The Manual
28 Mar 2018

The Manual: What's next after hormone therapy?

Hormone therapy is a standard treatment for men diagnosed with prostate cancer that’s spread outside of the prostate. It controls rather than cures, so we’re often asked what’s next if it stops working so well. Our Specialist Nurse, Patricia, looks at the options.

Why isn’t hormone therapy working as well for me as it was?

The treatment works in two ways: either by stopping your body from making the hormone testosterone, or by stopping testosterone from reaching the prostate cancer cells. Prostate cancer cells usually need testosterone to grow, so taking away or blocking it usually causes the cancer to shrink wherever it is in the body. Hormone therapy won’t cure your prostate cancer but it can keep it under control – often for several years – before more treatment is needed.

However, over time, the behaviour of your cancer cells may change and your cancer could start to grow again. At this point, your doctor or nurse may refer to your cancer as hormone refractory, hormone resistant, androgen independent or castrate resistant. This can happen even though the hormone therapy is still lowering your testosterone levels.

I’m worried my cancer will start to grow and I won’t know it’s happening. How will my doctor check?

We often get asked this question by men worried the cancer will ‘run away’ before they can have treatment. But while you’re having hormone therapy, you should have regular PSA (prostate specific antigen) blood tests to check how well the hormone therapy is working. A continuous rise in your PSA level may be the first sign that the hormone therapy is no longer working so well.

And your doctor or nurse may also ask you about any new symptoms you may have developed, such as urinary problems or bone pain. At this point you may also have scans, such as a magnetic resonance imaging (MRI) scan, a computerised tomography (CT) scan or a bone scan to see how the cancer is growing and which treatments might help.

What is the best order to have treatments in?

Although it’s something lots of men want to know, there’s currently no best treatment or best order to have them in. And you might have another hormone therapy drug, like abiraterone or enzalutamide, either before or after trying chemotherapy. However, if you’ve already had enzalutamide, abiraterone probably won’t be an option for you. And if you’ve already had abiraterone, enzalutamide probably won’t either. This is because early research suggests that each drug may only have a small effect in men who have already had the other. However, if you get severe side effects from either abiraterone or enzalutamide, you may be able to try the other one.

How will I know if my treatment is working?

During and after your treatment, your doctor or nurse will check how well your treatment is working – usually through regular PSA tests or other tests such as MRI or CT scans – along with how you’re feeling. One aim of your treatment is to help manage any symptoms from your cancer, so that your daily life is as good as possible. But treatments can cause side effects, so let your doctor or nurse know about any changes.

Can I get involved in a clinical trial to try a new treatment?

Yes, you might be able to go on a clinical trial, which aims to find new and improved ways of treating and managing illnesses. There are clinical trials looking at new treatments and ones looking at new ways of using existing treatments, and the best order to have treatments in. If you decide to take part in a clinical trial, you may be able to have a newer treatment that isn’t yet widely available. To find out about taking part in a clinical trial, ask your doctor or nurse, or speak to our Specialist Nurses.

Are there any treatment options after my first hormone therapy?

Yes, quite a few, including anti-androgens, enzalutamide, abiraterone, chemotherapy, steroids and radium-223 – as well as treatments to help manage symptoms (palliative treatments). And even though your prostate cancer isn’t responding to one type of hormone therapy, it may respond well to other types or a combination of treatments.

The treatments you can have will depend on lots of things, and you (with your doctor) will need to consider things like where your cancer has spread to, if you have any symptoms and your general health. Your doctor will also talk to you about the possible side effects of each treatment, how you feel about them, and how treatments will fit in with your daily life. You’ll probably continue with your first type of hormone therapy, too, because it will still help to keep the amount of testosterone in your body low and some cancer cells may keep responding to this.

What do we mean by your ‘first’ hormone therapy?

The first hormone therapy you have is sometimes called ‘first-line’ hormone therapy. It could be:

  • Injections or implants to stop your body making testosterone, such as goserelin (Zoladex or Novgos), leuprorelin acetate (Prostap or Lutrate), triptorelin (Decapeptyl or Gonapeptyl Depot) and buserelin acetate (Suprefact) or degarelix (Firmagon).
  • Tablets to block testosterone from getting to the cancer cells such as bicalutamide (Casodex).
  • Surgery to remove the testicles or the parts of the testicles that make testosterone. This is called an orchidectomy