Hormone therapy for prostate cancer

Prostate cancer relies on the male hormone, testosterone, to enable it to grow. One way of controlling the cancer is to starve it of testosterone. Hormone therapy (Androgen deprivation therapy) reduces the amount of testosterone in the body and can slow or stop the growth of cancer cells for many years. Hormone therapy can be given as injections or tablets and there are several types of drugs which all work in different ways to lower testosterone levels:
  • Luteinising hormone (LH) blockers which stop the pituitary gland making testosterone – they include goserelin (Zoladex), buserelin (Suprefact), leuprorelin (Prostap), histrelin (Vantas) and triptorelin (Decapeptyl) and are given by injection.
  • Gonadotrophin releasing hormone (GnRH) blockers work by blocking messages from the brain that tell the testicles to produce testosterone – degarelix (Firmagon) is given by injection.
  • Anti androgens stop testosterone from your testicles getting to the cancer cells – they include flutamide (also called Drogenil), bicalutamide (Casodex) and enzalutamide (Xtandi) and are taken as tablets.
  • Abiraterone (Zytiga) blocks an enzyme called cytochrome p17. Without this enzyme, the testicles and other body tissue can’t make testosterone. It is taken as a tablet.

Describes his hormone treatment and how Zoladex injections were given.

Age at interview 49

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It was brought home to me when the scan, the CT scan, showed up some spots on my ribs which the consultant said he was unsure about. He didn’t know whether that was a secondary infection or whether it was a previous injury. And as a result of that he prescribed that I should have radiation treatment and that he would also at the same time give me the hormone injections.

So I’ve had the hormone treatment now for 18 months, I suppose coming up for 2 years, in fact November’s one will be the last, it would complete the 2 year treatment. The PSA levels have gone down very significantly down to negligible, less than one and I don’t think there’s much point in talking about .1s or .2s because I don’t think it’s that accurate but it’s less than 1.
I had one monthly injection principally to test it, test my system to see that I didn’t get any untoward side effects and subsequent to that they are once every 3 months. And they consist of Zoladex, this consists of a slug of wax which is inserted below the skin in the tummy.

How does that feel?

Well it’s not the most pleasant sort of injection, it depends how well you are with injections. I mean they don’t bother me but we’re talking about a big needle, I mean we’re talking about a needle with a diameter of about 2mms, and it’s a solid slug that goes in under the skin. And it’s done that way because it slowly dissipates over a period of 3 months.

Do you have a local anaesthetic?

No, you can do if it bothers you, you can and the GP offered it to me, in fact he was more squeamish than I was (laughs). I had the cheek to tell him how to do it one time because the first time left me with a tremendous blue bruise.

Can you feel it once it’s under the skin?

No, no, no it depends. I mean if it’s given properly its all right, the needle, you know there’s a needle being pushed in your tummy but it’s sharp and it goes in quite easily.

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Expresses his inconvenience at taking Casodex tablets everyday.

Age at interview 70

Gender Male

Age at diagnosis 66

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But the only trouble was my PSA count had gone up to 67, which was outside the criteria for brachytherapy, and there was evidence it has spread to my bones, the rest of my body. I had a bone scan and they found a hot spot in my groin and I had to forget about brachytherapy from then on. And since then I’ve been on hormone therapy. I started off on Zoladex monthly injections, then I went on to Zoladex three monthly and then he asked if I would like to go on Casodex tablets which is one a day. And I find it very inconvenient because I have to remember every day to take one whereas the 3 monthly injections were very convenient. You had the injection and forgot about it but my PSA count, the last PSA count I had it was .9, it had gone down and I’m quite happy.

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Reports that he had no problems or pains after taking Zoladex.

Age at interview 75

Gender Male

Age at diagnosis 74

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The specialist said ‘You’ve got prostate cancer,’ and I knew nothing about prostate cancer. So I said to him ‘What’s the chances like you know?’ and he just didn’t answer because he said ‘You’re going to be fine,’ he said ‘just think positive. So the specialist told me I had prostate cancer and he was going to give me injections every 28 days. I honestly can’t remember what it is at the moment but I had an injection in the stomach while I was in the hospital and then every 28 days I went to the doctor. And it started in May 2000 the injections.

Was this Zoladex?

Zoladex that’s right, that’s right yes that’s it, yes.

And I’ve had the treatment every month, every 28 days since then until I had to have a blood test every quarter, every 3 months I had a blood test to see what my PSA was. Now the PSA was, I think it’s the magic figure of whatever they check in your blood system to see if that goes down it’s good. Well I started off at 1.9 in May and then in September it went down to 0.6 and now December it went to 0.8 but it’s nothing to worry about the specialist said ‘I’ll take you off the treatment for 2 months to see in fact if it’s stable or whether it goes back up again. If it goes back up again in February I must start the treatment again, if it goes back up again. I feel pretty good actually, no problems, no pains.

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Some doctors prescribe continuous hormone therapy (taken all the time) and others recommend taking it intermittently (a few months treatment followed by a break). Intermittent therapy cuts down on side effects but may not control the cancer for quite as long. How and when hormone therapy is recommended depends on the grade and stage of the cancer. Hormone therapy can be given as:
  • a long term follow on treatment after radiotherapy or surgery with the aim of reducing the chance of the cancer coming back (this is known as adjuvant therapy),
  • taken on its own if the cancer has spread to another part of the body,
  • if surgery or radiotherapy is not recommended because the cancer has grown too far into the tissue around the prostate gland for these treatments to be successful.

