About hormone therapy for prostate cancer
This page is about hormone therapy for prostate cancer. There is information about
Hormone therapy for prostate cancer
Cancer of the prostate depends on the male hormone testosterone for its growth. So if the amount of testosterone is reduced, it is possible to slow down or shrink the tumour. Sometimes the cancer symptoms disappear completely. This kind of treatment will usually work well for a few years. After that, in some men, the cancer stops responding to the hormone treatment and starts to grow again. This is called hormone refractory prostate cancer. There are two main types of drugs
- Tablets called anti androgens
- Injections called ‘pituitary down regulators’
You may have either on their own, or both together. Having both types of drugs together is called complete androgen blockade (CAB) or maximal androgen blockade (MAB). MAB is used to treat advanced prostate cancer.
How and when you have hormone therapy will depend on the grade and stage of your cancer. If your cancer has spread to another part of the body or it has grown too far locally to be successfully treated with surgery or radiotherapy, your doctor will suggest hormone treatment alone. If you are going to have potentially curative treatment, but your doctor thinks there is a high risk of your cancer coming back, you may have hormone therapy as well as your other treatment.
Some doctors prescribe hormone therapy for you to take all the time. Others prefer to give you a few months treatment, followed by a break, then by more treatment and so on. Both ways appear to work just as well.
Hormones occur naturally in your body. They control the growth and activity of normal cells. Cancer of the prostate depends on the male hormone testosterone for its growth. So if the amount of testosterone is reduced, it is possible to shrink a prostate tumour down or slow its growth. Sometimes the cancer symptoms disappear completely. This kind of treatment usually works well for a few years. After that, in some men, the cancer stops responding to the hormone treatment and starts to grow again. This is called hormone refractory prostate cancer.
Your testosterone levels can be reduced either by surgery to remove the testes, or by medicines. Testosterone is mainly made in the testes. These days, you are more likely to have drug based hormone treatment than surgery. Surgery is usually only used to reduce testosterone levels urgently, if your cancer has spread to the bone and is affecting your spinal cord. But it is an option that your doctors may suggest.
There are two main types of drugs that reduce testosterone levels - they are called
- Pituitary down regulators - they include goserelin (also called Zoladex), buserilin, leuprorelin (also called Prostap) and histrelin (Vantas)
- Anti androgens - they include flutamide (also called Drogenil) and bicalutamide (also called Casodex)
Pituitary down regulators
The testes make the male sex hormone, testosterone, because a hormone released by the pituitary gland in the brain 'tells' them to. Pituitary down regulators stop the pituitary gland making the hormone. So the testes do not receive the message telling them to make testosterone. Pituitary down regulators are also called LHRH agonists. LHRH stands for luteinising hormone releasing hormone. Examples include leuprorelin (Prostap), goserelin acetate (Zoladex), buserilin and histrelin (Vantas).
These drugs are given by injection under your skin, either once a month or once every three months. At first, the injections may make your symptoms worse. This is called 'tumour flare'. Your doctor should give you an anti androgen tablet to take for the first 4 to 6 weeks of your treatment with the pituitary down regulator, to stop tumour flare.
Anti androgens
Anti androgen tablets stop testosterone from your testicles from getting to the cancer cells. So the cancer cells can't grow. Examples of anti androgens include
- Cyproterone acetate (Cyprostat) - the Committee on the Safety of Medicines in the UK recommend that this is not used long term
- Flutamide (Drogenil)
- Bicalutamide (Casodex)
The advice on not taking Cyprostat long term is because it can cause liver problems if you take it for a long time. There are circumstances when your doctor may still suggest that this drug may be a better option than other available treatments.
You take bicalutamide once a day. Flutamide is taken three times a day. Some men find that flutamide gives them troublesome diarrhoea. If this is the case for you, talk to your doctor about it. There may be another treatment you can try or you may be able to take medicines to help with the diarrhoea.
You can have the anti androgen bicalutamide (Casodex) as a high dose treatment of 150mg on its own. But hormone treatment on its own is no longer recommended for men with early prostate cancer. Early prostate cancer means the cancer is completely within the prostate gland.
If you have locally advanced prostate cancer you may be prescribed bicalutamide with radiotherapy. Locally advanced means the cancer has either begun to spread outside the prostate gland or has spread into lymph nodes nearby.
Flutamide and high dose bicalutamide are less likely to cause erection problems and other side effects than leuprorelin (Prostap) or goserelin (Zoladex). But they are more likely to cause tender breast swelling. There is information about hormone therapy side effects in this section of CancerHelp UK.
There are different ways of combining hormone therapy drugs. You can have
- Pituitary down regulators on their own
- Anti androgens on their own
- Both types of drug together
Usually you will have either a pituitary down regulator or an anti androgen. But you may have them together for a short time to prevent tumour flare. You may also have them together if your cancer is showing signs of becoming resistant to one of the drugs taken on its own. Pituitary down regulators are generally thought to be more effective than anti androgens, but high dose bicalutamide (Casodex) is also sometimes used for locally advanced prostate cancer (stage 3).
Having both types of drugs together is called complete androgen blockade (CAB) or maximal androgen blockade (MAB). CAB can be used to treat advanced prostate cancer, if it has stopped responding to pituitary down regulators on their own. It is given to try to slow the growth or spread of the cancer. But there are increased side effects if you take both types of drug together.
You will probably want to discuss the choice of hormone treatment with your doctor. There are benefits and drawbacks to each type of drug, so you may prefer to make a decision based on the side effects of the treatments.
How and when you have hormone therapy will depend on the grade and stage of your cancer.
If you have a very early prostate cancer that can be cured with radiotherapy or surgery, and is at a low risk of coming back, you won't need to have hormone therapy.
You may have hormone therapy as well as radiotherapy to try to cure your cancer, if your doctor thinks there is a high risk of your cancer coming back because
- It has grown through the covering of the prostate (the capsule) (stage T3) or
- You had a very high PSA when you were diagnosed or
- You have a high Gleason score.
If your cancer has spread to another part of the body or it has grown too far into the tissue around the prostate gland to be successfully treated with surgery or radiotherapy, your doctor will suggest hormone treatment alone.
If your cancer is advanced when it is diagnosed, you may start hormone therapy straight away. If you have no symptoms, your doctor may suggest keeping an eye on you and only prescribe treatment when you have symptoms that need treating. But there is some evidence that men live longer and complication rates are lower with early hormone therapy. So doctors may sometimes suggest this approach.
Some doctors prescribe hormone therapy for you to take all the time (continuously). Others prefer to give you a few months treatment, followed by a break. Then you have more treatment and so on. This is called intermittent treatment. Both continuous and intermittent treatment appear to work just as well.
Histrelin (Vantas) is a newer type of pituitary down regulator. It is given as a small implant injected just under the skin once a year. In August 2009, the Scottish Medicines Consortium (SMC) recommended it as an option in the NHS in Scotland to control symptoms in advanced prostate cancer. The SMC recommend that it is used only for people who are expected to live only about a year.
There is information about research into hormone therapy in the prostate cancer research section of CancerHelp UK.
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