Flushing. Long-term side effect of orchiectomy in treatment of prostatic carcinoma

The Association Between Hot Flashes and Renal Dysfunction After Androgen Deprivation Therapy With Radiotherapy in Japanese Patients With High-risk Prostate Cancer

BACKGROUND/AIM

We investigated the changes in and characteristics of renal function in Japanese patients with high-risk prostate cancer (PCa) who underwent radiotherapy and long-term androgen deprivation therapy (ADT), including those seen after the ADT was discontinued.

PATIENTS AND METHODS

Among 60 patients who were pathologically diagnosed with PCa and received ADT for 24 months and radiotherapy, 36 patients who underwent treatment for stage B or C PCa were eligible. We assessed renal function using the estimated glomerular filtration rate (eGFR) and investigated the rate of change in the eGFR (ΔeGFR) during and after ADT. Univariate and multivariate logistic analyses were carried out to identify clinical factors that were significantly associated with renal dysfunction at 36 months.

RESULTS

The incidence of renal dysfunction at 36 months was 75% (27/36). Multivariate analysis showed that the presence/absence of HF was an independent predictor of renal dysfunction at 36 months.

CONCLUSION

Renal function tended to recover after ADT was received for 24 months and subsequently discontinued. The presence/absence of HF represents new and meaningful information for patients receiving ADT, and high-risk PCa patients prior to ADT.

Complementary and alternative medicine for natural and treatment-induced vasomotor symptoms: An overview of systematic reviews and meta-analyses

BACKGROUND AND PURPOSE

Vasomotor symptoms (VMS) are very common in menopausal populations and cancer patients and can cause physical and mental discomfort. We aim to summarize the findings of systematic reviews and meta-analyses (SRs/MAs) that assessed the effectiveness of complementary and alternative medicines(CAMs)on VMS to provide solid evidence for future practice.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to May 2019 to identify relevant SRs/MAs. The methodological quality of SRs/MAs and evidence levels of the outcomes were assessed.

RESULTS

A total of 29 SRs/MAs were reviewed. Evidence has shown that acupuncture, hypnosis, paced respiration, cognitive behavioural therapy, genistein, soy isoflavones, S-equol, combined preparations of black cohosh, and omega-3 supplements could significantly reduce VMS. The methodological quality of the SRs/MAs was moderate or high.

CONCLUSION

CAMs might be beneficial for reducing VMS, but the evidence levels were not high. Several priorities for future practice were identified.

Evaluating the prevalence and predictive factors of vasomotor and psychological symptoms in prostate cancer patients receiving hormonal therapy: Results from a single institution experience

•

We assessed vasomotor symptoms in patients on hormone therapy (ADT) for prostate cancer.

•

The commonest symptoms were hot flushes & sweats followed by fatigue & sleep disturbances.

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The short term side-effect profile of ADT for prostate cancer was favourable.

•

Younger age and higher BMI predicted for severe toxicity.

Background & purpose

The impact of vasomotor symptoms (VMS) occurring in prostate cancer (PC) patients whilst on androgen deprivation therapy (ADT) has not been extensively researched. This longitudinal study sought to assess the VMS and identify any predictive factors.

Material & methods

Data from 250 PC patients on ADT were prospectively evaluated between January 10 and August 13 using a physician-directed questionnaire, to assess the impact of VMS. Parameters including height, weight, body surface area (BSA), body mass index (BMI), duration/type of ADT, co-morbidities and ethnicity were recorded.

Results

Fifty (20%) men reported no toxicity, whilst 171 (68.4%), and 29 (11.6%) reported mild to moderate and severe symptoms, respectively. Drenching sweats and hot flashes were common, and coexisted with sleep disturbances and fatigue. Patients with severe toxicity were younger (73 vs. 77 yrs; p = 0.04), had higher BMI (28 vs. 26; p = 0.02), and higher BSA (1.99 vs. 1.90; p = 0.04), when compared with those experiencing no toxicity. On multivariate analysis, younger age was predictive of sweats and hot flushes, whilst Afro-Caribbean men were twice as likely to experience sweats (OR 2.03, p = 0.05).

Conclusions

The short-term side-effect profile of ADT for prostate cancer was favourable, though debilitating VMS can occur in a significant minority of cases. Younger age and higher BMI predicted for severe toxicity but not the duration of ADT.

Survivorship, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

Many cancer survivors experience menopausal symptoms, including female survivors taking aromatase inhibitors or with a history of oophorectomy or chemotherapy, and male survivors who received or are receiving androgen-ablative therapies. Sexual dysfunction is also common in cancer survivors. Sexual dysfunction and menopause-related symptoms can increase distress and have a significant negative impact on quality of life. This portion of the NCCN Guidelines for Survivorship provide recommendations for screening, evaluation, and treatment of sexual dysfunction and menopausal symptoms to help healthcare professionals who work with survivors of adult-onset cancer in the posttreatment period.

Physiology and Endocrinology of Hot Flashes in Prostate Cancer

The purpose of this article is to integrate the physiology of the male reproductive system and the role of hormones in the pathophysiology and treatment of prostate cancer. The primary focus is to review hormonal changes associated with androgen ablation treatment and to integrate the available hormonal data into a hypothesis. This review used a systematic search of Medline references from 1990 to 2006. All sources were critically evaluated to arrive at an understanding of androgen deprivation symptoms, such as hot flushes/flashes, and to identify research needed in this area. Research is needed to explore the physiological mechanisms of hot flashes to develop better therapeutic treatment options to ameliorate side effects of hormonal treatment. Studies are needed to investigate all aspects of hot flashes in populations other than those with breast cancer, such as men with prostate cancer, carcinoid tumors, medullary thyroid tumors, pancreatic islet-cell tumors, renal cell carcinoma, and phenochromocytoma.

A systematic review of non-hormonal treatments of vasomotor symptoms in climacteric and cancer patients

The cardinal climacteric symptoms of hot flushes and night sweats affect 24-93% of all women during the physiological transition from reproductive to post-reproductive life. Though efficacious, hormonal therapy and partial oestrogenic compounds are linked to a significant increase in breast cancer. Non-hormonal treatments are thus greatly appreciated.

