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Fankhauser CD, Wettstein MS, Reinhardt M, Gessendorfer A, Mostafid H, Hermanns T. Indications and Complications of Androgen Deprivation Therapy. Semin Oncol Nurs 2020; 36:151042. [PMID: 32773255 DOI: 10.1016/j.soncn.2020.151042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the indications for and side effects of androgen deprivation therapy (ADT) in men affected by prostate cancer. DATA SOURCES National guidelines, evidence-based summaries, peer-reviewed studies, and websites. CONCLUSION Indications for ADT include men with (1) intermediate- to high-risk localised prostate cancer undergoing radiation therapy, (2) biochemical recurrence after radical prostatectomy treated with salvage radiation therapy, or (3) metastatic prostate cancer. Several forms of ADT are available. To support self-management, body weight, diet, physical activity, alcohol consumption, and smoking should be discussed during clinical consultations. Important side effects of ADT may include flare-up phenomena of GnRH analogues, local reactions at injection sites, cardiovascular events, bone loss/fractures, drug-drug interactions, urinary tract dysfunction, hot flashes, cognitive impairment, seizure falls, and liver impairment. IMPLICATIONS FOR NURSING PRACTICE Nurses have a role in personalized cancer care and should be familiar with indications, side effects, and interventions to optimize quality of life for men affected by prostate cancer receiving ADT.
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Affiliation(s)
| | | | - Michèle Reinhardt
- Department of Urology, University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Hugh Mostafid
- Department of Urology, Royal Surrey Hospital, Guildford, Surrey, UK.
| | - Thomas Hermanns
- Department of Urology, University Hospital, University of Zürich, Zürich, Switzerland
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Treatment strategies to prevent and reduce gynecomastia and/or breast pain caused by antiandrogen therapy for prostate cancer : Statement from the DEGRO working group prostate cancer. Strahlenther Onkol 2020; 196:589-597. [PMID: 32166452 PMCID: PMC7305090 DOI: 10.1007/s00066-020-01598-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 02/18/2020] [Indexed: 11/23/2022]
Abstract
Aim To provide an overview on the available treatments to prevent and reduce gynecomastia and/or breast pain caused by antiandrogen therapy for prostate cancer. Methods The German Society of Radiation Oncology (DEGRO) expert panel summarized available evidence published and assessed the validity of the information on efficacy and treatment-related toxicity. Results Eight randomized controlled trials and one meta-analysis were identified. Two randomized trials demonstrated that prophylactic radiation therapy (RT) using 1 × 10 Gy or 2 × 6 Gy significantly reduced the rate of gynecomastia but not breast pain, as compared to observation. A randomized dose-finding trial identified the daily dose of 20 mg tamoxifen (TMX) as the most effective prophylactic dose and another randomized trial described that daily TMX use was superior to weekly use. Another randomized trial showed that prophylactic daily TMX is more effective than TMX given at the onset of gynecomastia. Two other randomized trials described that TMX was clearly superior to anastrozole in reducing the risk for gynecomastia and/or breast pain. One comparative randomized trial between prophylactic RT using 1 × 12 Gy and TMX concluded that prophylactic TMX is more effective compared to prophylactic RT and furthermore that TMX appears to be more effective to treat gynecomastia and/or breast pain when symptoms are already present. A meta-analysis confirmed that both prophylactic RT and TMX can reduce the risk of gynecomastia and/or breast pain with TMX being more effective; however, the rate of side effects after TMX including dizziness and hot flushes might be higher than after RT and must be taken into account. Less is known regarding the comparative effectiveness of different radiation fractionation schedules and more modern RT techniques. Conclusions Prophylactic RT as well as daily TMX can significantly reduce the incidence of gynecomastia and/or breast pain. TMX appears to be an effective alternative to RT also as a therapeutic treatment in the presence of gynecomastia but its side effects and off-label use must be considered.
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Fentiman IS. Managing Male Mammary Maladies. Eur J Breast Health 2018; 14:5-9. [PMID: 29322112 DOI: 10.5152/ejbh.2017.3841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/30/2017] [Indexed: 11/22/2022]
Abstract
This review examines the symptoms, need for referral and management of the benign breast conditions which afflict males, together with the steps that are necessary to exclude or confirm male breast cancer. The most common complaint is gynaecomastia, either true or pseudo, and the majority of these cases need reassurance without over-investigation. Drugs that induce breast enlargement are described in order that, when possible, a medication switch can be made. Men receiving endocrine therapy for prostate cancer may develop painful gynaecomastia and this can be relieved with tamoxifen. All men with breast cancer need mammography as part of their work-up but this should not be used as a screening technique for symptomatic males. Because of lack of lobular development, both cysts and fibroadenomas are very rare in men; but those with nipple discharge need referral and investigation as some will have underlying malignancy.
