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Hormone always needed first?

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User
Posted 14 Nov 2022 at 17:09

There's an assumption that surgery or radiotherapy for prostate cancer must be preceded by at least 3 months of hormone treatment.  This is said to make surgery/radiotherapy easier or more effective by shrinking the prostate. The hormone treatment is anti-androgen, that is, it blocks or counteracts the man's testosterone, and testosterone encourages prostates to grow.  


However: what if the man already has low testosterone? Is it really necessary to postpone surgery (or radiotherapy) for several months, in the hope of getting his testosterone down from very low to even lower? 


I ask because I'm told I have adenocarcinoma in 1 lobe of my prostate, PSA 7.3, Gleason 4+3, lesion 10mm, total prostate volume 50cc.  I want this cancer treated effectively.  I know I'll get side effects.  But I don't want unnecessary side effects from hormone treatment, as I have reason to believe my testosterone level is already low.  (I'm 72 and my sex drive is now very low, whereas 20 years ago it was strong. )


From looking up the various guidance, I've not seen anyone claiming that hormone treatment actually kills cancer cells like radiotherapy does, rather than just discourage them.  So I don't want to delay the really effective  treatment ( surgery or radio or focal therapy) for 3 or more months, in the hope of some marginal effect from anti-androgen pre-treatment.


I'm waiting to hear what the urology team propose to do about my cancer, but I fear they will assume hormone treatment first, as that's the usual pathway.  I'd welcome advice on what I can do to persuade them to go straight to the 'real' treatment.  Is it worth me getting a private testosterone test first, if such things are available?  If I do, would the NHS urology/oncology team take any notice of it?  Does anyone have experience of avoiding hormone treatment on account of existing low testosterone? 

User
Posted 14 Nov 2022 at 23:58
You are referring to the radiotherapy as the real treatment and therefore thinking of the HT as some kind of unnecessary delay; this is not correct. The HT starves the cancer and weakens it so that the RT can do more damage - years of data shows that 3 or 6 months of HT before RT is more likely to result in full remission. There is some new research to suggest that HT doesn't make a big difference in low risk cases (G3+3 / G3+4) but you don't fall into that group. Wait to see what your oncologist suggests - you may be pleasantly surprised!

The uro-oncos who believe that low testosterone may cause prostate cancer might be the same ones who prescribe HT because the two things are unrelated ... as you have rightly noted, the scene was set when you were a young man and you have probably had PCa since your 40s. Once a man has prostate cancer, HT to starve that cancer is standard practice if he is not having surgery.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 15 Nov 2022 at 09:17

Thanks, but can I ask, in what way does HT starve or weaken the cancer, other than by removing or blocking the testosterone?    The testosterone which the cancer likes  (helps it grow better) but doesn't actually need in order to survive and sit there? 


'Years of data show that HT before RT is more likely to result in full remission'.    But this data is likely to be from men who (mostly) have functional amounts of testosterone at the start of treatment.   Is there any data on the usefulness or otherwise of HT for men who at the start of treatment, already have low testosterone levels?   

User
Posted 15 Nov 2022 at 15:04
There is a difference between "low" testosterone and completely absent/blocked testosterone.

When I was put on HT prior to salvage RT it completely stopped any measurable PSA production. Now in my case the level was fairly low to start with (any significant amount after prostatectomy is a concern) but I am sure others on the forum will have similar experience of its effect on the higher PSA typical at the time of diagnosis. It is possible your cancer is growing more slowly than other men's due to your self-estimated low testosterone, but there is clearly high PSA and if the rate of increase hasn't been measured they will want to get a move on rather than delay by taking further measurements, and they will recommend the approach they have found most successful for other men with your sort of PSA and biopsy results.

I sympathise entirely with your worry about HT - I am currently frustrated that it is taking my testosterone so long to recover now HT has stopped. But from what I understand of the biology, it really does have the effect of making tumours respond better to radiotherapy. I think that is partly because it shrinks the tumour so the RT beam can deliver a higher energy to the target, but also because it causes the DNA to be more susceptible to radiation damage (which is how RT kills the cells). The higher the cancer risk (judged by the biopsy) the more important it is that the treatment is optimal.
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User
Posted 14 Nov 2022 at 20:30
It is not normal to have HT prior to prostatectomy.

For RT, some oncos are happy to not prescribe HT, especially where the cancer is very low risk. However, yours is not a low risk cancer and although no onco can force you to have the HT if you really don't want it, you are significantly reducing your chance of a successful outcome.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 14 Nov 2022 at 20:32
PS your testosterone may be low but it wasn't low enough to prevent you from developing a G4+3 :-(
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 14 Nov 2022 at 21:19

Yes as Lyn said, I hadn’t heard of it being normal practice before prostatectomy to have HT.


My husband did actually have 6 months of HT though before his op….the only reason being was that he was originally diagnosed with advanced cancer so he was put on it straight away. His operation was 6 months after diagnosis and because he’d already had spread we were probably glad that he had the HT to prevent further spread.


