The effect of short-term estradiol therapy on cognitive function in older men receiving hormonal suppression therapy for prostate cancer

The association of hypogonadism with depression and its treatments

According to World Health Organization estimates, 5% of the adult population worldwide suffers from depression. In addition to the affective, psychomotor and cognitive symptoms which characterize this mood disorder, sexual dysfunction has been frequently reported among men suffering from depression. The most common sexual manifestations are decreased libido, erectile dysfunction and orgasmic disorder. In addition, epidemiological studies have documented a reduction of testosterone concentrations in men with depression and, for these reasons, depressive disorders appear as one possible cause of male functional hypogonadism. Moreover, some largely used antidepressant medications can cause or worsen sexual complaints, thus depression and its treatments rise several andrological-relevant issues. The other way round, men with hypogonadism can manifest depressed mood, anxiety, insomnia, memory impairment which, if mild, may respond to testosterone replacement therapy (TRT). However, the prevalence of functional hypogonadism in depression, and of depressive symptoms in hypogonadal men, is not known. Severe depressive symptoms do not respond to TRT, while the effect of treating major depression on functional hypogonadism, has not been investigated. Overall, the clinical relevance of each condition to the other, as well as the physiopathological underpinnings of their relationship, are still to be clarified. The present review summarizes current evidence on the influence of testosterone on mood and of depression on the hypothalamic-pituitary-testis axis; the clinical association between male hypogonadism and depression; and the reciprocal effects of respective treatments.

Effect of estradiol on cognition in men undergoing androgen deprivation therapy: A randomized placebo-controlled trial

OBJECTIVE

Roles for estradiol in modulating cognition in men remain uncertain. We assessed the isolated effects of estradiol on cognition in men in the absence of testosterone.

DESIGN

Randomized trial of transdermal estradiol 0.9 mg daily, or matched placebo, for 6 months, hypothesizing that estradiol would improve verbal learning, verbal memory, and spatial problem solving over time.

PATIENTS

Men receiving androgen deprivation therapy (ADT) for prostate cancer.

MEASUREMENTS

Cognition was assessed by a tablet-based cognitive battery (Cogstate) at baseline, Month 1, Month 3, and Month 6. Anxiety and depression symptoms were assessed using the Hospital Anxiety and Depression Scale.

RESULTS

Seventy-eight participants were randomized. Baseline mean scores were 21.0 (standard deviation [SD] 4.1) for the International Shopping List test (ISL), assessing verbal learning and memory (higher scores better), and 60.4 (SD 19.5) for the Groton Maze Learning test (GML), assessing spatial problem solving (lower scores better). There was no significant difference in performance over time for the estradiol group versus the placebo group for the ISL, mean adjusted difference (MAD) 0.7 (95% confidence interval [CI] -1.2 to 2.5), p = .36, or the GML, MAD -3.2 (95% CI -12.0 to 5.6), p = 0.53. There was no significant difference between groups over time in performance in any other cognitive domain, or on depression or anxiety scores.

CONCLUSIONS

We found no major effects of estradiol on cognition in men with castrate testosterone concentrations. Although the cognitive effects of ADT are debated, this study suggests that any such effects are unlikely to be prevented by the administration of estradiol.

Effects of acupuncture versus cognitive behavioral therapy on cognitive function in cancer survivors with insomnia: A secondary analysis of a randomized clinical trial

BACKGROUND

Cancer-related cognitive impairment is a prevalent, disruptive condition potentially exacerbated by sleep disturbances. The current study was performed to evaluate the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on objective and subjective cognitive function in cancer survivors with insomnia.

METHODS

Using data from a randomized clinical trial (160 survivors) that compared acupuncture versus CBT-I for insomnia occurring in cancer survivors, the authors analyzed cognitive outcomes and their relationship to insomnia symptoms. Analysis was limited to 99 patients who reported baseline cognitive difficulties. Interventions were delivered over 8 weeks. Objective attention, learning, and memory were evaluated using the Buschke Selective Reminding Test. Subjective cognitive function was assessed using the Brown Attention-Deficit Disorder Scales. Insomnia symptoms were assessed using the Insomnia Severity Index. All outcomes were collected at baseline, week 8, and week 20.

