Hormone therapy for prostate cancer is any treatment that lowers the man’s testosterone levels. Testosterone is the main food or fuel for prostate cancer so blocking it slows the cancer’s growth by “starving it of food”. Types of hormone therapy include:

• Surgery to remove both testicles called bilateral orchiectomy. The testicles produce 90% of testosterone, so removing them produces castration or loss of testosterone permanently.
• Hormone medication, also called androgen deprivation therapy (ADT) is used to suppress testosterone production in the body. The medication used is luteinizing hormone releasing hormone (LH-RHs) antagonists or agonists, these are injections given either monthly sor every 6 months.

Some terms you may hear associated with this in advanced prostate cancer are:

Castration-resistant prostate cancer (CRPC)

CRPC is when your PSA has risen or your cancer has shown other signs of growing after using hormone therapy. At first, prostate cancer usually responds to hormone treatments. But eventually cancer cells “outsmart” the treatment. They learn how to grow even without testosterone to fuel its growth.

Metastatic castration-resistant prostate cancer (mCRPC)

If your PSA has risen while on hormone therapy and your cancer has spread far from the prostate, you have metastatic castration-resistant prostate cancer or mCRPC.

Possible side effects of hormone therapy include:

• Lower libido (sexual desire) in 90% of men
• Erectile dysfunction (inability to have or keep a strong enough erection for sex)
• Hot flashes (sudden spread of warmth to the face, neck and upper body, heavy sweating). Hot flashes are not a health risk, but can definitely affect your quality of life. Medicines can help control them if they are intolerable.
• Weight gain of 10 to 15 pounds with some men. Diet including fruits, vegetables and lean proteins, lower carbohydrate intake and exercise can help prevent this.
• Mood swings
• Depression caused by the treatment, reaction to side effects, or other cancer-related issues. Symptoms include loss of hope and loss of interest in usually enjoyable activities. Other symptoms include not being able to concentrate and changes in appetite and sleeping.
• Fatigue (tiredness) that doesn’t go away with rest or sleep, caused by lower testosterone. Exercise can help. Medications can help.
• Anemia (low red blood cell count). Less oxygen gets to tissues and organs, causing tiredness or weakness. It can be treated with medicines, vitamins and minerals.
• Loss of muscle mass. This may cause weakness or low strength. Weight-bearing exercise or use of resistant bands can help preserve strength.
• Osteoporosis (loss of bone mineral density). This means bones become thinner, brittle and break easier. It can be treated with medicines, calcium and vitamin D. Progressive weight-bearing exercise such as walking, can help maintain bone strength.
• Memory loss
• Breast nipple tenderness
• Increased risk of diabetes, 40% higher compared to men not on ADT
• Heart disease. Some studies show men on ADT are at higher risk for heart problems. Others have not shown this. The effect of ADT on the heart is still unknown. Cancer alone causes increased risk for blood clots.
• High cholesterol, especially LDL (“bad”) cholesterol. Can be managed with medications

Bone Health Therapy

Bone health is very important in metastatic prostate cancer. Bone metastases are very common in prostate cancer, this is when the prostate cancer travels to various bones in the body and starts to grow in that area. Prostate cancer cells are attracted to the bone because of a good blood supply. This is still prostate cancer and not bone cancer. Bone metastases put you at risk for:

• Pathological fractures (broken bones due to prostate cancer) can occur without any fall or trauma and may be painful and difficult to heal.
• Surgery to the bone to stabilize an area that is at high risk for breaking.
• Radiation to areas where bone metastases are causing moderate to severe pain.
• Spinal cord compression: occurs when the prostate cancer grows in the spinal bones and causes pressure on the spinal cord. This can compress the spinal cord nerves causing numbness, weakness or possibly paralysis.

Men who are on androgen deprivation hormone therapy, also lose bone density (thickness) that can lead to osteopenia or osteoporosis.

Sipuleucel-T (Provenge) is an immunotherapy specifically for metastatic castrate resistant prostate cancer. It works by stimulating your immune system to fight prostate cancer. It may extend survival by months. It is given intravenously (IV) into your bloodstream every 2 weeks for 3 treatments total. Prior to each infusion, you will need to go to the Red Cross Center in Harrisburg for apheresis (removal of white blood cells from you) which are then sent to the Provenge facility to then be exposed to prostate antigen to program the white blood cells to identify and attack prostate cancer cells.

