Treating prostate cancer after hormone therapy

If your prostate cancer is no longer responding to your original hormone therapy you can have further treatments. You may be able to have other types of hormone therapy, chemotherapy or a new treatment as part of a clinical trial.

Each hospital or specialist team will do things slightly differently. You can use this fact sheet as a general guide to what to expect and ask your doctor or specialist team for more details about treatment and help that may be available to you.

How does hormone therapy work?+

Hormone therapy for prostate cancer works by stopping testosterone reaching the prostate cancer cells. It works by either stopping the brain from telling your body to make testosterone or by stopping testosterone from reaching the cancer cells. If testosterone is taken away, it is usually possible to shrink the cancer wherever the cancer cells are in the body.
The first type of hormone therapy you have usually aims to reduce the amount of testosterone in your body. You may have had:

Injections of a type of drug called an LHRH agonist (such as Zoladex, Prostap,
Suprefact, Decapeptyl). Some of these drugs are available as a small implant inserted under the skin

Surgery to remove the testicles (orchidectomy)

Injections of a type of drug called a GnRH antagonist (such as Firmagon)

Some men may also have a type of hormone therapy drug that blocks testosterone from getting to the cancer cells. This is called an anti-androgen (such as Casodex).

Why is my hormone therapy not working as well?+

Your original hormone therapy may keep your cancer under control for many months or years. However, over time the behaviour of your cancer cells may change and your cancer may start to grow again. Your treatment is still reducing the amount of testosterone in your body but the cancer is able to grow again.

Although the prostate cancer is no longer responding to your original type of hormone therapy, it may still respond to other types of hormone therapy or a combination of other treatments.

Medical terms
Health professionals describe prostate cancer that is no longer responding as well to hormone therapy in different ways. You may hear the terms hormone refractory, hormone resistant, androgen independent or castration resistant prostate cancer. These all mean slightly different things. If you are not sure what stage your cancer is at or what treatments may be suitable for you, speak to your specialist team or call our confidential Helpline.

How will I know if my hormone therapy is not working as well?+

A persistent rise in your PSA level may be the first sign that your cancer is no longer responding as well to your original hormone therapy.

While you are having hormone therapy you will have regular PSA tests to check how well the treatment is working. Your specialist team should notice any changes in your PSA level from these regular tests. If they notice that your PSA is rising, then your specialist team may want to do repeat PSA tests to confirm that the hormone therapy has stopped controlling your cancer.

If your hormone therapy is no longer controlling your cancer then your specialist team will talk to you about other possible treatment options so you can consider what to do. If your PSA level is only rising very slowly and you do not have any symptoms that are bothering you, your specialist team may discuss delaying the start of a new treatment.

What treatments are available?+

If your original hormone therapy is not controlling your cancer as effectively then there are still other treatment options available. The aim of these treatments is to help control your cancer and delay or help manage any symptoms that you might have,[1] such as pain and urinary problems.

When discussing possible treatments, you and your specialist team will consider:

  • The stage of your cancer
  • If you have any symptoms
  • Your health and any other illnesses you have, as these may affect the treatments you can have
  • How well you are coping in your daily life

Your own preferences will also be very important. For example, thinking about how the treatment will fit in with your daily life and considering the possible side effects that treatment could cause.

You will normally continue with your original hormone therapy (see below), but your specialist team may also discuss new treatment options with you, including:

  • Other types of hormone therapy, sometimes called 'second line' hormone therapy
  • Chemotherapy
  • Clinical trials

Not all treatment centres will offer all of the treatments described here.

More hormone therapy+

If you are having LHRH agonist or GnRH antagonist injections, your specialist team may advise you to keep having these even after your PSA has started to rise. The injections could still be helping, as some cancer cells may still be stimulated by testosterone [2]. So keeping the amount of testosterone in your body low could still be important.

Your specialist team may also be able to adjust your current hormone therapy treatment. They will monitor your progress and response to any changes made to your treatment.

You may start taking another type of hormone therapy, called anti-androgen tablets, alongside your injections to see whether your cancer responds to this different type of hormone treatment. You may hear some health professionals call this combined androgen blockade or maximal androgen blockade. Some men may have started their hormone therapy treatment by having both types of hormone therapy.

Being on two types of hormone therapy at the same time could increase the risk of side effects [3]. You can read more about these in our booklet Living with hormone therapy: A guide for men with prostate cancer.

If you were already having injections and anti-androgen tablets at the same time, your specialist team may advise you to stop anti-androgen treatment for a little while to see if your PSA level falls. You may hear your specialist team call this a 'withdrawal response.' The effect of this varies and about 20 to 30 out of 100 men (20 to 30 per cent) may find that this lowers their PSA level for a few months[4] [5]. Some men may find that their PSA level stays lower for longer.

