Managing Complications of Androgen Deprivation Therapy for Prostate Cancer

Prostate cancer brain metastases: Monitoring response to treatment with PSMA PET/CT

Prostate cancer brain metastases are rare but increasingly recognized with prostate-specific membrane antigen (PSMA) PET/CT. Distinguishing tumor response from postradiation changes are challenging on MRI. PSMA PET/CT may clarify equivocal brain lesions after radiotherapy. A 71-year-old man with metastatic prostate cancer developed 2 new brain lesions on PSMA PET/CT. Lesions were high PSMA-avid and MRI follow up showed enhancing masses with edema, consistent with metastases. He underwent whole-brain radiation. Follow-up PSMA PET/CT after radiotherapy demonstrated significantly decreased lesion size and activity, with activity lower than blood pool, indicating a treatment response. MRI also showed near-resolution of the lesions. This case highlights the potential utility of PSMA PET/CT for detecting prostate cancer brain metastases and monitoring treatment response. PSMA PET/CT provides valuable complementary information to MRI for managing irradiated prostate cancer brain metastases.

Estetrol Prevents Hot Flushes and Improves Quality of Life in Patients with Advanced Prostate Cancer Treated with Androgen Deprivation Therapy: The PCombi Study

Background

Androgen deprivation therapy (ADT) for prostate cancer (PCa) is accompanied by side effects affecting health-related quality of life (HRQL).

Objective

To assess the effects of the fetal estrogen estetrol (E4) on symptoms related to estrogen and androgen deficiency, and on HRQL measured using the validated Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire.

Design, setting, and participants

This was a phase 2, double-blind, randomized, placebo-controlled study in patients with advanced PCa.

Intervention

Patients receiving ADT were randomly assigned at a 2:1 ratio to daily treatment with a high dose of E4 (HDE4; n = 41) or placebo (n = 21) for 24 wk.

Outcome measurements and statistical analysis

The primary outcome was the effect of HDE4 cotreatment on hot flushes (HFs). Secondary outcomes were the Q-Man questionnaire for evaluation of the effect on estrogen and androgen deficiency symptoms, and the FACT-P questionnaire for evaluating HRQL.

Results and limitations

At 24 wk, the number of patients experiencing HFs was significantly lower in the HDE4 group than in the placebo group (14.3% vs 60.0%; p < 0.001). HDE4 treatment was associated with lower incidence of night sweats, arthralgia, and fatigue, but more nipple tenderness and gynecomastia. At 24 wk, the mean HRQL score favored HDE4 over placebo for the FACT-P total score (122.2 ± 12.3 vs 118.7 ± 19.7) and for several other FACT subscales.

Conclusions

Daily HDE4 coadministration almost completely prevented HFs in patients with advanced PCa treated with ADT. HDE4 also had positive effects on HRQL and counteracted other estrogen deficiency symptoms caused by ADT. These data support the dual efficacy concept of ADT and HDE4 to improve HRQL and increase the antitumor effect of ADT.

Patient summary

For patients on androgen deprivation therapy for advanced prostate cancer, cotreatment with a high dose of estetrol almost completely prevents the occurrence of hot flushes and improves quality of life and well-being, but nipple sensitivity and an increase in breast size may occur.

Network meta-analysis of the efficacy and adverse effects of several treatments for advanced/metastatic prostate cancer

