Treatment options after your first hormone therapy

This page is for anyone with prostate cancer that is no longer responding so well to their first type of hormone therapy. The page will describe other treatments that may help. You may hear these called second-line therapy. Your partner, family or friends might also find this information helpful. 

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How does hormone therapy work?

Hormone therapy can work in two ways - either by stopping your body from making testosterone, or by stopping testosterone from reaching cancer cells. Prostate cancer cells usually need testosterone to grow. So if testosterone is taken away or blocked, the cancer will usually shrink, wherever in the body. 

Hormone therapy on its own won't cure your prostate cancer. If you have hormone therapy on its own, the treatment will aim to control your cancer and delay or manage any symptoms. 

Read more about hormone therapy, including the types of hormone therapy you may have already had. 

How will I know if my first hormone therapy is not working so well?

While you're having hormone therapy you will have regular PSA (prostate specific antigen) 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. If this happens, you might have more PSA tests to confirm this. Your doctor or nurse will also ask you about any symptoms you may have developed, such as urinary problems or bone pain. You may have scans, which will give your doctor a better idea of how the cancer is growing and which treatments might help.

Your doctor will talk to you about other possible treatment options if you need them. If your PSA level is only rising very slowly and you don't have any symptoms, you might not need to start a new treatment straight away. Your doctor will keep an eye on you with regular PSA tests and scans, as well as asking about your symptoms. They will talk to you about how often you should have these check-ups and if you need to book the appointments yourself.

Why is my first hormone therapy not working so well?

The first hormone therapy you have may keep your cancer under control for several months or years. But over time, the behaviour of your cancer cells may change and your cancer could start to grow again. This can happen even though the hormone therapy is still lowering your testosterone levels.

Although your prostate cancer is no longer responding so well to your first hormone therapy, it may respond well to other types of hormone therapy or a combination of treatments.

What further treatments are available?

The aim of treatment is to control your cancer and delay or manage any symptoms you might have. You will probably continue with your first type of hormone therapy – even though it's not working so well. This is because it will still help to keep your testosterone level low.

Further treatment options may include:

Which treatments will I have?

When your cancer stops responding to your first hormone therapy, there is no best treatment or best order to have treatments in. You might have more than one treatment, while some treatments might not be suitable for you.

The treatments you have will depend on lots of thing, including:

  • where your cancer has spread to
  • if you have any symptoms
  • how long your cancer responded to your first hormone therapy for
  • your general health and any other health problems you have
  • the possible side effects of each treatment
  • what your doctor thinks will work best for you
  • your own thoughts and feelings – for example, how you feel about the possible side effects and how a treatment would fit in with your daily life.

 

Since my father-in-law was diagnosed, we've always asked questions and armed ourselves with facts. Knowing where we stand helps us move onwards and upwards - it's become our family mantra
A personal experience

Anti-androgens

Anti-androgens, such as bicalutamide (Casodex®), are a type of hormone therapy that stop testosterone from reaching the prostate cancer cells. They may be an option if you've already had hormone therapy with injections, implants or surgery (an orchidectomy), which will have lowered the amount of testosterone in your blood.

If you're having LHRH agonist injections, you will probably start taking anti-androgens as well. You may hear this called combined androgen blockade, dual androgen blockade or maximal androgen blockade. It may be slightly more effective than using an LHRH agonist on its own if your PSA level is rising, or if your cancer has spread to other parts of the body (advanced prostate cancer).

If you are already having injections and anti-androgen tablets and your PSA level is rising, your doctor may suggest that you stop taking the anti-androgen for a little while to see if your PSA level falls. You may hear this called a ‘withdrawal response’. Some men find that their PSA level falls for a few months, or sometimes longer.

The side effects of anti-androgens can be similar to the side effects of other types of hormone therapy and can include breast swelling and breast tenderness.

Read more about the side effects of hormone therapy.

Abiraterone

Abiraterone (Zytiga®) is a type of hormone therapy for men with advanced prostate cancer. It's most commonly given to men whose cancer has stopped responding to other types of hormone therapy. It is taken as tablets and works by stopping the production of testosterone. It helps some men to live longer and can help treat or delay symptoms. 

You may be able to have abiraterone either before or after chemotherapy, but it isn’t usually given to men who’ve already had enzalutamide.

