Hormonal therapy for locally advanced prostate cancer This information is an extract from the booklet Understanding locally advanced prostate cancer. You may find the full booklet helpful. We can send you a free copy see page 6. Contents What is hormonal therapy? Injections Tablets Duration of hormone treatment Side effects Removal of part of the testicles (subcapsular orchidectomy) What is hormonal therapy? 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. Hormonal therapy is usually given with radiotherapy to treat locally advanced prostate cancer, but it can be given on its own. Giving hormonal therapy plus radiotherapy makes the treatment more effective. It may be given before radiotherapy to help shrink the tumour. This is known as neo-adjuvant treatment. It may be given during or after radiotherapy to reduce the chance of the cancer coming back. This is known as adjuvant treatment. Hormonal therapies can be given as injections or tablets. Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 1 of 6
Injections Some drugs switch off the production of male hormones by the testicles by reducing the levels of a hormone produced by the pituitary gland. They are known as leutenising hormone blockers or LHRH agonists. These include: goserelin (Zoladex ) leuprorelin (Prostap ) triptorelin (Decapeptyl ). Goserelin is a small pellet which is injected under the skin of the tummy (abdomen). Leuprorelin and triptorelin are given as liquids which are injected under the skin or into a muscle. Injections are given either monthly or every three months. Tablets Other 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. Commonly used anti-androgens are: bicalutamide (Casodex ) this is taken once daily flutamide (Drogenil ) this is taken three times a day cyproterone acetate (Cyprostat ) this is taken two or three times daily. Anti-androgen tablets are usually given for one or two weeks before and after the first injection of a leutenising hormone blocker. This prevents tumour flare, which is when symptoms from the prostate cancer get worse after the first dose of treatment. Page 2 of 6 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
Duration of hormone treatment Hormonal therapy for locally advanced prostate cancer Your doctor will advise how long you should have the hormonal therapy for. It may be stopped after the radiotherapy or continued for a period of 2 3 years, depending on the extent of the tumour at the start of treatment. Some men may be treated with intermittent hormonal therapy, which means that the treatment is started and stopped depending on their PSA blood test result. This is a blood test that measures the level of a protein called prostate-specific antigen (PSA). Intermittent therapy causes fewer side effects but you will need to have your PSA regularly monitored. It s only suitable for some men. Side effects Erection problems Most hormonal therapies cause erection difficulties (erectile dysfunction ED) and loss of sexual desire (libido) for as long as the treatment is given and for some time after. Some drugs (goserelin and leuprorelin) completely stop erections during treatment. Others (such as bicalutamide) stop erections in most but not all men. Once hormone treatment is stopped, the problem may improve with time or treatment. Bone thinning Hormonal therapy can cause bone thinning (osteoporosis). This 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. Your doctors may organise for you to have a DEXA scan (dual-energy x-ray absorptiometry scan) if you are due to start long-term hormone treatment. This scan allows doctors to monitor the bones for any areas of weakness or fractures. If your bones are thinning your doctor may advise you to take calcium and vitamin D tablets. You may also be asked to take bone-strengthening drugs called bisphosphonates or a drug called denosumab (Prolia ). Our booklet Bone health has more information. Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 3 of 6
Hormonal effects Most men experience hot flushes and sweating with hormonal therapy. Your doctor can give you medicines to help relieve this side effect while you re having treatment. The flushes and sweats will gradually stop if treatment is stopped. We can send you more information about this. Other effects Hormonal treatment can also make you put on weight (often around the tummy area) and feel constantly tired. Some drugs (most commonly flutamide and bicalutamide) may also cause breast swelling and breast tenderness. Different drugs have different side effects. It s important to discuss these effects with your doctor or specialist nurse before you start treatment so that you know what to expect. We have more information about individual hormonal therapies with details about how the drugs work and tips on coping with possible side effects. We also have information called Prostate cancer and hormonal symptoms, which we can send you. + Advantages of hormonal therapy It 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. Disadvantages of hormonal therapy It 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 erection problems (erectile dysfunction ED) and a lowered sex drive, hot flushes and breast swelling. Page 4 of 6 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
Removal of part of the testicles (subcapsular orchidectomy) Occasionally an operation called a subcapsular orchidectomy (or radical orchidectomy) is done to remove the part of the testicles that produces testosterone. This reduces the level of the male hormone testosterone and helps control the prostate cancer and reduce symptoms. Both testicles are operated on (bilateral orchidectomy). It s mostly used in men who can t or don t want to have the types of hormonal therapy mentioned in this information. A subcapsular or radical 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 be smaller than it was before. You usually have this operation as a day patient under a local or general anaesthetic. 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 loss of erections. Some men find the idea of this operation distressing. You may find it helpful to talk through the procedure with your cancer specialist. They will give you more information about what it involves. Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 5 of 6
+ Advantages of having an orchidectomy It s a simple operation that avoids the use of drugs and some of their side effects such as breast swelling and tenderness. It s equally effective as other hormonal treatments. Disadvantages of having an orchidectomy Some men find the idea of this operation difficult to cope with. There are some risks and side effects associated with surgery. Your specialist will give you more information about these. It can t be reversed once the procedure has been carried out. It s therefore not a good option for men who only need short-term hormonal therapy. If you are thinking about having a subcapsular orchidectomy talk to your doctor about this. More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. To order a copy of Understanding locally advanced prostate cancer, or any other cancer information, visit be.macmillan.org.uk or call 0808 808 00 00. We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or thirdparty information or websites included or referred to in it. Macmillan Cancer Support 2013. Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ REVISED IN FEBRUARY 2015 Planned review in 2017 Page 6 of 6 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk