THE STAGING GUIDE VIDEO SERIES | TRANSCRIPTION:
Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.
This video is going to cover primary hormone therapy for prostate cancer stage Teal or intermediate-risk. We are in the middle of a series of videos that are covering different treatment options. There are many options for Teal, and patients have a lot of choices and need to be good comparison shoppers.
Hormone therapy (or TIP) is typically given in conjunction with radiation. When we’re talking about Teal it’s usually for about four months. Hormone therapy as a primary treatment without any radiation whatsoever is a reasonable consideration for Teal. Prostate cancer regresses and dies quickly when testosterone is removed; it’s an excellent form of therapy. The problems with it are of course are it has its own set of side-effects—the advantage of them being that they’re reversible. The other problem primary hormone therapy is it’s not thought to be absolutely curative. The fact that it’s not absolutely curative has been a real bugaboo and one of the reasons that hormone therapy hasn’t been discussed as an option, but now many patients are aware and many doctors are aware that the concept of active surveillance is gaining a lot of steam. In other words, if you can watch prostate cancers that are very mild, you can have a better quality of life and avoid the risks of radiation and surgery which can cause permanent erectile dysfunction.
So to this point, hormone therapy as I’ve described it sound pretty darn attractive—reversible side-effects, it also treats the whole body and not just the prostate, so if there are any small specks that have spread outside the gland the hormone therapy will cover that. The problem of course is that the side-effects are notable. First of all, almost everyone loses their sex drive when they’re on the treatment, and the treatment for primary therapy would typically run for about nine months, but then there’s a three month recovery period after that, so we’re talking about a year without any sex drive. Other problems can be weight gain, fatigue, loss of muscle, loss of calcium from the bones called osteoporosis. Now a lot of these things can be worked around, and there are medications and activities that can compensate for the side-effects, but when you’re comparing something like modern radiation—something like SBRT where you can have two weeks of therapy and be cured—hormone therapy may not look quite as attractive; however, radiation will cause permanent erectile dysfunction in anywhere between ⅓ to ⅔ of men that undergo therapy depending on their age pre-existing function.
So hormone therapy is a way to temporize, postpone, or procrastinate with effective treatment that can put the disease in remission, turn the clock back, and possibly open the door to a better technology that may come in the next 5-10 years. How many men remain in remission after 5-7 years that have had a 9-12 month course of hormone therapy? In the small studies we’ve done in prostate oncology, specialists we saw that about half of the men who had a course of hormone therapy and stopped and were observed in an active surveillance protocol, about half of such men remained in remission without a need for further therapy after five years. So in those studies we found that men that had lower Gleason scores, smaller tumors were more likely to have long remissions.
So what kind of patients might want to consider hormone therapy? Number one of course is the gentleman that says that the loss of potency, the development of impotence is non-negotiable. Hormone therapy side-effects are reversible; with surgery and radiation a certain number of men are going to have irreversible impotence. It should also be mentioned that hormone therapy comes in stronger and milder forms; a stronger form being something like Lupron injections, and milder forms being something like Casodex. Primary hormone therapy is often a popular approach in the very elderly or people who are frail and the doctors feel some type of treatment is needed for the elderly patient, but they don’t want to put an aging individual through something that could have potential side-effects or inconvenience. So a pill like Casodex, a very mild form of hormone therapy, can be administered and PSA levels monitored and scans monitored to see how well the disease reacts.
So in summary, hormone therapy should be on the table and discussed as an option in men that are considering therapy for the Teal or intermediate stage of prostate cancer. Like all the other options there are advantages and disadvantages, and what one individual may deem appropriate or acceptable another would not. To learn more about the potential side-effects we have created an educational video on the side-effects of testosterone inactivating pharmaceuticals and obviously that would be an important ancillary area of study when pursuing this idea of primary hormone blockade for Teal.
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