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Affiliation(s)
- Ian S Fentiman
- Department of Research Oncology, Guy's Hospital, London, England
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Fricke A, Lehner GM, Stark GB, Penna V. Long-Term Follow-up of Recurrence and Patient Satisfaction After Surgical Treatment of Gynecomastia. Aesthetic Plast Surg 2017; 41:491-498. [PMID: 28280898 DOI: 10.1007/s00266-017-0827-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/10/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND "Gynecomastia" is an enlargement of the male breast. Our study aims to assess patient satisfaction as well as evaluate differences in recurrence rates in lipomatous and glandular gynecomastia 10-19 years postoperatively. METHODS Forty-one gynecomastia patients undergoing surgical treatment from 1997 to 2005 were invited for a follow-up examination 10-19 years postoperatively. Of these, 16 patients presented for a clinical examination. Patient satisfaction was measured with a validated questionnaire [consultation satisfaction questionnaire (CSQ)-9]. Furthermore, photo-material and patient charts were evaluated concerning preoperative macroscopical type of gynecomastia, BMI, and operative technique. RESULTS Mean follow-up time was 13.8 years (range: 10.5-19 years). Eight patients (50%) had presented with lipomatous and eight patients (50%) with glandular gynecomastia prior to surgery. One of the patients with glandular gynecomastia (12.5%) presented with recurrence at the time of follow-up, while five of the eight patients showing lipomatous gynecomastia (62.5%) presented with recurrence. Interestingly, younger patient groups tend to be more satisfied with the operative treatment of gynecomastia than older patient groups, especially regarding the improvement of self-esteem. CONCLUSIONS Long-term follow-up results showed that recurrence rates are significantly higher in patients with lipomatous gynecomastia than in patients with glandular gynecomastia, with BMI increase in patients with glandular and lipomatous gynecomastia showing no statistically significant differences. Furthermore, general patient satisfaction and improvement of self-esteem was higher in younger patient groups than older patient groups. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . CLINICAL TRIAL REGISTRATION NUMBER DRKS00009630.
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Wibowo E, Pollock PA, Hollis N, Wassersug RJ. Tamoxifen in men: a review of adverse events. Andrology 2016; 4:776-88. [DOI: 10.1111/andr.12197] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/09/2016] [Accepted: 03/12/2016] [Indexed: 12/16/2022]
Affiliation(s)
- E. Wibowo
- Vancouver Prostate Centre; Vancouver Coastal Health Research Institute; Vancouver BC Canada
| | - P. A. Pollock
- Vancouver Prostate Centre; Vancouver Coastal Health Research Institute; Vancouver BC Canada
| | - N. Hollis
- Solid Organ Transplant Clinic; Vancouver General Hospital; Vancouver BC Canada
| | - R. J. Wassersug
- Department of Urologic Sciences; University of British Columbia; Vancouver BC Canada
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Gaudet M, Vigneault É, Foster W, Meyer F, Martin AG. Randomized non-inferiority trial of Bicalutamide and Dutasteride versus LHRH agonists for prostate volume reduction prior to I-125 permanent implant brachytherapy for prostate cancer. Radiother Oncol 2016; 118:141-7. [DOI: 10.1016/j.radonc.2015.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/15/2015] [Accepted: 11/22/2015] [Indexed: 10/22/2022]
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Fagerlund A, Cormio L, Palangi L, Lewin R, Santanelli di Pompeo F, Elander A, Selvaggi G. Gynecomastia in Patients with Prostate Cancer: A Systematic Review. PLoS One 2015; 10:e0136094. [PMID: 26308532 PMCID: PMC4550398 DOI: 10.1371/journal.pone.0136094] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/29/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Gynecomastia and/or mastodynia is a common medical problem in patients receiving antiandrogen (bicalutamide or flutamide) treatment for prostate cancer; up to 70% of these patients result to be affected; furthermore, this can jeopardise patients' quality of life. AIMS To systematically review the quality of evidence of the current literature regarding treatment options for bicalutamide-induced gynecomastia, including efficacy, safety and patients' quality of life. METHODS The PubMed, Medline, Scopus, The Cochrane Library and SveMed+ databases were systematically searched between January 1, 2000 and December 31, 2014. All searches were undertaken between January and February 2015. The search phrase used was:"gynecomastia AND treatment AND prostate cancer". Two reviewers assessed 762 titles and abstracts identified. The search and review process was done in accordance with the PRISMA statement. The PICOS (patients, intervention, comparator, outcomes and study design) process was used to specify inclusion criteria. Quality of evidence was rated according to GRADE. MAIN OUTCOME MEASURES Primary outcomes were: treatment effects, number of complications and side effects. Secondary outcome was: Quality of Life. RESULTS Eleven studies met the inclusion criteria and are analysed in this review. Five studies reported pharmacological intervention with tamoxifen and/or anastrozole, either as prophylactic or therapeutic treatment. Four studies reported radiotherapy as prophylactic and/or therapeutic treatment. Two studies compared pharmacological treatment to radiotherapy. Most of the studies were randomized with varying risk of bias. According to GRADE, quality of evidence was moderate to high. CONCLUSIONS Bicalutamide-induced gynecomastia and/or mastodynia can effectively be managed by oral tamoxifen (10-20 mg daily) or radiotherapy without relevant side effects. Prophylaxis or therapeutic treatment with tamoxifen results to be more effective than radiotherapy.