RESULTS

From baseline to week 8, acupuncture produced statistically significant within-group improvements in objective attention (Cohen D, 0.29), learning (Cohen D, 0.31), and memory (Cohen D, 0.33) that persisted to week 20 (all P < .05), whereas CBT-I produced a statistically significant within-group improvement in objective attention from baseline to week 20 (Cohen D, 0.50; P < .05); between-group differences were not statistically significant. Both interventions produced statistically significant within-group improvements in subjective cognitive function at weeks 8 and 20 compared with baseline (all P < .001); between-group differences were not statistically significant. In the acupuncture group, patients with clinically meaningful responses with regard to insomnia symptoms demonstrated a significantly greater improvement in subjective cognitive function compared with those without clinically meaningful insomnia responses (P = .006).

CONCLUSIONS

Among cancer survivors with insomnia, both acupuncture and CBT-I produced significant improvements in objective and subjective cognitive function. However, the effect sizes varied and only survivors in the acupuncture group demonstrated a significant relationship between cognitive and sleep outcomes. These preliminary findings warrant further investigation to guide the personalized management of patients with cancer-related cognitive impairment.

The Role of Estrogen in Brain and Cognitive Aging

There are 3 common physiological estrogens, of which estradiol (E2) is seen to decline rapidly over the menopausal transition. This decline in E2 has been associated with a number of changes in the brain, including cognitive changes, effects on sleep, and effects on mood. These effects have been demonstrated in both rodent and non-human preclinical models. Furthermore, E2 interactions have been indicated in a number of neuropsychiatric disorders, including Alzheimer's disease, schizophrenia, and depression. In normal brain aging, there are a number of systems that undergo changes and a number of these show interactions with E2, particularly the cholinergic system, the dopaminergic system, and mitochondrial function. E2 treatment has been shown to ameliorate some of the behavioral and morphological changes seen in preclinical models of menopause; however, in clinical populations, the effects of E2 treatment on cognitive changes after menopause are mixed. The future use of sex hormone treatment will likely focus on personalized or precision medicine for the prevention or treatment of cognitive disturbances during aging, with a better understanding of who may benefit from such treatment.

Cognitive Impacts of Estrogen Treatment in Androgen-Deprived Males: What Needs to be Resolved

Background:

Many prostate cancer (PCa) patients are on androgen deprivation therapy (ADT) as part of their cancer treatments but ADT may lead to cognitive impairments. ADT depletes men of both androgen and estrogen. Whether estradiol supplementation can improve cognitive impairments in patients on ADT is understudied.

Objective:

To summarize data on the effects of estradiol treatment on cognitive function of androgen-deprived genetic male populations (PCa patients and male-to-female transsexuals) and castrated male animals.

Method:

Publications were identified by a literature search on PubMed and Google Scholar.

Results:

While some studies showed that estradiol improves cognitive function (most notably, spatial ability) for castrated rats, what remains uninvestigated are: 1) whether estradiol can improve cognition after long-term androgen deprivation, 2) how estradiol affects memory retention, and 3) how early vs. delayed estradiol treatment after castration influences cognition. For androgen-deprived genetic males, estradiol treatment may improve some cognitive functions (e.g., verbal and visual memory), but the findings are not consistent due to large variability in the study design between studies.

Conclusion:

Future studies are required to determine the best estradiol treatment protocol to maximize cognitive benefits for androgen-deprived genetic males. Tests that assess comparable cognitive domains in human and rodents are needed. What particularly under-investigated is how the effects of estradiol on cognitive ability intersect with other parameters; sleep, depression and physical fatigue. Such studies have clinical implications to improve the quality of life for both PCa patients on ADT as well as for male-to-female transsexuals.

Cognitive Effects of Cancer and Cancer Treatments

As the population of cancer survivors has grown into the millions, there has been increasing emphasis on understanding how the late effects of treatment affect survivors' ability to return to work/school, their capacity to function and live independently, and their overall quality of life. This review focuses on cognitive change associated with cancer and cancer treatments. Research in this area has progressed from a pharmacotoxicology perspective to a view of the cognitive change as a complex interaction of aspects of the treatment, vulnerability factors that increase risk for posttreatment cognitive decline, cancer biology, and the biology of aging. Methodological advances include the development of (a) measurement approaches that assess more fine-grained subcomponents of cognition based on cognitive neuroscience and (b) advanced statistical approaches. Conceptual issues that arise from this multidimensional perspective are described in relation to future directions, understanding of mechanisms, and development of innovative interventions.

