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

Androgen Deprivation Therapy Use and Risk of Mild Cognitive Impairment in Prostate Cancer Patients

INTRODUCTION

We examined the association between androgen deprivation therapy (ADT) use and the risk of mild cognitive impairment (MCI) among prostate cancer patients.

METHODS

We included 241 cognitively unimpaired men, aged 70 to 90, with a history of prostate cancer before enrollment in the population-based Mayo Clinic Study of Aging. Using the Rochester Epidemiology Project medical records-linkage system, ADT use and length of exposure were abstracted. Follow-up visits occurred every 15 months and MCI diagnoses were made based on clinical consensus. Cox proportional hazards models, with age as the timescale, were used to examine the association between ADT use (yes/no) and length of exposure with the risk of MCI adjusting for education, apolipoprotein E, depression, and the Charlson Index score.

RESULTS

There was no association between any ADT use (27.8% of participants) and the risk of MCI in the multivariable model [hazard ratio (HR), 1.25; 95% confidence interval (CI), 0.75-2.10]. Although not significant, there was an ADT dose-response relationship for risk of MCI: <5 years versus no use (HR, 1.08; 95% CI, 0.60-1.96) and ≥5 years versus not use (HR, 1.89; 95% CI, 0.83-4.27).

CONCLUSION

ADT use among prostate cancer patients was not associated with an increased risk of developing MCI.

Prostate Cancer, Use of Androgen Deprivation Therapy, and Cognitive Impairment: A Population-based Study

INTRODUCTION

The association of prostate cancer and androgen deprivation therapy (ADT) use with the odds of developing mild cognitive impairment (MCI) was determined in men from the population-based Mayo Clinic Study of Aging (MCSA).

METHODS

The study included 2513 men (mean age of 73.1 y) enrolled in the MCSA. A history of prostate cancer, ADT use, and length of ADT exposure before their first MCSA visit was abstracted using the Rochester Epidemiology Project medical records-linkage system. MCI was diagnosed at the baseline visit. Logistic regression was used to determine whether prostate cancer and ADT use was associated with odds of MCI.

RESULTS

Of the 2513 participants, 349 (13.9%) had a history of prostate cancer; among whom 99 (28.3%) were treated with ADT before MCSA enrollment. There were 382 (15.2%) with a diagnosis of MCI. In the univariate logistic regression models, prostate cancer (odds ratio, 1.50; 95% confidence interval, 1.12-2.00), and ADT exposure (odds ratio, 1.57; 95% confidence interval, 0.96-2.58) were associated with higher odds of MCI. These associations were greatly attenuated and not significant in multivariable models.

CONCLUSIONS

Neither a diagnosis of prostate cancer nor ADT use was associated with odds of MCI in this cross-sectional population-based study.

Quality of sleep in patients receiving androgen deprivation therapy for prostate cancer

Androgen deprivation is a therapeutic option for patients with prostate cancer (PC). However, it has negative effects on sleep quality and psychological condition. Here, we evaluated the appearance of sleep disturbances in patients on androgen deprivation therapy (ADT). We administered Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Epworth Sleepiness Scale (ESS), and Fatigue Severity Scale (FSS) to consecutive prostate cancer patients who had undergone radical prostatectomy and are presently either under adjuvant ADT or followed in an unmedicated program (non-ADT). The results of the tests in ADT and non-ADT groups in addition to the demographic data and the features of the malignancy were statistically compared. Of the 106 patients enrolled, 48 (45.3%) were receiving adjuvant ADT and 58 (54.7%) were not. Age, disease duration, and education levels showed no difference between the two groups. Compared with the non-ADT group, the patients receiving ADT showed higher levels of depression, worse quality of sleep, and more severe fatigue (p < 0.001, for each). There was no significant difference among the two groups regarding excessive daytime sleepiness (p = 0.856). The mean PSQI scores showed a positive correlation with BDI and FSS scores (r = 0.710, p < 0.001; r = 0.528, p < 0.001, respectively). Additionally, ADT was strongly associated with PSQI and FSS scores at multivariate analysis (p = 0.037, p = 0.043, respectively). We conclude that PC patients receiving ADT are likely to be fatigued, more depressed, and had poorer sleep quality. Our study showed that receiving ADT therapy is strongly associated with poor sleep quality and fatigue.

Gynaecomastia in 786 adult men: clinical and biochemical findings

OBJECTIVE

Gynaecomastia is a benign proliferation of glandular tissue of the breast; however, it is an important clinical observation because it can be the first symptom of an underlying disease. Some controversy exists concerning the clinical importance of an in-depth investigation of men who develop gynaecomastia. We hypothesise that a thorough work-up is required in adult men with gynaecomastia.

DESIGN

All adult men (n = 818) referred to a secondary level andrological department at Rigshospitalet in Copenhagen, Denmark during a four-year period (2008-2011) under the diagnosis of gynaecomastia (ICD-10: N62) were included.

METHODS

Thirty-two men who did not have gynaecomastia when examined were excluded; leaving 786 men for final analyses. They underwent an andrological examination, ultrasound of the testicles and analysis of endogenous serum hormones levels.