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Affiliation(s)
- Anders Fagerlund
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Luigi Cormio
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Lina Palangi
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Richard Lewin
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, at Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Anna Elander
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gennaro Selvaggi
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, at Sahlgrenska University Hospital, Gothenburg, Sweden
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Fischer S, Hirsch T, Hirche C, Kiefer J, Kueckelhaus M, Germann G, Reichenberger MA. Surgical treatment of primary gynecomastia in children and adolescents. Pediatr Surg Int 2014; 30:641-7. [PMID: 24763713 DOI: 10.1007/s00383-014-3508-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Idiopathic gynecomastia is a common diagnosis in children and adolescents. Though medical treatments reveal potentially harmful side effects, surgical interventions are performable in numerous techniques. In children and adolescents, only minimal evidence exists. This retrospective study presents our experiences with two common surgical techniques, namely subcutaneous mastectomy and combination with liposuction. PATIENTS AND METHODS This retrospective study included all patients <18 years who underwent surgery due to idiopathic gynecomastia. Height, weight and grade of gynecomastia according to Simon's classification before surgery were reviewed in all patients' files. Additionally, duration of surgery, inpatient stay and postoperative complications were documented. Follow-up examinations were performed with assessment of scar formation, numbness and retraction of the nipple region. Furthermore, patients were asked to report on general satisfaction with surgery (satisfactory/not satisfactory) and esthetic outcome on a numeric scale (1 = good, 6 = bad). RESULTS 37 patients underwent surgery for verified idiopathic gynecomastia. Grade of gynecomastia was I° in 13.5% (n = 5), II° in 40.5% (n = 15) and III° in 46% (n = 17) of cases. Subcutaneous mastectomy was applied in 11 patients (group I, 30%) and both subcutaneous mastectomy and liposuction in 26 patients (group II, 70.3%). Postoperative complications occurred in two patients. Long-term follow-up was performed in 32 patients after a median of 34 months (range 6-96 months). Hypertrophic scar formation was seen in one patient (3%) and nipple retraction in two patients (5%). Recurrence of gynecomastia occurred in two patients (5%). Patient rating was satisfactory in 9% of cases and esthetic outcome was received with a median of 2.0 (1-5). In comparing both surgical techniques, combination of mastectomy and liposuction revealed better results in every measure except for surgical duration (median 73 vs. 90 min). CONCLUSION Surgical correction of gynecomastia remains a purely elective intervention. In contrast to adults, skin in children and adolescents provides high retractability. Therefore, open reduction combined with minimally invasive liposuction was proven useful.
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Affiliation(s)
- Sebastian Fischer
- Department of Hand-, Plastic and Reconstructive Surgery, BG Trauma Centre Ludwigshafen, Burn Centre, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen, Germany,
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Abstract
Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.
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Affiliation(s)
- Neslihan Cuhaci
- Departments of Endocrinology and Metabolism, Ataturk Education and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
| | - Sefika Burcak Polat
- Departments of Endocrinology and Metabolism, Ataturk Education and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
| | - Berna Evranos
- Departments of Endocrinology and Metabolism, Ataturk Education and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
| | - Reyhan Ersoy
- Departments of Endocrinology and Metabolism, Ataturk Education and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
| | - Bekir Cakir
- Departments of Endocrinology and Metabolism, Ataturk Education and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
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Alesini D, Iacovelli R, Palazzo A, Altavilla A, Risi E, Urbano F, Manai C, Passaro A, Magri V, Cortesi E. Multimodality Treatment of Gynecomastia in Patients Receiving Antiandrogen Therapy for Prostate Cancer in the Era of Abiraterone Acetate and New Antiandrogen Molecules. Oncology 2013; 84:92-9. [DOI: 10.1159/000343821] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 09/17/2012] [Indexed: 11/19/2022]
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Serretta V, Altieri V, Morgia G, Nicolosi F, De Grande G, Mazza R, Melloni D, Allegro R, Ferraù F, Gebbia V. A randomized trial comparing tamoxifen therapy vs. tamoxifen prophylaxis in bicalutamide-induced gynecomastia. Clin Genitourin Cancer 2012; 10:174-179. [PMID: 22502790 DOI: 10.1016/j.clgc.2012.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 01/23/2012] [Accepted: 03/06/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tamoxifen (TAM) has been shown to be active against the bicalutamide-induced breast events (BEs) gynecomastia, and breast pain in patients with prostate cancer (PC). Optimal doses and schedules are not yet established. Debate still exists about whether prophylaxis with TAM is more effective than treatment of BEs when diagnosed. The results of a randomized study comparing TAM prophylaxis vs. TAM therapy are presented. METHODS One hundred seventy-six patients with prostate cancer (PC) who were candidates for bicalutamide monotherapy were randomized to receive TAM 20 mg daily orally within 1 month from the onset of BEs (arm A) vs. TAM 10 mg daily starting simultaneously with bicalutamide (arm B). TAM was administered for up to 1 year. BEs were evaluated by a self-administered visual analogue scale. Neither ultrasonography nor calipers were used to measure the degree of gynecomastia. RESULTS In arm A, BEs showed a prevalence, increasing with time up to 78.3%. After therapy with TAM they persisted in 27.7% of cases. Two patients (3%) interrupted TAM therapy because of dizziness, and 3 patients (4%) interrupted bicalutamide therapy because of painful gynecomastia. In arm B, the prevalence of BEs was 35% after 12 months of therapy. The difference in BEs between the 2 arms was statistically significant (P < .0001). The differences in prevalence of gynecomastia and breast pain between the 2 arms both favored TAM prophylaxis (P < .0001 and P < .001, respectively). Up to 35% of patients had BEs of low intensity, never requiring bicalutamide withdrawal. Two patients (3%) interrupted the treatment because of gastrointestinal intolerance. No difference emerged between the 2 arms in terms of prostate-specific antigen (PSA) response, plasma testosterone levels, and tumor progression. CONCLUSION Bicalutamide-induced BEs can be prevented to a significant degree by prophylaxis with TAM 10 mg/day or effectively treated with TAM therapy 20 mg/day. Persisting BEs are of higher intensity after therapy than after prophylaxis.