Estradiol for the mitigation of adverse effects of androgen deprivation therapy

Prostate cancer (PCa) is the second most commonly diagnosed cancer in men. Conventional endocrine treatment for PCa leads to global sex steroid deprivation. The ensuing severe hypogonadism is associated with well-documented adverse effects. Recently, it has become apparent that many of the biological actions attributed to androgens in men are in fact not direct, but mediated by estradiol. Available evidence supports a primary role for estradiol in vasomotor stability, skeletal maturation and maintenance, and prevention of fat accumulation. Hence there has been interest in revisiting estradiol as a treatment for PCa. Potential roles for estradiol could be in lieu of conventional androgen deprivation therapy or as low-dose add-back treatment while continuing androgen deprivation therapy. These strategies may limit some of the side effects associated with conventional androgen deprivation therapy. However, although available data are reassuring, the potential for cardiovascular risk and pro-carcinogenic effects on PCa via estrogen receptor signalling must be considered.

Symptoms and self-care strategies during and six months after radiotherapy for prostate cancer - Scoping the perspectives of patients, professionals and literature

PURPOSE

Under-diagnosed and uncontrolled symptoms in patients with prostate cancer during radiotherapy can have a negative impact on the individual's quality of life. An opportunity for patients to report their symptoms systematically, communicate these symptoms to cancer nurses and to receive self-care advice via an application in an Information and Communication Technology-platform could overcome this risk. The content in the application must precisely capture symptoms that are significant to both patients and health care professionals. Therefore, the aim of the study was to map and describe symptoms and self-care strategies identified by patients with prostate cancer undergoing radiotherapy, by health care professionals caring for these patients, and in the literature.

METHODS

The study combines data from interviews with patients (n = 8) and health care professionals (n = 10) and a scoping review of the literature (n = 26) focusing on the period during and up to 6 months after radiotherapy.

RESULTS

There was a concordance between the patients, health care professionals, and the literature on symptoms during and after radiotherapy. Urinary symptoms, bowel problems, pain, sexual problems, fatigue, anxiety, depression, cognitive impairment and irregular symptoms were commonly described during the initial treatment period. Self-care strategies were rarely described in all three of the sources.

CONCLUSIONS

The results show which symptoms to regularly assess using an Information and Communication Technology-platform for patients with newly-diagnosed prostate cancer during radiotherapy. The next step is to evaluate the efficacy of using the platform and the accuracy of the selected symptoms and self-care advice included in a smartphone application.

Interventions that may reduce depressive symptoms among prostate cancer patients: a systematic review and meta-analysis

OBJECTIVE

Prostate cancer patients are at increased risk of depression yet there is no standard intervention to address this. The purpose of this meta-analysis is to examine the efficacy of interventions in reducing depressive symptoms in men with prostate cancer.

METHODS

Searches for studies were conducted in four databases and by hand. Randomized controlled trials of any intervention relative to control for depression in prostate cancer patients at any stage of their cancer treatment were included.

RESULTS

We identified 11 studies that randomized men with prostate cancer to either an intervention meant to improve some aspect of quality of life or control and reported depressive symptoms scores before and after the intervention or control condition. Two of these were not used in our meta-analysis either for concerns about quality or for lack of depression scores. The interventions identified in the remaining nine articles were exercise (four), information (three), psychotherapy or peer support (three), massage therapy (one), and medication (one). Several publications included more than one type of intervention. A meta-analysis of all studies showed that an intervention of some types significantly improved depressive symptom scores relative to the control condition (improvement in depression score by -0.86 unit (95% CI: -1.42, -0.31)). Isolating the peer support/psychotherapy studies also showed significant improvement (improvement in depression score by -1.09 unit (95% CI: -2.05, -0.13)).

CONCLUSION

Treatments to improve depressive symptoms in men with prostate cancer may be effective, with the best evidence supporting the use of peer support/psychotherapy.

[Treatment of cognitive impairments in oncology: a review of longitudinal controlled studies]

Various studies highlight cognitive impairments in cancer patients. This paper proposes a review of longitudinal controlled studies evaluating the efficacy of interventions aiming to reduce these cognitive impairments. Longitudinal controlled studies evaluating the efficacy of interventions aiming to reduce cognitive impairments in adult cancer patients and published between 1993 and 2013 were identified, with the exception of studies that implied patients suffering from CNS tumor or metastasis. Pharmacological interventions (n = 11) suggested the positive impact of modafinil on memory and executive functions. Non-pharmacological interventions (n = 10) suggested the positive impact of cognitive revalidation and stimulation programs, psycho-education and meditation on several memory, attentional and executive objective as well as subjective functions. Non-pharmacological interventions show more significant cognitive benefits than pharmacological interventions. Some longitudinal controlled studies support the usefulness of interventions aiming to reduce cognitive impairments in cancer patients. Further studies should evaluate the effectiveness of programs combining technics aiming to reduce cognitive impairments and psychotherapeutic technics aiming to support patients' coping with illness.

