This reference material is aimed at men who are receiving, or about to receive, hormone therapy as a treatment on its own or as part of a combination treatment plan for prostate cancer. It contains information to help you understand the important factors surrounding hormone therapy for prostate cancer. It may also benefit partners, family members or support networks so they may better understand what can be a confusing area of medical practice. The content herein can provide points to discuss with your healthcare team when you feel comfortable and ready to do so. Your team will consist of a number of health professionals with different expertise, and they work together to make sure you are supported. Each member brings specialist skills that are important in managing your care and making decisions around your treatment needs.
The way you experience prostate cancer is entirely personal. It’s not the same for every man, even if it’s the same type of cancer. Depending on the stage of your prostate cancer (and other conditions), your experience might actually be very different to somebody else’s. When it comes to dealing with prostate cancer, it’s important to take each stage as it comes. It means that you can breakdown an overwhelming situation in smaller (and more manageable) steps. For some, prostate cancer and the impact of treatment might be minimal and quickly resolved. But, for others, the impact can be more difficult to deal with, which may require more support.
You can use the information we provide as a guide for further discussions with your healthcare team. Being informed about hormone therapy for prostate cancer treatment will enable you to participate in decisions that will lead to improved experiences and better care.
What Are Male Sex Hormones?
Hormones are substances that are produced by glands in the body which function as chemical signals. They travel through the bloodstream and affect actions of cells and tissues all around the body. Androgens (male sex hormones) control the maintenance and development of male characteristics and sex drive. Testosterone and dihydrotestosterone (DHT in short) are the most abundant androgens in men. The majority of testosterone is produced in the testicles, but a small amount is also produced by the adrenal glands (small glands found above each kidney).
How Do Hormones Stimulate Prostate Cancer Growth?
Androgens are needed for the normal function and growth of the prostate. They are also necessary for cancer to grow in the prostate. Androgens promote the growth of both healthy and cancerous cells by activating the androgen receptor. Once activated, the receptor stimulates the expression of particular genes that contribute to the growth of prostate cells. Early-stage prostate cancer needs a high level of androgens in order to grow. Such prostate cancers are known as androgen sensitive (also referred to as androgen dependent or castration sensitive) because treatments that block androgen activity or decrease androgen levels can suppress the cancers growth. Prostate cancers that are treated with surgery or drugs that block androgens will eventually become castration resistant. What this means is that they can continue to grow even when androgen levels are low. Historically, these types of tumours were also called androgen independent, hormone resistant or hormone refractory. However, these terms are not really used in the modern-day because tumours that they become castration resistant may respond to newer antiandrogen treatments.
How Does Hormone Therapy Treat Prostate Cancer
Hormone therapy might be used in several different ways to treat prostate cancer, including early-stage prostate cancer, relapsed/recurrent prostate cancer and advanced or metastatic prostate cancer.
Early Stage Prostate Cancer
Men with early stage prostate cancer (localised prostate cancer) will often receive hormone therapy before, during and after radiation therapy. Or, in rare circumstances they might receive hormone therapy following a prostatectomy (surgery to remove the entire prostate gland). When it comes to early stage prostate cancer, factors are used to determine the risk of it returning following treatment. These factors include the tumour’s grade (which is measured using a grading system called the Gleason score), the extent to which the tumour has spread, and whether the cells are found close to the lymph nodes. The length of treatment with hormone therapy for a man with early stage prostate cancer depends on the risk of recurrence. Hormone therapy for intermediate-risk prostate cancer is usually given for a period of 6 months. But, when prostate cancer is graded as high-risk, it may be prescribed for 18-24 months, or longer. Men who receive hormone therapy after having a prostatectomy may have less likelihood of recurrence than with a prostatectomy alone. However, there is no substantive evidence that they will live longer overall. Men who receive hormone therapy after having radiotherapy for intermediate or high-risk prostate cancer live longer overall without recurrence than men who just have radiotherapy.
The use of hormone therapy in early-stage prostate cancer is to essentially shrink the tumour to a size where treatment can be more effective and cause fewer side effects. Its use in surgery and radiotherapy is well established, and studies are also being carried out to see if it would be useful for patients undergoing ablation treatments such as HIFU (High intensity Focused Ultrasound) and Cryotherapy.