This systematic review of published hormonal and non-hormonal treatments for climacteric, and breast and prostate cancer-associated hot flushes, examines clinical efficacy and therapy-related cancer risk modulation.

A PubMed search included literature up to June 19, 2014 without limits for initial dates or language, with the search terms, (hot flush* OR hot flash*) AND (clinical trial* OR clinical stud*) AND (randomi* OR observational) NOT review). Retrieved references identified further papers. The focus was on hot flushes; other symptoms (night sweats, irritability, etc.) were not specifically screened. Included were some 610 clinical studies where a measured effect of the intervention, intensity and severity were documented, and where patients received treatment of pharmaceutical quality. Only 147 of these references described studies with alternative non-hormonal treatments in post-menopausal women and in breast and prostate cancer survivors; these results are presented in Additional file 1.

The most effective hot flush treatment is oestrogenic hormones, or a combination of oestrogen and progestins, though benefits are partially outweighed by a significantly increased risk for breast cancer development.

This review illustrates that certain non-hormonal treatments, including selective serotonin reuptake inhibitors, gabapentin/pregabalin, and Cimicifuga racemosa extracts, show a positive risk-benefit ratio.

Key points

Several non-hormonal alternatives to hormonal therapy have been established and registered for the treatment of vasomotor climacteric symptoms in peri- and post-menopausal women.

There are indications that non-hormonal treatments are useful alternatives in patients with a history of breast and prostate cancer. However, confirmation by larger clinical trials is required.

Androgen deprivation therapy complications

Androgen deprivation therapy (ADT) is increasingly used to treat advanced prostate cancer and is also utilised as adjuvant or neo-adjuvant treatment for high-risk disease. The resulting suppression of endogenous testosterone production has deleterious effects on quality of life, including hot flushes, reduced mood and cognition and diminished sexual function. Cross-sectional and longitudinal studies show that ADT has adverse bone and cardio-metabolic effects. The rate of bone loss is accelerated, increasing the risk of osteoporosis and subsequent fracture. Fat mass is increased and lean mass reduced, and adverse effects on lipid levels and insulin resistance are observed, the latter increasing the risk of developing type 2 diabetes. ADT also appears to increase the risk of incident cardiovascular events, although whether it increases cardiovascular mortality is not certain from the observational evidence published to date. Until high-quality evidence is available to guide management, it is reasonable to consider men undergoing ADT to be at a higher risk of psychosexual dysfunction, osteoporotic fracture, diabetes and cardiovascular disease, especially when treated for extended periods of time and therefore subjected to profound and prolonged hypoandrogenism. Health professionals caring for men undergoing treatment for prostate cancer should be aware of the potential risks of ADT and ensure appropriate monitoring and clinical management.

How long do the effects of acupuncture on hot flashes persist in cancer patients?

PURPOSE

Acupuncture has been suggested as therapy for hot flashes in women with breast cancer and men with prostate cancer. In this systematic review, we sought to evaluate the long-term effects on vasomotor symptoms after the end of a defined treatment period of acupuncture in women with breast cancer and men with prostate cancer.

METHODS

A literature search revealed 222 articles within the field. With defined exclusion criteria, we identified 17 studies. We also used the Jadad quality score and identified seven studies with a score of at least 3.

RESULTS

Six of seven identified studies qualified for inclusion in an analysis that measured frequency of hot flashes weighted in relation to number of patients (n=172). The average reduction from baseline to end of acupuncture (ranging between 5 and 12 weeks of treatment) showed 43.2 % reduction of hot flashes. At the last follow-up (mean 5.8 months, range 3-9 months) after the end of therapy, the weighted reduction from baseline was sustained at 45.6 % in the 153 of 172 patients (89 %) who were followed up.

CONCLUSIONS

Data from six prospective analyzed studies indicate at least 3-month effects after the end of acupuncture treatment for flashes in women with breast cancer and men with prostate cancer. However, larger randomized trials with long-term follow-up will be needed to confirm these preliminary findings.

Randomized trial to assess the impact of venlafaxine and soy protein on hot flashes and quality of life in men with prostate cancer

PURPOSE

Hot flashes occur in approximately 80% of androgen-deprived men. Few intervention studies have been conducted to relieve hot flashes in men.

PATIENTS AND METHODS

Eligible androgen-deprived men were randomly assigned to one of four daily regimens (2 × 2 factorial design) for 12 weeks: milk protein powder and placebo pill, venlafaxine and milk protein powder, soy protein powder and placebo pill, or venlafaxine and soy protein powder. The primary end point was hot flash symptom severity score (HFSSS), defined as number of hot flashes times severity. The secondary end point was quality of life (QoL), assessed by using the Functional Assessment of Cancer Therapy-Prostate.

RESULTS

In all, 120 men age 46 to 91 years participated. Most were white (78%) and overweight or obese (83%). Toxicity was minimal. Neither venlafaxine nor soy protein alone or in combination had a significant effect on HFSSS. Soy protein, but not venlafaxine, improved measures of QoL.

CONCLUSION

In androgen-deprived men, neither venlafaxine nor soy proved effective in reducing hot flashes. Interventions that appear effective for decreasing hot flashes in women may not always turn out to be effective in men.

The importance of supportive care in optimizing treatment outcomes of patients with advanced prostate cancer

Optimal oncologic care of older men with prostate cancer, including effective prevention and management of the disease and treatment side effects (so-called best supportive care measures) can prolong survival, improve quality of life, and reduce depressive symptoms. In addition, the proportion of treatment discontinuations can be reduced through early reporting and management of side effects. Pharmacologic care may be offered to manage the side effects of androgen-deprivation therapy and chemotherapy, which may include hot flashes, febrile neutropenia, fatigue, and diarrhea. Nonpharmacologic care (e.g., physical exercise, acupuncture, relaxation) has also been shown to benefit patients. At the Georges Pompidou European Hospital, the Program of Optimization of Chemotherapy Administration has demonstrated that improved outpatient follow-up by supportive care measures can reduce the occurrence of chemotherapy-related side effects, reduce cancellations and modifications of treatment, reduce chemotherapy wastage, and reduce the length of stay in the outpatient unit. The importance of supportive care measures to optimize management and outcomes of older men with advanced prostate cancer should not be overlooked.