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Affiliation(s)
- Vincenzo Serretta
- Section of Urology, Department of Internal Medicine, Cardiovascular and Nephro-Urological Diseases, University of Palermo, Italy
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Kunath F, Keck B, Antes G, Wullich B, Meerpohl JJ. Tamoxifen for the management of breast events induced by non-steroidal antiandrogens in patients with prostate cancer: a systematic review. BMC Med 2012; 10:96. [PMID: 22925442 PMCID: PMC3464149 DOI: 10.1186/1741-7015-10-96] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 08/28/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tamoxifen has emerged as a potential management option for gynecomastia and breast pain due to non-steroidal antiandrogens, and it is considered an alternative to surgery or radiotherapy. The objective of this systematic review was to assess the benefits and harms of tamoxifen, in comparison to other treatment options, for either the prophylaxis or treatment of breast events induced by non-steroidal antiandrogens in prostate cancer patients. METHODS We searched CENTRAL, MEDLINE, EMBASE, reference lists, the abstracts of three major conferences and three trial registers to identify ongoing randomized controlled trials (RCTs). Two authors independently screened the articles identified, assessed the trial quality and extracted data. The protocol was prospectively registered (CRD42011001320; http://www.crd.york.ac.uk/PROSPERO). RESULTS Four studies were identified. Tamoxifen significantly reduced the risk of suffering from gynecomastia (risk ratio 9RR0 0.10, 95% CI 0.05 to 0.22) or breast pain (RR 0.06, 95% CI 0.02 to 0.17) at six months compared to untreated controls. Tamoxifen also showed a significant benefit for the prevention of gynecomastia (RR 0.22, 95% CI 0.08 to 0.58) and breast pain (RR 0.25, 95% CI 0.10 to 0.64) when compared to anastrozole after a median of 12 months. One study showed a significant benefit of tamoxifen for the prevention of gynecomastia (RR 0.24, 95% CI 0.09 to 0.65) and breast pain (RR 0.20, 95% CI 0.06 to 0.65) when compared with radiotherapy at six months. Radiotherapy increased the risk of suffering from nipple erythema and skin irritation, but there were no significant differences for any other adverse events (all P>0.05). CONCLUSIONS The currently available evidence suggests good efficacy of tamoxifen for the prevention and treatment of breast events induced by non-steroidal antiandrogens. The impact of tamoxifen therapy on long-term adverse events, disease progression and survival remains unclear. Further large, well-designed RCTs, including long-term follow-ups, are warranted. Also, the optimal dose needs to be clarified.
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Affiliation(s)
- Frank Kunath
- German Cochrane Center, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Berliner Allee 29, 79110 Freiburg/Br., Germany.
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Tunio MA, Al-Asiri M, Al-Amro A, Bayoumi Y, Fareed M. Optimal prophylactic and definitive therapy for bicalutamide-induced gynecomastia: results of a meta-analysis. ACTA ACUST UNITED AC 2012; 19:e280-8. [PMID: 22876157 DOI: 10.3747/co.19.993] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Bicalutamide is approved as an adjuvant to primary treatments (radical prostatectomy or radiotherapy) or as monotherapy in men with locally advanced, nonmetastatic prostate cancer (pca). However, this treatment induces gynecomastia in most patients, which often results in treatment discontinuation. Optimal therapy for these breast events is not known so far. We undertook a meta-analysis to assess the efficacy of various treatment options for bicalutamide-induced gynecomastia. METHODS The medline, cancerlit, and Cochrane library databases were searched and the Google search engine was used to identify prospective and retrospective controlled studies published in English from January 2000 to December 2010 comparing prophylactic or curative treatment options with a control group (no treatment) for pca patients who developed bicalutamide-induced gynecomastia. Radiotherapy-induced cardiotoxicity was also evaluated. RESULTS The search identified nine controlled trials with a total patient population of 1573. Pooled results from prophylactic trials showed a significant reduction of gynecomastia in pca patients treated with prophylactic tamoxifen 20 mg daily (odds ratio: 0.06; 95% confidence interval: 0.05 to 0.09; p = 0.09), and pooled results from treatment trials showed a significant response of gynecomastia to definitive radiotherapy (odds ratio: 0.06; 95% confidence interval: 0.01 to 0.24; p < 0.0001). Aromatase inhibitors and weekly tamoxifen were not found to be effective as prophylactic and curative options. For the radiotherapy, skin-to-heart distance was found to be an important risk factor for cardiotoxicity (p = 0.006). A funnel plot of the meta-analysis showed significant heterogeneity (Egger test p < 0.00001) because of low sample size. CONCLUSIONS Our meta-analysis suggests using prophylactic tamoxifen 20 mg daily as the first-line preventive measure and radiotherapy as the first-line treatment option for bicalutamide-induced gynecomastia. Aromatase inhibitors and weekly tamoxifen are not recommended.