Relapsed/Recurrent Prostate Cancer
Hormone therapy is a standard treatment for men who have a prostate cancer recurrence after having radiotherapy or a prostatectomy. It is sometimes also recommended for men who have a biochemical recurrence or an increase in the prostate-specific antigen (PSA) level following surgery or radiotherapy (especially if the PSA level doubles in less than 3 months).
Advanced or Metastatic Prostate Cancer
Essentially prostate cancer when it spreads to other parts of the body remains a prostate cancer; in other words, it does not transform into another type of cancer. Hormone therapy therefore is used as a standard treatment for men who have metastatic prostate cancer (the cancer has spread to other areas of the body) when it is first diagnosed. It is used to shrink the cancer even if it has spread to other tissue, bones or organs. At this point it is not used as an aid to treat the cancer, but it can help to keep it under control (sometimes for a number of years). It can also help manage the symptoms of advanced or metastatic prostate cancer such a bone pain. How long hormone therapy controls for this grade of prostate cancer for varies from case and to case. It depends on how far the cancer has spread and how aggressive it is when treatment begins.
The Different Types of Hormone Therapy
The type of hormone therapy that men receive will depend on whether their cancer has spread, other treatments they are currently having, and their personal preference. It is possible to receive more than one type of hormone therapy simultaneously.
Implants or Injections
This type of hormone therapy is medically known as androgen deprivation therapy (ADT in short). It works by stopping the brain from telling the body to produce testosterone and is just as effective at controlling prostate cancer as surgically removing the testicles. Both implants and injections are administered via a needle. Injections are given in a way that is similar to a vaccination where liquid is injected into the muscle or under the skin. Men that receive injections will typically have them in their abdomen (stomach area), arm(s), thigh(s) or buttock, but it does depend on type of injections they are receiving. Implants, however, are administered via a larger needle that places a tiny tube that sits under the skin which releases the drug slower than an injection would.
LHRH (Luteinizing Hormone-Releasing Hormone) agonists are the most common type of implant or injection. They are used to effectively chemically castrate men.
When androgen levels are low, this causes the pituitary gland (a gland in the brain that controls hormones) to produce luteinizing hormones which stimulates the testes to produce androgens.
There are several different types of LHRH agonists that used in the UK, including:
GnRH (Gonadotrophin Releasing Hormone) antagonists are used less than LHRH agonists. GnRH antagonists can also be known as GnRH blockers. In the UK, there is one type currently available which is called Degarelix (Firmagon). It can be used as a first treatment for advanced or metastatic prostate cancer that has spread to the bones. It can also prevent metastatic spinal cord compression (MSCC for short), which can occur if cancerous cells grow in or near the spine.
This type of hormone therapy is used to reduce the ability of androgens to stimulate the growth of cancerous prostate cancer cells. It doesn’t lower the overall androgen level in the body and is usually used in combination with LHRH agonists. There are a few different types of antiandrogens that are used in the UK, which are:
Before we explain this type of hormone therapy, please note that even though it is medically classed as a type of hormone therapy, it is in fact, surgery. An orchidectomy is radical surgery to remove the testicles, or parts of the testicles that produce testosterone. It is not used as often as other types of hormone therapy. It is very effective at reducing testosterone levels which normally drop to their lowest very quickly. However, an orchidectomy can’t be reversed, so it is only offered as an option to men who require long-term hormone therapy.
How Will I Know That Hormone Therapy Is Working?
Unfortunately, doctors predict how long hormone therapy will be effective for in suppressing the growth of prostate cancer. Because of this, men who receive hormone therapy for more than a couple of months are tested on a regular basis to determine the level of PSA in their blood. An increase in PSA may indicate a man’s prostate cancer has started growing again. A PSA level that continues to increase while hormone therapy keeping androgen levels low is an indicator that a man’s prostate cancer may have become resistant to hormone therapy.
Intermittent Hormone Therapy
If a man is receiving life-long hormone therapy and experiencing problems with the side effects, they may be able to have intermittent hormone therapy instead. This involves halting the hormone therapy when their PSA level is low enough, and then starting it again if the PSA level rises or if the symptoms get worse.
