Hi, I’m Dr. Scholz. I’m a medical oncologist specializing exclusively in prostate cancer and a common question I get is, “Is one type of hormone therapy better than another?”

The answer would be—actually—yes, but it depends on your situation.

In men that have relatively mild situations with their prostate cancer or perhaps if they’re elderly a medicine called Casodex—an anti-androgen—has a lot fewer side effects but it’s still pretty potent. It’s no quite as potent as the standard thing they call hormone therapy which are the Lupron or Lupron related drugs. So a milder oral agent like Casodex is a very logical consideration in someone who has say a Basic-Teal or someone who is elderly or perhaps has some impaired health and can’t think about going on stronger therapy.

And another question that comes up is “well if casodex is relatively mild, can we add it to the Lupron?” And oftentimes this is done to avoid the flare of testosterone that occurs in first couple of weeks with Lupron, but for historical reasons oftentimes the Casodex gets stopped even though it doesn’t add a lot of additional side effects, and the history behind it is mostly rooted in finances. Casodex when it first came out was very very expensive, and so the powers that be decided that the addition of the Casodex, only giving a small benefits beyond the Lupron, wasn’t justified because of the high price. Well things have changed. Now you can get bicalutamide—generic Casodex—very inexpensively. And since it is so well tolerated, I believe that if a person is trying to get a maximum anti-cancer effect out of their hormone therapy that they should stay on the Casodex throughout the time that they’re on the Lupron. So the combination of Casodex and Lupron is a little more potent than Lupron alone, and it doesn’t really contribute much, if any, additional side effects as long as people are professionally managed.

There’s a third level of hormonal therapy which most people have heard about where agents such as Zytiga or Erleada or Xtandi can block testosterone function within the cancer cell. In selective cases is it appropriate to think about adding one of these agents--not a combination but one of these agents--to Lupron and this will enhance the anti-cancer effects further. Now these agents typically are also well tolerated and one could ask why aren’t they used routinely? And the answer is—as was the case with Casodex many years ago--is that they are very very expensive. So there’s a trade-off in terms of achieving a small incremental improvement in cure rates perhaps by the addition Erleada, Xtandi, or Zytiga, but at a very very substantial price, so this of course will have to be discussed on an individual basis between a doctor and a patient in terms of what the priorities should be.