer. He has had various tests and it now appears the cancer has spread to his bones. He has just begun hormone treatment. Can you explain what this means and how the treatment works? Is there need for surgery, ie removing the prostate?
A Unfortunately, your father’s problem is not uncommon. When a cancer moves from its original site the term used is metastatic cancer. Hormone treatment is the principal therapy for metastatic prostate cancer.
Treatment with hormones is used for men in whom radical treatments, such as surgery and radiotherapy, have not succeeded in curing the disease. They may also be used to shrink the tumour prior to, or in conjunction with, other treatments. Hormones are also used prior to radiotherapy treatment of the prostate as they tend to make this treatment more successful.
Hormone therapy is also called androgen deprivation therapy or androgen suppression therapy. The goal is to reduce levels of the male hormones, called androgens, in the body. The main androgen is testosterone which is produced by the testicles. Looking at it very simply, testosterone acts like a “fertilizer” for the prostate gland and the cancer within the gland, and it stimulates the prostate cancer cells to grow.
Lowering androgen levels often makes prostate cancers shrink or grow more slowly. Hormone therapy does not cure prostate cancer, but it does slow its growth considerably.
Hormone treatment for prostate cancer is normally given through injections into the abdominal wall by your GP monthly, three-monthly or six-monthly, and generally gives rise to a minimal amount of discomfort. There are various preparations available with broadly similar efficacy and side effects, and your doctor will choose the most appropriate one for your father.
One week prior to starting injection therapy, and for up to two weeks after the initial injection, patients usually take a course of tablets called anti-androgens.
Many of the side effects of hormone treatment are related to the lack of normal levels of the male hormone testosterone.
Typically, most men receiving hormone treatment suffer from erectile dysfunction and a reduced libido. Some men notice an alteration of their body hair, ie different texture or growth in new areas on the body. Lack of energy is often reported, with a feeling of tiredness all the time.
Hot flushes (similar to those experienced by women going through the menopause) are very common in the early stages of treatment but may disappear after several months.
Over many months or years, there may be a decline in muscle strength and some tenderness or enlargement in the breast area (called gynaecomastia).
The response of your father’s cancer to this treatment will be monitored closely by your doctor with regular PSA (prostate specific antigen) blood tests. The level of PSA in his blood should fall once he has started hormonal manipulation therapy. Continued low PSA levels indicate the hormones are suppressing growth or spread of the disease. Should these PSA levels start to rise, another form of treatment such as chemotherapy may have to be considered.
Intermittent hormone therapy is appropriate in some patients. It is possible to discontinue therapy and monitor the PSA closely, and recommence treatment if the PSA starts to rise again.
The treatment options for prostate cancer depend in part on whether the tumour has spread. In your father’s case, removal of the prostate would not cure him of the disease as it has spread outside the gland.
The operation to remove the entire prostate (radical prostatectomy) or radiation therapy to the prostate (which involves X-rays that kill the prostate cancer cells) is appropriate only for tumours that are still confined to the prostate.
If significant urinary symptoms are experienced due to the prostate, then surgery to “core out” the centre of the prostate gland may be helpful. This operation, called a transurethral resection of the prostate (TURP), may allow him to pass his urine with a greater flow and less discomfort. It is often better to wait a few months after beginning hormone treatment to see if the prostate shrinks, thus relieving these urinary symptoms without the need for surgical intervention.
There are also various types of chemotherapy available for more advanced disease and you should speak to your father’s urologist about all these issues.
- This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, Dublin with a contribution from Mr James Forde, urology registrar, St James's Hospital, Dublin. Please send your questions to healthsupplement@irishtimes.com