Hot flashes: a review of pathophysiology and treatment modalities

Many therapies are being studied for the treatment of hot flashes for individuals with cancer, yet few studies have demonstrated safe and effective clinical benefit for those who suffer from this distressing symptom. The purpose of this paper is to assess the current options for the management of hot flashes, examining key endpoints from recent clinical trials and reviewing future directions. Hot flashes are a common stressful symptom for individuals with cancer, particularly women with a history of breast cancer and men with prostate cancer. Lifestyle modifications are proposed as the first step in the management of less severe hot flashes. Several publications have addressed nonhormonal agents as a treatment option for hot flashes. Newer antidepressant and anticonvulsant agents have been studied and show potential in treating vasomotor symptoms. Although many complementary and alternative therapies, including herbal medications and phytoestrogens, have been studied for the treatment of hot flashes, none are clinically recommended at this time. Additionally, further evidence is needed for supportive exercise such as yoga and relaxation techniques. Acupuncture may warrant further investigation in the reduction and severity of hot flashes in both men and women. Hormonal therapies, including estrogens and progestogens, are the most well-known and efficient agents in alleviating hot flashes; however, the safety of these agents is disputable.

Dong Quai (angelica sinensis) in the treatment of hot flashes for men on androgen deprivation therapy: results of a randomized double-blind placebo controlled trial

OBJECTIVE

To determine whether Dong Quai, a Chinese herbal compound purported to be efficacious in treating menopausal vasomotor symptoms, has a therapeutic benefit in treating hot flashes among prostate cancer patients receiving androgen deprivation therapy.

METHODS

A randomized double-blind placebo controlled trial was conducted involving 22 men receiving luteinizing hormone-releasing hormone agonist therapy for prostate cancer with bothersome hot flashes. After recording a baseline log of the frequency, duration and severity of daily hot flashes, patients were randomly assigned in a 1:1 ratio to receive daily placebo or Dong Quai for 3 months. Vasomotor and adverse events were recorded daily. Blood work including serum prostate-specific antigen (PSA), international normalized ratio of prothrombin time and partial thromoboplastin time were recorded at baseline and at the termination of the study.

RESULTS

Seventeen of the 22 patients enrolled completed the trial. Baseline vasomotor duration and severity were equivalent between the groups, however the number of hot flashes were significantly more in the Dong Quai group (p = 0.02). With respect to the change in number of hot flashes per day, there was a slight decrease in the mean number among the Dong Quai group which was insignificant. The absolute change and average percentage change in perceived hot flash severity was similar in both groups. There was no significant decrease in the duration of the hot flashes between the 2 groups. Disease progression based on either PSA increase or change in digital rectal exam was not observed in any patient.

CONCLUSION

In this small pilot study, there were no significant differences in the severity, frequency or duration of hot flashes among men receiving placebo or Dong Quai.

Acupuncture for hot flashes in patients with prostate cancer

OBJECTIVES

To determine the effect of acupuncture on hot flash frequency and intensity, quality of life, and sleep quality in patients undergoing hormonal therapy for prostate cancer. Hot flashes are a common adverse effect of hormonal therapy for prostate cancer.

METHODS

Men who had a hot flash score > 4 who were receiving androgen deprivation therapy for prostate cancer underwent acupuncture with electrostimulation biweekly for 4 weeks, then weekly for 6 weeks, using a predefined treatment plan. The primary endpoint was a 50% reduction in the hot flash score after 4 weeks of therapy, calculated from the patients' daily hot flash diaries. The hot flash-related quality of life and sleep quality and biomarkers potentially related to hot flashes, including serotonin, calcitonin gene-related peptide, and urinary 5-hydroxyindoleacetic acid, were examined.

RESULTS

A total of 25 men were enrolled from September 2003 to April 2007. Of these, 22 were eligible and evaluable. After 4 weeks, 9 (41%, 95% confidence interval 21%-64%) of 22 patients had had a > 50% reduction in the hot flash score. Of the 22 patients, 12 (55%, 95% confidence interval 32%-76%) met this response definition at any point during the therapy course. No patient had a significant increase in hot flash score during therapy. A reduced hot flash score was associated with improvement in the hot flash-related quality of life and sleep quality.

CONCLUSIONS

Multiple placebo-controlled trials have demonstrated a 25% response rate to placebo treatment for hot flashes. Of the 22 patients, 41% had responded by week 4 and 55% overall in the present pilot study, providing evidence of a potentially meaningful benefit. Additional studies of acupuncture for hot flashes in this population are warranted.

Managing hot flushes in men after prostate cancer--a systematic review

CONTEXT AND OBJECTIVE

The aim of this study was to describe hot flushes in men with prostate cancer, and their treatment methods.

METHOD

A systematic review was conducted of the literature indexed between 1966 and 2009 on the MEDLINE, the ISI Web of Knowledge, Cinahl and PsycINFO. Of 252 articles identified, 32 were selected for consideration of their complete texts, of which five were subject to detailed analysis.

RESULTS

Diethylstilbestrol, megestrol acetate and cyproterone acetate have the strongest effect, giving a 75% or larger decrease of the number of hot flushes, but they may have severe or bothersome side-effects. Gabapentin has an uncertain effect. Clonidine is not proven effective for hot flushes. Long-term effects were not evaluated in any of the studies. SSRI/SNRI and acupuncture may have a moderate effect on hot flushes but are not proven in any RCTs.

