Fatigue in People with Cancer

What is fatigue?

Fatigue is feeling tired -- physically, mentally, and emotionally. It means having less energy to do the things you normally do or want to do. It can be caused by cancer, cancer treatment, and other factors. Fatigue can last a long time and can affect your day to day activities.

The fatigue that comes with cancer is different from the fatigue of everyday life. Everyday, normal fatigue is most often a short-term problem that gets better with rest. Cancer-related fatigue is worse and it causes more distress. Rest does not make it go away. And even a small amount of activity may make you feel exhausted. For some people, this kind of fatigue can cause even more distress than pain, nausea, vomiting, or depression. Cancer-related fatigue can:

* Differ from one day to the next in how bad it is and how much it bothers you
* Be overwhelming and make it hard for you to feel well
* Make it hard for you to be with your friends and family
* Make it hard for you to do your normal activities, including going to work
* Make it harder for you to follow your cancer treatment plan
* Last different lengths of time, which makes it hard to guess how long yours will go on

Cancer patients say fatigue is the most distressing side effect of cancer and its treatment -- it can have a major affect on a person's quality of life.


Fatigue is very common in people with cancer

Cancer-related fatigue is the most common side effect of cancer and cancer treatment. Research suggests that anywhere between 70% to 100% of cancer patients getting treatment have fatigue. And about 30% to 50% of cancer survivors have reported fatigue that lasts for months or even years after they finish treatment.

Even though fatigue is a very distressing symptom, doctors and nurses seldom focus on it, and patients and caregivers rarely report it. It may be hard to talk about, but fatigue is normal and common for people with cancer. There are things that can be done to help if your health care team knows you are having this problem.


Talk about your fatigue

Treating fatigue is an important part of care for you and your family. But before anything can be done to help you, your health care team must know about your level of fatigue, or how bad your fatigue is.

People with fatigue describe it in many ways. They may say they feel tired, weak, exhausted, weary, worn-out, or slow; have no energy; and cannot concentrate. They also talk about having heavy arms and legs; little drive to do anything; being unable to sleep or sleeping too much; or feeling moody, sad, irritable, or frustrated. Patients rarely describe their symptom as "fatigue" unless their health care team suggests it.

Only you know if you have fatigue and how bad it is. No laboratory tests or x-rays can diagnose or show your level of fatigue. The best measure of fatigue comes from your own report of your fatigue level to your health care team. But fatigue can be hard to describe.

You can describe your level of fatigue as none, mild, moderate, or severe. Or you can use a scale of 0 to 10, where a 0 means no fatigue at all, and a 10 means the worst fatigue you can imagine. Talk to your doctor or nurse about how to describe your fatigue so they can understand how it is affecting your everyday life.


How bad is your fatigue?

If you have moderate (4 to 6) to severe (7 to 10) fatigue, your doctor may ask you to give as much information as you can about your fatigue. You may be asked questions like:


When did the fatigue first start?

* When did you first notice that this fatigue is different than usual for you?
* How long has it lasted?
* Has it changed over time? How so?
* Does anything make it better? Worse?
* Do you have any other problems or concerns?
* How has the fatigue affected the things you do every day or the activities that give meaning and enjoyment to your life?

In planning how to treat your fatigue, your doctor may take into account your cancer, the type and length of treatment, how likely the treatment is to cause fatigue, and your response to treatment.


What causes fatigue in people with cancer?

Cancer itself can cause fatigue directly by spreading to the bone marrow, causing anemia (low red blood cell count), or indirectly, by forming toxic substances in the body that change the way normal cells work.

Fatigue is also very common with many cancer treatments, such as chemotherapy, radiation therapy, bone marrow transplant, and immunotherapy. Cancer treatments often kill fast-growing healthy cells, especially the blood-making cells in the bone marrow. This causes fatigue because red blood cells carry oxygen to fuel all the cells in the body.

Too few red blood cells (anemia) means too little energy to meet the body's needs. Treatments can kill normal cells and cancer cells, which leads to a build-up of cell waste. The body needs extra energy to clean up this waste and repair damaged tissue.


