Our Greatest Wealth Is Health

Andrew Siegel MD    9/21/2019          Prostate Cancer Awareness Month

Thank you Marijana1 at Pixabay for image above

“Androgens” are the male sex hormones, the main one of which is testosterone.  Androgen deprivation therapy (ADT), a.k.a. hormonal therapy, deprives the body of testosterone and can be an effective means of helping to manage prostate cancer. Most testosterone is produced in the testes and by suppressing testosterone, the growth of prostate cancer can be restrained. For many years, ADT has been the standard of care for advanced prostate cancer. Although it does not cure the cancer, it results in shrinkage of the cancer, slower growth and many patients will experience long-term remissions. Although it delays cancer progression, the effects on survival are less clear.  Because of potential side effects, ADT should only be used when clearly indicated and avoided when possible.  It is important to know that given enough time, prostate cancer cells are capable of mutating and ultimately becoming able to survive in a low testosterone environment, a condition known as castrate resistant prostate cancer.

Thank you Darko Djurin at Pixabay for image above

ADT is useful in the following circumstances:

• As a delaying tactic because of the need to defer treatment
• In a man who desires treatment, but is unable to tolerate surgery or radiation because of poor health or advanced age
• In conjunction with radiation therapy since radiation and ADT have a synergistic effect (combined effect is greater than sum of separate effects)
• Prior to surgery, radiation, or ablative therapies to shrink the prostate
• To treat surgery or radiation failures
• As primary treatment for metastatic disease

ADT for prostate cancer can be achieved either surgically or medically:

Orchiectomy (surgical castration) is an operation in which the urologist removes the testicles. With the source of testosterone removed, most prostate cancers stop growing or shrink for a time. This is a simple outpatient procedure and is the least expensive and most uncomplicated way to reduce testosterone levels in the body. Unlike other methods of lowering testosterone levels, it is permanent and irreversible, and many men — understandably so — do not relish the concept of having their testicles removed. However, it is a possible choice for someone who favors an inexpensive and one-and-done approach to ADT.

Luteinizing hormone-releasing hormone (LHRH) analogs (also called LHRH agonists) lower testosterone levels as effectively as surgical castration, only chemically as opposed to surgically.  They are the most commonly used means of ADT in the United States.  LHRH analogs are given by needle injection either monthly or every 3, 4, or 6 months. The LHRH analogs available in the United States include leuprolide (Lupron, Viadur, Eligard), goserelin (Zoladex), and triptorelin (Trelstar).

When LHRH analogs are initially given, testosterone production increases before it falls to very low levels. This effect is called the “flare” or “surge” phenomenon. Men whose cancer has spread to the bones may experience bone pain because of this initial surge in testosterone.  If the cancer has spread to the spine, even a short-term increase in cancer growth could compress the spinal cord and cause pain or paralysis. This flare can be avoided by giving anti-androgen medications for a few weeks before starting treatment with LHRH analogs or, alternatively, using a luteinizing hormone-releasing hormone antagonist.

Luteinizing hormone-releasing hormone (LHRH) antagonists are a newer class of medication that reduce testosterone without the flare. Degarelix (Firmagon) is an LHRH antagonist that induces “castrate” levels of testosterone within 3 days of the injection.

Possible side effects of all forms of ADT may include the following:

• hot flashes
• diminished sex drive
• erectile dysfunction
• breast tenderness and growth of breast tissue
• osteoporosis (bone thinning), which can lead to broken bones
• anemia (low red blood cell count)
• decreased mental acuity
• loss of muscle mass
• increase in body fat
• weight gain
• fatigue
• weakness
• altered lipid profiles: increase in cholesterol, triglycerides, and decrease in HDL (“good”) cholesterol
• increased insulin resistance, type 2 diabetes and coronary disease
• depression

Reducing risk of ADT complications

Since ADT can have negative effects including fatigue and loss in muscle and bone mass, it is important to take measures to minimize these potential complications.  Studies have clearly demonstrated that physical exercise, including aerobic and resistance training, will help maintain muscle and bone mass and improve fatigue and vitality. More about this in the chapter on bone health.

Controversies in ADT

There are many ADT issues that lack a clear consensus.

Early vs. delayed treatment

Some urologists feel that ADT works better if it is started as soon as possible after the diagnosis of advanced stage prostate cancer has been made, even if the patient is feeling well. These circumstances include the following: high stage (T3), high Gleason score, metastases to lymph nodes, and/or if the PSA starts rising after initial therapy. Alternatively, other urologists feel that because of side effects and the probability that the cancer could become resistant to ADT therapy sooner, treatment should not be started until after symptoms appear.

Intermittent vs. continuous hormone therapy

Since many prostate cancers treated with ADT become resistant after several years, some urologists advise intermittent (on-again, off-again) cycles of treatment. ADT is stopped once the PSA level drops to a low level and when the PSA level begins to rise, the ADT is re-started. An advantage of intermittent treatment is minimizing side effects of ADT, with the return of testosterone to near normal levels fostering better sexual function and less ADT side effects.

Wishing you the best of health,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Tags: Andrew Siegel MD, androgen deprivation therapy, hormonal therapy, LHRH analogs and antagonists, orchiectomy, prostate cancer, Prostate Cancer 20/20, testosterone, testosterone suppression

This entry was posted on September 21, 2019 at 7:32 AM and is filed under health and wellness. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.