Steroids
A small amount of testosterone comes from the adrenal glands, which are above your kidneys. Taking steroid tablets such as dexamethasone, prednisolone or hydrocortisone may help reduce the production of testosterone from the adrenal glands [7] [1]. Steroids might also help improve your appetite and in some cases your mood.[8] You might have steroids in combination with other treatments. Side effects of steroids include a risk of developing diabetes, bone thinning (osteoporosis) and water retention[9], so your specialist team will monitor you for any signs of these.

Oestrogens
Diethylstilbestrol (previously called stilboestrol) is a manufactured drug similar to the hormone oestrogen. Oestrogen is found in both men and women, but women usually produce more.

Some studies have shown that diethylstilbestrol may be useful for treating prostate cancer that is no longer responding to other types of hormone therapy [10] [11]. It is not clear exactly how diethylstilbestrol controls this stage of prostate cancer, but in some men it helps lower their PSA level [1].

Taking diethylstilbestrol tablets can increase your risk of circulation problems such as blood clots[12] so you will usually take aspirin at the same time to reduce this risk [13]. You may not be able to take diesthylstilbestrol if you have a history of high blood pressure, heart disease or strokes. Your specialist team will advise you about this and can explain the potential risks and benefits.

Ketoconazole
Ketoconazole is a type of anti-fungal treatment that may also help treat prostate cancer by helping to stop testosterone production from the adrenal glands.

If you are taking ketoconazole you may have it at the same time as other treatments such as steroids. Ketoconazole may help lower PSA levels in about three out of ten men (30 per cent) [14], but this varies.

Your specialist team will need to monitor how well your liver is working because ketoconazole can cause liver problems [15]. If there are any problems then you can stop taking the drug and your liver will return to normal. Ketoconazole can also cause a dry mouth and make some people feel very tired.

Chemotherapy+

Chemotherapy uses anti-cancer (cytotoxic) drugs to kill cancer cells. In the UK, docetaxel (Taxotere) is the standard chemotherapy option for men with advanced (metastatic) prostate cancer that is no longer responding to hormone therapy. You may also have another type of chemotherapy, for example mitoxantrone if you do not respond well to docetaxel, or if you or your doctor thinks that you may not be able to tolerate the possible side effects of docetaxel. This might be because you are already quite ill or have other health conditions [1].

If you have chemotherapy you will usually have up to ten treatment sessions at the hospital once every three weeks. At each treatment session you will be given the chemotherapy drug through a drip (infusion). This involves running a liquid containing the drug through a fine tube (cannula) into a vein in your arm. This allows the drug to enter the bloodstream and travel throughout the body. You will also have steroid tablets such as prednisolone, as part of your chemotherapy treatment. Research has shown that using a combination of docetaxel (Taxotere) and prednisolone can help to reduce symptoms such as pain and improve quality of life and control the cancer [16].

Chemotherapy may not be suitable for every man as the side effects are sometimes difficult to cope with. Your specialist team will first assess your general health. This may involve checking that your heart, lungs, liver and kidneys are working normally, as well as making sure that you are well enough to care for yourself with some occasional help[17]. People react in different ways to chemotherapy. Some men may get a lot of side effects whilst others will only have a few. Side effects include: temporary problems with your bone marrow and blood cells (that make you more at risk of getting an infection), tiredness, hair thinning, sore mouth, loss of appetite and feeling sick

For more information read our Tool Kit fact sheet Chemotherapy.

Clinical trials+

A clinical trial is a medical research study involving people, who are always volunteers. They may involve testing new drugs and combinations of drugs, as well as new technologies and procedures. There are a number of clinical trials currently looking into treatments for prostate cancer that is no longer responding as well to hormone therapy. Some of these are new treatments and some are looking at combinations of current treatments. They include:

  • New types of hormone therapy and chemotherapy
  • Chemotherapy combined with medication to treat cancer that has spread to the bones
  • Cancer growth blockers that help stop cancer cells dividing and growing
  • Antibodies that find abnormal proteins on cancer cells and 'mark' them so the immune system will destroy them (monoclonal anti-bodies)
  • Vaccines that stimulate the immune system so that it attacks the prostate cancer (immunotherapy)

Some of the trials use combinations of these types of treatments.
You can ask your specialist team whether there are any clinical trials that you could take part in. This could be at your hospital or if you are willing to travel then you may be able to join a trial at another treatment centre in the UK. In some cases your travel costs will be repaid to you but this varies. To find out about different types of clinical trials you can search the CancerHelp UK clinical trials database.