Potential Side Effects Of Hormone Therapy
Like all hormone therapy for prostate cancer there can be side effects. Not all men experience side effects in the same way. Side effects are also not an indicator that treatment isn’t working. Some men find that their side effects get easier to cope with the longer they’re on hormone therapy. Sides effects can include:
- Depression and Anxiety
Some men experience depression and anxiety while on hormone therapy. The therapy itself can cause this, or because they have prostate cancer (or a combination of both). Another contributing factor can also be the impact that the cancer and hormone therapy might be having on their personal relationships.
- Weight Gain
Some men find that they put on weight while on hormone therapy, particularly around their waistline. Hormone therapy affects the way the body metabolises food which can cause this. Physical changes can be difficult to deal with, particularly if a man has never had any problems with their weight in the past.
- Breast Tenderness and Swelling
Hormone therapy can cause tenderness and swelling (gynaecomastia) in a man’s breasts. It is caused when testosterone and oestrogen levels change. Tenderness can affect one or both breasts and can sometimes cause long-lasting pain. Enlargement that is entirely due to adipose (fatty) tissue is called pseudogynaecomastia.
- Hot Flushes
Hot flushes are one of the most common sides effects of men on antiandrogens or LHRH agonists. They can differ from a few seconds of feeling overheated to hours of sweating, which can be uncomfortable to experience. Hot flushes can be similar to the ones that women get when they are going through the menopause.
Hormone therapy for prostate cancer can cause various levels of tiredness (fatigue) from mild to severe. Some men find that this effects the way they live their day-to-day life. It can affect energy levels, motivation and emotions. Some men find that tiredness can come on quite suddenly, which means that there needs to be caution in some situations; for example, when driving.
- Loss of Bone Mass
Long-term hormone therapy can cause bones to lose their bulk because testosterone helps to keep them strong. GnRH antagonists, LHRH agonists and an orchidectomy (surgery to remove the testicles) can all have this effect. Antiandrogens as less likely to cause a loss of bone mass.
- Erectile Dysfunction
Lower amounts of testosterone can cause issues with getting and maintaining an erection which is known as erectile dysfunction. Other prostate cancer treatments, such as radiotherapy and surgery, can also cause erection problems.
- Muscle Mass Loss
Testosterone plays a major role in how men’s bodies are physically made up. Hormone therapy can cause a decrease in muscle mass and an increase in body fat. This can change the way the body looks. Some men can also experience aches and pains in their muscles while they are on hormone therapy.
- Loss of Body Hair
Some men lose body hair while on hormone therapy. This is because testosterone plays a key role in the growth of hair. It is less common for men to lose hair from their head, but if this does happen, it normally grows back once they stop their hormone therapy.
- Lack of Libido
A lack of libido (reduced interest in sex) is common for men on hormone therapy for prostate cancer. However, it is often caused by anxiety and fatigue rather than the therapy itself (although, it can contribute to it). Most men notice their sex drive returns when their hormone therapy ends, but for some, it’s an on-going problem.
- Problems Concentrating
Men who are currently on hormone therapy might find it difficult to concentrate or focus on specific tasks. However, there isn’t much evidence to suggest that this is directly caused by hormone therapy. For example, feeling depressed and stressed is normal for men with prostate cancer and can affect concentration levels and memory.
Side effects normally last for as long as a man is on hormone therapy. They normally improve once testosterone levels start to rise again. Depending on the type of therapy, this could take months or several years, and for some, the side effects may never go away completely. But, this ultimately depends on the type of hormone therapy, how long a man has it for, and what other treatment they are receiving at the same time.
What Can Be Done to Reduce the Side Effects?
Men who experience loss of bone mass during long term hormone therapy might be prescribed medication to slow down or reverse it. Exercise may also help to reduce side effects, including loss of bone mass, weight gain and fatigue. The sexual side effects of hormone therapy can be some of the hardest to deal with. Medication such as Viagra doesn’t normally work for men who are undergoing hormone therapy because it does not address the loss of libido that is caused by a lack of androgens. When men stop taking hormone therapy, the loss of libido will eventually go away. However, if hormone therapy has been used for a number of years, then these side effects may not completely disappear.