RESULTS

In 43% of men with adult onset of gynaecomastia (≥18 years) an underlying, and often treatable, cause could be detected. In men younger at onset an underlying cause for gynaecomastia could be detected in merely 7.7%. The study is limited by the fact that we did not have access to investigate men who were referred directly by their GP to private clinics for plastic surgery or who sought cosmetic correction without consulting their GP first.

CONCLUSIONS

Our study demonstrates the importance of a thorough examination and provides a comprehensible examination strategy to disclose the underlying pathology leading to the development of gynaecomastia in adulthood.

A phase I study of muscadine grape skin extract in men with biochemically recurrent prostate cancer: Safety, tolerability, and dose determination

BACKGROUND

New therapies are being explored as therapeutic options for men with biochemically recurrent prostate cancer (BRPC) who wish to defer androgen deprivation therapy. MPX is pulverized muscadine grape (Vitis rotundifolia) skin that contains ellagic acid, quercetin, and resveratrol and demonstrates preclinical activity against prostate cancer cells in vitro.

METHODS

In the phase I portion of this phase I/II study, non-metastatic BRPC patients were assigned to increasing doses of MPX (Muscadine Naturals. Inc., Clemmons, NC) in cohorts of two patients, with six patients at the highest dose, using a modified continual reassessment method. Initial dose selection was based on preclinical data showing the equivalent of 500 to 4,000 mg of MPX to be safe in mouse models. The primary endpoint was the recommended phase II dosing regimen.

RESULTS

The cohort (n = 14, 71% Caucasian, 29% black) had a median follow-up of 19.2 (6.2-29.7) months, median age of 61 years, and median Gleason score of 7. Four patients had possibly related gastrointestinal symptoms, including grade 1 flatulence, grade 1 soft stools, and grade 1 eructation. No other related adverse events were reported and one patient reported improvement of chronic constipation. Six of 14 patients came off study for disease progression (five metastatic, one rising PSA) after exposure for a median of 15 months. One patient came off for myasthenia gravis that was unrelated to treatment. Seven patients remain on study. The lack of dose-limiting toxicities led to the selection of 4,000 mg/d as the highest dose for further study. Median within-patient PSADT increased by 5.3 months (non-significant, P = 0.17). No patients experienced a maintained decline in serum PSA from baseline.

CONCLUSION

These data suggest that 4,000 mg of MPX is safe, and exploratory review of a lengthening in PSADT of a median of 5.3 months supports further exploration of MPX. Both low-dose (500 mg) and high-dose (4,000 mg) MPX are being further investigated in a randomized, multicenter, placebo-controlled, dose-evaluating phase II trial.

Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners

The clinical benefits of androgen-deprivation therapy (ADT) for men with prostate cancer (PC) have been well documented and include living free from the symptoms of metastases for longer periods and improved quality of life. However, ADT comes with a host of its own serious side effects. There is considerable evidence of the adverse cardiovascular, metabolic, and musculoskeletal effects of ADT. Far less has been written about the psychological effects of ADT. This review highlights several adverse psychological effects of ADT. The authors provide evidence for the effect of ADT on men's sexual function, their partner, and their sexual relationship. Evidence of increased emotional lability and depressed mood in men who receive ADT is also presented, and the risk of depression in the patient's partner is discussed. The evidence for adverse cognitive effects with ADT is still emerging but suggests that ADT is associated with impairment in multiple cognitive domains. Finally, the available literature is reviewed on interventions to mitigate the psychological effects of ADT. Across the array of adverse effects, physical exercise appears to have the greatest potential to address the psychological effects of ADT both in men who are receiving ADT and in their partners.

Anticancer treatment and fertility: Effect of therapeutic modalities on reproductive system and functions

The significant improvement of cancer treatments entailed a longer life in cancer survivors and raised expectations for higher quality of life with minimized long-term toxicity. Infertility and gonadal dysfunction are adverse effects of anticancer therapy or may be related to specific tumors. In female cancer survivors, premature ovarian failure is common after antineoplastic treatments resulting in infertility and other morbidities related to oestrogen deficiency such as osteoporosis. In male cancer survivors, infertility and persistent a zoospermia is a more common long-term adverse effect than hypogonadism because germ cells are more sensitive to chemotherapy and radiotherapy than leydig cells. Gonadal toxicity and compromise of reproductive functions will be more efficiently prevented and treated if addressed before treatment initiation. This review focuses on these issues in young cancer survivors of childbearing age, where methods of protecting or restoring endocrine function and fertility need to be considered.

An investigation of the support needs of men and partners throughout the prostate cancer journey

OBJECTIVE

Prostate cancer is one of the mostly commonly diagnosed cancers in men. Unfortunately, the treatment for this cancer can have a number of negative side effects, both for the man himself and his partner. This study investigated the support needs of both men and partners throughout the prostate cancer journey and how this journey may be optimally managed.

METHODS

Thirty-one men who had undergone prostate cancer treatment within the last 6 years and 31 partners answered a questionnaire, which explored support care issues as identified in the literature and from focus groups.