This network meta-analysis was conducted to compare the efficacy and adverse effects of several treatments for advanced/metastatic prostate cancer (PC). The PubMed and Cochrane Library databases were searched for randomized controlled trials of treatments for advanced/metastatic PC. Eighteen studies covering 6,340 patients were included in this analysis. The calculated were odds ratios, 95% confidence intervals, and the surface under the cumulative ranking (SUCRA) curve. Pairwise meta-analysis showed that overall survival rates achieved with radiotherapy or endocrine therapy were lower than obtained with radiotherapy + endocrine therapy. The endocrine therapy includes estrogen therapy, luteinizing hormone-releasing hormone agonist (LHRH-A), anti-androgen therapy (ADT), ADT + LHRH-A and estrogen therapy + LHRH-A, and its SUCRA values indicated that for overall response rate, estrogen therapy + LHRH-A ranked the highest (92.6%); for overall survival rate, ADT ranked the highest (75.2%); for anemia, estrogen therapy ranked the highest (88.2%); and for diarrhea and hot flushes, ADT ranked the highest (diarrhea, 87.4%; hot flushes, 89.3%). Cluster analysis on the endocrine therapy showed that ADT + LHRH-A achieved the highest overall survival and overall response rates in the treatment of advanced/metastatic PC. Estrogen therapy and ADT had the lowest incidences of diarrhea and anemia. Thus, combined radiotherapy + endocrine therapy had higher overall survival rate, and among the endocrine therapy, in terms of overall response rate and overall survival rate, ADT + LHRH-A may be a better regimen in the treatment of advanced or metastatic PC.

Cognitive impairment among prostate cancer patients: An overview of reviews

To identify and clarify definitions and methods of measuring cancer-related cognitive impairment among prostate cancer patients treated with androgen deprivation therapy (ADT) and to assess the incidence and prevalence of cognitive impairment. A systematic review of Medline, EMBASE, PubMed, PsycINFO and CINAHL up to December 2015 was undertaken to identify English-language reviews. A total of 28 reviews were identified describing 20 primary studies. There were no studies of incidence. Reported prevalence rates varied between 10% and 69%. Cognitive domains impaired by ADT included: verbal memory, visuospatial ability and executive functions. Cognitive impairment was infrequently defined and four definitions were reported. A variety of measures and methods were used to assess cognitive function including neuropsychological tests, self-report measures and clinical assessments. The finding that, often, one measure was used to assess more than one aspect of cognition is likely to have contributed to imprecise estimates. There is a need to agree a definition of cognitive impairment in the clinical epidemiology of cancer and to standardise the selection of measures in order to aid accurate assessment and fair comparisons across studies regarding the prevalence of cognitive impairment among prostate cancer patients.

Penile Rehabilitation Strategies Among Prostate Cancer Survivors

Despite advances in technical and surgical approaches, erectile dysfunction (ED) remains the most common complication among prostate cancer survivors, adversely impacting quality of life. This article analyzes the concept and rationale of ED rehabilitation programs in prostate cancer patients. Emphasis is placed on the pathophysiology of ED after diagnosis and treatment of prostate cancer to understand the efficacy of rehabilitation programs in clinical practice. Available evidence shows that ED is a transient complication following prostate biopsy and cancer diagnosis, with no evidence to support rehabilitation programs in these patients. A small increase in ED and in the use of phosphodiesterase type 5 (PDE5) inhibitors was reported in patients under active surveillance. Patients should be advised that active surveillance is unlikely to severely affect erectile function, but clinically significant changes in sexual function are possible. Focal therapy could be an intermediate option for patients demanding treatment/refusing active surveillance and invested in maintaining sexual activity. Unlike radical prostatectomy, there is no support for PDE5 inhibitor use to prevent ED after highly conformal external radiotherapy or low-dose rate brachytherapy. Despite progress in the understanding of the pathophysiologic mechanisms responsible for ED in prostate cancer patients, the success rates of rehabilitation programs remain low in clinical practice. Alternative strategies to prevent ED appear warranted, with attention toward neuromodulation, nerve grafting, nerve preservation, stem cell therapy, investigation of neuroprotective interventions, and further refinements of radiotherapy dosing and delivery methods.

Health care costs for prostate cancer patients receiving androgen deprivation therapy: treatment and adverse events

BACKGROUND

Serious adverse events have been associated with androgen deprivation therapy (adt) for prostate cancer (pca), but few studies address the costs of those events.