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Viani GA, Bernardes da Silva LG, Stefano EJ. Prevention of gynecomastia and breast pain caused by androgen deprivation therapy in prostate cancer: tamoxifen or radiotherapy? Int J Radiat Oncol Biol Phys 2012; 83:e519-24. [PMID: 22704706 DOI: 10.1016/j.ijrobp.2012.01.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine, in a meta-analysis, whether gynecomastia and breast pain rates in men with prostate cancer treated with androgen deprivation therapy (ADT) are reduced if treated with prophylactic radiotherapy (RT) or tamoxifen (TMX). METHODS AND MATERIALS The MEDLINE, EMBASE, CANCERLIT, and Cochrane Library databases, as well as proceedings of annual meetings, were systematically searched to identify randomized, controlled studies comparing RT or TMX with observation for men with prostate cancer using ADT. RESULTS Six RCTs (three RT trials and three TMX trials, N = 777 patients total) were identified that met the study criteria. Pooled results from these RCTs comparing RT vs. observation showed a significant reduction in the incidence of gynecomastia and breast pain rates in patients treated with RT (odds ratio [OR] = 0.21, 95% confidence interval [CI] = 0.12-0.37, p < 0.0001, and OR = 0.34, 95% CI 0.20-0.57, p < 0.0001, respectively). Use of RT resulted in an absolute risk reduction (ARR) of 29.4% and 19.9%, with a number needed to treat (NNT) of 3.4 and 5 to avoid one case of gynecomastia and breast pain, respectively. Pooled results from trials comparing TMX vs. observation showed a statistical benefit for breast pain and gynecomastia in favor of TMX arms (OR = 0.04, 95% CI = 0.02-0.08, p < 0.0001 and OR = 0.07, 95% CI = 0.0-0.14, p < 0.00001). TMX resulted in an ARR = 64.1% and 47.6%, with an NNT of 1.56 and 2.1 to avoid one case of gynecomastia and breast pain, respectively. Considering adverse effects, TMX was 6 times more adverse effects than RT. CONCLUSIONS Our data have shown that both TMX and RT prevented gynecomastia and breast pain in patients with prostate cancer receiving ADT for prostate cancer. Although TMX was two times more effective in preventing gynecomastia, RT should represent an effective and safe treatment option, to take into account mainly in patients with cardiovascular risk factors or thrombotic diathesis.
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Affiliation(s)
- Gustavo Arruda Viani
- Department of Radiation Oncology, Marilia Medical School, Marília, São Paulo, Brazil.
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Low rate of clinician-scored gynecomastia induced by 6 months of combined androgen blockade in a randomized trial: Implications for prophylactic breast irradiation. Pract Radiat Oncol 2012; 2:172-178. [PMID: 24674120 DOI: 10.1016/j.prro.2011.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 08/18/2011] [Accepted: 08/18/2011] [Indexed: 11/22/2022]
Abstract
PURPOSE To determine the incidence and predictors of clinician-scored gynecomastia induced by 6 months of combined androgen blockade (CAB) in a randomized trial. METHODS We studied 94 men with intermediate or high-risk prostate cancer randomized to radiation plus 6 months of neoadjuvant CAB consisting of a gonadotropin-releasing hormone agonist and antiandrogen (flutamide). Patients were assessed for breast symptoms monthly as per protocol. Patients reporting breast tenderness or enlargement were then examined shirtless. RESULTS Median age at entry was 72.1 years. While 52 patients (55.3%) reported either breast tenderness or enlargement, only 9 patients (9.6%) were scored as having gynecomastia when examined shirtless by a single clinician. Four patients received radiation for self-reported breast tenderness or enlargement without clinician-scored gynecomastia. If these 4 had not been radiated, the total incidence of clinician-scored gynecomastia may have been as high as 13 of 94 (13.8%). No patient variable, such as age, body-mass index, and Adult Comorbidity Evaluation-27 score, or discontinuation of the antiandrogen, was associated with the development of gynecomastia. CONCLUSIONS While many patients self-reported breast tenderness or enlargement with short-course CAB, the incidence of breast enlargement noticeable to an examiner when the patient was shirtless was less than 15%, which is much lower than the 60% to 80% rates typically reported with antiandrogen monotherapy. Given that the long-term risks of prophylactic breast irradiation are not well characterized, these data suggest that prophylactic breast irradiation may not be as necessary in men receiving short-course CAB.