RESULTS

Men and partners were moderately satisfied with information given regarding diagnosis, treatment and side effects, but partners were more satisfied with information relating to the particular chosen treatment. Men's understanding of their chosen treatment's potential side effects was significantly different from their understanding of diagnosis, cancer outcome, treatment options and selected treatment. Timing of information delivery was preferred by men at diagnosis, whereas partners preferred after the diagnosis. Men wanted more time to think about the diagnosis and treatment, whereas partners wanted an opportunity to discuss the diagnosis. The management of common side effects such as emotional changes, incontinence and erectile dysfunction was rated as 'somewhat' satisfactory.

CONCLUSION

Men and partners may have different educational and supportive needs throughout the prostate cancer journey that require attention and tailored management.

Obesity and the Odds of Weight Gain following Androgen Deprivation Therapy for Prostate Cancer

Background. Increasing body mass index (BMI) is associated with increased risk of mortality; however, quantifying weight gain in men undergoing androgen deprivation therapy (ADT) for prostate cancer (PC) remains unexplored. Methods. Between 1995 and 2001, 206 men were enrolled in a randomized trial evaluating the survival difference of adding 6 months of ADT to radiation therapy (RT). BMI measurements were available in 171 men comprising the study cohort. The primary endpoint was weight gain of ≥10 lbs by 6-month followup. Logistic regression analysis was performed to assess whether baseline BMI or treatment received was associated with this endpoint adjusting for known prognostic factors. Results. By the 6-month followup, 12 men gained ≥10 lbs, of which 10 (83%) received RT + ADT and, of these, 7 (70%) were obese at randomization. Men treated with RT as compared to RT + ADT were less likely to gain ≥10 lbs (adjusted odds ratio (AOR): 0.18 [95% CI: 0.04–0.89]; P = 0.04), whereas this risk increased with increasing BMI (AOR: 1.15 [95% CI: 1.01–1.31]; P = 0.04). Conclusions. Consideration should be given to avoid ADT in obese men with low- or favorable-intermediate risk PC where improved cancer control has not been observed, but shortened life expectancy from weight gain is expected.

Reproductive health in the adolescent and young adult cancer patient: an innovative training program for oncology nurses

In 2008, approximately 69,200 adolescents and young adults (AYAs) were diagnosed with cancer, second only to heart disease for males in this age group. Despite recent guidelines from professional organizations and clinical research that AYA oncology patients want information about reproductive health topics and physician support for nurses to address these issues with patients, existing research finds few oncology nurses discuss this topic with patients due to barriers such as lack of training. This article describes an innovative eLearning training program, entitled Educating Nurses about Reproductive Issues in Cancer Healthcare. The threefold purpose of this article is to: (1) highlight major reproductive health concerns relevant to cancer patients, (2) describe the current status of reproductive health and oncology communication and the target audience for the training, and (3) present a systematic approach to curriculum development, including the content analysis and design stages as well as the utilization of feedback from a panel of experts. The resulting 10-week curriculum contains a broad-based approach to reproductive health communication aimed at creating individual- and practice-level change.

Drug-induced gynecomastia

Drugs account for about 20% of gynecomastia cases in men. As a number of factors can alter the estrogen:androgen ratio, several pathophysiologic mechanisms are associated with drugs causing this disorder. Antiandrogens, protease inhibitors, and nucleoside reverse transcriptase inhibitors are the most common drug causes of gynecomastia, whereas first-generation antipsychotics, spironolactone, verapamil, and cimetidine are less common causes. Other drugs have been reported rarely as causes. Treatment may involve switching to an alternative agent or may require surgery or irradiation if the causative agent cannot be discontinued. We reviewed the literature on drug-induced gynecomastia and provided another perspective by reviewing data from the United States Food and Drug Administration's Adverse Event Reporting System. Epidemiologic studies are needed to provide a more accurate description of the frequency of drug-induced gynecomastia.

[Current evidence about intermittent androgenic deprivation in prostate cancer]

OBJECTIVES

To identify clinical application of intermittent hormonotherapy in prostatic carcinoma.

MATERIAL AND METHODS

We conducted a systematic review in MEDLINE database and COCHRANE Library using the words MeSH "prostate cancer, androgenic deprivation and intermittent". There were included those with the best level of evidence and published in the last 10 years.

RESULTS

Intermittent hormone therapy is one of the tools we use in urological armamentarium for special circumstances. This analysis highlights: possibility to regain sexual function during the period of suspension of treatment (time off) due to the recovery of testosterone levels also demonstrating an improvement in symptoms, decreased costs preserving the same oncological control compared to complete androgenic deprivation.

CONCLUSIONS

There is still controversy about the benefits in quality of life and the emergence of long-term side effects typical of continuous hormonal therapy. Therefore and until now, we should only propose intermittent therapy in selected patients.