METHODS

All pca patients (ICD-9-CM 185) in Ontario who started 90 days or more of adt or had orchiectomy at the age of 66 or older during 1995-2005 (n = 26,809) were identified using the Ontario Cancer Registry and drug and hospital data. Diagnosis dates of adverse events-myocardial infarction, acute coronary syndrome, congestive heart failure, stroke, deep vein thrombosis or pulmonary embolism, any diabetes, and fracture or osteoporosis-before and after adt initiation were determined from administrative data. We excluded patients with the same diagnosis before and after adt, and we allocated each patient's time from adt initiation to death or December 31, 2007, into health states: adt (no adverse event), adt-ae (specified single adverse event), Multiple (>1 event), and Final (≤180 days before death). We used methods for Canadian health administrative data to estimate annual total health care costs during each state, and we examined monthly trends.

RESULTS

Approximately 50% of 21,811 patients with no pre-adt adverse event developed 1 or more events after adt. The costliest adverse event state was stroke ($26,432/year). Multiple was the most frequent (n = 2,336) and the second most costly health state ($24,374/year). Costs were highest in the first month after diagnosis (from $1,714 for diabetes to $14,068 for myocardial infarction). Costs declined within 18 months, ranging from $784 per 30 days (diabetes) to $1,852 per 30 days (stroke). Adverse events increased the costs of adt by 100% to 265%.

CONCLUSIONS

The economic burden of adverse events is relevant to programs and policies from clinic to government, and that burden merits consideration in the risks and benefits of adt.

A randomized phase II trial evaluating different schedules of zoledronic acid on bone mineral density in patients with prostate cancer beginning androgen deprivation therapy

OBJECTIVE

To assess the effects of timing and schedule of zoledronic acid (ZA) administration on bone mineral density (BMD) in patients beginning androgen deprivation therapy (ADT) for the treatment of recurrent prostate cancer.

PATIENTS AND METHODS

In this randomized, 3-arm trial, we evaluated changes in BMD after 3 different ZA administration schedules in men with recurrent prostate cancer who were beginning ADT. Forty-four patients were enrolled and randomized to receive a single dose of ZA given 1 week before beginning ADT (arm 1), a single dose of ZA given 6 months after beginning ADT (arm 2), or monthly administration of ZA starting 6 months after beginning ADT, for a total of 6 doses (arm 3).

RESULTS

Patients who received ZA before ADT had a significant improvement in BMD at the total proximal femur and trochanter after 6 months compared with the other groups. In addition, only patients in the arm that received multiple doses improved lumbar spine BMD while on ADT, with these findings persisting to 24 months. However, this group also experienced more grade 1 adverse events.

CONCLUSIONS

Analysis of these data suggests that ZA administration before initiation of ADT was superior to treatment 6 months after starting ADT in maintaining BMD. In addition, monthly ZA administration can increase BMD above baseline but is associated with more adverse events. Further study is needed to examine whether the timing and frequency of ZA therapy in patients on ADT can reduce fracture risk.

The side effects of hormonal therapy at the patients with prostate cancer

Prostate cancer is one of most frequent malignant tumours at men. The androgen-deprivation therapy is the part of cancer treatment. It could be used both in the early stage of prostate cancer and in the bone metastates. From this reason the antiandrogen drugs waste systematically grows. Unfortunately androgen-deprivation therapy has numerous side effects such as: the inferior quality of live, sexual disturbances, the fatigue, the anaemia, the bone mineral density loss and the increase of the risk of breaks the bone, the increase of body mass, insulinresistance, hypercholesterolemia, the increase risk of cardiac disorders. The aim of this article is the introduction of the reader with possibly complications androgen-deprivation therapy and with possibilities in diagnosis and treatment.

Long-term quality of life in disadvantaged men with prostate cancer on androgen-deprivation therapy

BACKGROUND

To explore the effects of androgen-deprivation therapy (ADT) on general, disease-specific and hormone-specific health-related quality of life (HRQOL) among minority men.