Here are some questions about fatigue and your cancer treatment that you may want to ask:

* Will the cancer treatment that I am getting cause fatigue?
* How bad will my fatigue likely get?
* Are there ways to control my fatigue or make it better?
* If my fatigue gets bad, how will you decide how to treat it?
* What can be done if the treatment does not make my fatigue better?
* What are the likely side effects of the treatments for fatigue?
* What other health care professionals can help manage my fatigue?
* Is my fatigue caused by anemia? If so, how will it be treated?

Other things that can affect fatigue

Fatigue is different for every cancer patient. Many treatment-related and disease-related factors have been linked to fatigue, but doctors still don't know exactly what causes cancer-related fatigue.

There are some other factors that often worsen fatigue, and you should be checked for them. Managing these factors can greatly help reduce the fatigue.

* Anemia
* Pain
* Emotional distress (including depression and anxiety)
* Sleep problems
* Medicines you are taking that could worsen your symptoms
* Other medical problems (such as infection; low thyroid function; and heart, lung, liver, kidney, or nervous system disease)
* Nutrition problems
* Low level of physical activity

Anemia

A low red blood cell count is called anemia (uh-nee-me-uh). Your red blood cell count will be measured with a blood test called a CBC. (CBC stands for complete blood count.) Doctors often define anemia as a blood hemoglobin (Hb) level of less than 12 g/dL (grams per deciliter). But many people do not feel much different until the hemoglobin level falls below 11 g/dL. Symptoms of anemia get worse as the hemoglobin gets lower. These symptoms can include:

* Rapid heart beat
* Shortness of breath
* Trouble breathing on exertion (such as when walking or climbing stairs)
* Dizziness
* Pale skin
* Fatigue

There are many different causes of anemia. Your health care team will try to find out the cause of your anemia so they can give you treatment that makes it better.


Pain

Cancer pain can make you less active, decrease your appetite, cause sleep problems, and cause depression -- all of which can lead to fatigue. Cancer pain should not be accepted as part of cancer treatment. There is always something that can be done to make pain better.

For more information about treating cancer pain, talk to your doctor or nurse. You can also learn more in our document, Pain Control: A Guide for People With Cancer and Their Families.


Emotional distress

People diagnosed with cancer go through many unpleasant emotions. There are many different types of feelings, from anger to depression, but their overall effect is distress. Distress can include a feeling of sadness about the loss of good health or fear of what will happen in the future. These are normal feelings. But sometimes the distress becomes so great that it causes physical problems like fatigue. Depression and anxiety are common types of distress that can cause the physical symptom of fatigue.


Sleep problems

If you wake up often during the night, have trouble falling asleep, or wake up early in the morning and cannot go back to sleep, you are most likely not getting the rest you need. This change in your sleep can lead to fatigue. Tell your doctor or nurse about your sleeping problems. They will try to find out why you are having trouble sleeping so they can help plan the best treatment for this problem.


Medicines

Many medicines can cause symptoms of fatigue and problems with thinking. This includes over-the-counter drugs, vitamins, herbs, and other supplements, as well as prescription medicines. The drugs most likely to cause fatigue are pain medicines; sleep medicines; anti-depressants; and anti-nausea and anti-seizure medicines. Some heart medicines can also cause fatigue. The degree of sleepiness varies from patient to patient. Taking many drugs with many side effects may make fatigue worse, too. It is important to tell your health care team about all vitamins, herbs, supplements, and medicines you are taking. Keeping a journal may help you keep track of your medicines and symptoms.


Other medical problems

Many people have other medical problems or illnesses that are not related to cancer, but may add to fatigue. These illnesses should be identified and treated. Examples of other medical problems that may be part of fatigue are:

* Heart problems, such as congestive heart failure
* Lung problems, such as emphysema or shortness of breath
* Kidney problems, such as kidney failure
* Brain problems, such as seizures or dementia
* Infections, such as pneumonia or viral illnesses
* Low thyroid function

Low thyroid gland function is very common in people in the United States. Anyone with fatigue should be tested for this. Blood tests are done to find out how much thyroid hormone is present in the blood. If the level of thyroid hormone is low, treatment can be given to replace the thyroid hormone so that the body gets what it needs.