Sexuality in adult cancer survivors: challenges and intervention

Sexual dysfunction is one of the most common and distressing consequences of cancer treatment. Although some treatment-related sexual adverse effects are short-term, many survivors face long-term effects such as treatment-induced menopause, altered gonadal function, and significant surgical disfigurement. Profound sexual dysfunction has been shown to have a significant negative effect on quality of life. Although these problems have been well documented and there are a range of intervention strategies that can help patients cope with treatment-related sexual problems, many survivors do not feel prepared for potential sexual changes and often do not receive adequate support to manage sexual dysfunction. Numerous barriers contribute to this underprovided aspect of survivorship care, including lack of provider training and access to readily available resources. In addition, psychological, relational, and cultural factors significantly influence sexuality but are often not taken into consideration in research and clinical practice. By taking an integrative approach and providing survivors with appropriate screening, information, and support, sexual dysfunction and accompanying distress can be significantly alleviated. In this article, we aim to provide a concise review of the most common sexual problems experienced by survivors and highlight some of the most promising evidence-based practices for assessment and intervention. We also address limitations encountered in research and practice and explore future directions, including suggestions for adopting an integrative treatment model to address sexual dysfunction in a cancer survivorship treatment setting.

A randomized phase II study of pomegranate extract for men with rising PSA following initial therapy for localized prostate cancer

BACKGROUND

Pomegranate juice has been associated with PSA doubling time (PSADT) elongation in a single-arm phase II trial. This study assesses biological activity of two doses of pomegranate extract (POMx) in men with recurrent prostate cancer, using changes in PSADT as the primary outcome.

METHODS

This randomized, multi-center, double-blind phase II, dose-exploring trial randomized men with a rising PSA and without metastases to receive 1 or 3 g of POMx, stratified by baseline PSADT and Gleason score. Patients (104) were enrolled and treated for up to 18 months. The intent-to-treat (ITT) population was 96% white, with median age 74.5 years and median Gleason score 7. This study was designed to detect a 6-month on-study increase in PSADT from baseline in each arm.

RESULTS

Overall, median PSADT in the ITT population lengthened from 11.9 months at baseline to 18.5 months after treatment (P < 0.001). PSADT lengthened in the low-dose group from 11.9 to 18.8 months and 12.2 to 17.5 months in the high-dose group, with no significant difference between dose groups (P = 0.554). PSADT increases >100% of baseline were observed in 43% of patients. Declining PSA levels were observed in 13 patients (13%). In all, 42% of patients discontinued treatment before meeting the protocol-definition of PSA progression, or 18 months, primarily due to a rising PSA. No significant changes occurred in testosterone. Although no clinically significant toxicities were seen, diarrhea was seen in 1.9% and 13.5% of patients in the 1- and 3-g dose groups, respectively.

CONCLUSIONS

POMx treatment was associated with ≥ 6 month increases in PSADT in both treatment arms without adverse effects. The significance of this on-study slowing of PSADT remains unclear, reinforcing the need for placebo-controlled studies in this patient population.

Early salvage hormonal therapy for biochemical failure improved survival in prostate cancer patients after neoadjuvant hormonal therapy plus radiation therapy--a secondary analysis of irish clinical oncology research group 97-01

PURPOSE

To assess the survival benefit of early vs late salvage hormonal therapy (HT), we performed a secondary analysis on patients who developed recurrence from Irish Clinical Oncology Research Group 97-01, a randomized trial comparing 4 vs 8 months neoadjuvant HT plus radiation therapy (RT) in intermediate- and high-risk prostate adenocarcinoma.

METHODS AND MATERIALS

A total of 102 patients from the trial who recurred were analyzed at a median follow-up of 8.5 years. The patients were divided into 3 groups based on the timing of salvage HT: 57 patients had prostate-specific antigen (PSA)≤10 ng/mL and absent distant metastases (group 1, early), 21 patients had PSA>10 ng/mL and absent distant metastases (group 2, late), and 24 patients had distant metastases (group 3, late). The endpoint analyzed was overall survival (OS) calculated from 2 different time points: date of enrolment in the trial (OS1) and date of initiation of salvage HT (OS2). Survival was estimated using Kaplan-Meier curves and a Cox regression model.

RESULTS

The OS1 differed significantly between groups (P<.0005): OS1 at 10 years was 78% in group 1, 42% in group 2, and 29% in group 3. The OS2 also differed significantly between groups (P<.0005): OS2 at 6 years was 70% in group 1, 47% in group 2, and 22% in group 3. Group 1 had the longest median time from end of RT to biochemical failure compared with groups 2 and 3 (3.3, 0.9, and 1.7 years, respectively; P<.0005). Group 1 also had the longest median PSA doubling time compared with groups 2 and 3 (9.9, 3.6, and 2.4 months, respectively; P<.0005). On multivariate analysis, timing of salvage HT, time from end of RT to biochemical failure, and PSA nadir on salvage HT were significant predictors of survival.

CONCLUSION

Early salvage HT based on PSA≤10 ng/mL and absent distant metastases improved survival in patients with prostate cancer after failure of initial treatment with neoadjuvant HT plus RT.