METHODS

Men enrolled in a state-funded program, providing free prostate cancer treatment for underserved men, were recruited, if they had received at least 3 months of continuous ADT and/or other forms of primary treatment. HRQOL was assessed with validated measures including the RAND Medical Outcomes Study 12-item Health Short Form Survey (SF-12), the UCLA Prostate Cancer Index Survey and the Expanded Prostate Cancer Index Composite Survey. Repeated measures analysis was performed to evaluate the association between clinical and sociodemographic covariates with HRQOL.

RESULTS

We enrolled 322 men, including 94 on ADT and 228 who received other forms of treatment. When controlling for patient characteristics, men receiving ADT had poorer outcomes relative to sexual function (P<0.01), sexual bother (P<0.01), hormonal function (P<0.01) and hormonal bother (P=0.02). ADT use was significantly associated with worsening sexual function (P<0.01) and sexual bother (P=0.01) over two years compared with non-ADT users. Analysis also demonstrated significant differences between whites, Hispanics and Others (African American (n=43, 16%), Asian (n=13, 5%), multiracial (n=1, 0.4%), Native American (n=1, 0.4%) and other (n=9, 3%)) relative to urinary bother (P=0.01), urinary function (P=0.01) and hormonal bother (P=0.03). ADT users had better urinary function and less bother than non-ADT users among the Other group, while the opposite was true for whites and Hispanics. For hormonal bother, ADT use was associated with worse outcomes across all three race/ethnicity groups; however, Hispanics were less bothered by their hormonal symptoms than whites or Others.

CONCLUSION

Men of disadvantaged backgrounds on hormone therapy for prostate cancer experience declines in sexual and hormonal HRQOL. Whites and non-whites on ADT have significantly different HRQOL outcomes.

Gynecomastia: physiopathology, evaluation and treatment

Gynecomastia (GM) is characterized by enlargement of the male breast, caused by glandular proliferation and fat deposition. GM is common and occurs in adolescents, adults and in old age. The aim of this review is to discuss the pathophysiology, etiology, evaluation and therapy of GM. A hormonal imbalance between estrogens and androgens is the key hallmark of GM generation. The etiology of GM is attributable to physiological factors, endocrine tumors or dysfunctions, non-endocrine diseases, drug use or idiopathic causes. Clinical evaluation must address diagnostic confirmation, search for an etiological factor and classify GM into severity grades to guide the treatment. A proposal for tailored therapy is presented. Weight loss, reassurance, pharmacotherapy with tamoxifen and surgical correction are the therapeutic options. For long-standing GM, the best results are generally achieved through surgery, combining liposuction and mammary adenectomy.

Adverse effects of androgen deprivation therapy in prostate cancer: Current management issues

Prostate cancer (CaP) is the most common visceral malignancy and a leading cause of cancer death in men. Androgen deprivation therapy (ADT) is an established treatment for locally advanced and metastatic CaP, and often used as primary therapy in select patients. As ADT has continued to assume an important role in the treatment of CaP, a greater appreciation of potential adverse effects has been acknowledged in men receiving this therapy. Given that all treatments for CaP are frequently associated with some degree of morbidity and can have a negative impact on health-related quality of life (HRQOL), the potential benefits of any treatment, including ADT, must outweigh the risks, particularly in patients with asymptomatic disease. Once the choice to proceed with ADT is complete, it is imperative for the urologist to possess comprehensive knowledge of the potential adverse effects of ADT. This permits the urologist to properly monitor for, perhaps diminish, and to treat any linked morbidities. Patient complaints related to ADT such as a decrease in HRQOL, cognitive and sexual dysfunction, hot flashes, endocrine abnormalities, cardiovascular disease, and alterations in skeletal and body composition are commonly reported throughout the literature. Herein, we review the principal adverse effects linked with ADT in CaP patients and suggest various universal strategies that may diminish these potential adverse consequences associated with this therapy.