Side effects of the treatment are usually minimal and may include fever, chills, headache, nausea, vomiting and diarrhea over 24 hours after the infusion. Usually it is very well tolerated. As with any treatment there is a risk of an allergic reaction but it is a rare occurrence.

Sipuleucel-T (Provenge) is usually given early in the disease process when you are asymptomatic with metastatic castrate resistant prostate cancer.

Additional information can be found at www.Provenge.com

When prostate cancer has spread to your bones, Xofigo is a therapy that can target the cancer cells in the bone to possibly help slow the spread of the cancer and lessen symptoms. Xofigo® is a therapy that is used to treat prostate cancer that has spread to the bones and that is resistant to other medical and surgical treatments that lower testosterone.

What is Xofigo

Xofigo contains radium 223, which is a radioactive material. Xofigo goes to the bones, targeting rapidly growing prostate cancer on the bones. The radiation from Xofigo targets and kills the cancer cells in your bones but does limited damage to surrounding, healthy cells.

How is Xofigo Given

Xofigo is administered through an intravenous injection. You will receive a total of six injections – one every four weeks. The injection only takes a few minutes and you will be able to leave our office after treatment and go on with your normal daily activities. It is usually very well tolerated, some men may have some fatigue, nausea or diarrhea which can be managed.
Even though Xofigo contains radioactive material, there are no restrictions regarding contact with others after treatments.

Benefits of Xofigo

In a clinical trial that studied Xofigo in men with castration-resistant prostate cancer, the men who received Xofigo:

• Lived 3.6 months longer than those who did not take Xofigo
• Had a median overall survival of 14.9 months versus 11.3 months in placebo-treated men.
• May help with bone pain
• Targets bone metastatic disease only

Additional patient information is also available at www.xofigo-us.com/patient/.

There are numerous oral medications being used in advanced prostate cancer with new ones being approved frequently which is a very exciting development in this disease. The medications help extend survival and help maintain the man’s quality of life.

Abiraterone (ZYTIGA)

A once-daily oral prescription medicine that is used along with prednisone to treat men with hormone sensitive metastatic prostate cancer or metastatic castrate-resistant prostate cancer.

This medication works by blocking other pathways prostate cancer can use testosterone to continue to grow.

Enzalutamide (XTANDI)

A prescription medicine approved to treat men with castration-resistant prostate cancer (prostate cancer that is resistant to medical or surgical treatments that lower testosterone) with rapid PSA rises or metastatic disease. XTANDI is taken orally – four capsules once a day.

XTANDI is an androgen (think testosterone) receptor inhibitor that, in clinical studies, has been shown to work within prostate cancer cells to:

• Induce cell death
• Decrease proliferation
• Decrease tumor volume

Apalutamide (ERLEADA)

A prescription medicine used for the treatment of prostate cancer: that is metastatic but still responding to hormonal or surgical treatment that lowers testosterone or that non metastatic, and no longer responding to hormonal or surgical treatment that lowers testosterone with rapid PSA progression. It is taken orally once daily

Darolutamide (NUBEQA)

A prescription medication used for the treatment of non-metastatic castrate resistant prostate cancer with rapid PSA progression. It is taken orally twice daily.

Chemotherapy is the delivery of powerful drugs intravenously to kill or reduce prostate cancer cells. Currently there are two approved chemotherapy drugs that have shown benefit in prostate cancer.

Docetaxel (Taxotere)

Docetaxel is used upfront in new presentation of hormone sensitive prostate cancer in combination with ADT therapy. It has demonstrated a survival benefit of 17 months. It is 6 cycles of medication given over 3 months. It is fairly well tolerated at this stage. Docetaxol may also be used later in the disease process when other medications have stopped working.

Cabazitaxel (Jevtana)

A second line therapy later in the disease process when Docetaxel is no longer effective. It may work in tumors that have become resistant to docetaxel.

Radiation therapy in advanced prostate cancer is used palliatively to help with bone pain or spinal cord impingement. The length of treatment is determined by the area of the bones affected, it may require 1 treatment or multiple treatments. It may be used at any time during the course of the disease in combination with any of the medications.