Safety and tolerability of intermittent androgen deprivation therapy: a literature review

Androgen deprivation therapy is commonly used in men with advanced prostate cancer; however, it is associated with many short- and long-term side-effects. Intermittent androgen deprivation therapy was first suggested as an alternative regimen in the early 1990s and is now part of treatment guidelines as a result of its ability to reduce adverse events associated with continuous androgen deprivation therapy without decreasing its efficacy. Although many publications evaluated intermittent androgen deprivation therapy's efficacy, the safety and tolerability information of this regimen is relatively limited. The goal of this literature review was to analyze clinical trials that have reported safety and tolerability data in prostate cancer patients treated with intermittent androgen deprivation therapy, as well as assessing quality of life outcomes. A literature search was carried out using biomedical and pharmaceutical databases for published information comparing intermittent androgen deprivation therapy with continuous androgen deprivation therapy. A total of 13 randomized and non-randomized studies were selected and reviewed based on their relevance to the safety, tolerability and quality of life of intermittent androgen deprivation therapy. Benefits for intermittent androgen deprivation therapy were observed for the short-term side-effects (hot flushes and sexual functions) mainly during the off-treatment phase, whereas the data for the long-term side-effects were not as conclusive. Quality of life evaluations are more in support of intermittent androgen deprivation therapy. Although there are some safety, tolerability and quality of life benefits associated with intermittent androgen deprivation therapy, the overall evidence is still limited.

Androgen deprivation therapy-associated vasomotor symptoms

Androgen deprivation therapy (ADT) is widely used as standard therapy in the treatment of locally advanced and metastatic prostate cancer. While efficacious, ADT is associated with multiple side effects, including decreased libido, erectile dysfunction, diabetes, loss of muscle tone and altered body composition, osteoporosis, lipid changes, memory loss, gynecomastia and hot flashes. The breadth of literature for the treatment of hot flashes is much smaller in men than that in women. While hormonal therapy of hot flashes has been shown to be effective, multiple non-hormonal medications and treatment methods have also been developed. This article reviews current options for the treatment of hot flashes in patients taking ADT.

Andropause syndrome in men treated for metastatic prostate cancer: a qualitative study of the impact of symptoms

BACKGROUND

Androgen deprivation therapy (ADT) has become the cornerstone of treatment for men with metastatic prostate cancer. However, treatments are associated with a number of adverse effects that collectively are referred to as andropause syndrome, or the male menopause.

OBJECTIVE

This study explored the experience and impact of andropause symptoms, particularly hot flashes, among men undergoing ADT for metastatic prostate cancer.

METHODS

Twenty-one men receiving ADT for metastatic prostate cancer underwent a qualitative interview focusing on the adverse effects of ADT and the impact of these symptoms on daily living and coping strategies.

RESULTS

The most frequently mentioned adverse effects were hot flashes and night sweats, gynecomastia, cognitive decline, and changes in sexual function. Hot flashes did impact on everyday functioning, and night sweats regularly disturbed sleep patterns and led to participants feeling tired and irritable. Participants reported a lack of control over their hot flashes and night sweats. There was reluctance among our sample to disclose the type of symptoms experienced to others.

CONCLUSION

The occurrence of andropause symptoms, including hot flashes and night sweats, was common among this sample. Participants reported a range of cognitive and behavioral responses to these symptoms. There was some reluctance about discussing a prostate cancer diagnosis or the occurrence of symptoms with others.

IMPLICATIONS FOR PRACTICE

The findings have implications for a range of individual and couple interventions to manage the impact of this constellation of symptoms.

Psychological aspects of prostate cancer: a clinical review

Prostate cancer is the most common non-skin cancer in men. It is fraught with both physical and psychological symptomatology. Depression, anxiety, stress, fatigue, pain and psychosocial factors all affect the patient with prostate cancer. Impotence, erectile dysfunction, sexual issues and incontinence in these patients complicate matters further. Anxiety may exist both before testing and while awaiting test results. Confusion over choosing from various interventions often adds to anxiety and depression in these patients. Various demographic factors and the developmental stage of the couple affect these psychological symptoms. The caregiver may undergo significant psychological turmoil while caring for a patient diagnosed with prostate cancer, which is addressed. The role of nurses in the management of prostate cancer is discussed. The present review looks at psychological issues in patients with prostate cancer from a clinical perspective, with the aim of highlighting these issues for the clinical urologist dealing with these patients. It also explores the consultation-liaison relationship between psychiatrists, psychologists and urologists as a team for the multimodal management of prostate cancer.

Cancer in the elderly

A considerable knowledge has been collected in the last 20 years through retrospective and prospective trials on the medical management of cancer in older patients. Today a better approach to prevention and treatment of chemotherapy-related complications in older patients is provided by specific guide-lines.In this review, a synthetic information on the medical treatment specifically required by patients with age associated conditions for the most common tumor types (breast, non-small-cell lung prostate, colrectal cancer, and aggressive non-Hodgkin's lymphoma) is presented.

Short term testosterone replacement therapy improves libido and body composition

OBJECTIVE

To assess the efficacy and safety of testosterone replacement in males with late-onset hypogonadism compared to hypogonadal men without replacement, and controls, during six months.