Comparison of cognitive functions between male and female medical students: a pilot study

BACKGROUND

There are gender differences in cognitive abilities. The major enigma is whether males or females perform better in various cognitive tasks. The reports were found to be contradictory. Studies have shown that oestrogen and testosterone accentuate cognitive functions. But the effects of progesterone on cognitive functions are still contradictory.

OBJECTIVE

To assess and compare the cognitive functions between male and female students.

METHODS

This study was conducted on healthy male (n=21) and female (n=21) volunteers who were aged between 19-37 years. Cognitive functions which were assessed in males (one time) and females (two times: during preovulatory and postovulatory phases of the menstrual cycle) were attentional: visual reaction time (VRT) and Go/No-Go VRT; perceptual: fast counting (FC), executive: Erisken Flanker Test (EFT) and Stroop Test (ST), and working memory. Data were compared by using Mann-Whitney U-test.

RESULTS

Cognitive functions in female preovulatory phase were comparable to male cognitive functions. In addition, the female postovulatory phase cognitive functions were also similar to those of males in all the tasks, except those seen in VRT and ST. Male performed better than females in VRT (M: 331.66 ms, IQR: 286.99-375.33 vs. M: 367.8 ms, IQR: 340.66-435.66; p=0.05). However, in ST, females showed higher accuracies in reading colour interferences than males (M: 100%, IQR: 95.12-100 vs. M: 95.24%, IQR: 86.36-100; p=0.04). In addition, males showed trend of a poorer performance than females in Go/No-Go VRT, ST colour reading normal time and interference time and in working-memory time.

CONCLUSION

Male cognitive functions were comparable to female preovulatory phase cognitive functions. However, females, during postovulatory phase of their cycle, may have advantages in executive tasks (Stroop test) and disadvantages in attentional tasks (VRT), as compared to males.

Memory and cancer: a review of the literature

The mental health of cancer survivors has not always been the primary emphasis of treatment protocols since physical health outcomes have taken precedence. Older cancer survivors experience a double jeopardy since they are at risk for memory impairments and mild cognitive impairment and because they are greater than 55 years of age. Of the 9.6 million cancer survivors in the US who have completed active treatment, many report cognitive difficulties, with labels such as "chemo brain," "not as sharp," "woolly-headedness," or the "mind does not work as quickly". To date, most of our knowledge of cognitive impairment in cancer survivors comes from female breast cancer survivors. Studies indicate that these survivors have diminished executive function, verbal memory, and motor function. Cancer survivors want to live independently in the community for as long as possible however, these cognitive deficits may prevent this desired lifestyle. To broaden our understanding this paper reviews the literature on the cognitive impairment and memory deficits experienced by three groups of cancer survivors breast, colorectal, and prostate cancer, that make up 60% of all survivors nationally. Even though mental health declined after a cancer diagnosis, the long-term outcomes of cancer survivors did not differ from persons without cancer in depression or cognitive function.

Review of recent studies on interventions for cognitive deficits in patients with cancer

Research has demonstrated that patients with cancer experience cognitive deficits, often due to aggressive anticancer treatments. In this article, we critically review the interventional studies that have been conducted to investigate beneficial effects on cognitive function in cancer patients. Pharmacological agents that have been studied include psychostimulants, such as methylphenidate and modafinil, erythropoietin, and hormonal (supplement) treatments for patients who receive hormonal suppression therapy. In addition, several cognitive rehabilitation programs have been evaluated in cancer patients. Recently, the approach of physical exercise to treat cognitive deficits has received great interest, and findings from novel studies are keenly anticipated. Although, in general, the studies reviewed were well designed, future studies may wish to include larger sample sizes and pay more attention to the accurate assessment of cognitive function.

Differences in self-reported attentional fatigue between patients with breast and prostate cancer at the initiation of radiation therapy

BACKGROUND

Attentional fatigue is experienced as a decreased ability to concentrate, engage in purposeful activity, and maintain social relationships when there are competing demands on attention. Breast and prostate cancer are the 2 most common cancers in women and men, respectively. Most previous studies on self-reported attentional fatigue evaluated patients with breast cancer.

OBJECTIVES

The objectives of the study were to determine if self-reported attentional fatigue differed in patients with breast cancer and prostate cancer before radiation therapy (RT) and to determine the relationships between attentional fatigue and other symptoms in these 2 groups.