Androgen deprivation therapy in prostate cancer: are rising concerns leading to falling use?

OBJECTIVE

To describe patterns of initiation of androgen deprivation therapy (ADT) in a population-based cohort of patients with prostate cancer.

PATIENTS AND METHODS

All patients with prostate cancer in Ontario, Canada, who started ≥90 days of ADT at age ≥66 years in 1995-2005 were classified by ADT regimen: medical castration [oestrogen and/or luteinizing hormone-releasing hormone (LHRH) agonist); orchidectomy; antiandrogen monotherapy; combined androgen blockade (CAB) medical (medical castration plus antiandrogen); CAB surgical (orchidectomy plus antiandrogen). Indications for ADT were as follows: neoadjuvant (short-term before prostatectomy or radiation therapy); adjuvant (long-term with prostatectomy or radiation therapy); metastatic disease; biochemical recurrence; primary (localized disease); other. We examined trends in ADT regimen and indication over time.

RESULTS

The number of patients initiating ADT increased from 1995 to 2001 (2106-2916 per year) and declined thereafter to 2200-2300 annually (total n= 26,809). However, prostate cancer prevalence doubled over these years, and the rate of ADT initiation decreased from 16 to 7 per 100 person-years. Patterns varied by regimen and indication. Medical castration increased from 12% of all ADT in 1995 to 47% in 2005; orchidectomy decreased from 17 to 4%. Use for metastatic disease remained stable, but adjuvant therapy increased from <3% of all ADT in 1995 to 13% in 2005. Primary therapy was the most common indication, but decreased over time.

CONCLUSIONS

ADT initiation has fallen and marked changes occurred in treatment patterns for prostate cancer. Changes might be driven by increasing awareness of potential harms and costs, and by new evidence supporting ADT for specific indications.

Radiotherapy combined with hormonal therapy in prostate cancer: the state of the art

Androgen-deprivation therapy (ADT) is used routinely in combination with definitive external beam radiation therapy (EBRT) in patients with high-risk clinically localized or locally advanced disease. The combined treatment (ADT-EBRT) also seems to play a significant role in improving treatment results in the intermediate-risk group of prostate cancer patients. On the other hand, there is a growing body of evidence that treatment with ADT can be associated with serious and lifelong adverse events including osteoporosis, cardiovascular disease, diabetes, and many others. Almost all ADT adverse events are time dependant and tend to increase in severity with prolongation of hormonal manipulation. Therefore, it is crucial to clearly state the optimal schedule for ADT in combination with EBRT, that maintaining the positive effect on treatment efficacy would keep the adverse events risk at reasonable level. To achieve this goal, treatment schedule may have to be highly individualized on the basis of the patient-specific potential vulnerability to adverse events. In this study, the concise and evidence-based review of current literature concerning the general rationales for combining radiotherapy and hormonal therapy, its mechanism, treatment results, and toxicity profile is presented.

Clomiphene citrate and enclomiphene for the treatment of hypogonadal androgen deficiency

Hypogonadism has a number of important clinical consequences related to androgen deficiency and impaired spermatogenesis. The cause of this condition is multifactorial and can result from hypothalamic, pituitary or gonadal dysfunction as well as factors that affect hormonal signaling along the hypothalamic-pituitary-gonadal axis. While testosterone replacement is the most common treatment, it can paradoxically lead to infertility, and may be a less physiologic therapy for patients with secondary hypogonadism due to pituitary dysfunction. Clomiphene citrate, and its derivatives, may allow for restoration of gonadal function by restoring physiologic pituitary function in a subset of patients with hypogonadism.