METHODS

We assessed, through ADAM, AMS, IIEF-5 and SF-36 questionnaires, and through clinical and laboratory examinations, 62 patients divided into three groups: 17 hypogonadal males (HR) used intramuscular testosterone every three weeks; 14 hypogonadal males (HV) and 31 non-hypogonadal males (CV) used oral vitamins daily.

RESULTS

When compared to others, HR group obtained libido improvement assessed by ADAM 1 (p = 0.004), and borderline sexual potency improvement assessed by IIEF-5 (p = 0.053), besides a decrease in waist circumference after eight weeks (p = 0.018). The remaining parameters did not differ between the groups. PSA and hematocrit remained stable in those using testosterone.

CONCLUSION

Six months of testosterone replacement improved sexuality and body composition, with prostatic and hematological safety.

Clinical results of iridium-192 high dose rate brachytherapy with external beam radiotherapy

OBJECTIVE

Here, we report the clinical results of iridium-192 high dose rate brachytherapy at Kanazawa University Hospital.

METHODS

The study population consisted of 166 patients diagnosed with T1c-T3bN0M0 prostate cancer treated with high dose rate brachytherapy and external beam radiotherapy and followed up for 6 months or longer. Treatment consisted of external beam radiotherapy to the prostate at 44 Gy/22 fractions and high dose rate brachytherapy at 18 Gy/3 fractions.

RESULTS

Median follow-up interval was 31.5 months (range 6.2-88.7). The overall 5-year biological recurrence-free survival rate was 93.0%. The 5-year biological recurrence-free survival rates for the patients in low-, intermediate- and high-risk groups according to the D'Amico risk classification criteria were 96.1%, 89.0% and 91.6%, respectively. When limited to the group that did not receive adjuvant hormonal therapy, the 5-year biological recurrence-free survival rates for the patients in low-, intermediate- and high-risk groups were 96.0%, 96.3% and 82.9%, respectively. Grade 3 or greater adverse effects were rare. Urethral stricture was observed in only 1.0% of the patients. Eighty percent of patients retained erectile function after high dose rate brachytherapy and reported satisfaction with sexual function.

CONCLUSIONS

High dose rate brachytherapy is considered a good form of treatment for localized prostate cancer, although longer follow-up is necessary.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Takeda Laboratories, Puteaux, France.

Prostate cancer: psychosocial implications and management

This review summarizes some of the key psychosocial issues related to prostate cancer, both generally and for an older adult population. It focuses on three main areas: quality-of-life issues, psychosocial implications and management of these psychosocial issues. Broadly, the article presents information on the general background, screening guidelines, common side effects of treatment and current psychiatric and psychological management strategies in prostate cancer. The article addresses the clinical approaches, as well as the complexities that surface when deciding the treatment for patients with prostate cancer. Clinical and future implications are also discussed.

Cognitive effects of hormone therapy in men with prostate cancer: a review

BACKGROUND

Men who receive androgen-deprivation therapy (ADT) for prostate cancer experience several side effects from this treatment. A few recent studies have examined the cognitive implications of ADT and how they impact a patient's treatment decision-making, occupational pursuits, and quality of life. For this report, the authors explored possible mechanisms for this association, reviewed research in animal studies and aging men, and examined the growing literature focused on the relation between ADT and cognitive functioning in patients with prostate cancer.

METHODS

A systematic literature search was conducted using the PubMed and Information Sciences Institute Web of Knowledge-Web of Science databases to identify relevant studies that investigated the relation between ADT in men with prostate cancer and its cognitive effects.

RESULTS

Testosterone and its derivatives may have an impact on cognition through several mechanisms in the brain, as supported by studies of animals and in aging men. Studies that researched the impact of ADT on cognition in patients with prostate cancer patients were designed relatively well but suffered from small sample sizes. Between 47% and 69% of men on ADT declined in at least 1 cognitive area, most commonly in visuospatial abilities and executive functioning. Some studies reported contradictory results with increased functioning in verbal memory.

CONCLUSIONS

There is a strong argument that androgen-ablation therapy is linked to subtle but significant cognitive declines in men with prostate cancer. The authors believe that clinicians should become aware of this correlation as the use of ADT increases and should inform and monitor patients for this possible side effect of treatment.

Management of complications of prostate cancer treatment

Prostate cancer is the most commonly diagnosed noncutaneous cancer in men in the United States. Treatment of men with prostate cancer commonly involves surgical, radiation, or hormone therapy. Most men with prostate cancer live for many years after diagnosis and may never suffer morbidity or mortality attributable to prostate cancer. The short-term and long-term adverse consequences of therapy are, therefore, of great importance. Adverse effects of radical prostatectomy include immediate postoperative complications and long-term urinary and sexual complications. External beam or interstitial radiation therapy in men with localized prostate cancer may lead to urinary, gastrointestinal, and sexual complications. Improvements in surgical and radiation techniques have reduced the incidence of many of these complications. Hormone treatment typically consists of androgen deprivation therapy, and consequences of such therapy may include vasomotor flushing, anemia, and bone density loss. Numerous clinical trials have studied the role of bone antiresorptive therapy for prevention of bone density loss and fractures. Other long-term consequences of androgen deprivation therapy may include adverse body composition changes and increased risk of insulin resistance, diabetes, and cardiovascular disease. Ongoing and planned clinical trials will continue to address strategies to prevent treatment-related side effects and improve quality of life for men with prostate cancer.