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Neu B, Sautter V, Momm F, Melcher U, Seegenschmiedt H, Micke O, Sautter-Bihl ML. Radiotherapy for Prevention and Therapy of Gynecomastia Due to Antiandrogen Treatment in Prostate Cancer Patients. Strahlenther Onkol 2011; 187:771-7. [DOI: 10.1007/s00066-011-2283-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 06/16/2011] [Indexed: 10/15/2022]
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Barboro P, Repaci E, Ferrari N, Rubagotti A, Boccardo F, Balbi C. Androgen receptor and heterogeneous nuclear ribonucleoprotein K colocalize in the nucleoplasm and are modulated by bicalutamide and 4-hydroxy-tamoxifen in prostatic cancer cell lines. Prostate 2011; 71:1466-79. [PMID: 21321982 DOI: 10.1002/pros.21366] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 01/24/2011] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bicalutamide (BIC) is widely used in prostate cancer therapy. The dose and schedule employed are well tolerated, but about 50% of patients develop gynecomastia. Several studies have shown a significant reduction of the troublesome effects when Tamoxifen is concomitantly administered with BIC. However, the results reported in the literature seem to be preliminary and possible interferences could be present. In order to clarify the molecular mechanisms of the combination of the two drugs, we have investigated whether the expression of the proteins belonging to nuclear matrix (NM), one modulator of hormone action, is altered by BIC and/or 4-hydroxy-tamoxifen (4OHT) in LNCaP cells. We focused above all on heterogeneous nuclear ribonucleoprotein K (hnRNP K) a NM protein with a key role in prostate carcinoma. METHODS NM proteins were analyzed by two-dimensional gel electrophoresis. Modulation and compartmentalization of the androgen receptor and the hnRNP K were studied by Western blotting, confocal microscopy, and immunoprecipitation. RESULTS Proteomic analysis revealed that there is a similarity in the changes of the NM proteins elicited by drugs alone but that their combination does not result in a simple additive effect. Moreover, we found that in the nucleoplasm the androgen receptor and the hnRNP K colocalize in a complex that is highly proximal to DNA and that both proteins were synchronously modulated by BIC and/or 4OHT treatment. CONCLUSION This study confirm the pivotal role of hnRNP K in prostate carcinoma and suggest that this role might be played by the interaction with the androgen receptor.
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Affiliation(s)
- Paola Barboro
- Istituto Nazionale per la Ricerca sul Cancro, Università di Genova, Largo Rosanna Benzi, Genova, Italy
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Johnson RE, Kermott CA, Murad MH. Gynecomastia - evaluation and current treatment options. Ther Clin Risk Manag 2011; 7:145-8. [PMID: 21479145 PMCID: PMC3071351 DOI: 10.2147/tcrm.s10181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Indexed: 11/23/2022] Open
Abstract
CLINICAL QUESTION What is the best management approach for gynecomastia? RESULTS In most patients, surgical correction usually leads to immediate cosmetic and symptomatic improvement and is considered the best approach. In men who are being treated with antiandrogen therapies, pharmacological intervention with tamoxifen is the most effective approach, followed by radiotherapy. IMPLEMENTATION Pitfalls to avoid when treating gynecomastia Failure to detect the very rare male breast cancerOverly aggressive early intervention or evaluationAppropriate medical interventionWhen to refer to specialist treatment.
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Affiliation(s)
- Ruth E Johnson
- Mayo Clinic, Division of Preventive, Occupational and Aerospace Medicine, Rochester, Minnesota, USA
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Johnson JJ, Syed DN, Suh Y, Heren CR, Saleem M, Siddiqui IA, Mukhtar H. Disruption of androgen and estrogen receptor activity in prostate cancer by a novel dietary diterpene carnosol: implications for chemoprevention. Cancer Prev Res (Phila) 2010; 3:1112-23. [PMID: 20736335 DOI: 10.1158/1940-6207.capr-10-0168] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emerging data are suggesting that estrogens, in addition to androgens, may also be contributing to the development of prostate cancer (PCa). In view of this notion, agents that target estrogens, in addition to androgens, may be a novel approach for PCa chemoprevention and treatment. Thus, the identification and development of nontoxic dietary agents capable of disrupting androgen receptor (AR) in addition to estrogen receptor (ER) could be extremely useful in the management of PCa. Through molecular modeling, we found that carnosol, a dietary diterpene, fits within the ligand-binding domain of both AR and ER-alpha. Using a time-resolved fluorescence resonance energy transfer assay, we found that carnosol interacts with both AR and ER-alpha and additional experiments confirmed that it functions as a receptor antagonist with no agonist effects. LNCaP, 22Rv1, and MCF7 cells treated with carnosol (20-40 mumol/L) showed decreased protein expression of AR and ER-alpha. Oral administration of carnosol at 30 mg/kg 5 days weekly for 28 days to 22Rv1 PCa xenografted mice suppressed tumor growth by 36% (P = 0.028) and was associated with a decrease in serum prostate-specific antigen by 26% (P = 0.0042). These properties make carnosol unique to any known antiandrogen or antiestrogen investigated thus far for the simultaneous disruption of AR and ER-alpha. We suggest that carnosol may be developed or chemically modified through more rigorous structure-activity relationship studies for a new class of investigational agents-a dual AR/ER modulator.
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Affiliation(s)
- Jeremy J Johnson
- Division of Pharmacy Practice, University of Wisconsin School of Pharmacy, 1031 Rennebohm Hall, Madison, WI 53705, USA.
