THE "NEW" PROSTATE CANCER INFOLINK

Three recent publications are focused on the importance of the management of complications of long-term androgen deprivation therapy (ADT) in men with progressive or more advanced forms of prostate cancer.

In a BJU International mini-review, which is available in full on line if you sign up as a member of UroToday, Saad et al. focus on the use of bisphosphonates in the prevention and management of bone health in patients with hormone-sensitive prostate cancer (HSPC).

The authors suggest that patients with HSPC likely need early evaluation and monitoring of their skeletal health because of the rapid bone loss associated with the initiation of ADT and the increased risk for developing bone metastases. They also provide a set of monitoring and treatment guidelines recommended for management of patients with prostate cancer who are undergoing ADT. Finally, they discuss ongoping clinical trials that may expand our understanding of the use of bisphosphonate therapy in managing bone health for prostate cancer patients. This paper does not, however, comment specifically on the use of bisphosphonates to extend survival in men with metastatic disease (which has been demonstrated in a randomized trial with clodronate — an older form of bisphosphonate).

Saylor et al. have provided a broader review of the side effects of ADT for the primary care physician community. They note that, in the USA today, perhaps 700,000 prostate cancer survivors are receiving ADT and are therefore vulnerable to loss of libido, hot flashes, anemia, fatigue, accelerated bone loss, increased fat mass, increased cholesterol and triglyceride levels, and decreased insulin sensitivity. These adverse metabolic effects are, of course, associated with greater risks for fractures, diabetes and cardiovascular disease.

This group of authors emphasize that primary care physicians and patients should be aware of the potential benefits and harms of ADT. They state that, “Screening and intervention to prevent treatment-related morbidity should be incorporated into the routine care of prostate cancer survivors.” They also note that evidence-based guidelines to prevent fractures, diabetes, and cardiovascular disease in prostate cancer survivors (similar to those provided by Saad et al. in the article mentioned above) should be incorporated into the management of all patients on long-term ADT.

Finally, Freedland et al. have also emphasized the importance of a proactive approach to the management of potential side effects of ADT, noting that ADT is not only the standard of care for patients with metastatic prostate cancer but that it is also increasingly used to treat asymptomatic patients with biochemical recurrence(a rising PSA) after failed primary therapy.

The “New” Prostate Cancer InfoLink is of the opinion that early use of long-term hormone therapy can in fact be seriously detrimental for at least some patients. Each patient and his doctor need to look carefully, together, at the pros and cons of early hormone therapy and how they will approach management of the well-known side effects of this form of treatment. Whether one is a younger patient who might need to be on hormone therapy for years or a much older patient with a rising PSA but a shorter reasonable life expectancy is just one of the issues that might affect when to start the use of hormones and how to manage risk over time. The idea that “every patient” with a rising PSA after first-line therapy needs to start taking hormones as soon as his PSA goes over some pre-designated value is probably not the most sensible approach to long-term care.

Filed under: Living with Prostate Cancer, Management, Treatment Tagged: | ADT, androgen deprivation therapy, Management, side effects