I came across the following in my research and it gave me some reason to pause and reconsider the way forward!
I'm due to see my Urologist on 14 February, we'll have a bit to talk about I think. On 8 February, I am due to have my next PSA test - hoping that the result is a continued improvement.
After 3 months [almost] on Hormone Therapy, I have seen my PSA level drop from '84.8' to '12' and [hopefully] to zero [or close to it] - this time.
Advanced Cancer
Patients with advanced prostate cancer are generally men who have extensive disease in the pelvis [No], metastases in the lymph nodes [No] or bone [No] or a PSA level greater than 50 ng/mL [Yes, 84.8 ... hmm, definitely me] or men in whom local treatment has failed [No].
Bilateral orchidectomy is the gold standard for testosterone reduction. However, although it offers immediate relief from metastatic pain and eliminates problems of compliance, orchidectomy is psychologically unacceptable to most men. Hormone therapy is the mainstay of treatment in this group.
When hormone therapy is commenced, the vast majority of patients get excellent initial symptomatic relief, even in the presence of painful metastases. Regular PSA measurements are the best way to monitor response. Some patients elect to delay hormone therapy in the interest of avoiding side effects. These men may have had a PSA recurrence after failed initial therapy or be older asymptomatic men with metastatic disease.
In patients who have less advanced disease the cancer ultimately becomes refractory [resistant] to hormone therapy' (after three to five years, or even longer).
Most patients who develop hormone refractory disease die within 12 months.
Which hormones should be used?
Leuprorelin acetate (Lucrin) and goserelin acetate (Zoladex), which are LHRH analogues, are commonly used for chemical castration. However, these agents cause an initial testosterone flare that should be prevented with concomitant use of an antiandrogen for the first two to four weeksí duration. LHRH analogues are available in monthly, three-monthly and, more recently, four-monthly depot preparations.
The nonsteroidal antiandrogens flutamide (Eulexin, Flutamin, Fugerel), bicalutamide (Cosudex) and nilutamide (Anandron) have similar action. These agents are generally used in association with LHRH analogues, but can be used alone in sexually active men to sometimes prevent impotence. Careful monitoring of liver function tests is essential in patients taking antiandrogens.
Cyproterone acetate (Androcur, Cyprone, Procur) is a steroidal antiandrogen that can be used alone or with LHRH analogues. Oestrogens have fallen out of favour because of their cardiovascular side effects.
Should hormones be commenced immediately or later, or intermittently?
Immediate hormone therapy is appropriate for symptomatic patients; however, its timing in asymptomatic patients remains controversial. There is increasing evidence to suggest that earlier use of hormone therapy improves survival, but this benefit must be balanced against side effects.
Most patients choose immediate therapy, although older asymptomatic patients may choose delayed therapy after informed consent. Patients with a PSA recurrence after previous failed surgery or radiotherapy often opt for a period of observation to ascertain the rate of PSA rise prior to commencing hormone therapy.
The use of intermittent hormone therapy has become increasingly popular in patients with less advanced disease. Although the benefits of intermittent therapy are less proven, it clearly improves quality of life in patients with less advanced disease who are destined to use hormones for very long periods.
The aim of this therapy is to depress PSA to undetectable levels, wait until it rises again to a predetermined level (such as 10 ng/mL), then commence a further pulse of hormones. This approach gives patients longer periods free of side effects of hormone therapy, such as impotence, depression, lethargy and osteoporosis.
How should hormone therapy be monitored?
Hormonal therapy is best monitored by regular measurement of PSA levels. To assess effectiveness in suppressing testosterone, a serum testosterone can be used and, if not completely suppressed, an anti-androgen can be added. A combination of castration (medical or surgical) and anti-androgen therapy may be used to block both testicular and adrenal androgen activity.
Since the results of major trials have recently become available, enthusiasm for this combination has decreased, but it still tends to be used in young men with early metastatic disease.
How should side effects of hormone therapy be managed?
The side effects of hormones must be managed individually. Hot flushes may be treated with cyproterone, clonidine (Catapres 100) or oestrogen; lethargy may be improved by giving hormones intermittently. Osteoporosis may develop in patients destined to use hormone therapy for long periods; in this group, bone density should be checked at 12 months and therapy such as intravenous or oral bisphosphonates should be used if significant deminerali-sation is present.
What can we do when hormones no longer work?
When hormone therapy fails, most treatment is palliative. Serum testosterone should always be checked to ensure hor-mone therapy has been achieving castrate levels of testosterone. Therapeutic options include:
Localised radiotherapy or strontium-89 (Metastron) radiotherapy to painful metastatic deposits - second-line hormone therapy - chemotherapy - cyclophosphamide (Cycloblastin, Endoxan-Asta), mitozantrone hydrochloride (Mitozantrone Injection, Novantrone, Onkotrone), docetaxel (Taxotere) - corticosteroids and pain relief.
A team approach to palliation is important to provide maximal quality of life in men who have hormone refractory cancer, and may include antidepressants, psychological support and hospice services. Promising new approaches include gene therapy, antiangiogenesis drugs such as thalidomide, immunological approaches, and growth factor blocking drugs.
Conclusion
It is mandatory to tailor therapy for prostate cancer to the individual. Modern treatments, including newer surgical techniques and improved conformal delivery of radiotherapy, have resulted in a significant decrease in side effects and improved outcomes. Further knowledge about biochemical markers, the results of new and improved techniques and more established results of known treatments will help us to individualise treatment, resulting in better control of the disease and fewer side effects.
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