Surgical castration by orchidectomy
Surgical castration is the simplest and cheapest way to treat metastatic prostate cancer. The obvious disadvantage is the psychological effect of the loss of the testicles.
LHRH-analogues and oestrogen achieve a “medical castration” by stopping the testicular production of testosterone. LHRH-analogues are injections that have to be given monthly or three monthly for the rest of the patient’s life. They are effective but very expensive.
Oestrogen can be taken orally on a daily basis. It has a high incidence of thrombotic complications such as stroke and myocardial infarction.
Anti-androgens oppose the action of testosterone by blocking the androgen receptors. The incidence of erectile dysfunction is less than with surgical or medical orchidectomy because testosterone levels are maintained in the bloodstream. Anti-androgens alone are probably not adequate treatment for metastatic disease. Total androgen blockade by a combination of steroidal anti-androgens and LHRH-analogues or orchidectomy has not been shown to be better than LHRH-analogues or orchidectomy alone. However, non-steroidal anti-androgens yields slightly better results than castration alone.
Locally advanced disease without metastases.
The overall results of treatment of patients with disease beyond the prostate are not good. Some patients with early disease beyond the prostatic capsule, and no evidence of metastases, benefit from radical treatment. The most widely used treatment regimens consist of a combination of radiotherapy and hormonal treatment. Treatment options for locally advanced and metastatic disease.
Early hormonal treatment Watchful waiting with hormonal treatment once symptoms develop Disease that has spread to the seminal vesicles and beyond is not real curable.
Prostate cancer is dependent on the male hormone testosterone. 80% of patients will respond to hormonal treatment that deprives the tumor of testosterone. This response usually involves the shrinkage of metastases and symptomatic improvement for the patient. The response to hormonal treatment is not a cure but can last for many years in some patients. The average duration of response is 2 years. Most cancers eventually escape hormonal manipulation. This is referred to as hormone independent disease and is usually followed by death within a few months.
Controversy exists regarding the timing of hormonal treatment. Most studies indicate a survival benefit for early rather than late hormonal maneuver. Testosterone deprivation has side effects like erectile dysfunction, breast enlargement and osteoporosis. The earlier hormonal treatment is instituted the greater the chance of complications. Once again treatment has to be individualized to the needs of the specific patient.
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