Two modes of acupuncture as a treatment for hot flushes in men with prostate cancer--a prospective multicenter study with long-term follow-up

BACKGROUND

Hot flushes are common and distressing among men with castrational treatment for prostate cancer. Of the few treatments, most have side effects.

OBJECTIVE

Assess changes in hot flushes of electrostimulated (EA) and traditional acupuncture (TA).

DESIGN, SETTING, AND PARTICIPANTS

Thirty-one men with hot flushes due to prostate cancer treatment were recruited from three urological departments in Sweden, from 2001 to 2004.

INTERVENTION

Thirty-one men were randomized to EA (12 needle points, with 4 electrostimulated) or TA (12 needle points) weekly for 12 wk.

MEASUREMENTS

PRIMARY OUTCOME

number of and distress from hot flushes in 24 h and change in "hot flush score." Secondary outcome: change in 24-h urine excretion of CGRP (calcitonin gene-related peptide).

RESULTS AND LIMITATIONS

Twenty-nine men completed the treatment. Hot flushes per 24 h decreased significantly, from a median of 7.6 (interquartile range [IQR], 6.0-12.3) at baseline in the EA group to 4.1 (IQR, 2.0-6.5) (p=0.012) after 12 wk, and from 5.7 (IQR, 5.1-9.5) in the TA group to 3.4 (IQR1.8-6.3) (p=0.001). Distress by flushes decreased from 8.2 (IQR, 6.5-10.7) in the EA group to 3.3 (IQR, 0.3-8.1) (p=0.003), and from 7.6 (IQR, 4.7-8.3) to 3.4 (IQR, 2.0-5.6) (p=0.001) in the TA group after 12 wk, (78% and 73% reduction in "hot flush score," respectively). The effect lasted up to 9 mo after treatment ended. CGRP did not change significantly. Few, minor side effects were reported.

LIMITATIONS

small number of patients; no placebo control, instead a small group controlled for 6 wk pretreatment.

CONCLUSIONS

EA and TA lowered number of and distress from hot flushes. The hot flush score decreased 78% and 73%, respectively, in line with or better than medical regimens for these symptoms. Acupuncture should be considered an alternative treatment for these symptoms, but further evaluation is needed, preferably with a non- or placebo-treated control group.

Pathologic effects of testosterone deprivation

PURPOSE OF REVIEW

Androgen deprivation therapy remains the cornerstone of treatment for advanced prostate cancer. There are significant adverse effects associated with prolonged androgen deprivation therapy, with recent findings associating it with the metabolic syndrome and its associated health risks.

RECENT FINDINGS

A review of the adverse pathologic effects of testosterone deprivation is performed. Recent findings associate androgen deprivation therapy with endocrine and metabolic disarray, specifically the metabolic syndrome, resulting in increased rates of diabetes and myocardial infarction in patients on testosterone deprivation.

SUMMARY

The increased incidence of the metabolic syndrome in patients receiving androgen deprivation therapy and the associated morbidity and possibly mortality require significant investigation into alternatives to complete testosterone deprivation and ways to counteract these adverse effects.

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.

Age-Related Structural and Metabolic Changes in the Pelvic Reproductive End Organs

In this work, we provide preliminary data and a review of the literature regarding normal structural and functional changes that occur in the aging uterus, ovary, testicle, and prostate gland. It is expected that such knowledge will help physicians to distinguish physiologic changes from pathologic changes at an early stage. We retrospectively reviewed pelvic magnetic resonance imaging (MRI) scans of 131 female and 79 male subjects ages 13 to 86 years to determine changes in volume of the uterus, ovary, and prostate gland with age. Scrotal ultrasound examinations of 150 male subjects ages 0 to 96 years also were analyzed retrospectively to determine changes in testicular volume with age. In addition, (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scans of 145 male subjects ages 11 to 90 years were analyzed retrospectively to assess for changes in maximum standardized uptake value (SUV(max)) of the testicles with age. The uterus had a mean volume of 38.55 +/- 3.68 cm(3) at 17 to 19 years of age, increased to a peak volume of 71.76 +/- 19.81 cm(3) between 35 to 40 years, and then declined to 24.02 +/- 8.11 cm(3) by the eighth decade of life. The maximal ovarian volume per subject maintained a relatively stable size in early life, measuring 9.46 +/- 3.25 cm(3) during the second decade of life, 8.46 +/- 3.32 cm(3) in the mid-fourth decade of life, and 7.46 +/- 3.33 cm(3) at 45 years of age, after which it declined to 4.44 +/- 2.02 cm(3) by the late fifth decade of life. The ovaries were not identifiable on MRI in subjects beyond the sixth decade of life. The volume of the prostate increased from 23.45 +/- 6.20 cm(3) during the second decade of life to 47.5 +/- 41.59 cm(3) by the late eighth decade of life; the central gland of the prostate increased from 9.96 +/- 3.99 cm(3) to 29.49 +/- 28.88 cm(3) during the same age range. Mean testicular volume was 11.2 +/- 5.9 cm(3). Testicular volume increased with age from birth to 25 years. After age 25, there was a significant decline in the testicular volume. The mean SUV(max) for the testicles was 1.9 +/- 0.5. Testicular metabolic activity demonstrated an increasing trend until the age of 35 years. A plateau in SUV(max) was observed after the age of 35 years until the age of 65 years. A slight decrease in SUV(max) was observed after the age of 65 years. The pelvic structures of men and women change both structurally and functionally over the lifespan, and such changes can be quantified using ultrasound, MRI, and (18)F-FDG-PET.