CONCLUSION

Hot flushes are common and bothersome symptoms in men with prostate cancer and those taking anti-androgen treatment, and reduce quality of life. Few treatments are available and some are avoided for these patients. Additional prospective treatment studies are needed, with long-term follow-up, in order to evaluate the effects and risks of treatments. Treatments with few or no severe side-effects should be prioritised in future investigations. Experimental studies are also needed to elucidate the mechanism behind hot flushes in men and to suggest routes for the development of new treatments.

Efficacy of venlafaxine, medroxyprogesterone acetate, and cyproterone acetate for the treatment of vasomotor hot flushes in men taking gonadotropin-releasing hormone analogues for prostate cancer: a double-blind, randomised trial

BACKGROUND

Hot flushes are the most common complaints reported by men undergoing androgen suppression treatment for prostate cancer. We designed a randomised double-blind trial to compare the efficacy of three drugs, each of which has proven effective for preventing hot flushes in previous studies.

METHODS

Men with prostate cancer with an indication for androgen suppression were enrolled in the study at 106 urology centres in France between April 14, 2004, and April 20, 2007. All patients were treated for 6 months with leuprorelin (11.25 mg). At month 6, patients who spontaneously asked for treatment, or those who presented with 14 hot flushes or more during the week before the visit, were randomly assigned to either venlafaxine 75 mg daily, medroxyprogesterone acetate 20 mg daily, or cyproterone acetate 100 mg daily. All patients received two indistinguishable pills in the morning and one in the evening from week 1 to week 8, and one indistinguishable pill in the morning from week 9 to week 10, to comply with the double-blind design. Random assignment with a block size of three was done centrally, by fax, and each patient was given a randomisation number. The allocation sequence was stratified by centre. Assessment was done at inclusion, at randomisation, and then at 4 weeks, 8 weeks, and 12 weeks after randomisation. Participants completed a daily hot-flush diary for 1 week, and a quality of life questionnaire before each visit throughout the study. The primary outcome was the change in median daily hot-flush score between randomisation and 1 month. All patients who received at least one study treatment dose were included in the efficacy analysis. This trial is registered with ClinicalTrials.gov, number NCT01011751.

FINDINGS

Of the 919 men initially enrolled, 311 were randomly assigned to one of the study treatments at 6 months: 102 to venlafaxine, 101 to cyproterone, and 108 to medroxyprogesterone. 309 patients were included in the efficacy analysis, since two were excluded for protocol deviations (one in the cyproterone and one in the medroxyprogesterone group; both were excluded because they were already undergoing treatment with serotonin reuptake inhibitor antidepressants at randomisation). The change in median daily hot-flush score between randomisation and 1 month was -47.2% (IQR -74.3 to -2.5) in the venlafaxine group, -94.5% (-100.0 to -74.5) in the cyproterone group, and -83.7% (-98.9 to -64.3) in the medroxyprogesterone group. The decrease from baseline was significant for all three groups (p<0.0001). Pairwise comparison of treatment groups adjusted by the Bonferroni method confirmed that the decreases in hot-flush score were significantly larger in the cyproterone and medroxyprogesterone groups than in the venlafaxine group, regardless of the interval considered (p<0.0001 in all cases). There was no significant difference between the cyproterone and medroxyprogesterone groups (p>0.2 in all cases). Serious side-effects occurred in four, seven, and five patients in the venlafaxine, cyproterone, and medroxyprogesterone groups, respectively, of which none, one (dyspnoea), and one (urticaria) were considered related to the drug, respectively.

INTERPRETATION

After 6 months of treatment with leuprorelin, venlafaxine, cyproterone, and medroxyprogesterone proved to be effective in reducing hot flushes. However, the hormonal treatments cyproterone and medroxyprogesterone were significantly more effective than venlafaxine. As cyproterone is a recognised treatment in prostate cancer, and its use could interfere with hormonal therapy, medroxyprogesterone could be considered to be the standard treatment for hot flushes in men undergoing androgen suppression for prostate cancer.

FUNDING

Takeda Laboratories, Puteaux, France.

Climacteric-Like Disorders in Prostate Cancer Patients Treated With LHRH Agonists

We assessed long-term side effects with characteristics of female climacteric disorders in prostate cancer patients treated with luteinizing hormone-releasing hormone (LHRH) agonists. Such side effects are not considered to be serious, though they can significantly affect patient quality of life. Sixty-four prostate cancer patients treated with LHRH agonists and 30 benign prostatic hyperplasia patients, as a control group, were surveyed by questionnaire. The median age of the cancer patients was 74.9 years old, ranging from 60 to 94 years, and the median LHRH agonist dosing period was 16.5 months, ranging from 1 to 64 months. The results of the questionnaires were compared between the patients and the controls, as well as between different variables. Sixty (93.8%) of 64 patients claimed symptoms similar to female climacteric disorders. Further, more than 50% of the symptoms included in the questionnaire were reported by 14 (21.9%) of the patients. Symptoms reported by the patients were more severe than those by the controls. Hot flashes, sleep disturbance, and fatigue recorded high scores in the patient questionnaires as compared with those of the controls. In addition, as the term of LHRH agonist use increased, complaints of sweating or coldness in hands and feet increased. Patients without bone metastasis frequently experienced heaviness in the head and headaches compared to those with bone metastasis. The results of our questionnaire-based outcome study showed that side effects similar to female climacteric disorders in prostate cancer patients treated with LHRH agonists were more severe than in the control group, which could be detrimental to quality of life and general well-being.

[Physiopathological mechanism of hot flushes-perspiration induced by androgen deprivation in prostate carcinoma]

Hot flushes and perspiration are common problems during androgen deprivation therapy for prostate carcinoma, and largely contribute to worsen patient quality of life. Different hypotheses have been proposed to explain the underlying physiopathological mechanisms, though all are very complex, basically because of the multiple causal factors involved. The present review offers a pondered and updated perspective of the origin of hot flushes-perspiration in such patients. Negative feedback of the plasma sexual hormones upon the hypothalamic secretion of noradrenalin and serotonin appears to be the main cause. Likewise, the direct action of such mechanisms upon the LH-RH producing hypothalamic center located close to the thermoregulatory center, together with shortening of the thermoneutral interval, would also play a role. Improved understanding of the causal mechanism may help improve the treatment of such symptoms.