Poor nutrition

The body needs protein, carbohydrates, fats, vitamins, minerals, and water to do its work. In people with cancer, changes in nutrition can affect fatigue. These changes include how well the body can process nutrients; the need for more energy than usual; and poor intake of food, fluids, and certain minerals. The changes can be caused by:

* Changes in metabolism (the body's ability to break down and use food)
* The need to repair damaged cells
* Uncontrolled tumor growth competing for nutrients
* Poor appetite
* Nausea and vomiting
* Diarrhea

You may have blood tests to measure things like sodium, potassium, calcium, and magnesium -- these are important minerals that your body needs. You may ask to be referred to a registered dietitian who can help you learn how to best meet your nutrition during this time.

You can find more information on nutrition in our document, Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families.


Inactivity

Cancer treatment along with less physical activity can make you less able to do the things you used to do. And you may find that it takes much more effort and more energy to do the things you need to do. This can worsen fatigue. Physical exercise can help you build up your energy level. If you have more energy, it can help you do your usual activities and have less fatigue. Talk to your doctor before you start any exercises. A careful work-up by a physical therapist can help plan the right exercise program for you.

You can find more information in Nutrition and Physical Activity During and After Cancer Treatment: Answers to Common Questions.


Treating fatigue

Many health professionals may be part of fatigue treatment. Treatment may involve doctors, nurses, social workers, physical therapists, nutritionists, and a number of others. Education and counseling are part of the treatment and help you learn how to save energy, reduce stress, and use distraction to think about things other than the fatigue.

Fatigue is often caused by more than one problem. Treating a certain problem, like anemia, may make you feel better, but other things may still need to be done. For this reason your health care team may have you try many different things to ease your fatigue. These may or may not include medicines.

If the cause of fatigue is known, treatment will focus on the cause. For example, if anemia is adding to your fatigue, the anemia can be treated. In another patient, treatment may include correcting fluid and mineral imbalances. A program of regular exercise, managing your stress, and finding ways to deal with anxiety and depression seem to work the best in dealing with fatigue. Still, treating sleep problems and correcting nutrition problems can help decrease fatigue, too.


Tips for managing fatigue

* Save your energy

Saving or conserving energy is one way to make sure you have enough energy to do what needs to be done on a daily basis. You may need to accept the fact that you can't do everything you want to do at your current level of energy. Each day, decide which things are the most important to do and focus on those tasks. Do things slowly, so that you will not use too much energy as you go. Let others help you. This can help them feel useful and get your tasks done, too.

* Distraction

Sometimes feeling tired can become so discouraging and frustrating that it's easy to let it become the focus of your thoughts. Try to distract yourself with other things, like listening to music, having relaxing visits with friends or family, or reading a book. These things can give you an escape from your fatigue without using up too much energy.

* Attention-restoring activities

Certain activities can help you relax, focus better, and direct your attention under stress. These activities include things like walking on a beach, sitting in a peaceful setting, gardening, doing volunteer activities not related to your illness, or bird watching.

* Reduce stress

Having cancer is stressful and cancer treatment can cause even more stress. Talk with a social worker or nurse on your health care team about your level of stress. This can help you know if it is "normal" stress or more worrisome anxiety or depression. Feeling tired may be related to feeling depressed and anxious. Support groups, mental health counseling, stress management training, and relaxation exercises are some ways you can improve the feelings related to fatigue and help you overcome the tiredness you feel.

* Exercise

Research has shown that there are some ways to improve your energy and activity level that do not involve medicine. An aerobic exercise program -- started only with your doctor's OK -- can lead to better heart and lung function, as well as more positive feelings about your life and well-being. You may need to see a physical therapist to learn the best exercise routine for you to follow at this time. You must be careful about any form of exercise if you have any of these:

* Bone metastasis (cancer that has spread to your bones)
* A low white blood cell count
* A low platelet count
* A fever
* Anemia

These factors can lead to more physical problems if they are not taken into account when planning an exercise program.

