Are there different types of hormone therapy? Do I need to have my testicles removed?

Hormone therapy is a form of prostate cancer treatment designed to eliminate the male hormones (androgens) from the body. The most common androgen is testosterone[1]. Androgens are primarily produced by the testicles, under control of various parts of the brain. A small number of androgens are produced by the adrenal glands, which are small glands located above the kidneys and produce many important chemicals. Prostate cancer cells may be hormone sensitive, hormone insensitive, or hormone resistant. Cancer cells that are hormone sensitive require androgens for growth. Thus, elimination of the androgens would prevent the growth of such cells and cause them to shrink. Normal prostate cells are also hormone sensitive and also shrink in response to hormone therapy. Prostate cancer cells that are hormone resistant continue to grow despite hormone therapy.

Hormone therapy is not a curative therapy because it does not eliminate the prostate cancer cells; rather, it is palliative in that its goal is to slow down the progression, or growth, of the prostate cancer. Hormone therapy for patients with metastatic disease may work effectively for several years; however, over time, the hormone-resistant cells will emerge, and the cancer will grow.

Hormone therapy may be used as a primary, secondary, or neoadjuvant therapy[2]. Hormone therapy is often used as a primary therapy in older men who are not candidates for surgery or radiation therapy and who are not interested in watchful waiting. It is also used in men who have metastatic disease at the time that their prostate cancer is detected. Men who experience a rise in their PSA after radical prostatectomy, radiation therapy, or

Hormone therapy is often used as a primary therapy in older men who are not candidates for surgery or radiation therapy and who are not interested in watchful waiting.

cryotherapy are given hormone therapy to slow down the growth of the recurrent prostate cancer. Lastly, hormone therapy may be given for a period of time before radical prostatectomy or radiation therapy to shrink the prostate gland and make the procedure easier to perform (neoadjuvant therapy). It is unclear whether this type of therapy affects the time to disease progression or survival. However, neoadjuvant therapy has a significant impact on the pathology, such that it is very difficult for the pathologist to grade the cancer cells after 3 months of hormone therapy.

In men with recurrent prostate cancer after EBRT or radical prostatectomy or in those who do not have organ-confined prostate cancer at the time of diagnosis, the time at which hormone therapy should be started is not clear. For this reason, one must weigh the potential benefits and side effects of hormone therapy. Hormone therapy may delay disease progression, but its effect on survival does not appear to be significant. In one study in men with prostate cancer, delaying hormone therapy for 1 year was associated with an 18% increase in the risk of death due to prostate cancer. Although this was a large study, it is still only one study, and more information is needed.

Many different forms of hormone therapy exist, both surgical therapy and medical therapy. The surgical approach is a bilateral orchiectomy[3], whereby the main source of androgen production, the testicles, are removed.

Bilateral orchiectomy is performed in men with prostate cancer to remove most of the testosterone production. Typically, this procedure can be performed as a minor surgical procedure under local anesthesia.

The advantages of bilateral orchiectomy are that it causes a quick drop in the testosterone level (the testosterone level drops to its lowest level by 3 to 12 hours after the procedure [average is 8.6 hours]), it is a one-time procedure, and it is more cost effective than the shots, which require several office visits per year and are more expensive. The disadvantages of orchiectomy are those of any surgical procedure and include bleeding, infection, permanence, and scrotal changes. In men who have undergone bilateral orchiectomy and are bothered by an empty scrotum, bilateral testicular prostheses may be placed that are the same size as the adult testes. Most men who undergo bilateral orchiectomy lose their libido and have erectile dysfunction after the testosterone level is lowered. Other long-term side effects of bilateral orchiectomy, related to testosterone depletion, include hot flashes, osteoporosis, fatigue, loss of muscle mass, anemia, and weight gain.

Medical therapy is designed to stop the production of androgens by the testicles. The three types of medical therapies are luteinizing hormone-releasing hormone (LHRH) analogues, antiandrogens, and gonadotropin-releasing hormone (GnRH) antagonists. These prevent the action of testosterone on the prostate cancer and on normal prostate cells (antiandrogen), or prevent the production of adrenal androgens.

  • [1] The male hormone or androgen that is produced primarily by the testes and is needed for sexual function and fertility.
  • [2] The use of a treatment, such as chemotherapy, hormone therapy, and radiation therapy, before surgery.
  • [3] Removal of the testicle(s).
 
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