When is hormone replacement therapy (HRT) indicated in patients with prostate cancer?

Hormone Replacement Therapy in Prostate Cancer

Hormone replacement therapy (HRT) in prostate cancer is primarily indicated as neoadjuvant and adjuvant therapy in combination with radiotherapy for intermediate and high-risk disease, with specific durations based on risk stratification. 1

Indications for HRT in Prostate Cancer

For Radiotherapy Patients:

• High-Risk Disease:

  • Neoadjuvant LHRH agonist therapy for 4-6 months before and during radiotherapy 1
  • Adjuvant hormonal therapy for 2-3 years after radiotherapy 1
  • This combination significantly improves overall survival compared to radiotherapy alone 1

• Intermediate-Risk Disease:

  • Neoadjuvant LHRH agonist therapy for 4-6 months should be considered 1
  • Evidence shows improved disease control, metastases-free survival, and cancer-specific survival 1

For Locally Advanced Disease:

• External beam radiotherapy plus hormone treatment for at least 2 years 1
• The SPCG-7 trial showed improved cause-specific mortality (11.9% vs 23.9%) and overall mortality (29.6% vs 39.4%) with combined therapy 1
• The NCIC/MRC trial demonstrated improved 7-year survival from 66% to 74% with the addition of RT to ADT 1

For Post-Prostatectomy Patients:

• Adjuvant hormone therapy after radical prostatectomy is not recommended 1
• For salvage radiotherapy after prostatectomy for PSA failure:
  • Limited evidence suggests benefit from adding 6-24 months of androgen deprivation 1
  • The RTOG 96-01 trial showed improved freedom from PSA progression with 24 months of bicalutamide during and after salvage RT 1

For Metastatic Disease:

• First-line hormonal management should be based on chemical or surgical castration 1
• For castration-resistant prostate cancer (CRPC), continue androgen suppression and consider additional hormone therapies 1

HRT Options and Considerations

Primary Agents:

• LHRH agonists (standard approach) 1, 2
• Surgical castration (bilateral orchiectomy) - equally effective alternative 2
• Bicalutamide 150mg daily can be considered as an alternative to LHRH agonists for patients who prioritize sexual function 1
  • Men on long-term bicalutamide should consider prophylactic RT to breast buds or tamoxifen 1

Treatment Intensification:

• For high-risk features, consider adding:
  • Abiraterone and prednisolone to ADT for locally advanced non-metastatic disease 2
  • Docetaxel for very high-risk features (6 cycles at 75 mg/m² every 3 weeks) 2

Special Considerations

Cardiovascular Risk:

• Use LHRH agonists with caution in patients with pre-existing cardiovascular morbidity 1
• Bicalutamide 150mg may be preferred in these patients based on EPC trial results 1

Quality of Life Management:

• Regular exercise may reduce fatigue and improve quality of life for patients on LHRH agonist therapy 1
• Monitor for ADT-related side effects including metabolic changes, bone density loss, hot flashes, and sexual dysfunction 2

Testosterone Replacement After Cancer Treatment:

• Historically contraindicated but emerging evidence suggests it may be safe in select patients after definitive treatment for non-metastatic prostate cancer 3
• Consider only in hypogonadal men with history of definitively treated prostate cancer without evidence of active disease 3, 4
• Requires vigilant monitoring with PSA measurements 5

Monitoring Recommendations

• PSA measurements every 3 months during first year of treatment 2
• Regular digital rectal examinations 2
• After radiotherapy, PSA determination and digital rectal examination every 6 months indefinitely 2

When to Avoid HRT

• Low-risk disease patients (observation is preferred) 1
• After radical prostatectomy as adjuvant therapy 1
• For biochemical recurrence without symptoms, proven metastases, or PSA doubling time <3 months 1, 2

Remember that hormone therapy decisions should be based on the patient's risk stratification, treatment modality, and specific disease characteristics to optimize survival outcomes while minimizing treatment-related morbidity.