Many of the men interviewed were having hormone therapy, sometimes in combination with other treatments such as radiotherapy. Most were taking Casodex (bicalutamide) tablets or Zoladex (goserelin) injections, or a combination of the two. Drugs may be changed during the course of the disease.

Describes the change in his course of drugs.

Age at interview 65

Gender Male

Age at diagnosis 59

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I’ve been under two of the local consultants, the first one was the one that put me on Zoladex, it was after 3 years when I started having problems that I was asked would I like to be referred to a second consultant locally to go on a trial of another drug which was flutamide. I immediately said yes because I was then starting to experience bone pain. I was told that the flutamide may help to reduce that. I saw the second consultant and was told that this was a European wide trial of the drug flutamide and would I be prepared to take part. I was again given very little information about what it was, about what the drug did, all I was told was that it would probably cause some breast tenderness and probably growth in the breast as well which it did. I was on that for 9 months

You said you had some problems and that’s why you went to the other consultant, was that problems with the drug or problems with pain?

Well that’s why I was referred, no I started having pain after 3 years on Zoladex. I had another bone scan and they said ‘Well the cancer is spreading and we need to do something else,’ which is when I was referred for this trial of flutamide. The flutamide again settled me down and lasted for about 9 months at which time I started getting bone pain back again and the consultant decided that the flutamide was no longer working. I’d since, whilst I was on it I found out more about it, what the drug did, the fact that it could stop working after a certain length of time. I was the told that stopping flutamide would probably have a beneficial effect so we stopped the flutamide and I just went back on the Zoladex. There was a beneficial effect by stopping it, it’s strange but stopping the drug can have as beneficial effect as starting on the drug.

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Having tried Zolodex, and then Casodex, David went back to Zoladex. He is now taking a small dose…

Age at interview 61

Gender Male

Age at diagnosis 52

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This time that I’m on Zoladex I’ve also been put on to a very small dose of medication that’s used, or a drug that’s used for the treatment of breast cancer. I think it’s called Megace, and what I have to do is take a quarter tablet of that every day, and that helps to suppress the effects of hot flushes and so on, and it does work quite well, although you get the strange feeling of feeling hot and cold at the same time, you’re not sure whether you’re hot or cold, (laughs) that’s a very weird, but I do think on balance it’s better. I feel very tired at times, I mean I could just suddenly, about two o’clock in the afternoon, many days, just suddenly feel really exhausted, and I really want to go and lie down, but there’s nowhere to go and lie down, but you recover from it about half an hour later.

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At first Stephen was given Zoladex but he had a bad reaction to this hormone, so he was given…

Age at interview 62

Gender Male

Age at diagnosis 60

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I was given Zoladex, but unfortunately I had a bad reaction to that, the skin on my face started peeling off, and it looked horrible, I think it looked worse than it was, but it wasn’t very nice, so the hospital, came to the concl-, decided, after lots of discussion, that the risks of me continuing to take Zoladex was too great, they thought I could have an anaphylactic shock, which would have been pretty serious, so I’m now on bicalutamide (Casodex), I take that, one pill in the evening, which is fine, when I was first diagnosed, I had a very aggressive form of prostate cancer it seems, but the treatment is working at the moment, very well, my PSA level is down to 0.06, which is very good, so I keep taking the medicine, and that is where I am at the moment, I have a few side effects from the medication, they’re not serious, the worse is that I’ve grown, sort of breasts, which are very tender, and I find them embarrassing, I wouldn’t, I don’t want to go to a swimming pool, because I feel that I look odd, soI keep my shirt on, and I wouldn’t want to take my shirt off, if I was say gardening in the front garden, I don’t want people to see, but apart from that, the treatment is working well, the side effects are very few, when I first started the treatment, because I had a combination of morphine for the pain, radiotherapy and steroids, I was very tired, but after a couple of months I came off the morphine, and I’m not on any painkillers now, and I don’t feel as tired as I did, I don’t think I feel any more tired than other people of my age, so I’m now at a stage where things have settled down, and hopefully for the foreseeable future I will just carry on taking the medicine, and hopefully, carry on living a pretty normal life.

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Hormone treatment can dramatically reduce the PSA level.

Highlights how dramatically the hormone treatment reduced his PSA level.

Age at interview 55

Gender Male

Age at diagnosis 51

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But again the medical profession in London still gave me enormous encouragement and I was immediately referred to an oncologist who started me off on another treatment which has brought my PSA levels down dramatically.

So what is this treatment?

This is just basic old fashioned hormone treatment which has got my PSA levels down from over 2,000 to now 300 and something which is still extraordinarily high level but appreciably less than what it was. And they intend to continue to do that with me and as long as I show signs of reduction I’ll continue with that form of treatment. But with the understanding that it will turn around and go the other way again, but that they have got several new irons in the fire and they’re perfectly willing to give things a try because I’m perfectly willing to try anything to get out of the woods. And I come away from there every time encouraged, I find them great. And the latest one I think they mentioned today if my PSA starts to rise again I may even be put on Thalidomide.

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Casodex taken without other hormones has relatively little effect on a man’s sex life, but it has to be taken daily, which may be hard to remember. One man reported that he had chosen to take Casodex alone, but he had by mistake been given too low a dose to make it effective. Although some men reported that hormone treatment suited them, others reported side effects such as erectile problems, hot flushes and sweating, breast tenderness, feeling tired and weak and mood swings. Other side effect include memory loss, weight gain, tumour flare (bone pain) and bone thinning (osteoporosis) for more information see ‘Side effects of treatments‘.

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