Treatment-Related Symptom Clusters

OBJECTIVES

To provide a clinical overview of treatment-related symptom clusters.

DATA SOURCES

Journal articles, research reports, state of the science papers, and clinical practice experience.

CONCLUSION

Although understanding the etiology and interaction of symptoms may lead to targeted interventions, the nurse must often manage symptoms in which the cause or causes cannot be changed or in which there are multiple overlapping etiologies that lead to complex and challenging clinical presentations. Systematic and ongoing evaluation of symptoms, their treatment-related trajectory, and their response to interventions is essential.

IMPLICATIONS FOR NURSING PRACTICE

Systematic assessment of symptoms and symptom cluster presence, severity, and distress can guide the practitioner to intervene using evidence-based practice. Individualized care and evaluation of response is needed.

Hot Flash Experience in Men With Prostate Cancer: A Concept Analysis

PURPOSE/OBJECTIVES

To provide a clear definition of the hot flash experience in men with prostate cancer receiving hormonal treatment.

DATA SOURCES

Articles, book chapters, and electronic sources.

DATA SYNTHESIS

The hot flash experience has not been explored previously in men with prostate cancer. The physiologic and psychological scopes of the phenomenon are described as a multidimensional experience.

CONCLUSIONS

The essential attributes of hot flashes in men consist of physiologic (e.g., warmth, sweating, chills) and psychological (e.g., anxiety, impaired memory, agitation) factors. Antecedents to the experience include demographics, disease, and treatment modality. Consequences include effects on sleep, cognition, and health-related quality of life.

IMPLICATIONS FOR NURSING

Evaluation of the hot flash experience in men receiving hormonal ablation should include assessment of the symptoms associated with the treatment modality and nursing interventions to help ameliorate symptoms. Future research is needed to focus on providing symptom management to decrease the severity or prevent the occurrence of multiple symptoms related to androgen ablation therapy.

Prostate cancer: a practical approach to current management of recurrent disease

Prostate cancer is the leading cause of cancer in men in the United States, with 234,460 men expected to be diagnosed as having the disease in 2006 (33% of cancers in men), and the third leading cause of cancer deaths in men, with 27,350 men expected to die of the disease (9% of cancer deaths). Through early detection and improved local therapies, including surgery or radiation therapy, a large number of men will be cured, but unfortunately, a significant number of men will still experience relapse of disease and require continued surveillance and ongoing therapy. This article discusses approaches to treatment of men who have recurrent disease, including active surveillance, androgen ablation therapy, secondary hormone therapy, chemotherapy, bisphosphonates, radiation therapy, and future directions.

Risk of the "androgen deprivation syndrome" in men receiving androgen deprivation for prostate cancer

BACKGROUND

Androgen deprivation therapy for prostate cancer has been associated with a spectrum of adverse effects, such as depression, memory difficulties, and fatigue, termed the androgen deprivation syndrome. Primary care physicians providing follow-up care for men with prostate cancer will be faced with managing these effects. We therefore sought to estimate the incidence of these effects and, by using a control group, ascertain whether these effects were related to androgen deprivation itself.

METHODS

We assessed the risk of physician diagnoses of depression, cognitive impairment, or constitutional symptoms in Medicare data following androgen deprivation using a sample of 50 613 men with incident prostate cancer and 50 476 men without cancer, from 1992 through 1997, in the linked Surveillance, Epidemiology, and End Results-Medicare database. Cox proportional hazards regression was used to adjust for confounding variables.

RESULTS

Of men surviving at least 5 years after diagnosis, 31.3% of those receiving androgen deprivation developed at least 1 depressive, cognitive, or constitutional diagnosis compared with 23.7% in those who did not (P<.001). After adjustment for variables such as comorbidity, tumor characteristics, and age, the risks associated with androgen deprivation were substantially reduced or abolished: relative risk (RR) for depression diagnosis, 1.08 (95% confidence interval [CI], 1.02-1.15); RR for cognitive impairment, 0.99 (95% CI, 0.94-1.04); and RR for constitutional symptoms, 1.17 (95% CI, 1.13-1.22).

CONCLUSION

Depressive, cognitive, and constitutional disorders occur more commonly in patients receiving androgen deprivation, but this appears to be primarily because patients receiving androgen deprivation are older and have more comorbid conditions and more advanced cancers.