Prostatic cancer: treatment with long-acting LHRH analogue

Bone loss and the evolving role of bisphosphonate therapy in prostate cancer

Androgen deprivation therapy (ADT) can result in significant loss of bone mineral density (BMD) but to date, there are no prospective studies that document the true severity of bone loss and resulting fracture rates. In the general population, however, the incidence of low BMD is increasing in elderly men. Men suffer more morbidity and mortality from fractures associated with low BMD than women. Problems of underdiagnosis and undertreatment in men can be addressed with enhanced awareness of the risk factors for bone loss in men and the available treatment options. Guidelines for diagnosis of low BMD in women can probably be applied to men. Treatment options have not been studied as extensively in men. For men treated with ADT for prostate cancer, however, use of intravenous zoledronic acid at the initiation of ADT has been shown to prevent and even reverse bone loss. Although the routine use of bisphosphonates to prevent bone loss is not yet recommended, zoledronic acid is a logical choice of therapy in men who have low BMD at baseline or who develop bone loss during the course of therapy. In addition to its effects on BMD, zoledronic acid has also been shown to decrease skeletal morbidity in men with metastatic hormone-refractory prostate cancer. Whether zoledronic acid or other bisphosphonates might actually prevent or delay the development of bone metastases remains to be studied in randomized clinical trials.

Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders

Paraphilic disorders are psychiatric syndromes primarily characterized by deviant sexual thoughts, cravings, urges, and/or behaviors. Paraphilic men may engage in inappropriate sexual behaviors when cravings for socially unacceptable sexual acts become overpowering. These often chronic disorders may not only cause emotional distress and social embarrassment to the afflicted patient but also to the targets of their paraphilic focus. The primary objective of this article is to examine and review data on the efficacy and tolerability of the testosterone-lowering agents medroxprogesterone acetate, cyproterone acetate, and leuprolide acetate. The secondary goal is to review data on less conventional and more innovative pharmacological treatments, particularly the serotonin-specific reuptake inhibitors.

The role of endocrine therapy in prostatic cancer

When judged by randomized clinical trial, current endocrine therapies offer symptomatic relief to prostatic cancer patients for an average period of 1-2 years following initiation of therapy. Medical castration with LHRH analogues is a safe and effective way of achieving 'castrate' levels of circulating androgens without the undesirable aspects of surgery. While there is some evidence for the value of combined therapies using these agents in combination with anti-androgens for 'total androgen blockade' in some patients, overall this approach has not been shown to offer advantages over castration, either surgical or medical, alone in controlled trials. Secondary endocrine therapy does not offer convincing objective response rates, suggesting that disease progression is independent of androgens.

Flushing. Long-term side effect of orchiectomy in treatment of prostatic carcinoma

Orchiectomy is considered a safe and simple procedure, free from serious side effects, in the treatment of prostatic carcinoma. We have found that 76 percent of patients experienced postorchiectomy flushes, and 30 percent believed their symptoms warranted treatment. The flushing started at between one and twelve months (average 2.7 months) postoperatively and lasted an average of thirty months or, in some cases, up to the time of death (average 33 months). No single precipitating factor was found, and no single hormone seemed to be responsible. Special attention was given to the nonflushers to see whether or not it was of prognostic significance, and it appears that the slight elevation in the testosterone level sufficient to prevent flushing may indicate a nontesticular source of androgen. Medroxyprogesterone acetate (Provera), 5 mg twice daily, appeared to be an effective agent for controlling the flushes.

Phase II study of Zoladex depot in advanced prostatic cancer with special reference to criteria of response and survival

Zoladex is a potent decapeptide analogue of luteinising hormone releasing hormone (LHRH). The drug is formulated as a 3.6 mg depot dispersed in a matrix of d,l-lactide-glycolide copolymer, which is totally biodegradable. This formula releases drug continuously for at least 28 days and reliably suppresses serum testosterone into the castrate range. The effect of the depot was studied in 29 patients with locally advanced or metastatic carcinoma of the prostate. Average age at entry was 71 years (range 52-87) and follow-up was from 13.5 to 34.5 months (median 23). Endocrine studies showed that medical castration was maintained in all cases. Three patients experienced bone pain in the first month of treatment and two others had temporary nephrostomies for worsening ureteric obstruction. Subjective improvement was seen in 23/28 cases (82%). There were no complete responses, but partial response was seen in 24/28 (85.7%) using our own criteria, 24/28 (85.7%) using the criteria recommended by the British Prostate Group (BPG) and 15/28 (53.6%) using NPCP criteria. Stable disease was seen in 3/28 patients (10.7%) by our own or BPG criteria, and in 12/28 patients (42.9%) according to NPCP criteria. Progression of disease was measurable in 21 patients (72.4%) whatever criteria were applied; 11/29 (37.9%) have died, giving a median survival of 10 months (range 2.4-26). Following these encouraging results, a multicentre randomised comparative study with stilboestrol 3 mg daily is being undertaken.

Current concepts in the treatment of prostate cancer

Carcinoma of the prostate is one of the most common cancers in men over 50 years of age and is the second leading cause of cancer death in men over 75. As a general rule, symptoms usually are not apparent until the tumor is far advanced. Between 80 to 90 percent of patients have metastatic disease at the time of presentation and are not curable by surgery. Endocrine manipulation remains the most effective and commonly used treatment for metastatic carcinoma of the prostate.

Treatment of advanced carcinoma of the prostate with a depot luteinizing hormone-releasing hormone analogue (ICI-118630)

We treated 37 patients with newly diagnosed advanced prostatic cancer with monthly injections of a long acting depot preparation of a luteinizing hormone-releasing hormone superagonist. Serum testosterone levels were reduced to and maintained within the castrate range, even in cases of objective progression. The partial objective regression rate was 43 per cent, with 36 per cent of the patients having objectively stable disease and 21 per cent having objective progression. The subjective improvement rate was 67 per cent. The addition of a short course of diethylstilbestrol at the initiation of therapy appeared to shorten the delay for the subjective improvement. Patient acceptance was excellent and side effects were minimal. Depot luteinizing hormone-releasing hormone analogues, alone or in combination, may well become a preferred alternative treatment for patients with advanced prostatic cancer.

Orchiectomy and delayed radiotherapy as treatment for prostatic carcinoma. A 10-year survey

One hundred and fifty patients with carcinoma of the prostate treated between 1967 and 1982 have been reviewed. Thirty-three patients were treated with stilboestrol alone, 36 by orchiectomy alone and in 81 cases radical radiotherapy was given to the prostate (and in 10 of the 81 cases to the regional and para-aortic lymph nodes) 5 or 6 months after orchiectomy. Although there was no significant difference between the results of those treated by stilboestrol alone and those treated by orchiectomy alone, in those patients receiving orchiectomy and delayed radiotherapy there was a significant improvement in survival. If patients with Stage D disease are excluded, this is a highly significant difference and indeed the survival in these patients does not differ significantly from the expected survival at this age. The 5-year survival rate of Stage D patients treated by this method was 35%.

Biodegradable polymer luteinising hormone releasing hormone analogue for prostatic cancer: use of a new peptide delivery system

Images