Archive - Hormonal Therapy
Questions & Answers
INTERMITTENT HORMONAL THERAPY: You told me about a patient who had undetectable PSA for 19 years after he initiated with hormonal therapy for locally advanced prostate cancer. Was this patient on continuous or intermittent 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.
HORMONAL THERAPY, SURGICAL CASTRATION OR MEDICAL CASTRATION: I had my last Lupron (3 months) injection 4 months ago. How long will the side effects continue?
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.
POST-OPERATIVE HORMONE THERAPY: My pathology report showed T3a with two focally present positive surgical margins. My PSA post-surgery was not undetectable, but it was 0.1 at the 6-week and 10-week checks. My doctor recommended adjuvant radiation along with hormone therapy using combined androgen blockade for 6 months. Would continuing on the hormone therapy for a longer time provide a better chance for a cure?
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.
ANDROGEN-DEPRIVATION THERAPY: I am 59 years old and originally had Gleason grade 7 prostate cancer at age 41. In my radical prostatectomy specimen the tumor invaded the prostate capsule, and 2 years later I had external beam radiotherapy for a rising PSA. More than 16 years later, my PSA again began to rise, and I have been on Lupron for 2 years. My PSA has since remained 0.01. I can’t seem to get an answer as to my life expectancy and prognosis. Can you direct me to that answer?
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.
HORMONAL THERAPY, SURGICAL CASTRATION OR MEDICAL CASTRATION: My 82-year-old father developed recurrent prostate cancer after surgery and radiotherapy. He had a serious skin reaction that may have been related to hormonal therapy with Eligard. We are considering surgical castration as opposed to further medical castration. Should we try other hormonal drug therapy first?
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.
HORMONAL THERAPY: In a recent Quest article on intermittent hormonal therapy, you said the treatment can work from a few months to 18 years. How can a man in treatment know which time period applies to him?
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.
POSTOPERATIVE RADIOTHERAPY: After surgery is radiation required?
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: Should an anti-estrogen be prescribed for a post-prostatecomy patient (contained cancer/Gleason 6) with high estrogen and low testosterone?
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.
TESTOSTERONE REPLACEMENT THERAPY AFTER RADICAL PROSTATECTOMY: I had low testosterone before I had surgery. I had the nerve sparing surgery and the cancer was contained to the prostate. I was not on any hormones prior to the surgery. It has been 5 months since my surgery and I am still experiencing problems with desire and erections. Can I take hormones? If not is there something I can do to raise my testosterone level?
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.
REMOVAL OF TESTICLES INSTEAD OF LUPRON: My father is currently on the Lupron shot that is administered every four months. He has recently had to switch doctors and was told that if he has a vasectomy, he no longer may need to get the injection. A combination of the Lupron injections and a daily casodex pill has kept his PSA level down to almost 0. Will the vasectomy be an answer to not having to get this costly shot every four months but also keep his PSA level down?
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.
PERSONALITY CHANGE WITH HORMONAL THERAPY: My dad was diagnosed prostate cancer a year ago. He received hormone therapy and his PSA level decreased from 180 to <0.1 ng/mL. Currently his cancer is well under control. I believe that he has a total change of character. His changed into a dominant, unreasonable man. What information do you have about this side effect of the hormone therapy?
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: I had a radical prostatectomy 12 months ago. It was a small cancer and my current PSA reading has been .1 the last two checkups. I have now been diagnosed with low testosterone. What is your opinion of testosterone replacement therapy?
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.
I know that this is a very controversial subject, but in your opinion, what do you feel is the length of time that a person should be on the Lupron/Casodex protocol? Background Info: Diagnosed 4/03, PSA 33, Gleason 8, T3a, no bone mets, 40 IMRT’s. PSA one month after completion of RT 0.04. Thank you.
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.
Please tell me about plenaxis.
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.
How long to continue Flutamide after Orchiectomy?
I do not believe that it is necessary as long as the PSA level is very low following orchiectomy.
How quickly does Zoladex(the 3 month shot) take effect?
Usually within a month.
My 85-yr old father had PSA 16 and six months later, he started having shoulder pain. PSA at that time was 34. A bone scan was done, showing extensive metastis (lesions in most areas of the skeleton). Biopsy showed prostate cancer (aggressive, fast-growing) in all samples (Gleason 9). In 2 days he will have orchiectomy. There will be no further treatment. We asked about treatment for increasing bone mass to avoid fractures. Is he doing the right thing? Can he take Fosamax to increase bone mass? Can we expect remission with this surgery? Can you suggest prognosis? Is there anything else to do?
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.
I had Zoladex along with my radiation treatments. I stopped the Zoladex 16 months ago. How long do I have these “hot flashes?”
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.
I underwent radiation in 1992–and after five years my PSA went up to 5.3. I have undergone treatment with Lupron–I take three four ( 4 } month shots and then I am off the shots for one year. I have taken three series of Lupron shots. Is there any alternative to this procedure. I understand that Lupron may affect my bone mass, but I have never been directed to take any tests for loss of bone mass. Is there any other condition that might be affected by Lupron.
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.
Do you recommend hormone therapy in conjunction with 3-D radiation in a 69 yr old male 11 years since radical…with a psa of 1.8.
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.
EFFECT OF PROSCAR ON GLEASON GRADE:I read that Gleason grading should not be used after treatment with Proscar, because the treatment falsely biases the results. This is of interest to me, since I was treated with Proscar in the 3 months leading up to my RRP, and my post-op Gleason was graded at 8, compared with pre-op at 6. Is it possible that my post-op Gleason was actually lower than the 8 grading?
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.
INTERMITTENT HORMONAL THERAPY AFTER SURGERY: I am 72 years old and underwent a radical prostatectomy 20 years ago with salvage radiation therapy for a rising PSA 12 years ago. My PSA has now risen to 5.8. I feel in good health. At my age should I continue to monitor my PSA every year? I hate to think about hormone therapy.
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 â€œintermittent hormonal therapy.â€
PSA AFTER RADIATION: I am 64 years old and was treated with external beam radiation therapy and Zoladex for a Gleason 3+3 = 6 prostate cancer with a PSA of 25. My PSA decreased to 0.46, but three months later it increased to 0.81 off hormonal treatment. I feel perfectly healthy. Is the PSA rise something to worry about?
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 â€œintermittent hormonal therapy.”
FREQUENCY OF LUPRON: I was treated with radical prostatectomy followed by salvage radiation therapy 13 years later. Five years after that my PSA again began to rise slowly, and I received my first Lupron injection. One year later the PSA had risen to 0.43 and another urologist recommended another Lupron injection. Now, 2 years later, my PSA is 0.18, almost unchanged from the reading 6 months ago. I would very much appreciate your opinion of what guidelines I should be following regarding the frequency of Lupron injections in my case.
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.
What is involved in beginning hormonal therapy for prostate cancer?
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.