A phase III randomized, double-blind, placebo-controlled trial of gabapentin in the management of hot flashes in men (N00CB)

INTRODUCTION

Hot flashes represent a significant problem in men undergoing androgen deprivation therapy.

MATERIALS AND METHODS

Via a prospective, double-blind, placebo-controlled clinical trial, men with hot flashes, on a stable androgen deprivation therapy program for prostate cancer, received a placebo or gabapentin at target doses of 300, 600, or 900 mg/day. Hot flash frequencies and severities were recorded daily during a baseline week and for 4 weeks while the patients took the study medication.

RESULTS

In the 214 eligible patients who began the study drug on this trial, comparing the fourth treatment week to the baseline week, mean hot flash scores decreased in the placebo group by 4.1 units and in the three increasing dose gabapentin groups by, 3.2, 4.6, and 7.0 units. Comparing the three combined gabapentin arms to the placebo arm did not result in significant hot flash differences. Wilcoxon rank-sum P values for change in hot flash scores and frequencies after 4 weeks of treatment were 0.10 and 0.02, comparing the highest dose gabapentin arm to the placebo arm, respectively. The gabapentin was well tolerated in this trial.

CONCLUSION

These results support that gabapentin decreases hot flashes, to a moderate degree, in men with androgen ablation-related vasomotor dysfunction.

[Management of the side effects of androgenic deprivation]

Androgeno-deprivation is the treatment of reference for metastatic prostate cancer but it generates side effects which are too often ignored by physicians due to concentration on hopes of carcinologic benefit. Hot flashes, metabolic syndrome (body mass and lipid changes), decreased libido, erectile dysfunction, anemia, cognitive dysfunction, gynecomastia, decreased muscular mass and osteoporosis are the most frequent symptoms. They can and must be prevented by advice on physical activity and nutrition.

[Development of a questionnaire to evaluate the impact of hot flashes in quality of life in patients with advanced prostate cancer. The ESCAPA study]

BACKGROUND AND OBJECTIVE

Although the use of the androgen deprivation in advanced prostate cancer (APC) is extended, the impact of one of its frequent secondary effects, hot flashes, remains not deeply studied. Our aim is the design and validation of a specific questionnaire to evaluate the impact of hot flashes in APC patients with hormonal ablative treatment.

PATIENTS AND METHOD

Observational, prospective, multicenter study of 496 patients with APC, who were included in one of 2 groups -A (reliability): 56 patients without expected significative state changes; and B (sensitivity): 440 patients, who were either naïve or under changes in hormonal therapy because of intolerance or disease progression-, during 9 months. Hot Flashes Questionnaire (19 items) and the Rotterdam Symptoms Checklist (RSCL) were administered. Variables as disease stage, prostate-specific antigen and Karnofsky index were collected.

RESULTS

Response rate of questionnaire: 85.5%. Correlations observed between different items were high, ranging from 0.545 to 0.957. Effect size between initial visit and follow-up were 0.34, 0.41 and 0.53 at 3, 6 and 9 months. At 3 months, patients with progression showed a mean reduction (standard deviation) of hot flashes impact on daily life activities of 35.76 (37.05). Intern consistency, measured through Cronbach alpha, was of 0.98. Test-retest reliability, measured through intraclass correlation coefficient, resulted significative (0.84; 95% confidence interval, 0.69-0.91).

CONCLUSIONS

Hot Flashes Questionnaire presents good results in feasibility, validity, reliability and sensitivity to change. It's the first questionnaire in evaluating hot flashes impact on APC patients, showing good measure properties that make proper its use both for clinical practice and investigation.

Auricular acupuncture: a novel treatment for vasomotor symptoms associated with luteinizing-hormone releasing hormone agonist treatment for prostate cancer

OBJECTIVES

To evaluate the role of auricular acupuncture (AA) in men receiving luteinizing-hormone releasing hormone (LHRH) analogues for carcinoma of the prostate, as vasomotor symptoms can affect the quality of life in such men, and similar symptoms in postmenopausal women have been successfully treated with AA.

PATIENTS AND METHODS

In all, 60 consecutive patients with prostate cancer and on LHRH agonist treatment (median age 74 years, range 58-83) consented to weekly AA for 10 weeks. The validated 'Measure Yourself Concerns and Well-Being' questionnaire (a six-point scale to assess symptom severity) was used to assess concerns and well-being before and after treatment.

RESULTS

All men completed the treatment with no adverse events recorded, apart from transient exacerbation of symptoms in two men; 95% of patients reported a decrease in the severity of symptoms, from a mean 5.0 to 2.1 (Student's t-test, P < 0.01).

CONCLUSIONS

The symptomatic improvement was at levels comparable with that from pharmacotherapy, and cost analysis showed AA to be a viable alternative. Larger randomized studies are needed to fully evaluate AA against more conventional treatments, and these are planned.

Androgen deprivation therapy: monitoring and managing the complications

Because many patients who have biochemical relapse will live for many years,preventing additional morbidity in those who are treated with ADT is of the utmost importance. No standard therapy is currently available for men who have biochemical relapse, although data are beginning to show that earlierADT may result in improved survival, at least in patients who have somewhat more advanced disease or rapid PSA doubling times or velocities. Treatment with intermittent ADT may attenuate some of the morbidities, such as loss of bone mineral density. Not all patients will experience all or even many of these complications, but patients can be empowered by learning about these beforehand and under-standing what can be done to prevent, monitor, or treat the side effects. Table 2 summarizes recommendations for baseline evaluations of men prior to initiation of ADT, and Table 3 summarizes interventions for specific complications. Better markers to distinguish patients who will benefit from ADT are needed. Newer hormonal agents or supplements are being researched. In the meantime, patients and the health care team can work together to combat complications related to ADT.