 

User
Posted 14 Nov 2022 at 21:24

There are some urologists/andrologists who think low Testosterone levels (but not as low as castrate levels) may be a cause of prostate cancer.

User
Posted 14 Nov 2022 at 22:20

Thanks for replies.


LynEyre - re significantly reducing my chance of a successful outcome - how exactly?  What would the anti- androgens do to the 10mm cancerous lesion, to compensate for the 3 months (or 6 months) delay in killing it with radiation? ( or surgery). 


Even if the hormone therapy would totally prevent any spread in the meantime (rather than just slow it) I don't see how it could compensate fully for delay to the 'real' treatment.


Having said that, I realise my testosterone hasn't been low enough to prevent me growing a G4+3.  I guess the cancer is there in spite of my testosterone level rather than because of it. 


Although I suppose the cancer could have started invisibly 20+ years ago  when I did apparently have plenty of testosterone.


I also note Andy62's comment, though the urologists he mentions presumably aren't the ones who favour HT as  the standard pathway!

User
Posted 14 Nov 2022 at 23:58
You are referring to the radiotherapy as the real treatment and therefore thinking of the HT as some kind of unnecessary delay; this is not correct. The HT starves the cancer and weakens it so that the RT can do more damage - years of data shows that 3 or 6 months of HT before RT is more likely to result in full remission. There is some new research to suggest that HT doesn't make a big difference in low risk cases (G3+3 / G3+4) but you don't fall into that group. Wait to see what your oncologist suggests - you may be pleasantly surprised!

The uro-oncos who believe that low testosterone may cause prostate cancer might be the same ones who prescribe HT because the two things are unrelated ... as you have rightly noted, the scene was set when you were a young man and you have probably had PCa since your 40s. Once a man has prostate cancer, HT to starve that cancer is standard practice if he is not having surgery.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 15 Nov 2022 at 09:17

Thanks, but can I ask, in what way does HT starve or weaken the cancer, other than by removing or blocking the testosterone?    The testosterone which the cancer likes  (helps it grow better) but doesn't actually need in order to survive and sit there? 


'Years of data show that HT before RT is more likely to result in full remission'.    But this data is likely to be from men who (mostly) have functional amounts of testosterone at the start of treatment.   Is there any data on the usefulness or otherwise of HT for men who at the start of treatment, already have low testosterone levels?   

User
Posted 15 Nov 2022 at 15:04
There is a difference between "low" testosterone and completely absent/blocked testosterone.

When I was put on HT prior to salvage RT it completely stopped any measurable PSA production. Now in my case the level was fairly low to start with (any significant amount after prostatectomy is a concern) but I am sure others on the forum will have similar experience of its effect on the higher PSA typical at the time of diagnosis. It is possible your cancer is growing more slowly than other men's due to your self-estimated low testosterone, but there is clearly high PSA and if the rate of increase hasn't been measured they will want to get a move on rather than delay by taking further measurements, and they will recommend the approach they have found most successful for other men with your sort of PSA and biopsy results.

I sympathise entirely with your worry about HT - I am currently frustrated that it is taking my testosterone so long to recover now HT has stopped. But from what I understand of the biology, it really does have the effect of making tumours respond better to radiotherapy. I think that is partly because it shrinks the tumour so the RT beam can deliver a higher energy to the target, but also because it causes the DNA to be more susceptible to radiation damage (which is how RT kills the cells). The higher the cancer risk (judged by the biopsy) the more important it is that the treatment is optimal.
User
Posted 15 Nov 2022 at 19:37

The recovery period from HT is suggested to be about as long as the period you were on it, so if you're only given three months of treatment prior to RT and that's it, your recovery could be reasonably rapid.


The big question both for you and many of us here is, how long to stay on HT after RT. With a G7 and psa of 7.3 a guesstimate might suggest a long spell of HT post RT won't be likely, so if you can get through this with only 3 months of HT you'd be doing extremely well.


Jules

User
Posted 15 Nov 2022 at 20:38
Interesting Micro. Not so good for me, it means I might need as much as another six months to shake off the effects of HT - but for Hopeful, if he can get his oncologist to schedule RT with only 3 months of HT he will get the main benefit while minimising the downside. Could be the perfect compromise.

Although many treatment schedules keep patients on HT for months to years after RT, the benefit is thought to be less than from the HT prior.
User
Posted 15 Nov 2022 at 21:24
Cancer cells are sometimes radio resistant so HT in conjunction helps effectiveness.

I had 8 months HT which also spanned the RT treatment period in 2008. However, I steered clear of HT after the RT, although I was offered it. I did have HIFU twice though as salvage treatment for failed RT, the last being in December 2021, since when each of three PSA tests has carded 0.02. Would I have done better to have had say eighteen months of HT post RT or worse if I had not started HT prior to RT? One can only speculate if you must, because cancer develops and responds to treatment in men in different ways. So Consultants tend to go on what is most generally the experience in the circumstances and it is up to the patient to accept or decline, assuming the consultant will do what is requested, which is not always the case.
Barry
 
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