For more information about the advantages and disadvantages of taking part in a clinical trial, read our Tool Kit fact sheet A guide to prostate cancer clinical trials.

Other treatments+

If you have prostate cancer that has come back in the prostate, spread to the bones or other parts of the body you may also receive treatments to help with this. Sometimes these are called palliative treatments because they aim to reduce symptoms rather than get rid of the cancer. These types of treatments include:

Who will be involved in my treatment?+

If your prostate cancer is no longer responding to your original hormone treatment then your specialist team may change. This will depend on the treatment you are having. For example an oncologist may lead your care rather than an urologist. If you have chemotherapy you may start seeing a specialist chemotherapy nurse. You may also be referred to community services, for example palliative care nurses who are able to give advice about ways to control symptoms and help at home.

You might also have appointments and check-ups more often than before. This depends on what treatments you are having and if you have any symptoms.

How will I know how well my treatment is working?+

During and after your treatment your specialist team will monitor your progress. A major goal of your treatment will be to help manage any symptoms from your cancer and ensure that your daily life is as good as possible.

You should let your specialist team know about how you are feeling and any symptoms you may have. Depending on the stage of your prostate cancer you may experience symptoms such as pain and urinary problems. Treatment that is helping to control your cancer may also cause side effects that affect how you are feeling. If you have symptoms in between your check-ups try to tell your specialist team as soon as possible.

Your specialist team may measure your PSA levels or do further tests such as scans. Your PSA levels alone are not enough to know if your treatment is working. Your specialist team may use these results along with information about how you are feeling to monitor how well the treatment is working. They may also give you advice and treatment to help manage any symptoms you are having, for example pain-relieving medication.

If you are feeling better this could be a sign that the treatment is working. So you could let your specialist team know about this at your check-up as well.

If the treatment is not controlling the cancer then you and your specialist team can discuss what other combinations of treatments are possible.

Coping with prostate cancer that is no longer responding to hormone therapy+

All men are different but if your hormone therapy is no longer controlling your cancer you may feel disappointed, angry or worried about the future. While you may still be able to have treatment to control your cancer, you may find that you feel depressed or anxious during this stage[18]. You may find that it helps to talk to someone or get support. There is further information about sources of support below.


If you have advanced prostate cancer you might feel tired and not as active as usual.[19] But it is important that you are still able to do some things that you enjoy. You could get some advice from your specialist team about what activities you can still do.


If you are a partner, family or friend of someone with prostate cancer that is no longer responding to hormone therapy you may also need support in emotional and practical ways

Where can I get support?+

Friends and family
Some men get all the help and support they need from their family and friends. Talking to a partner, friend or relative may help you to cope with your cancer. Explaining how you feel to those close to you could also help them understand and find a way to offer you support that is right for you.

Counselling
It can sometimes be difficult to speak to those close to you because you do not want to upset them, or you may find it hard to show your emotions. Some people find it easier to talk to someone they do not know. Counsellors are trained to listen and can help you to understand your feelings and find your own answers. Your GP may be able to refer you to a counsellor or you can see a private counsellor. There are different types of counselling available. To find out more contact the British Association for Counselling and Psychotherapy or the UK Council for Psychotherapy.

Your specialist team
You can talk to your specialist nurse, doctor or other health professionals about concerns you may have. You can also call our specialist Helpline nurses.

Palliative care team
The aim of palliative care is to control pain and other symptoms and to meet a person's psychological, social and spiritual needs. In some hospitals you may be referred to a palliative care team quite early on. They can offer treatment to control any symptoms you are having and offer practical support to you and your friends and relatives. The palliative care team could be made up of specialist doctors and nurses, social workers and other health professionals, such as dieticians or physiotherapists. You may see them in the hospital or in some cases they can visit you at home.

One-to-one telephone peer support
If you would like to speak to someone who has been personally affected by prostate cancer you can call our confidential Helpline. A specialist nurse will take a contact phone number for you and a short history of your treatment to date. You will be matched, where possible, with one of our volunteers who may have had similar experiences or treatments. Our volunteers include both men and women whose lives have been affected by prostate cancer either as a patient, spouse or other family member.

Support groups
You might like to get in touch with your local prostate cancer support group. Support groups can be a great way for you to meet people with similar experiences. These groups are often set up by local health professionals, or by people who have experience of prostate cancer. Meetings are usually informal and offer an opportunity to find out about other people's experiences as well as discussing your own thoughts and concerns. Many support groups also welcome partners, friends and relatives. A list of some groups in the UK is available online or you can call our confidential Helpline for more information.

Questions to ask your specialist team+

If my hormone therapy is not working as well, what other treatments are available to me?