Possible side effects of abiraterone include:

  • a build-up of fluid in your body (fluid retention), which can cause swelling in your legs or feed
  • a drop in the level of potassium in your blood, which can cause weakness or twitches in your muscles, or a fast, pounding heartbeat - speak to your doctor straight away if you notice these symptoms
  • liver problems
  • high blood pressure.

You will need to take a steroid called prednisolone or prednisone with abiraterone to lower the risk of some side effects.

Read more about abiraterone.

Enzalutamide

Enzalutamide (Xtandi®) is another type of hormone therapy for men with advanced prostate cancer. It's most commonly given to men whose cancer has stopped responding to other types of hormone therapy. It is taken as capsules and works by blocking the effect of testosterone on prostate cancer cells. It may help some men to live longer and can help treat or delay symptoms.

Enzalutamide can be given before or after chemotherapy. But it isn’t usually given to men who’ve already had abiraterone.

Possible side effects of enzalutamide include:

  • extreme tiredness (fatigue)
  • headaches
  • hot flushes
  • high blood pressure
  • feeling nervous
  • problems with memory and concentration
  • dry or itchy skin
  • breast swelling (gynaecomastia)
  • an urge to move a part of your body, usually your legs (restless leg syndrome)

Read more about enzalutamide, including the possible side effects.

Chemotherapy

Chemotherapy uses anti-cancer drugs to kill cancer cells, wherever they are in the body. It can help some men to live longer, and improve and delay symptoms such as pain.

In the UK, docetaxel (Taxotere®) is the most common type of chemotherapy for men with advanced prostate cancer.

If you’ve already had docetaxel and your cancer has started to grow again, you might be offered a different chemotherapy drug called cabazitaxel (Jevtana®).

If you're having chemotherapy, you will be given steroid tablets, such as prednisolone or dexamethasone. This can help make the treatment more effective and reduce the side effects.

Chemotherapy isn't suitable for everyone as the side effects can be difficult to deal with. Side effects include a increased risk of infection and feeling more tired than usual. Some men get a lot of side effects, while others only have a few. Your doctor will check your general health to make sure you're fit enough for chemotherapy.

Read more about chemotherapy.

Steroids

Steroids are sometimes used to treat prostate cancer that is no longer responding to other types of hormone therapy. Steroids can stop the adrenal glands producing as much testosterone, which can help to control your cancer. They can also improve your appetite, make you feel more energetic, and help with symptoms such as pain.

You might have steroids alone or in combination with other treatments, including chemotherapy and abiraterone. Common steroids include dexamethasone, prednisolone and hydrocortisone.

Steroids can cause side effects. But because they are given in a low dose to treat prostate cancer, most men don’t get many side effects and some men don't get any.

Before you start taking steroids, talk to your doctor or nurse about the possible side effects.

They can include:

  • indigestion and irritation of the stomach lining – take steroids after a meal and ask your doctor about medicines that could help
  • a bigger appetite – try to eat a healthy, balanced diet to keep your weight under control
  • having more energy and a more active mind, which could make you feel irritable or anxious or give you trouble sleeping – take steroids before 4pm and tell your doctor or nurse if this is a problem
  • water retention, which can cause swollen hands and feet
  • a slightly higher risk of getting infections – tell your GP if you have a high temperature or other signs of infection
  • bruising more easily
  • raised blood sugar levels – tell your doctor if you need to urinate (wee) more often or get very thirsty, as these can be signs of high blood sugar
  • weak bones – you might need to take medicines or supplements such as calcium and vitamin D.

Don’t suddenly stop taking steroids as this can make you ill.

You'll be given a steroid treatment card that says you're taking steroids. You should carry this with you at all times and show it to anyone treating you (such as a doctor, nurse or dentist). It’s important that they know you're taking steroids.

Radium-223

Radium-223 (Xofigo®) is a treatment for men whose prostate cancer  has stopped responding to hormone therapy and is causing bone pain. It helps some men live longer. It can also help to reduce bone pain and delay some symptoms.

Radium-223 is a type of internal radiotherapy called a radioisotope. A very small amount of radioactive liquid is injected into a vein in your arm. You will normally have an injection every four weeks, for up to six injections. 