METHODS

Patients (n = 155) completed questionnaires before RT. Descriptive statistics, Pearson correlations, and analysis of covariance were used for data analyses.

RESULTS

After controlling for age, patients with breast cancer reported significantly higher levels of attentional fatigue. In both groups, more attentional fatigue correlated significantly with more anxiety, depression, sleep disturbance, and physical fatigue. These correlations were stronger for patients with breast cancer.

CONCLUSIONS

The present study is the first to identify differences in self-reported attentional fatigue between these 2 groups before RT. Additional research is warranted to determine factors that contribute to these differences, as well as mechanisms that underlie the development of attentional fatigue.

IMPLICATIONS FOR PRACTICE

Clinicians should consider the capacity of their patients to direct attention when learning about RT and other treatments. It is important to simplify confusing healthcare terminology and reinforce teaching that is most important both verbally and in writing. Appropriate interventions for anxiety and depression may decrease attentional fatigue in these patients.

Hormonal influences on cognition and risk for Alzheimer's disease

Research increasingly suggests that changes in estrogen levels during aging may increase the risk of Alzheimer's disease, the most common type of dementia. This update reviews the newest information about estrogen and cognitive aging, including information regarding the role of bioavailable estrogen in older women and men, use of selective estrogen receptor modulators to improve cognition, and studies of genetic risk factors to elucidate the effects of endogenous estrogen on aging and cognition. Future trials are needed to determine whether alternate timing, dosage, formulation, or method of administration of hormone replacement can reduce the risk of dementia.

A randomized controlled trial of add-back estrogen or placebo on cognition in men with prostate cancer receiving an antiandrogen and a gonadotropin-releasing hormone analog

The effects of testosterone (T) and estradiol (E(2)) on cognition in men are confounded in extant studies. This randomized, placebo-controlled trial was undertaken to investigate the possible effects of E(2) on cognition in older men. Twenty-five men with prostate cancer (mean age: 71.0+/-8.8 years) who required combined androgen blockade treatment were enrolled. Performance on cognitive tests was evaluated at pre-treatment baseline and following 12 weeks of treatment with a gonadotropin-releasing hormone analog and the nonsteroidal antiandrogen bicalutamide to determine whether specific cognitive functions would decline when the production of both T and E(2) were suppressed. In the second phase of the study, either micronized E(2) 1mg/day or an oral daily placebo was randomly added to the combined androgen blockade for an additional 12 weeks to determine whether E(2) would enhance performance in specific cognitive domains (verbal memory, spatial ability, visuomotor abilities and working memory). Compared to pretreatment, no differences in scores occurred on any cognitive test following 12 weeks of combined androgen blockade. In the add-back phase of the study (Visit 3), the placebo-treated men, but not the E(2)-treated men, exhibited a trend towards improvement in their scores on both the immediate (p=.075) and delayed recall (p=.095) portions of a verbal memory task compared to baseline. Moreover, at Visit 3, placebo-treated men performed significantly better than the E(2)-treated men on both the immediate (p=.020) and delayed recall (p=.016) portions of the verbal memory task. Thus, combined androgen blockade plus add-back E(2) failed to improve short- or long-term verbal memory performance in this sample of older men being treated for prostate cancer.

Cognitive and mood changes in men undergoing intermittent combined androgen blockade for non-metastatic prostate cancer

PURPOSE

Men with prostate-specific antigen (PSA)-only relapse of prostate cancer after primary therapy are generally fully functional and asymptomatic with a life expectancy of up to 10 or more years. Androgen deprivation therapy (ADT) is a common treatment option. This study examined mood and cognitive changes in otherwise healthy men with prostate cancer prior to, during and after ADT.

EXPERIMENTAL DESIGN

Twenty hormone naïve, eugonadal prostate cancer patients without evidence of metastases and with a rising PSA were treated with intermittent ADT consisting of 9 months of complete androgen blockade (CAB) achieved with combined leuprolide and flutamide followed by an 'off treatment' period. Cognitive function tests and mood measures were administered at baseline, after 3 and 9 months of ADT and after 3 months of no treatment. Twenty healthy control patients without prostate cancer range matched for age and education were tested at the same time intervals.

RESULTS

ADT patients evidenced a significant decline in spatial reasoning, spatial abilities and working memory during treatment compared with baseline. No changes were noted for measures of verbal or spatial memory, selective attention or language. Significant changes in self-rated mood such as increased depression, tension, anxiety, fatigue and irritability were evident during treatment compared with baseline for ADT patients. No significant changes in either cognitive tests or mood measures were noted for the healthy control group.

