Archive - Hormonal Therapy

For a patient on intermittent hormonal therapy, when the hormonal therapy wore off his PSA would have gradually risen until it reached a point that the next hormone injection would have been given. In my practice that point is 4 ng/mL.

Different doses of leuprolide (Lupron) last for different periods of time. For instance, a 7.5 mg dose should last for 1 month, while a 30 mg dose should last for 4 months. However, since every patient is a little different, the pharmaceutical companies want to ensure that the injection would last at least as long as it should in all patients. Thus, for example, a 30 mg dose should last for 4 months in all patients but may last for longer in some patients.

When the PSA does not fall below 0.1 after surgery and postoperative radiotherapy is given, it is called “salvage radiotherapy.” Studies in men with locally advanced (aggressive) prostate cancer treated by radiotherapy alone (no surgery) have shown that there is a large benefit for giving hormonal therapy before, during, and for 2 years after radiotherapy if they had a high Gleason grade tumor, such as 8, 9, or 10. Hormone therapy has not been adequately tested in men who have had their prostate removed, but many experts believe that it might be beneficial in the post-surgery setting as well. Not all experts agree with this, and some believe that 2 years or more of hormonal therapy might be excessive. I usually recommend hormone therapy before, during and after salvage radiotherapy for a least 1 year in patients with Gleason grade 4+3 or higher, and then discuss with the patient whether he wants to continue the hormonal therapy for another year.

Because of the tremendous variability in the response to androgen-deprivation therapy (in this case Lupron), there is no certain answer. I have seen patients respond for intervals as short as a few months and as long as more than 20 years. The fact that your PSA has been undetectable for 2 years is a favorable sign, but nobody can accurately predict the future in your individual case. See the Q&A on page 5 for possible future treatment options.

In the past, surgical castration was a mainstay of androgen-deprivation therapy for prostate cancer because it was relatively free of other side effects. With the development of new and far more expensive drugs, it has largely been replaced by medical castration that is more acceptable to most men and is usually reversible. Other drugs might not induce the same allergic reaction. Your father might want to try these. In my opinion, his personal preference should guide the decision.

At the present, no one can predict the duration of response to hormonal therapy.

Eventually, genetic studies will show us which tumors are going to be responsive to hormonal therapy for a long time and which are destined not to respond as well. Most likely, when a biopsy is performed, the tumor tissue will be tested on a gene chip array to see which genes are “turned on” and which are “turned off.”Gene expression patterns will show which are characteristic of hormonally-responsive tumors and which are characteristic of non-responsive tumors. Thus, therapy will be tailored somewhat to the pattern of gene
expression in the individual patient’s tumor.

Sometimes it is strongly advised when the pathology report shows positive surgical margins or extension of the tumor beyond the prostate gland. It is also sometimes advised when the PSA begins to rise after surgery. See Quest articles posted on this topic on this website for additional information.

Antiestrogens, such as tamixifen, have been tested in prostate cancer. Although, some studies have reported a benefit, the results have not been consistently good. Most experienced clinicians do not use antiestrogens routinely in prostate cancer patients.

It is possible that the testosterone level is low. It would be useful to measure free and total testosterone. If they are low, and it is believed that all of the prostate cancer has been removed, you could have testosterone replacement therapy by injection (more reliable and less expensive) or by patch. I advise my patients to monitor their PSA level monthly for the first three months after starting replacement therapy. If the PSA rises, the treatment should be stopped and adjuvant therapy for prostate cancer should be considered.

I believe that your are referring to an operation for removal of the testicles, called orchiectomy, not vasectomy. Yes, orchiectomy is virtually equivalent to Lupron in terms of its therapeutic benefits.

Usually, patients are characterized as being less “perky” on hormonal therapy. The diagnosis of prostate cancer is usually devastating to patients, at least at first, and that alone can make it more difficult to interact with them.

Testosterone replacement therapy should be used with caution. If there are any cancer cells remaining in your body, testosterone replacement therapy could stimulate their growth.

