The Staging Guide Video Series | Transcription
Hi, I’m Dr. Scholz, let’s talk about prostate cancer.
In today’s video we’re going to cover how to reduce the side effects of hormonal therapy when it’s used for the treatment of prostate cancer. Hormonal therapy has a variety of different names: Androgen Deprivation Therapy (ADT for short), Testosterone Inactivating Pharmaceuticals (TIP for short. Hormonal blockade comes in various forms and various intensities. I’m not going to try and emphasize that very much in this video. We’re going to focus primarily on how do you reduce the side effects, and this is a really big issue because the side effects can be very notable and if managed properly they can be greatly reduced.
So the common medicines that are called hormone blockade are the injections such as Lurpon, Trelstar, Firmagon, Eligard, and Zoladex. The common pills that you think of is Casodex (otherwise known as bicalutamide) and then the second generation hormone blockades such as xtandi (generic name is enzalutamide) or Zytiga (generic name is abiraterone). These medicines can be used singly or in combination in various settings depending on what is required for the treatment of each specific individual.
Let me start by saying that the number one issue with hormonal blockade is not loss of libido—loss of libido is reversible. The number one problem is loss of muscle and besetting fatigue. Tiredness that you just can’t believe. The important thing to know about this loss of muscle and tiredness is that it’s very treatable; it’s one of the most treatable side effects. If men will commit to doing weight training—lifting weights two or three times a week for 30 to 45 minutes—they can maintain and sometimes even build muscle mass and retain the sense of normalcy that they’ve always had. The problem is when you don’t have testosterone you lose muscle quickly. Some men will lose up to 30 or 40 percent of their muscle and this translates into notable fatigue. Men just start to feel old. So whenever I start someone on hormonal blockade I emphasize passionately that they must do weight training, preferably under the supervision of a trainer. This brings about accountability and makes sure that people don’t get injured and of course it helps ensure that they do the program. When on hormonal blockade you cannot take a holiday from doing weight training because the muscle mass loss is so brisk. You must sustain the activity and if you’re faithful and continue in that pattern the problems that are so commonly associated such as fatigue are greatly reduced and sometimes eliminated altogether.
The next aspect of hormonal block I want to cover has to do with weight gain. When men have low testosterone their metabolic rate drops and if they just eat the same diet that they’ve always eaten they’re going to start gaining weight—particularly around the middle—and this is a difficult problem to control if men just stay on the same diet. When men are starting on hormone blockade I counsel them to consider cutting back on their caloric intake in preparation for the fact that their metabolic rate will be slower.
The third point I want to cover—I already mentioned—and that is a loss of sex drive. When men lose testosterone almost everybody loses their libido (or their sex drive). This doesn’t mean that they can’t function sexually with normal vigor with things like viagra and cialis, but they don’t have the usual interest or desire. This is fortunately reversible when the treatment has stopped but the loss of libido is dramatic and oftentimes complete, and so men have to prepare and their significant others need to be prepared for a radical change in interest levels while the treatment is ongoing. As of right now we don’t have any interventions to correct this other than to simply stop treatment.
Next I’d like to cover some of the other metabolic effects of low testosterone levels. One is the possibility of breast enlargement. Breast enlargement (called Gynecomastia) occurs in maybe a third to a half of men if they take Casodex alone (a pill type of hormone blockade) and maybe 25-30% of men when they’re on Lupron. The breast enlargement is irreversible and if a man wants to try and treat that problem he has to have plastic surgery. So the point of this is to prevent its development in the first place. There are two potential ways to accomplish that. One is to take an estrogen blocking pill originally FDA approved for the treatment of breast cancer called Femara, 2.5 milligrams once a day. In men this doesn’t have any side effects at all other than limiting the breast enlargement. The other possibility is to visit a radiation therapist and have a couple of radiation treatments ot the nipple area prior to starting the hormonal blockade. Both of these approaches are pretty effective and in general there won’t be any breast enlargement. There are some exceptions and men that want to be particularly fastidious can consider doing both approaches with radiation plus femoral.
The next thing to cover is the male menopause symptom of hot flashes. Hot flashes are not dangerous although they can be very disquieting and I would anticipate that they occur perhaps in two-thirds of the men that go hormonal blockade and maybe in one-third of the men the hot flashes are really intrusive—they may wake you up at night. These hot flashes can be treated effectively. The most effective treatment in my option is a small dose of estrogen delivered by a patch—one trade name is something called Vivelle Dot—and this in most cases will greatly reduce hot flashes or eliminate them altogether. Other approaches which are not as effective but don’t require the use of estrogen are pills called Effexor which is used mainly as an antidepressant (very small doses, say 37 milligrams are effective) or Neurontin a medicine that is FDA approved for peripheral neuropathy for seizures can also be helpful for hot flashes.
The next thing to talk about is mood swings. Men are generally thought to be a little less emotional than women and in my experience it is because of the testosterone levels. When testosterone is removed many of my patients have reported that they feel emotion more strongly—that they’re crying in movies for the first time in their lives. Some men enjoy this greater range of emotion. Other men are somewhat concerned by that, and that same medicine we mentioned for hot flashes Effexor which is of the antidepressant category can help restore the mood stability that they were used to prior to going on hormone blockade.
Finally I’d like to talk about a couple of laboratory abnormalities that can occur. Number one is anemia. Loss or reduction in red blood cells. Women who don’t have high testosterone levels run somewhat lower red blood cell levels compared to men, and when men go on testosterone blockade their red cells will decline to some degree. This usually doesn’t have much consequence. If it became very severe it could cause some fatigue. The main consequence is that many physicians that are not familiar with hormone blockade will think that there’s iron deficiency or something else going on, put people on iron or start a lot of investigations. Just reassure the doctor that the mild anemia is normal for men that are taking hormonal blockade.
The other abnormality to consider is irritation of the liver with medicines like Casodex and Zytiga. So whenever people start on those pills they need to have their blood tested periodically especially initially in the first couple months to make sure that they’re not in that rare subgroup of men that is going to have a reaction. If such abnormalities are observed the medicines must be stopped immediately.
The last side effect that we sometimes we observe with the new second-generation hormone blockade such as Zytiga or Xtandi is high blood pressure. This is fairly common, maybe 10-20% of men encountered these problems, and it can usually be handled with typical blood pressure medicines. Sometimes the blood pressure elevation is so severe that the Zytiga or Xtandi may have to be stopped. So this is something that certainly needs to be monitored when men are starting on these medicines.
Another problem with hormone blockade is that men can lose calcium from their bone—the technical name is called osteoporosis. Osteoporosis can also occur in men who aren’t on hormone blockade. This is a big topic and we’re going to cover that in a separate video.