Not only can the right amount and type of exercise help fatigue, it can also help you sleep better. Another benefit of exercise is that it may make your mood better, too.


Nutritional counseling

Many cancer patients have changes in the way they eat, swallow, and taste during treatment. Talking with a registered dietician may help you learn ways to manage problems like loss of appetite, diarrhea, nausea, or vomiting. A nutritionist also can make sure you are getting enough fluids and nutrients so that your blood chemistry is balanced.


Sleep improvement

Sleep problems are common during cancer treatment. You may have trouble falling asleep or sleep too much. Sleep experts tell us that having a regular time to go to bed and get up helps us keep a healthy sleep routine. Avoiding caffeine in fluids (like coffee or soda), or even in foods (like chocolate) can help, too. Do not exercise too late in the evening; this may cause sleep problems. Naps may be needed, but try to keep them short (less than 45 minutes long) and early in the day so they don't interfere with nighttime sleep.


Medicines

There is no magic pill that can make you less tired and give you more energy. But there are some medicines that may help you with your fatigue. In some cases, fatigue may be bad enough that your doctor or nurse may recommend a stimulant medicine for a short period of time. Examples of this type of medicine are methylphenidate hydrochloride (Ritalin®) or modafanil (Provigil®). Anti-depressant drugs and steroids have also been used to ease fatigue. If you are having problems sleeping, your doctor or nurse may suggest a medicine to help you sleep.

More research is needed and is being done in this area, but there are drugs available that may give you relief if your fatigue gets bad.


Coping with fatigue

Learning about fatigue patterns, how bad it might be, and how long it may last are key parts of dealing with fatigue. Many times, a family member who learns with you can help you talk to your health care team about your fatigue.

Here is a recap of things you can do to manage and reduce your fatigue:

* List your activities in order of how important they are to you, so you can do the more important ones when you have the most energy.

* Ask for help and have other people do tasks for you when possible.

* Put things that you often use within easy reach.

* Set up and follow a structured daily routine, keeping as normal a level of activity as possible.

* Balance rest and activity. Too much time in bed can make you weak. Try to avoid it. Schedule activities so that you have time for plenty of rest that does not interfere with nighttime sleep. Shorter rest periods are reported to be better than one long one.

* Learn ways to deal with your stress. Try to reduce it using things like deep breathing, imagery, meditation, prayer, talking with others, reading, listening to music, painting, or any other things you like to do.

* Keep a record of how you feel each day. Take it with you when you see your doctor.

* Talk to your doctor about how to manage any pain, nausea, or depression you may have.

* Talk to your doctor about physical exercise before you start an exercise program.

* Get fresh air, if possible.

* Unless you are given other instructions, eat a balanced diet that includes protein (meat, milk, eggs, and beans) and drink about 8 to 10 glasses of water a day.

The best thing you can do for fatigue is talk to your doctor or nurse about it. Let them know how bad it is so you can get the help you need to deal with it.


Watch for signs of fatigue

Here is a list of some signs of fatigue that you and your family can watch for. Talk to your doctor if you have any symptoms of fatigue.

* You feel tired and it does not get better, it keeps coming back, or it becomes severe.

* You are more tired than usual during or after an activity.

* You are feeling tired and it is not related to an activity.

* Your tiredness does not get better with rest or sleep.

* You sleep more.

* You become confused or cannot concentrate or focus your thoughts.

* You have no energy.

* You are unable to get out of bed for more than 24 hours.

* Your tiredness disrupts your work, social life, or daily routine.

* You have no desire to do the things you normally do.

* You feel negative, sad, or irritable.

Fatigue can lead to distress. It can interfere with your daily activities and keep you from doing the things you need and want to do. Fatigue can make you unable to take care of yourself, affect your will to do things, and sometimes make you feel like you cannot continue your cancer treatment. Work with your health care team to find and treat the causes of your fatigue.

Remember: There is no one way to diagnose or treat fatigue. The best treatment for you is most likely to be found through open discussions with your doctor and your nurse.