Nobody knows for certain. In practice, most people recommend from as little as a few months to two years. Some recommend continuing it indefinitely. In my opinion, it can be discontinued a few months after radiotherapy and then if the PSA rises, the options would be to resume continuous or intermittent hormonal therapy.

You should check the internet for a more detailed description, but, briefly, Plenaxis is an injectable drug that is similar to Lupron or Zoladex except that it does not cause an increase in testosterone levels (“flare response”) before lowering them. Thus, it is possible to give it without using an antiandrogen, such as Casodex or Flutamide to block the testosterone “flare” response that occurs during the first 10 days or so after an injection. It probably would have been a significant improvement over the drugs currently used; however, disadvantage are that relatively large quantities of the drug have to be injected, and some patients have had an allergic reaction to it. It has been approved by the FDA for use when other drugs cannot be used.

I do not believe that it is necessary as long as the PSA level is very low following orchiectomy.

Usually within a month.

Usually it is not necessary to begin medication to prevent bone loss immediately after starting hormonal therapy, because it takes some time for the bones to lose calcium. However, in a patient with known bone metastases, therapy is probably not a bad idea. Most patients respond to hormonal therapy. (please see Quest Articles on Hormonal Therapy Explained and other Q&As on the website). The prognosis is uncertain in an individual patient and will depend on how well he responds to hormonal therapy.

They can last for a considerable time, but by 16 months, they should be going away. I would advise you to have your testosterone level checked.

A: I prefer to use one 3-month Lupron injection and if the PSA is undetectable, hold off on the Lupron until the PSA reaches 4.0. With this regimen, the patient has a frequent opportunity to re-calcify his bones and restore his muscle mass.

I do because the PSA of 1.8 is pretty high to be just starting radiotherapy, and especially so if the tumor was high-grade.

Any form of hormonal therapy can induce changes in the cancer cells that make them more difficult to grade. I believe the jury is still out on this matter, but it is possible that the Gleason grade would have been lower without the Proscar. The question is whether Proscar just makes the tumor cells look more aggressive or whether it encourages them to become more aggressive.

Some physicians would argue that it would be okay for you not to monitor your PSA and wait until you have symptoms from metastases to bones or other places before starting hormone therapy. In fact, this is a common practice in some countries. However, I usually recommend intermittent hormonal therapy beginning when the PSA reaches 4.0. A 4-month hormone injection usually results in the PSA decreasing to zero, and then the patients may go for months or years before needing the next cycle of hormonal therapy. Please visit my website, www.drcatalona.com, for more information and search “intermittent hormonal therapy.”

The PSA is not expected to decrease to zero after external beam radiation therapy, because you still have a prostate gland in your body. Thus, a persistently rising PSA could be due to normal or inflamed prostate tissue, persistence of your original prostate cancer in the prostate gland or elsewhere in your body, or to the development of a new prostate cancer in the remaining prostate tissue. Accordingly, I advise you to monitor your PSA levels every 4 months, and if it continues to rise, your treatment options before the PSA increases above 2 would include salvage radical prostatectomy (high complication rate) or freezing the prostate, called cryoablation (uncertain effectiveness). Perhaps the safest option would be salvage hormonal therapy when the PSA rises above 4.0. Please visit my website, www.drcatalona.com, for more information and search “intermittent hormonal therapy.”

Your prostate cancer seems to progress very slowly. Now, more than 20 years following surgery, your PSA is only 0.18. I would recommend monitoring the PSA every 4 months and having the next Lupron injection when the PSA reaches 4.0.

In my practice, I usually recommend beginning standard hormonal therapy or ADT(androgen-deprivation therapy) with a 10-day course of bicalutamide(Casodex) 50 mg by mouth once a day and a 30mg leuprolide (Lupron) injection on day two of the Casodex pills. Within a month, the male hormone level (testosterone) decreases to very low levels and remains there for four months. If the ADT is to be continued beyond this time, the Lupron injection alone is sufficient without the Casodex. In some clinical situations, more intensive treatments with different drugs are used.