CONCLUSIONS

These findings, suggest that 9 months of combined androgen blockade may result in some adverse changes in cognition and mood. However, many but not all of these changes can return to baseline after cessation of ADT.

[Effects by androgen suppression with luteinizing hormone on cognitive functions in men treated for cancer of prostate]

OBJECTIVE

To evaluate secondary effects on cognitive functions as memory and attention impairments in men treated by androgen suppression for cancer of prostate.

MATERIAL AND METHODS

A prospective study on men treated with luteinizing hormone-realising hormone analogues (LH-RH analogues) for cancer of prostate was designed. Eighteen men were evaluated with cognitive tests as Mini Mental State (MMS), memory evaluation (Grober-Buschke, Rey Test), attention and executive test (Trail Making Test and Montgomery Asberg Depression Rating Scale [MADRS]) before beginning androgen suppression. Base line pretreatment assessments of every patient were compared with similar tests after six and 12 months of hormone therapy.

RESULTS

On 18 patients, 14 were eligible with pretreatment-median PSA of 22ng/ml (13-659), testosterone of 477ng/dl (398-583), which decreased to 1 and 37ng/dl, respectively. Visual-memory test (Rey test) was significantly improved at M6 (p: 0,001) and M12 (p: 0,02) as was the inversed number-memory test (WAIS) after M6 of androgen suppression and (p: 0,03).

CONCLUSION

After 12 months of androgen suppression, global cognitive performances were preserved. Our results failed to observe impairment of cognitive function. This deserves more important prospective study.

Management of complications of androgen deprivation therapy in the older man

Prostate cancer is the most common malignancy in older men. With the aging of the population, the number of older men with prostate cancer will grow rapidly. Androgen deprivation therapy (ADT) is the mainstay of treatment for men with systemic disease and is increasingly utilized as primary therapy or in combination with other therapies for localized disease. Side effects of therapy are multifold and include hot flashes, osteoporosis, and adverse psychological and metabolic effects. Recent research has illustrated that ADT can negatively impact the functional, cognitive, and physical performance of older men. Patients with prostate cancer, despite recurrence of the disease, have a long life expectancy and may be subjected to the side effects of ADT for many years. This review highlights the complications of ADT and approaches to management. We also provide recommendations for assessment and management of ADT complications among the most vulnerable and frail older male patients.

Viral vector-mediated blockade of the endocrine stress-response modulates non-spatial memory

Stress results in the release of glucocorticoids (GCs) which at high levels, impair performance on hippocampus-dependent tasks. Estrogen is neurotrophic and can rescue stress-induced memory impairments. Here we report the use of a viral vector to overexpress a chimeric gene (ER/GR) that converts the deleterious effects of glucocorticoids into beneficial estrogenic effects. A short immobilization stress regimen was sufficient to impair non-spatial memory. In contrast, viral vector-mediated overexpression of ER/GR in the dentate gyrus of the hippocampus protected against stress-induced impairments of non-spatial memory. These data add to the growing evidence that increasing estrogenic signaling can protect against the impairing effects of stress on non-spatial memory.

Hot flashes in prostate cancer: state of the science

The lack of progress concerning the concept of the hot flash experience in men is an indication of the need for exploration of this phenomenon. The hot flash experience in men is a problem that can no longer be ignored. The results of this literature review will provide a foundation for additional development of the concept and facilitate further inquiry into the phenomenon. The purpose of the article is to provide the current state of the science of hot flashes related to androgen ablation treatment in prostate cancer patients; sleep, sweating, cognitive impairment, and the implications on health-related quality of life. Due to the sparse literature on this concept in men, information is extrapolated from the literature on female breast cancer patients treated with hormones and on menopausal women.

Long-term side effects of androgen deprivation therapy in men with non-metastatic prostate cancer: A systematic literature review

Increasing numbers of men with non-metastatic disease are receiving androgen deprivation therapy (ADT) for a variety of indications, some of which are supported by evidence from randomized trials. Balanced against possible survival benefits and better disease control are data that ADT adversely affects quality of life, particularly in the areas of sexual function, physical function, and energy. There is some evidence of worsening upper extremity physical strength but no clear evidence of decline in daily function with ADT. The impact of ADT on cognitive function is not clear at this time. ADT is associated with declines in bone mineral density within 6-12 months of commencing treatment, with increased fracture rates within 5 years of treatment. ADT use is also associated with a 10-15g/L decline in hemoglobin, although the clinical significance of this drop appears to be limited for most patients. It is reasonable for physicians who are about to start men on ADT to obtain a baseline bone mineral density, to counsel them about the impact on sexual function and possible treatments for sexual dysfunction, and to encourage regular exercise. Further insight into adverse effects of ADT and strategies to minimize these adverse effects await data from ongoing studies.