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Sikora MJ, Rae JM, Johnson MD, Desta Z. Efavirenz directly modulates the oestrogen receptor and induces breast cancer cell growth. HIV Med 2010; 11:603-7. [PMID: 20408889 DOI: 10.1111/j.1468-1293.2010.00831.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Efavirenz-based HIV therapy is associated with breast hypertrophy and gynaecomastia. Here, we tested the hypothesis that efavirenz induces gynaecomastia through direct binding and modulation of the oestrogen receptor (ER). METHODS To determine the effect of efavirenz on growth, the oestrogen-dependent, ER-positive breast cancer cell lines MCF-7, T47D and ZR-75-1 were treated with efavirenz under oestrogen-free conditions in the presence or absence of the anti-oestrogen ICI 182,780. Cells treated with 17β-oestradiol in the absence or presence of ICI 182,780 served as positive and negative controls, respectively. Cellular growth was assayed using the crystal violet staining method and an in vitro receptor binding assay was used to measure the ER binding affinity of efavirenz. RESULTS Efavirenz induced growth in MCF-7 cells with an estimated effective concentration for half-maximal growth (EC(50)) of 15.7 μM. This growth was reversed by ICI 182,780. Further, efavirenz binds directly to the ER [inhibitory concentration for half maximal binding (IC(50)) of ∼52 μM] at a roughly 1000-fold higher concentration than observed with 17β-oestradiol. CONCLUSIONS Our data suggest that efavirenz-induced gynaecomastia may be caused, at least in part, by drug-induced ER activation in breast tissues.
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Affiliation(s)
- M J Sikora
- Department of Pharmacology, University of Michigan Medical Center, Ann Arbor, MI, USA
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An open, randomised, multicentre, phase 3 trial comparing the efficacy of two tamoxifen schedules in preventing gynaecomastia induced by bicalutamide monotherapy in prostate cancer patients. Eur Urol 2009; 57:238-45. [PMID: 19481335 DOI: 10.1016/j.eururo.2009.05.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 05/07/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Bicalutamide monotherapy is a valuable option for prostate cancer (PCa) patients who wish to avoid the consequences of androgen deprivation; however, this treatment induces gynaecomastia and mastalgia in most patients. Tamoxifen is safe and effective in preventing breast events induced by bicalutamide monotherapy without affecting antitumor activity, but possible interference between bicalutamide and tamoxifen remains a matter of concern. To reduce the exposure to tamoxifen, we considered the putative advantages of weekly administration. OBJECTIVE To compare the efficacy of two different schedules of tamoxifen in preventing breast events. Toxicity, prostate-specific antigen behaviour, and sexual-functioning scores were also evaluated. DESIGN, SETTING, AND PARTICIPANTS This was a noninferiority trial. From December 2003 to February 2006, 80 patients with localised/locally advanced or biochemically recurrent PCa who were also candidates for bicalutamide single therapy were randomised to receive two different schedules of tamoxifen: daily (n=41) and weekly (n=39). Median follow-up was 24.2 mo. INTERVENTION Daily bicalutamide (150 mg) plus daily tamoxifen 20mg continuously (daily group) or the same but with tamoxifen at 20mg weekly after the first 8 wk of daily treatment (weekly group). Three patients in the weekly group and one in the daily group were discontinued for adverse events. MEASUREMENTS For gynaecomastia, we used ultrasonography. For mastalgia and sexual functioning, we used questionnaires. RESULTS AND LIMITATIONS Gynaecomastia developed in 31.7% of patients in the daily group and in 74.4% of patients in the weekly group (p<0.0001), and it was more severe in patients who switched to weekly tamoxifen (p=0.001). Mastalgia occurred in 12.2% and 46.1% of patients, respectively (p=0.001). There were no major differences among treatment schedules relative to sexual functioning scores and incidence and severity of adverse events. No differences between groups in PSA behaviour and disease progression have been detected so far. CONCLUSIONS This study demonstrated that tamoxifen 20mg/wk is inferior to tamoxifen 20mg/d in preventing the incidence and severity of bicalutamide-induced breast events. The safety and efficacy of tamoxifen at the common daily dose of 20mg for the prophylaxis of bicalutamide-induced breast events were confirmed.