Radium-223 travels around the body in the blood and is drawn towards the bones that have been damaged by the cancer. It collects in these parts of the bones and kills the cancer cells there. It doesn't damage many healthy cells so it doesn't cause may side effects. Possible side effects include:

  • feeling or being sick (nausea or vomiting)
  • diarrhoea (loose and watery bowel movements)
  • low levels of blood cells, which can cause bruising or bleeding.

In England, Wales and Northern Ireland, you can only have radium-223 if you've already had chemotherapy, or if chemotherapy isn't suitable for you. In Scotland, you can have radium-223 before or after chemotherapy.

Read more about radium-223.

Oestrogens

Oestrogens are a type of hormone therapy that can be used to treat prostate cancer that's no longer responding to other types of hormone therapy. They aren't used very often and may not be suitable if you have other health problems. Oestrogen is a hormone that's naturally found in both men and women, but women usually produce more.

Oestrogens can be given as a tablet called diethylstilbestrol (Stilboestrol®) or through a patch that sticks to your skin like a plaster.

The side effects can be similar to the side effects of other types of hormone therapy.

Clinical trials and new treatments

A clinical trial is a type of medical research. It helps researchers and medical teams to find new and improved ways of preventing, diagnosing, treating and managing health problems such as prostate cancer. Clinical trials often test new medicines, medical procedures or medical equipment. There are clinical trials looking at new treatments for prostate cancer and new ways of using existing treatments. 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 more about taking part in a clinical trial, ask your doctor or nurse, or speak to our specialist Nurses.

Read more about clinical trials or speak to your doctor or nurse.

Clinical trials gave us hope and my dad felt that he was doing some good too
A personal experience

Other treatments to manage symptoms

If your prostate cancer has spread to the bones or other parts of your body, you may get symptoms such as pain.

Or if the cancer inside your prostate is pressing on your urethra (the tube you urinate through), you may get urinary problems. There are treatments to help manage symptoms. These are sometimes called palliative treatments. They include:

  • pain-relieving drugs such as paracetamol, ibuprofen, codeine or morphine
  • radiotherapy to slow down the growth of the cancer and reduce symptoms
  • drugs called bisphosphonates to treat bone problems such as pain
  • medicines or surgery to make it easier to urinate.

Who will be involved in my treatment?

You may see different health professionals depending on the treatment you have. For example, if you have chemotherapy you may see an oncologist (a doctor who specialises in treating cancer with treatments other than surgery) and a chemotherapy nurse. You may also see a pharmacist, who will check you're having the right medicines at the right doses.

You may be offered a referral to community services, such as district nurses and palliative care nurses who can help control symptoms. 

Read more about the different health and social care professionals you might see. 

Ask your doctor or nurse anything, including things that may seem small. This can save confusion later.
A personal experience

How will I know how well my treatment is working?

During and after your treatment your doctor or nurse will check how well your treatment is working.

You may have regular PSA tests, and other tests such as MRI scans or CT scans. Your PSA levels alone aren't always enough to know if your treatment is working. So your doctor will use your PSA level and any other test results, along with information about how you're feeling, to check how well the treatment is working.

If you are feeling better this could be a sign that the treatment is working. If the treatment isn't controlling the cancer, then you and your doctor can discuss which treatment to try next.

One aim of your treatment will be to help manage any symptoms from your cancer, so that your daily life is as good as possible. But treatments can cause side effects. Let your doctor or nurse know how you are feeling and about any symptoms or side effects. If you have symptoms in between check-ups, tell your doctor or nurse as soon as possible. Your doctor will talk you through the advantages and disadvantages of each treatment, whether or not they are suitable for you. 

I'm certainly a lot weaker than I was, although I can still enjoy a round of golf.
A personal experience

References

Updated: November 2020 | Due for review: November 2023

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The following people helped to review this information:

  • Will Ince, Specialty Doctor in Oncology and General Practitioner, Norfolk
  • Helen Johnson, Macmillan Urology Oncology Clinical Nurse Specialist, The Christie NHS Foundation Trust
  • Patricia McClurey, Prostate Cancer Clinical Nurse Specialist, South Tees Hospitals NHS Foundation Trust
  • Alison Moorhouse, Urology Oncology Clinical Nurse Specialist, Nottingham University Hospitals NHS Trust
  • Alastair Thomson, Consultant Oncologist, Royal Cornwall Hospitals NHS Trust
  • Our Specialist Nurses
  • Our Volunteers.