Utility and health-related quality of life in prostate cancer patients 12 months after radical prostatectomy or radiation therapy

This study aims to examine and compare changes in quality of life after two common treatments for prostate cancer (PC), radical prostatectomy (RP) and radiation therapy (RT). Patients newly diagnosed with localized PC, scheduled to receive RP (n=68) or RT (n=66), completed three cancer/PC-specific psychometric instruments and three PC-specific utility instruments before treatment, and 2 and 12 months after treatment. We assessed the magnitude and time course of changes in psychometric and utility measures, and differences between treatments. The results showed that RP was associated with significant urinary and sexual dysfunction; RT caused bowel problems. Fatigue and pain were common to both. RP patients reported more problems with physical, role and social function. Utilities decreased significantly after both treatments. Effects were most severe 2 months post treatment, and then showed some recovery, but many endured for 1 year. After 1 year, 30-60% of patients had utility scores that were clinically significantly worse than at baseline. Secondary androgen deprivation therapy also significantly decreased psychometric and utility measures of quality of life. Many adverse symptoms reported 2 months after RP and RT endure for 1 year. Despite different symptom profiles, RP and RT result in similar utility decrements.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

[Management of the side effects of androgenic deprivation]

Androgeno-deprivation is the treatment of reference for metastatic prostate cancer but it generates side effects which are too often ignored by physicians due to concentration on hopes of carcinologic benefit. Hot flashes, metabolic syndrome (body mass and lipid changes), decreased libido, erectile dysfunction, anemia, cognitive dysfunction, gynecomastia, decreased muscular mass and osteoporosis are the most frequent symptoms. They can and must be prevented by advice on physical activity and nutrition.

Caring for a patient with metastatic prostate cancer

Learn about the latest treatments and what your patient needs to know at this difficult time.

Androgen deprivation therapy for prostate cancer

Androgen deprivation continues to play a crucial role in the treatment of advanced and metastatic prostate cancer. In the 65 years since its use was first described, urologists and medical oncologists have developed new and innovative ways to manipulate the hypothalamic-pituitary-gonadal axis with the goal of alleviating symptoms and prolonging the life of men with prostate cancer. Despite the successes that androgen deprivation therapy has brought, each method and regimen possesses unique benefits and burdens, of which the clinician and patient must be cognizant. This review discusses the first-line androgen deprivation methods and regimens presently in use with special attention paid to their side effects and the management of them, as well as the question of when to initiate androgen deprivation therapy.

Contemporary use of hormonal therapy in prostate cancer: managing complications and addressing quality-of-life issues

While both short- and long-term androgen deprivation therapy (ADT) are effective for treating prostate cancer, with the clinical benefits patients can often have significant side-effects. It is important that these complications are recognized and managed appropriately so that adverse effects on the patient's quality of life (QoL) are minimized. The incidence of deaths from prostate cancer has decreased over the last decade, probably as a result of various factors including improved screening and diagnosis, improved treatments, and better risk assessment to help guide therapy. A meta-analysis of prostate cancer trials comparing the use of early vs late hormonal therapy found that 10-year overall survival increased by up to 20% between 1990 and 2000, and this was attributed to the earlier use of hormone therapy (HT) in these patients. Data from the USA Cancer of the Prostate Strategic Urological Research Endeavor database also suggest a significant decrease in risk in the last two decades in the USA, with more patients being identified with low-risk disease at diagnosis. In addition, there has been an increase in recent years in the use of HT at all stages of prostate cancer. The extensive use of ADT has raised concerns about potential adverse effects. ADT might be associated with a range of adverse effects that vary in their degree of morbidity and effect on the patient's QoL. They include hot flashes, osteoporosis, loss of libido or impotence, and psychological effects, e.g. depression, memory difficulties or emotional lability. Effective strategies are available for managing the major side-effects of HT, but to many patients these unwanted effects are often less important than the benefits of treatment. An investigation of health-related QoL found that men with prostate cancer receiving ADT had a poorer QoL than those not receiving ADT, but the difference was less pronounced after controlling for comorbidities. Many new therapies are currently under investigation which aim to maximize the clinical effects of ADT while reducing the adverse effects.