(Hormonal therapy is a frequent subject in QUEST. Please use the website search engine for additional coverage of this topic. Also for a more complete discussion of hormonal therapy, please see QUEST Fall 2000, Hormonal Therapy Explained.)

1. Q: What are the differences between intermittent and continuous hormonal therapy? And would you recommend one over the other?
A: A downside of hormone therapy for men with prostate cancer is that with continuous therapy you don’t feel normal because of hot flashes, loss of muscle mass, losing calcium from the bone, dryness of the skin and sometimes loss of energy or mental alertness.

The advantage of the intermittent therapy is that the patient takes the hormonal therapy until the PSA goes to zero and then stops until it drifts back to 4 and then goes back on it until the PSA goes to zero again.

With the intermittent therapy, men are only on hormonal therapy about half the time of those on continuous treatment.

The important question to answer is: Is intermittent therapy as effective as continuous hormonal therapy? And now some studies are showing that the men on intermittent hormonal therapy actually do better than men on continuous therapy.

I think intermittent therapy is a good choice for most men and does spare some of the side effects of the continuous therapy. Some men can stay off therapy for two or three years before they have to start again.

2. Q: Do you recommend hormonal therapy in conjunction with radiotherapy?
A: Studies seem to show that hormonal therapy added to radiotherapy is beneficial in “high –risk” (locally advanced or high Gleason grade) tumors treated primarily with radiotherapy. Since there is little downside risk to hormonal therapy, I usually recommend that my patients take hormonal therapy one month before and a few months after radiotherapy.

3. Q: How long will Lupron and Casodex work and what comes after they don’t?
A: The answer to how long they will work is unknown. At the present, no one can predict the duration of response to hormonal therapy.

I usually tell men starting hormonal therapy about my most successful patient – who at the time he was diagnosed had cancer spread to his bones and all over his body, and he was not a candidate for surgery or radiation.

He was placed on hormonal therapy and his PSA remained undetectable for 19 years.

Some men will stay in a remission for long periods of time – 10, 12, or 15 years – and there are other patients for whom the time will be much shorter. The remission time is completely unpredictable in individual patients.

If the PSA rises while on Lupron and Casodex, other types of hormones are available and a more effective form of chemotherapy is also available.

In the pipeline are new experimental treatments involving immunotherapy, gene therapy. They are not ready for “prime-time” now, but in three to four years from now may offer better and more effective treatments with less side effects than treatments we have now.

Eventually, genetic studies will show us which tumors are going to be responsive to hormonal therapy for a long time and which are destined not to respond as well.

4. Q: How do you treat for prevention of bone loss as a result of hormone treatment?
A: My practice is to order bone density tests annually on patients who are on continuous hormonal therapy or by virtue of removal of the testicles.

If the bone density is significantly reduced, I advise vitamin D and calcium supplements and consider using bisphosphonates. In addition with established bone metastases, clinical evidence suggests that bisphosphonates might reduce significant skeletal problems.

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