Does Hormone Therapy Help With HIFU?
Hormone therapy is sometimes given to men for about 2 to 3 months prior to HIFU (high-intensity focused ultrasound). It can make the prostate gland smaller and ultimately easier to treat. Some men may also be offered an operation called transurethral resection of the prostate (TURP) which removes prostate tissue to improve urine flow. It is sometimes used before a man receives HIFU to reduce the risk of urinary issues following the treatment. However, please note that if a man has a large prostate, they might be offered alternative treatments before receiving HIFU. The grade of the prostate cancer and Gleason score will also be used to determine the best course of treatment.
How Does HIFU Treat Prostate Cancer?
High-intensity focused ultrasound (HIFU) is a non-invasive procedure that uses high-frequency ultrasound energy to heat and destroy cancerous prostate cells. Ultrasound energy travels into the prostate gland from a transducer (transrectal probe) that enters through the back passage (rectum). The basic concept of how HIFU works is that it targets, burns and destroys cancerous prostate tissue similar to the way a magnifying glass can use the sun’s rays to burn a hole in a leaf. However, instead of using light as a source of energy, HIFU uses sound. When the sound waves are aimed at the prostate, they increase tissue temperature, only destroy cancerous cells and protect the surrounding healthy tissue.
HIFU can be suitable for men whose cancer is still within their prostate (localised prostate cancer). It can sometimes also be an option if the cancer has started to break out of the prostate or has spread to the tissue that surrounds the prostate (locally advanced prostate cancer). It is not an option if the cancer spread outside of the prostate and to other areas of the body (advanced prostate cancer). HIFU can also be used to treat prostate cancer that has returned after a man receives radiotherapy (recurrent prostate cancer). This is known as salvage HIFU but is only a treatment option for men with localised or locally advanced prostate cancer.
What Happens During the HIFU Procedure?
A typical HIFU procedure takes about 1 to 1 and a half hours. However, it does depend on the size of a man’s prostate and how much of it is being treated. Some HIFU procedures can take up to 3 hours. Once under anaesthetic, a surgeon will place a thin, hollow tube called a catheter into the bladder. This will be placed either through the penis (urethra) or through the wall of the abdomen (stomach area). The surgeon will then place the transducer (transrectal probe) into the man’s back passage. The transducer will then give out beams of ultrasound waves that will kill the cancerous prostate cells. The surgeon will use ultrasound scanning throughout the procedure to ensure that the transducer is in the right position and targeting the right area of the prostate. The transducer only treats a very small area at a time (but with pinpoint accuracy), so the surgeon will move it until all cancerous tissue has been destroyed. Most men are able to go home on the same day that they receive HIFU. A doctor or nurse will check that they have recovered from the anaesthetic and that they are fit enough to go home. Before leaving the hospital, they will also be shown how to look after their catheter, which will remain in place (usually for a week) to help with passing urine.
What Happens Following HIFU?
Following HIFU, men will have regular check-ups with their doctor or nurse at the hospital to begin with, and then with their GP. The purpose of these check-ups is to:
- Monitor how the cancer has responded to HIFU
- Deal with any side effects that men might be experiencing
- Allow men to ask questions or raise concerns.
A PSA test will also be carried out every 3 to 6 months for the first couple of years following HIFU to determine how well it has worked. A PSA level is most likely to reach its lowest within a few months following the treatment. A steady rise in a PSA level can be a sign that the prostate cancer has come back. If it does come back, then a doctor or nurse will discuss further treatment options. Some men may also need to have other tests such as an MRI scan, CT scan or bone scan. These are to determine whether the prostate cancer has spread to other parts of the body.
Why Prost8 UK Are Campaigning For HIFU
At Prost8 UK, we strongly believe in campaigning for less invasive treatments for prostate cancer like HIFU (and cryotherapy) for men with early-stage prostate cancer. We also campaign for earlier awareness of the symptoms of prostate cancer through newer, simpler and more accurate cancer screening. If you would like to support our cause and help us help all men in the UK, then please make a donation today via the website, or by calling 0203 858 0848.