Pilot evaluation of selective serotonin reuptake inhibitor antidepressants in hot flash patients under androgen-deprivation therapy for prostate cancer

PURPOSE

Hot flash (HF) is a common side effect in prostate cancer patient undergoing androgen-deprivation therapy (ADT). In this study, we evaluated the efficacy of paroxetine (selective serotonin reuptake inhibitors (SSRIs)) for HF.

PATIENTS AND METHODS

In total, 10 men with prostate cancer under ADH who were suffering with HF entered this study. Self-report questionnaire was used for the evaluation.

RESULTS

The average rating for HF frequency decreased (P=0.009) and HF severity decreased (P=0.0332) also, reported QOL score increased (P=0.0218).

CONCLUSION

These preliminary data suggest that low dose (10 mg/day) of antidepressant paroxetine can be helpful in the treatment of HFs in patients under ADT for prostate cancer. Further controlled studies are needed to more fully evaluate the efficacy of the SSRIs.

Managing Complications of Androgen Deprivation Therapy for Prostate Cancer

With the increase in the number of prostate cancer cases seen in the United States, the use of androgen deprivation therapy (ADT) as a form of treatment has continued to rise. With the increasing use of ADT, it is important for the urologist to recognize the potential side effects from the use of ADT and ways in which to minimize or eliminate the risks from these side effects. This article describes the potential complications of ADT and the recommendations for treatment or prevention of these complications. In addition,we examine the role of nontraditional forms of ADT and the potential benefits they offer.

Mirtazapine: Hot Flashes

Off-Label Drug Uses — This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Wolters Kluwer Health. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form, so the reader can easily identify the scope of information available. A summary of the data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments regarding “Off-Label Drug Uses” to hospital pharmacy@drugfacts.com .

Parenteral medroxyprogesterone for the management of luteinizing hormone releasing hormone induced hot flashes in men with advanced prostate cancer

PURPOSE

Luteinizing hormone releasing hormone (LHRH) agonist therapy for advanced prostate cancer can manifest significant side effects affecting quality of life, most notably hot flashes. This study evaluated the effectiveness of parenteral medroxyprogesterone acetate (MPA) in reducing the frequency and severity of these hot flashes.

MATERIALS AND METHODS

A multi-institutional retrospective review of hot flashes from LHRH therapy for prostate cancer was conducted. The hot flashes were quantified and the severity was graded (3-point analogue scale) before and after treatment with MPA. Two doses of MPA (400 or 150 mg intramuscularly) were administered. Statistical analysis (Student's t test) evaluated the quantity of hot flashes, the quality of hot flashes, and dose effectiveness.

RESULTS

A total of 48 men (40 at 400 mg, 8 at 150 mg) with a mean age of 71.4 years (range 54 to 87) from 3 institutions were evaluated. There were 91% with symptomatic improvement with MPA, and half (46%) had a complete response defined as total elimination of hot flashes. The median number of the hot flashes per day decreased from 4 to 1 and the median severity score decreased from 2 to 1 (p <0.05). Significance was not achieved comparing the 2 doses. Complete responders were not noted with the 150 mg dose. Anticipated response to MPA did not correlate with the number or severity of the hot flashes.

CONCLUSIONS

This study is the first multi-institutional evaluation of hot flashes demonstrating significant reduction in quantity and severity with MPA. Based on these data we now manage hot flashes associated with LHRH analogues with 400 mg of MPA.

Prevention by 17β-estradiol and progesterone of calcitonin gene-related peptide-induced elevation of skin temperature in castrated male rats

OBJECTIVES

To clarify the relationship between calcitonin gene-related peptide (CGRP) and ovarian hormones (17beta-estradiol and progesterone) in hot flashes in men who undergo androgen deprivation therapy for prostate cancer, we studied the effects of ovarian hormones on CGRP-induced elevation of skin temperature in castrated male rats. The results were compared with those from rats treated with testosterone replacement.

METHODS

Adult male rats were castrated by either a single injection of gonadotropin-releasing hormone analogue (Leuplin, 1.0 mg/kg, subcutaneously) or bilateral orchiectomy. The castrated animals were subcutaneously injected daily for 14 days with ovarian hormones, testosterone, or olive oil as the vehicle. On the day after the final administration of the drug, the changes in skin temperature induced by exogenous CGRP (10 mug/kg intravenously), serum testosterone concentration, and prostate weight were measured.

RESULTS

The CGRP-induced elevation of skin temperature was significantly greater in the castrated rats than in the sham-treated rats. This potentiation was significantly inhibited by treatment with ovarian hormones, as well as by testosterone replacement. The testosterone replacement restored decreases in both the serum testosterone level and the prostate weight due to castration; the treatment with ovarian hormones did not affect them.

CONCLUSIONS

17beta-Estradiol and progesterone, which do not confer testosterone activity on serum, may be useful for the treatment of hot flashes in patients for whom testosterone replacement therapy is contraindicated, such as those with prostate carcinoma. In addition, we suggest that CGRP is closely involved in the amelioration of hot flashes by ovarian hormones in men who undergo androgen deprivation therapy.

Pilot evaluation of paroxetine for treating hot flashes in men

OBJECTIVE

To provide prospective information on the potential utility of paroxetine for treating hot flashes In men receiving androgen ablation therapy for prostate cancer.

PATIENTS AND METHODS

Men with symptomatic androgen ablation therapy-related hot flashes were entered into this clinical trial between August 2001 and October 2003. After a baseline week of documentation of the frequency of hot flashes, patients were assigned to receive paroxetine; the initial dosage was 12.5 mg/d, and it was increased to 37.5 mg/d over the ensuing 4 weeks.

RESULTS

Of the 24 patients in whom medication was initiated, 18 completed the 5-week study. In these patients, the median frequency of hot flashes decreased from 6.2 per day during the baseline week to 2.5 per day during the last study week. Hot flash scores (frequency x mean severity) during the same period decreased from 10.6 per day to 3.0 per day. Overall, paroxetine was well tolerated by most patients.