Androgen deprivation impairs memory in older men

Androgen deprivation leads to a profound loss of synaptic density in the hippocampus and changes in learning and memory in animal models. The authors examined group differences in verbal memory between men on androgen deprivation therapy (ADT), a commonly used treatment for prostate cancer, and healthy men. The authors found that men on ADT have a specific impairment of retention but normal encoding and retrieval processes on a word list-learning task. Speed and accuracy for both perceptual and semantic encoding, as well as retrieval at a very short retention interval, were not affected; however, recognition fell to chance after a 2-min retention interval in men on ADT. Healthy men showed only moderate forgetting, and performance was still above chance at 12 min. This pattern of preserved encoding and retrieval but impaired retention suggests that androgens play a role in hippocampally mediated memory processes, possibly having a specific affect on consolidation.

Testosterone loss and estradiol administration modify memory in men

PURPOSE

Little is known about the effect of androgen deprivation therapy on the brain despite the fact that sex steroid receptors are abundant in cortical brain regions that mediate memory and other cognitive functions. We characterized the impact of androgen deprivation and of subsequent estradiol therapy on the long-term and working memory of patients with prostate cancer.

MATERIALS AND METHODS

Long-term memory (immediate and delayed paragraph recall tests), working memory (SOP and Trails tests) and Profile of Mood States were assessed at baseline and 4 weeks later in 18 patients with androgen independent prostate cancer beginning second line hormonal therapy with transdermal estradiol 0.6 mg/24 hours. The same assessments were performed in 2 age matched control groups of 18 patients with prostate cancer undergoing androgen deprivation continuing on hormonal therapy and 17 community dwelling healthy men.

RESULTS

Immediate and delayed verbal memory were significantly worse in patients with prostate cancer on androgen deprivation than in age matched healthy controls. In addition, men with prostate cancer took more time to complete the Trails A task, indicating slower processing speed, but did not differ significantly from healthy controls in working memory tasks. In individual repeated measures analyses, verbal memory performance improved with estradiol therapy but did not change in the 2 control groups.

CONCLUSIONS

Sex steroid loss and replacement have effects on specific cognitive processes in older men. Furthermore, estrogen has the potential to reverse the neurotoxic effects on memory performance caused by androgen deprivation.

The role of androgens in cognition and brain aging in men

Losses of working and long-term memory are hallmarks of human aging and may signal impending neurodegenerative disease. The maintenance of neural elements in brain systems that support memory, such as synapse formation in prefrontal cortex and hippocampus, are critical for cognitive health in aging. This paper reviews the biological basis for androgens as neuroprotectants or neuromodulators in aging and the importance of androgens on the brain systems important for memory. We relate biological effects to cognitive outcomes in elderly men under a variety of androgen conditions. In brief, androgen deprivation causes significant loss of synapses in the hippocampus in rodent and nonhuman primates, increases amyloid deposition in human and rodent models and causes changes in neurotransmission in prefrontal cortex in rodent models. Recent work suggests that these changes modify age-related cognitive loss, particularly to memory in men. In addition, the conversion of testosterone to its androgen metabolites or to estradiol may play a special role in the preservation of memory in aging. This paper reviews discrepancies between studies using animal models and studies of human cognition, and suggests new directions that are likely to be fruitful in the future for understanding the role of androgens in brain aging. This review suggests that studies of low androgen levels in older men may not index the same biological mechanisms and behavioral effects as the studies of gonadectomy in animal models.

Clinical Pharmacology and Differential Cognitive Efficacy of Estrogen Preparations

Menopause is associated with a significant decline in levels of estrogen, which reportedly leads to several distressing symptoms and adverse health effects on various target tissues including those on bones, heart, and brain. Although effective, the long-term safety and feasibility of therapy with both unopposed and opposed oral conjugated equine estrogen has been questioned by the recent findings of both the Women's Health Initiative (WHI) and the Women's Health Initiative Memory Study (WHIMS). The findings of both these studies have raised several critical issues related to hormone therapy that need to be systematically evaluated in clinical studies. Specifically, these issues relate to the differential efficacy and adverse-effects profile of various forms of estrogen and progestins, the importance of the route of administration of estrogen, the best timing to initiate postmenopausal hormone therapy, and the efficacy of cyclic versus continuous hormone therapy. This article focuses on estrogen and discusses issues related to selecting the best form and route of administration of the hormone. It includes information on basic clinical pharmacology of various forms of estrogen, neuroendocrinology of the menopause, neurobiology of estradiol and estrone, and results of selected basic science and human intervention studies with relevance to identifying the best form and route of administration of estrogen.