Hormone (Androgen Deprivation) Therapy

Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of the male hormones, called androgens, in the body. The main androgens are testosterone and dihydrotestosterone (DHT). Androgens, produced mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels often makes prostate cancers shrink or grow more slowly. However, hormone therapy does not cure prostate cancer.


Hormone therapy may be used in several situations:

* If you are not able to have surgery or radiation or can't be cured by these treatments because the cancer has already spread beyond the prostate gland
* If your cancer remains or comes back after treatment with surgery or radiation therapy
* As an addition to radiation therapy as initial treatment if you are at high risk for cancer recurrence
* Before surgery or radiation to try and shrink the cancer to make other treatments more effective

Types of Hormone Therapy

There are several types of hormone therapy used to treat prostate cancer.

Orchiectomy (surgical castration): Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where more than 90% of the androgens, mostly testosterone, are made. With this source removed, most prostate cancers stop growing or shrink for a time.

This is done as a simple outpatient procedure. It is probably the least expensive and simplest way to reduce androgen levels in the body. But unlike some of the other methods of lowering androgen levels, it is permanent, and many men have trouble accepting the removal of their testicles. Some men having the procedure are concerned about how it will look. If wanted, artificial silicone sacs filled with saline (salt water) can be inserted into the scrotum. These look and feel like testicles.

Possible side effects of orchiectomy are generally related to changing levels of hormones in the body. About 90% of men who have had this operation have reduced or absent libido (sexual desire) and impotence. Some men also experience:

* Hot flashes (these may go away with time)
* Breast tenderness and growth of breast tissue
* Osteoporosis (bone thinning) which can lead to broken bones
* Anemia (low red blood cell counts)
* Decreased mental acuity (sharpness)
* Loss of muscle mass
* Weight gain
* Fatigue
* Decrease in HDL ("good") cholesterol
* Depression

Many of these side effects can be prevented or treated. For example, sometimes the hot flashes will be helped by treatment with antidepressants. Brief radiation treatment to the breasts before surgery can help prevent their enlargement.

Men getting this treatment should be watched and treated for osteoporosis to help prevent broken bones. There are several different drugs available. Exercise is a good way to reduce fatigue, weight gain, and the chance of loss of bone and muscle mass. If anemia occurs, it is often very mild and usually doesn't cause symptoms. Depression can be treated by antidepressants and/or counseling.

Luteinizing hormone-releasing hormone (LHRH) analogs: Even though LHRH analogs (also called LHRH agonists) cost more and require more frequent doctor visits, most men choose this method over orchiectomy. These drugs lower testosterone levels just as well as orchiectomy by lowering the levels of androgens (mainly testosterone) made by your testicles.

LHRH analogs are injected or placed as small implants under the skin. They are given either monthly or every 3, 4, 6, or 12 months. The LHRH analogs available in the United States include leuprolide (Lupron, Viadur, Eligard), goserelin (Zoladex), and triptorelin (Trelstar).

Possible side effects of LHRH analogs such as hot flashes, osteoporosis, and others are similar to those of orchiectomy (see above), and are largely due to low testosterone levels.

When LHRH analogs are first given, testosterone production increases briefly before falling to very low levels. This effect is called flare and results from the complex way in which LHRH analogs work. Men whose cancer has spread to the bones may experience bone pain. If the cancer has spread to the spine, even a short-term increase in growth could compress the spinal cord and cause pain or paralysis. Flare can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH analogs. (For more on anti-androgens, see below.)

Luteinizing hormone-releasing hormone (LHRH) antagonists: A newer drug, abarelix (Plenaxis), is an LHRH antagonist. It is thought to work like LHRH agonists, but it appears to reduce testosterone levels more quickly and does not cause tumor flare like the LHRH agonists do.

A small percentage of men (fewer than 5%) have serious allergic reactions to the drug. Because of this, it is only approved for use in men who have serious symptoms from advanced prostate cancer and who cannot or refuse to take other forms of hormone therapy.

The possible side effects are similar to those with orchiectomy (see above) or LHRH agonists.

Abarelix is given only in qualified doctors' offices. It is injected into the buttocks every 2 weeks for the first month, then every 4 weeks. You will be asked to remain in the office for 30 minutes after the injection to make sure you are not having an allergic reaction.