CONCLUSION

The results from this trial suggest that paroxetine Is an effective agent for diminishing hot flashes in men receiving androgen ablation therapy.

Complications of androgen deprivation therapy for prostate cancer

PURPOSE OF REVIEW

Androgen deprivation as a form of treatment for prostate cancer has been used for decades. Within the last decade, however, there has been a significant increase in its use. Therefore, it is incumbent upon the physician to be familiar with the side effects associated with this treatment.

RECENT FINDINGS

Some of the side effects such as osteoporosis, changes in lipid profiles, and anemia may have significant morbidity associated with them, while other side effects such as impotence, decreased libido, fatigue, and hot flashes primarily affect the patient's quality of life. Prevention strategies and treatments exist for many of these side effects.

SUMMARY

This review will update physicians treating patients with androgen deprivation therapy on the side effects associated with this treatment. Once physicians are aware of the potential side effects, they can educate patients on what to expect when starting androgen deprivation therapy. More importantly, physicians can now prevent some of these complications prior to their occurrence, and when these complications occur they have knowledge of the latest treatments.

Influence of hot flashes on quality of life in patients with prostate cancer treated with androgen deprivation therapy

BACKGROUND

We surveyed patients with prostate cancer treated with androgen deprivation therapy to examine the influence of hot flashes on quality of life (QOL).

METHODS

Fifty-five outpatients with prostate cancer (M0, 39; M1, 16) treated with androgen deprivation therapy (castration, 15; castration and antiandrogen, 40) were enrolled in this study. Mean duration of androgen deprivation therapy was 21 months (2-91 months). The patients were still being treated with androgen deprivation therapy at the time of the survey. The functional assessment of cancer therapy (FACT) was used as a QOL questionnaire for outpatients with prostate cancer treated with androgen deprivation therapy. Hot flash assessments were used to document the number and severity (mild, moderate, and severe) of daily hot flashes. The patients prescribed fluvoxamine maleate were reassessed for hot flashes 2 weeks after the prescription.

RESULTS

Thirty-two of the 55 patients (58.2%) suffered from hot flashes. Hot flashes deteriorated the physical well-being subscale of QOL in patients with prostate cancer treated with androgen deprivation therapy (P = 0.043). There was a significant relationship between the desire to be treated for hot flashes and the hot flash assessments (P = 0.038). Fluvoxamine maleate was significantly effective in reducing hot flashes (P = 0.001).

CONCLUSIONS

Hot flashes had adverse effects on the patients' physical status and deteriorated the patients' QOL. New treatment options such as fluvoxamine maleate might help simplify the often difficult management of hot flashes in patients with prostate cancer treated with androgen deprivation therapy.

Place des antidépresseurs sérotoninergiques dans la prise en charge des bouffées de chaleur en cancérologie

INTRODUCTION

Menopausal women or patients treated by chemotherapy or hormonotherapy for breast cancer have often disabled hot flashes. Men with prostate cancer confronted to castration can also suffer from the same problem. In both situations, many arguments go against implementation of estrogenic treatment. Albeit, many complementary therapeutics exist, they are often unsatisfying.

CURRENT KNOWLEDGE AND KEY POINTS

Since some years, anecdotal case reports and controlled studies have reported interest of selective serotonin reuptake inhibitors (SSRIs) antidepressants in this indication. These treatments often appear efficient and well tolerated.

FUTURE AND PROJECTS

Through a review of literature and clinical vignette, we will specify physiopathology and prescription modalities in this new type of indication.

Complications of Androgen-Deprivation Therapy for Prostate Cancer

With the increasing indications for the use of androgen-deprivation therapy in the treatment of men with prostate cancer, side effects of the therapy deserve greater attention. Side effects such as hot flashes, decreased libido, decreased sexual function, and fatigue primarily affect the patients quality of life. Other side effects such as osteoporosis and changes in lipid profiles may also affect the patients overall health. Treatments such as estrogen, megestrol acetate, antidepressants, and bisphosphonates are useful in the management of many of the deleterious side effects of androgen deprivation. In addition, alternative management strategies such as intermittent androgen ablation and antiandrogen monotherapy may be useful in minimizing side effects caused by androgen ablation. Patients and physicians should be well aware of the potential side effects of androgen-deprivation therapy as well as the preventive and treatment strategies for these side effects in order to improve patients quality of life and health.

Andropause: Symptom Management for Prostate Cancer Patients Treated With Hormonal Ablation

Andropause, or the age-related decline in serum testosterone, has become a popular topic in the medical literature over the past several years. Andropause includes a constellation of symptoms related to lack of androgens, including diminished libido, decreased generalized feeling of well-being, osteoporosis, and a host of other symptoms. The andropause syndrome is very prominent in men undergoing hormonal ablation therapy for prostate cancer. Most significant in this population are the side effects of hot flashes, anemia, gynecomastia, depression, cognitive decline, sarcopenia, a decreased overall quality of life, sexual dysfunction, and osteoporosis with subsequent bone fractures. The concept of andropause in prostate cancer patients is poorly represented in the literature. In this article, we review the current literature on the symptoms, signs, and possible therapies available to men who cannot take replacement testosterone.

An eight-month clinical study of LA-2575 30.0 mg: a new 4-month, subcutaneous delivery system for leuprolide acetate in the treatment of prostate cancer

OBJECTIVES

To investigate the safety, efficacy, and pharmacokinetics of a new 4-month subcutaneous depot of leuprolide acetate in patients with prostate cancer.

METHODS

Ninety patients diagnosed with adenocarcinoma of the prostate were enrolled in an open-label, multicenter study. LA-2575 30.0 mg was administered subcutaneously once every 4 months for 8 months. The primary efficacy parameter was a serum testosterone level of 50 ng/dL or less. The pharmacokinetics of leuprolide acetate were analyzed in the first 24 enrolled patients. The values are reported as the mean +/- standard error.

