Hormone Therapy for Metastatic Prostate Cancer

Metastatic prostate cancer is cancer that began in the prostate but has spread to other parts of the body. There's no cure, but there are a number of effective treatments you can discuss with a healthcare provider that may be able to prolong your life and keep you doing the things you love.

A mainstay of prostate cancer treatment at all stages is a type of hormone therapy called androgen deprivation therapy (ADT). And, newer hormone therapies and combinations with chemotherapy can extend life even more, says Nancy A. Dawson, MD, professor of medicine at Georgetown University in Washington, DC. "Many patients respond to treatment for years, not months," she says.

If you have metastatic prostate cancer, what combination of hormone therapy may be right for you? Keep reading for answers to these questions and more.

If you or a loved one has metastatic prostate cancer, you may already be familiar with hormone therapy. Here's a quick refresher.

Hormone therapy for prostate cancer is aimed at reducing or eliminating the amount of testosterone in your body to slow or stop prostate cancer cells from growing and multiplying.

Hormone therapy for metastatic prostate cancer comes in three main types: ADT, androgen synthesis inhibitors, and androgen receptor blockers.

Although ADT is a common and effective form of prostate cancer treatment at all stages, it has one major challenge for treating metastatic prostate cancer: Eventually it stops working. Enter other forms of hormone therapy.

"Over the last 10 to 15 years, newer therapies, which are hormonal, block the receptor or block the synthesis of androgens," says Andrew J. Armstrong, MD, professor of medicine at the Duke University Medical School in Durham, North Carolina. "These are not ADT; they're given in addition to ADT to further extend life and further extend remissions, improve quality of life, and delay progression."

Dr. Dawson calls this "doublet therapy." And "triplet therapy" is ADT, another form of hormone therapy, and chemotherapy — usually docetaxel, she says.

"The drugs approved to be added to ADT have all been shown in large clinical trials to extend the time patients are hormone-sensitive and to improve overall survival," says Dawson. "Very importantly, they also improve quality of life. That's why I say everyone should get at least doublet therapy."

"Back then men were dying of prostate cancer with no known effective therapy, and the discovery was that androgens were very important promoters of the growth and survival of prostate cancer cells," Armstrong explains. "When you would perform surgical castration in those men you would see a dramatic improvement in how they feel and how long they live."

There are three main forms of ADT:

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

• leuprolide (Camcevi, Eligard, Lupron)
• goserelin (Zoladex)
• triptorelin (Trelstar)

LHRH Antagonists

• degarelix (Firmagon)
• relugolix (Orgovyx)

Orchiectomy

• apalutamide (Erleada)
• bicalutamide (Casodex)
• darolutamide (Nubeqa)
• enzalutamide (Xtandi)
• flutamide (Eulexin)
• nilutamide (Nilandron)

• cabazitaxel (Jevtana)
• carboplatin (Paraplatin)
• estramustine (Emcyt)
• mitoxantrone (Novantrone)

It's because of this variability in cases, goals, and treatment paths that you'll be empowered to help guide your own treatment.

Here are some factors to consider when you and your healthcare providers are deciding on hormone therapy for metastatic prostate cancer:

Side Effects of Hormone Therapy

• Diarrhea
• Erectile dysfunction
• Fatigue
• Gynecomastia (breast tissue growth)
• Hot flashes
• Insulin resistance
• Nausea and vomiting
• Low libido
• Osteopenia and osteoporosis (weakened bones)
• Sarcopenia (loss of muscle mass)

Armstrong points out that androgen synthesis inhibitors are taken with corticosteroids, which come with their own side effects, such as mood swings, weight gain, headaches, and osteoporosis.

Treatment Goals

Your own goals — and what you want from treatment — will inform just about all of your treatment decisions. "It's not so much that some treatments are good and some are bad, it's more like each has advantages and disadvantages," says Dawson.

"Some patients will say, 'I want the best quality of life, the treatment that interferes with my life the least.' Others say, 'Anything to extend life.'" says Dawson. "Some people will want pills; some say they take enough pills already and want injections. Some are willing to do chemo with hormone therapy, while others think it will interfere too much with quality of life."

And the burning question: "Patients want to know how long they'll live," says Dawson. "I expect they'd respond to treatment for years. I don't like to get pinned down with an average because people hone in on that and it's not in their best interest. In a person with aggressive disease, they may stop responding within six months. In others, it could be 10 to 15 years."

As variable as cases and treatments are, many people with metastatic prostate cancer are living with it for a long time, so treatments are tailored to their goals and lifestyle. "People [taking hormone therapy] usually feel pretty good, so they're traveling and spending time with their families," says Dawson. "People on hormone therapy are out there living their lives. You wouldn't know who's on hormone therapy."

"There are so many stressors for men diagnosed with metastatic prostate cancer," says Armstrong. "There's facing your own mortality, the side effects of therapy, and the uncertainty in your life. You want to be there for your family and when you're diagnosed with stage 4 cancer, that does have a major mortality effect," says Armstrong. "Men can live much longer than they used to, but it's still a very stressful time for a lot of patients."

Luckily, there are many support resources available, starting with your treatment center. "Many cancer centers will have social workers, counselors, patient support groups, psychologists, and educational seminars by doctors or patients," says Armstrong.

Dawson concurs, and adds that many of her patients benefit from support groups such as Us TOO from Zero Prostate Cancer. The Prostate Cancer Foundation and Man2Man also offer support groups and other resources for patients and caregivers. "Like treatment, mental health needs and support are very individual," she says. "Every person handles this in their own way."

"There's a lot of support out there," says Armstrong. "Men just need to ask for help and doctors need to ask men about their mental health. That's a really important aspect of treatment."

• Metastatic prostate cancer cannot be cured, but it can be managed with a range of hormone therapies that may control the disease for years.
• Androgen deprivation therapy (ADT) becomes less effective over time, but additional therapies like androgen receptor blockers and androgen synthesis inhibitors may extend life and improve the quality of life.
• When considering which therapies are the best options for you, it's important to think about your overall treatment goals and how the potential side effects may impact your quality of life.
• There are many support groups and mental health resources, such as those from the Prostate Cancer Foundation or Zero Prostate Cancer, that may be beneficial for those receiving treatment.