Anti-androgens: Anti-androgens block the body's ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, a small amount of androgens is still made by the adrenal glands.

Drugs of this type, such as flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron), are taken daily as pills.

Anti-androgens are not often used by themselves (see below). An anti-androgen may be added if treatment with orchiectomy or an LHRH analog is no longer working by itself.

Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH analog alone. If there is a benefit, it appears to be small.

Some doctors are testing the use of anti-androgens instead of orchiectomy or LHRH analogs. Several recent studies have compared the effectiveness of anti-androgens alone with that of LHRH agonists. Most found no difference in survival rates, but a few found anti-androgens to be slightly less effective.

If hormone therapy including an anti-androgen stops working, some men seem to benefit for a short time from simply stopping the anti-androgen. Doctors call this the "anti-androgen withdrawal" effect, although they are not sure why it happens.

Side effects of anti-androgens in patients already being treated by orchiectomy or with LHRH agonists are usually not serious. Diarrhea is the major side effect, although nausea, liver problems, and tiredness can also occur.

The major difference from LHRH agonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone libido and potency can often be maintained.

Other androgen-suppressing drugs: Estrogens were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been largely replaced by LHRH analogs and anti-androgens. Still, estrogens may be tried if androgen deprivation is no longer working.

Ketoconazole (Nizoral), first used for treating fungal infections, blocks production of androgens and is sometimes used.


Current Controversies in Hormone Therapy

There are many issues around hormone therapy that not all doctors agree on, such as the best time to start and stop it and the best way to give it. Studies looking at these issues are now under way. A few of the issues are discussed here.

Early vs. delayed treatment: Some doctors think that hormone therapy works better if it is started as soon as possible if the cancer has reached an advanced stage (for example, when it has spread to lymph nodes), if it is large (T3) or has a high Gleason score, or if the PSA starts rising after initial therapy, even though the patient feels well. Some studies have shown that hormone treatment may slow down the disease and perhaps even lengthen patient survival. But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the likely side effects and the chance that the cancer could become resistant to therapy sooner, treatment should not be started until symptoms from the disease appear. Studies addressing these questions are now under way.

Intermittent vs. continuous hormone therapy: Nearly all prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression may not be needed, so they advise intermittent (on-again, off-again) treatment.

In one form of intermittent therapy, androgen suppression is stopped once the blood PSA level drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy involves using androgen suppression for fixed periods of time -- for example, 6 months on followed by 6 months off.

Clinical trials of intermittent hormonal therapy are still in progress. It is too early to say whether this new approach is better or worse than continuous hormonal therapy. However, one advantage of intermittent treatment is that for a while some men are able to avoid the side effects of hormonal therapy such as impotence, hot flashes, and loss of sex drive.

Combined androgen blockade (CAB): Some doctors treat patients with both androgen deprivation (orchiectomy or an LHRH agonist) and an anti-androgen. But most doctors are not convinced there's enough evidence that this combined therapy is better than one drug alone.

Triple androgen blockade (TAB): Some doctors have suggested taking combined therapy one step further, by adding a drug called a 5-alpha reductase inhibitor -- either finasteride (Proscar, Propecia) or dutasteride (Avodart) -- to the combined androgen blockade. There is very little evidence to support the use of this "triple androgen blockade" at this time.

Last Revised: 08/25/2008

What to Consider When Your PSA Is Rising After Initial Treatment

This section summarizes key points to consider when your PSA is rising after undergoing initial treatment. The list is by no means exhaustive, and there might be other points that you want to think about as well. The goal is to help you focus on what you need to know about each stage of disease so you can hold meaningful, regular dialogues with all members of your health care team as you find the treatment path that’s right for you.

1) In the post-prostatectomy setting, the most widely accepted definition of a recurrence is a PSA > 0.3 ng/mL that has risen on at least two separate occasions at least two weeks apart and measured by the same lab. In the post-radiation therapy setting, the most widely accepted definition is a PSA that has risen from nadir in at least three consecutive tests conducted at least two weeks apart and measured by the same lab. It’s important to always use the same lab for all of your PSA tests because PSA values can fluctuate somewhat from lab to lab.