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Drudge-Coates L, Roberts J, Thompson P. Gynaecomastia: a case study review of the effect of hormone therapy in the management of prostate cancer. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2008. [DOI: 10.1111/j.1749-771x.2008.00065.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wassersug RJ, Oliffe JL. The social context for psychological distress from iatrogenic gynecomastia with suggestions for its management. J Sex Med 2008; 6:989-1000. [PMID: 19175864 DOI: 10.1111/j.1743-6109.2008.01053.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Gynecomastia (breast development in males) is a side effect of androgen deprivation therapy (ADT) for prostate cancer (PCa). Medical interventions to prevent or treat gynecomastia carry risk of additional detrimental side effects. However, untreated gynecomastia can be physically uncomfortable and psychologically distressing. Shame from gynecomastia can lead patients to stop otherwise beneficial exercise. AIMS Our first aim is to explore the social context for gynecomastia and how it is interpreted by men with the condition, as well as by others, both male and female. Subsequently, we use our understanding of why gynecomastia is psychologically distressing to propose psychosocial interventions that could help men accept this side effect of ADT. METHODS We draw on academic literature, media accounts, and web-based testimonials from men with gynecomastia, to understand how gynecomastia is perceived by both patients and the medical community. We examine these resources in light of gynecomastia's impact on sex roles, sexuality, and gender identity issues. MAIN OUTCOME MEASURES By exploring what breasts in a male mean to the individual, we produce an understanding of the social context for distress from gynecomastia. From this understanding, we derive hypotheses about who might be most distressed from gynecomastia and strategies for alleviating this distress. RESULTS The shame and stigma of gynecomastia is linked to the objectification of women. We suggest that men fear that their breasts will marginalize and subordinate them within gender hierarchies. There is little evidence that breasts on a male erotically attract either men or women. Novel options for living with gynecomastia are contrasted with medicalized strategies including mastectomy. CONCLUSION Assessment instruments need to be developed to identify patients most likely to experience distress from gynecomastia and seek out medical interventions. Surgical, radiological, or pharmacological interventions may not be universally necessary if greater acceptance of gynecomastia is made available through psychosocial support programs. For example, PCa patients may learn to accept gynecomastia through reconceptualizing their breasts as autoerotic. Support programs modeled on those of the breast cancer community, including Encore and dragon boat racing, may also help to build communities to serve patients with gynecomastia while defending individuals against shame, isolation, and loss of self-esteem.
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Affiliation(s)
| | - John L Oliffe
- University of British Columbia-School of Nursing, Vancouver, Canada
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Iversen P, Roder MA. The Early Prostate Cancer program: bicalutamide in nonmetastatic prostate cancer. Expert Rev Anticancer Ther 2008; 8:361-9. [PMID: 18366284 DOI: 10.1586/14737140.8.3.361] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Early Prostate Cancer program is investigating the addition of bicalutamide 150 mg to standard care for localized or locally advanced, nonmetastatic prostate cancer. The third program analysis, at 7.4 years' median follow-up, has shown that bicalutamide 150 mg does not benefit patients with localized disease, but does confer significant progression-free survival benefits in patients with locally advanced disease, irrespective of standard care received. In patients receiving radiotherapy for locally advanced disease, bicalutamide 150 mg significantly reduced the risk of death by 35%; the magnitude of this benefit compares favorably with that of adjuvant luteinizing hormone-releasing hormone agonist therapy in a similar population. Bicalutamide 150 mg represents an alternative to castration for patients with locally advanced disease who wish to avoid the side effects associated with castration.
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Affiliation(s)
- Peter Iversen
- University of Copenhagen, Department of Urology D-2112, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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Abstract
Androgens can increase muscular mass and strength and remain the most frequently abused and widely available drugs used in sports doping. Banning the administration of natural or synthetic androgens has led to a variety of strategies to circumvent the ban of the most effective ergogenic agents for power sports. Among these, a variety of indirect androgen doping strategies aiming to produce a sustained rise in endogenous testosterone have been utilized. These include oestrogen blockade by drugs that act as oestrogen receptor antagonists (antioestrogen) or aromatase inhibitors. The physiological and pharmacological basis for the effects of oestrogen blockade in men, but not women, are reviewed.
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Singer EA, Golijanin DJ, Miyamoto H, Messing EM. Androgen deprivation therapy for prostate cancer. Expert Opin Pharmacother 2008; 9:211-28. [PMID: 18201145 DOI: 10.1517/14656566.9.2.211] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Androgen deprivation continues to play a crucial role in the treatment of advanced and metastatic prostate cancer. In the 65 years since its use was first described, urologists and medical oncologists have developed new and innovative ways to manipulate the hypothalamic-pituitary-gonadal axis with the goal of alleviating symptoms and prolonging the life of men with prostate cancer. Despite the successes that androgen deprivation therapy has brought, each method and regimen possesses unique benefits and burdens, of which the clinician and patient must be cognizant. This review discusses the first-line androgen deprivation methods and regimens presently in use with special attention paid to their side effects and the management of them, as well as the question of when to initiate androgen deprivation therapy.
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Affiliation(s)
- Eric A Singer
- Department of Urology, University of Rochester Medical Center, Rochester, NY 14642, USA
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Boudreaux KJ, Chang SS. Treating asymptomatic patients with hormone-refractory prostate cancer: hormonal manipulations for the urologist. BJU Int 2008; 101:671-4. [DOI: 10.1111/j.1464-410x.2007.07336.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Van Poppel H. Editorial Comment on: Tamoxifen as Prophylaxis for Prevention of Gynaecomastia and Breast Pain Associated with Bicalutamide 150mg Monotherapy in Patients with Prostate Cancer: A Randomised, Placebo-Controlled, Dose–Response Study. Eur Urol 2007; 52:115. [PMID: 17270341 DOI: 10.1016/j.eururo.2007.01.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Lorenzo G, Autorino R. Bicalutamide-induced gynaecomastia: do we have the answer? Eur Urol 2007; 52:5-8. [PMID: 17258386 DOI: 10.1016/j.eururo.2007.01.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 01/15/2007] [Indexed: 11/19/2022]
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