Associations between serum testosterone fall and cognitive function in prostate cancer patients

Data on the association between cognition and testosterone levels in elderly men are inconclusive. Androgen deprivation therapy is commonly used in the treatment of prostate cancer with the aim of achieving castration levels of serum testosterone. The study group comprised 26 elderly men (mean age 65 years) with newly diagnosed prostate cancer. Cognitive testing was done at baseline and at 6 and 12 months on androgen deprivation therapy. Cognitive performances were evaluated using verbal, visuomotor, and memory tests as well as tests of processing speed and attention. Castration levels of testosterone were achieved in all patients by 6 months. Significant associations between cognitive performances and testosterone decline were documented: visuomotor slowing, slowed reaction times in some attentional domains including working memory and impaired hit rate in a vigilance test, impaired delayed recall and recognition speed of letters, but improvement in object recall. The results suggest selective associations between testosterone decline and cognition. Documentation of cognitive performance with changes in serum testosterone levels has substantial implications for informed patient support in prostate cancer.

Depression in men with prostate cancer

PURPOSE/OBJECTIVES

To summarize the current empirical knowledge base on depression in men with prostate cancer to inform psychosocial supportive care interventions for this population and chart directions for future research.

DATA SOURCES

Reports in English of quantitative studies that included measures of depression or mood in samples of men with prostate cancer published from 1988-2004.

DATA SYNTHESIS

Nurse researchers are playing a key role in establishing the scientific knowledge base upon which a better understanding of the relative importance of depression in men with prostate cancer will emerge. This review indicates that (a) predictable risk factors exist for depression among men with prostate cancer, (b) different prostate cancer treatments do not tend to be associated with differential outcomes in depression or mood, and (c) overall, men with prostate cancer report fewer depressive symptoms than women with breast cancer.

CONCLUSIONS

The small body of research addressing depression in men with prostate cancer is methodologically inadequate to estimate the overall prevalence of depression among men with prostate cancer and determine the clinical significance of psychoeducational interventions targeting depression or mood in this population.

IMPLICATIONS FOR NURSING

Nurses can use current knowledge to identify men with prostate cancer who are most at risk for depression. Evidence supporting the benefit of psychoeducational interventions for depression in other cancer populations (e.g., women with breast cancer) may be applicable to men with prostate cancer.

The role of luteinizing hormone-releasing hormone therapy in locally advanced prostate cancer and biochemical failure: considerations for optimal use

BACKGROUND

More patients are being diagnosed with prostate cancer at an earlier age with earlier stage disease because of advances in screening and detection. Investigators continue to explore the use of hormone therapy, particularly luteinizing hormone-releasing hormone (LHRH) analogues, earlier in the course of disease.

OBJECTIVE

This review summarizes clinical evidence regarding the safety and efficacy of LHRH analogues in the treatment of locoregional disease or following biochemical failure.

METHODS

Relevant information from clinical studies was identified through a MEDLINE search of the medical literature published in English in the last 5 years (search terms: LHRH and prostate cancer). The search included prospective and retrospective clinical studies on LHRH therapy in locally advanced prostate cancer. Additional relevant publications published before 1999 were identified from citations in the resulting articles.

RESULTS

The available clinical evidence suggests that the use of LHRH analogues as adjuvant or neoadjuvant therapy in conjunction with radiation therapy may improve survival outcomes. Few studies have evaluated the use of LHRH analogues after biochemical failure. However, several related studies indicate that initiating hormone therapy earlier rather than later may provide some clinical benefit. When considering early initiation of LHRH therapy, the potential risks of long-term treatment must be considered. Physiologic changes, such as deterioration of body composition and bone quality, may have important effects on the risk of developing cardiovascular disease and osteoporosis.

CONCLUSIONS

Although some clinical evidence supports the use of LHRH analogues as adjuvant or neoadjuvant therapy or following biochemical failure, further study is needed. In the meantime, clinicians should carefully weigh the potential benefits and risks of early hormone therapy when making treatment decisions.