2) PSA velocity or PSA doubling time, both of which measure the rate at which your PSA rises, can be a very significant factor in determining is the aggressiveness of your cancer. Men with a shorter PSA doubling time or a more rapid PSA velocity after initial therapy tend to have more aggressive disease, and are therefore more likely to need more aggressive therapies.

3) If your PSA starts to rise after you’ve undergone prostatectomy, "salvage" radiation therapy might be a good option to explore. With this approach, external beam radiation is delivered to the area immediately surrounding where the prostate was, in the hopes of eradicating any remaining prostate cells that have been left behind.

4) With 3D conformal radiotherapy, IMRT, and brachytherapy, local tissue damage is often kept at a minimum, and surgeons at some of the larger cancer centers have been seeing improved results with “salvage” prostatectomy. But even under the best of circumstances, post-radiation surgery is a very difficult operation to perform, and few surgeons across the country perform it regularly.

5) Regular monitoring of PSA levels after primary therapy is key, as is prompt initiation of treatment upon disease recurrence. The earlier the treatment is begun, the better the likelihood of improved results.

6) Androgen deprivation therapy ("hormone therapy") is a key treatment strategy for prostate cancer that has recurred following local treatment. The goal of all hormone therapies is to stop the production and/or interfere with the effects of testosterone which fuels the growth of prostate cancer cells. However, because not all prostate cancer cells are sensitive to increases or decreases in testosterone levels, hormone therapy is a treatment for prostate cancer but does not cure the disease.

7) There are several approaches to blocking the secretion of testosterone including the surgical removal of the testes, drugs known as LHRH agonists, and estrogens.

8) Antiandrogens block the action of testosterone by preventing the active form of testosterone known as DHT from entering the central part of the prostate cancer cell; without DHT, the growth of prostate cancer cells is halted.

9) Testosterone is the primary male hormone, playing an important role in establishing and maintaining the typical male characteristics, such as body hair growth, muscle mass, sexual desire, and erectile function. Most men who are on hormone therapy experience at least some of the effects related to the loss of testosterone, but the degree to which you will be affected by any one drug regimen is impossible to predict.

10) LHRH agonists, the most commonly used drug class for hormone therapy, are given in the form of regular shots: once a month, once every three months, once every four months, or once per year. These long-acting drugs are injected under the skin and release the drug slowly over time.

11) Antiandrogens can be helpful in preventing the "flare" reaction associated with LHRH agonists resulting from an initial transient rise in testosterone. Their use for at least the first 4 weeks of LHRH therapy can relieve the symptoms often seen from the flare reaction, ranging from bone pain to urinary frequency or difficulty.

12) With intermittent hormone therapy, the LHRH agonist is used for six to twelve months, during which time a low PSA level is maintained. The drug is stopped until the PSA rises to a predetermined level, at which point the drug is restarted. During the "drug holidays" in between cycles, sexual function and other important quality of life measures might return. However, the clinical benefits of this approach remain unclear, and large clinical trials are currently underway to evaluate its use in this setting.

13) Deferring hormone therapy until metastatic disease can be detected might be an appropriate option for some men. In such cases, the goal would be to reserve an effective, albeit temporary, treatment option until it’s clearly needed.

14) Hormone therapy typically is effective for only a few years. For many men who were using an antiandrogen in combination with an LHRH agonist, stopping the antiandrogen, or antiandrogen withdrawal, is the most common first step in secondary hormone therapy. Switching to a different antiandrogen might also be able to offer an extra few months of benefit, and drugs known as ketoconazole or aminoglutethimide can be used to block the small amounts of testosterone produced by the adrenal glands from being released.

15) Carefully review the side effect profile of the different hormone therapy regimens, and discuss with your health care team potential ways to minimize the effects. In the end, it’s important that you not only understand the value of the therapy in the management of your prostate cancer, but also that you learn how to live your life as best as possible while fighting the disease.

(http://www.prostatecancerfoundation.org/)