Will I still have my original hormone therapy even if it has stopped working as well?

What are the possible side effects of my new treatment (s)?

Will I see any new health professionals?

Are there any clinical trials I can take part in?

What treatments are there to manage symptoms (for example pain or tiredness)?

More information+

British Association of Counselling and Psychotherapy (BACP)
www.bacp.co.uk
Telephone 01455 883300
BACP will help you locate qualified counsellors.
They are happy to discuss any queries or concerns which may arise whilst choosing a counsellor or during the counselling process.

Cancer Research UK Clinical Trials
http://cancerhelp.cancerresearchuk.org/trials/

Freephone 0808 800 4040
Mon - Fri 9am-5pm
Information about current clinical trials for cancer.

Macmillan Cancer Support
www.macmillan.org.uk
Free helpline 0808 808 00 00 (Monday to Friday
9.00am-8.00pm)
Practical, financial and emotional support for people
with cancer, their family and friends.

UK Council for Psychotherapy
www.pysychotherapy.org.uk
020 70149955
Holds a national register of psychotherapists and counsellors and gives information to help you choose a therapist.

References+

1] National Institute for Health and Clinical Excellence. 2008. Prostate cancer: diagnosis and treatment. Available at http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11924..

[2] Ryan CJ, Small EJ. Role of secondary hormonal therapy in the management of recurrent prostate cancer. Urology 2003 62:6B 87-94

[3] Lukka H, Waldron T, Klotz L, Winquist E, Trachtenberg J. Maximal androgen blockade for the treatment of metastatic prostate cancer - a systematic review.

Curr Oncol. 2006 Jun; 13(3): 81-93
[4] Small EJ, Vogelzang NJ. Second-line hormonal therapy for advanced prostate cancer: a shifting paradigm. J Clin Oncol. 1997; 15(1): 382-388.

[5] European Association of Urology. Guidelines on prostate cancer. 2010
www.uroweb.org

[7] Berthold DR, Sternberg CN, Tannock IF. Management of advanced prostate cancer after first-line chemotherapy. J Clin Oncol (2005) 23: 8247-8252

[8] Multi-disciplinary Team Guidance for Managing Prostate Cancer. 2nd Edition (November 2009) British Uro-oncolgy Group, British Association of Urolgical (BAUS): Section of Oncolgy, British Prostate Group (BPG)

[9] Muthuramalingam S.R, Patel K, Protheroe. Management of Patients with Hormone Refractory Prostate Cancer. Clinical Oncology (2004) 16: 505-516

[10] Smith D, Redman BG, Flaherty LE et al. A phase II trial of oral diethylstilbestrol as second-line hormonal agent in advanced prostate cancer. Urology 52: 257-260, 1998

[11] Small E, Kantoff P, Weinberg VK et al. A prospective multicenter randomized trial of the herbal supplement, PC-SPES vs diethylstilbestrol (DES) in patients with advanced, androgen independent prostate cancer. Proc Am Soc Clin Oncol 21: 709a. 2002

[12] British National Formulary http://www.bnf.org.uk/ accessed August 2010

[13] Burns-Cox N, Basketter V, Higgins B, Holmes S. Prospective randomized trial comparing diethylstilboestrol and flutamide in the treatment of hormone relapsed prostate cancer. International Journal of Urology 2002; 9(8): 431-434

[14] Small EJ, Halabi S, Dawson NA, et al. Antiandrogen withdrawal alone or in combination with Ketoconazole in androgen-independent prostate cancer patients: a phase III trial (CALGB 9583).J Clin Oncol 2004; 22: 1025−1033.

[15] British National Formulary Ketaconazole http://www.bnf.org.uk/ accessed June 2010

[16] Collins R, Fenwick E, Trowman R et al. A systematic review and economic model of the clinical effectiveness and cost-effectiveness of docetaxel in combination with prednisone or prednisolone for the treatment of hormone-refractory metastatic prostate cancer. Health Technol Assess. 2007;11(2):iii-iv, xv-xviii, 1-179.

[17] NICE. Docetaxel for the treatment of hormone refractory metastatic prostate cancer. Technology Appraisal Guidance No. 101. 2006.

[18]Tiernam E. Palliative care in urological cancer. Uro-Oncology 2000;1:7-10

[19] Bryant-Lukosius D, Browne G, DiCenso A, Whelan T, Gafni A, Neville A, Sathya J.Evaluation of health related quality of life and priority health problems in patients with prostate cancer: a strategy for defining the role of the advanced prostate cancer: a strategy for defining the role of the advanced practice nurse. Can Oncol Nurs Journal. 2010 Winter; 20 (1): 5-14