RESULTS

Of 90 enrolled patients, 82 (91%) completed the 8-month study. Eight patients voluntarily withdrew from the study for the following reasons: nonmedical reasons (n = 3), treatment-related adverse events (n = 3), disease progression (n = 1), and cardiovascular disease (n = 1). By day 28, 85 (94%) of the 90 patients had achieved a serum testosterone level less than 50 ng/dL. At study completion, 88 (98%) of the 90 patients had a testosterone value less than the castrate level (mean 12.4 +/- 0.8 ng/dL), with 81 (90%) at less than 20 ng/dL. From baseline to month 6, the mean luteinizing hormone level had decreased from 7.51 +/- 0.69 mIU/mL to 0.12 +/- 0.02 mIU/mL. The mean prostate-specific antigen level had decreased 90% from 13.2 +/- 2.0 ng/mL at baseline to 1.3 +/- 0.3 ng/mL at 8 months. No clinically significant flare reactions were observed. The most common treatment-related adverse event was mild hot flashes.

CONCLUSIONS

LA-2575 30.0-mg depot consistently produced and maintained safe and effective suppression of serum testosterone, with total serum testosterone concentrations well below the medical castrate level of less than 50 ng/dL.

The memorial anxiety scale for prostate cancer: validation of a new scale to measure anxiety in men with with prostate cancer

BACKGROUND

The psychological difficulties facing men with prostate cancer are acknowledged widely, yet identifying men who may benefit from mental health treatment has proven to be a challenging task. The authors developed the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) to facilitate the identification and assessment of men with prostate cancer-related anxiety. This scale consists of three subscales that measure general prostate cancer anxiety, anxiety related to prostate specific antigen (PSA) levels in particular, and fear of recurrence.

METHODS

Ambulatory men with prostate cancer (n = 385 patients) were recruited from clinics throughout the United States. Prior to routine PSA tests, participants completed a baseline assessment packet that included the Hospital Anxiety and Depression Scale; the Distress Thermometer; the Functional Assessment of Cancer Therapy Scale, Prostate Module; and measures of role functioning, sleep, and urinary functioning. PSA values from the last three tests also were collected. Follow-up evaluation was completed within 2 weeks after patients learned of their PSA test result using a subset of these scales.

RESULTS

Analysis of the MAX-PC revealed a high degree of internal consistency and test-retest reliability for the total score and for the three subscales, although reliability was somewhat weaker for the PSA Anxiety Scale. Concurrent validity was demonstrated by correlations between the MAX-PC and measures of anxiety. Overall changes in PSA levels were correlated only modestly with changes in MAX-PC scores (correlation coefficient, 0.13; P = 0.02).

CONCLUSIONS

The MAX-PC appears to be a valid and reliable measure of anxiety in men with prostate cancer receiving ambulatory care.

Side effects of androgen deprivation therapy: monitoring and minimizing toxicity

The current trends in favor of androgen deprivation therapy (ADT) for nonmetastatic prostate cancer at the stage of biochemical recurrence or increasing prostate-specific antigen (PSA) raises the issue of exposing otherwise asymptomatic patients to potential side effects over the longer term. Some of these side effects can have deleterious effects on quality of life, and others may contribute to increased risks for serious health concerns associated with aging. Sexual side effects are the most well-recognized adverse effects from ADT and include loss of libido, erectile dysfunction (ED), and hot flashes. Loss of libido is distressing to many men, and they may not pursue treatments for ED. However, for those who do maintain sexual interest, various remedies are available. The incidence of hot flashes, which may not abate over the course of ADT, is close to 80%. Estrogens, progestin megestrol acetate, medroxyprogesterone acetate, venlafaxine, and cyproterone acetate have been shown to alleviate hot flashes and associated symptoms. Physiologic effects, including gynecomastia, changes in body composition (weight gain, reduced muscle mass, increase in body fat), and changes in lipids, are less commonly recognized as side effects of ADT. These may lead to an exacerbation of potentially more serious conditions, such as hypertension, diabetes, and coronary artery disease. Loss of bone mineral density, anemia, and hair changes also may occur. Additionally, both the diagnosis of prostate cancer and the hormonal therapy can cause psychological distress. These side effects need more systematic study in clinical trials. Physicians should be aware of far-reaching consequences of ADT and should incorporate strategies for preventing and managing toxicities into routine practice.

Depomedroxyprogesterone acetate for hot flashes

To evaluate the efficacy of a long-acting preparation of medroxyprogesterone acetate for hot flash management, 3 men receiving androgen ablation therapy for prostate cancer and 15 women with a history of breast cancer were treated as part of clinical practice with three biweekly intramuscular injections of 500 mg depomedroxyprogesterone. A review of hot flash diaries and patient charts were completed to evaluate the effectiveness and tolerability of these injections for managing hot flashes. Treatment was associated with an approximate 90% decrease in hot flashes (95% CI 82-97%). Daily hot flash frequency decreased from a mean of 10.9 on the first day of treatment (95% CI 8.0-13.8 hot flashes per day) to a mean of 1.1 hot flashes 6 weeks later (95% CI 0.5-1.8 hot flashes) and to a mean of 0.7 hot flashes 12 weeks following therapy initiation (95% CI 0.1-1.2). Improvement in the hot flashes remained for months after discontinuing the injections in many patients. Reported side effects were minimal. This experience suggests that treatment with depomedroxyprogesterone may be an effective and well-tolerated option for the treatment of hot flashes.

Gabapentin: Hot Flashes

Off-Label Drug Uses

This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Facts and Comparisons. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form so that the reader can easily identify the scope of information available. A summary of the data–including, background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations–precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments on “Off-Label Drug Uses” to hospitalpharmacy@drugfacts.com .

Fever and sweats in the patient with advanced cancer

Fever and sweats are common complications of cancer and its treatment. This article reviews potential causes and pathophysiologic mechanisms of fever and sweat. Management recommendations, consisting of primary interventions directed at contributing causes and pathophysiologic mechanisms, and non-specific palliative measures are discussed. Optimal management is contingent on the physician's integration of medical expertise with patient-derived goals of care.