Should a man with stage T3, T4, or N+ (C or D1) cancer—but no symptoms— begin hormone therapy? Many doctors believe he should, the sooner the better. “Treat the tumor while a greater percentage of cells are responsive to hormones, and the patient should do better,” says one oncologist.
That is certainly one option, but we doubt that ultimately it will make a difference in prolonging life. Hormone therapy never cures; at best, it palliates cancer. An excellent example of this is a study done by the Veterans Administration Cooperative Urological Research Group, in which 1,764 men received either a placebo, surgical castration, 5 milligrams of DES a day, or the DES plus surgical castration. When prostate cancer began to progress in the men on the placebos—this happened to 70 percent of the men with stage T3 or T4 (C), and to all of the men with stage N+ and M+ (D) cancer—they began hormone therapy. The study, though not originally intended for this purpose, turned into a comparison of early hormone therapy versus delayed treatment. There was no difference in survival between the men who started hormone therapy late and the men who had been on it all along.
So what this means is that whether we treat a man with castration immediately—as soon as the diagnosis of advanced disease is made—or we wait until he has symptoms and then perform the castration, the survival is exactly the same. There is no evidence that any kind of hormone therapy works better earlier than later, when a man begins experiencing symptoms such as urinary obstruction or bone pain. We don’t believe that any man who is asymptomatic—feeling no symptoms—is going to feel any better once he has been deprived of his normal hormones. To repeat a point: The cancer cells that ultimately prove fatal in prostate cancer are the hormone-insensitive cells. They keep right on growing, unfazed by hormone therapy. To these cells, whether hormone therapy comes earlier or later does not matter.
For an asymptomatic man, early hormonal therapy means going from feeling fine and “normal” to experiencing hot flashes, loss of libido and the ability to have an erection, weight gain, changes in muscle mass, skin and hair growth and the subtle changes in personality that accompany the loss of male hormones. The long-term effects of hormone therapy can include osteoporosis— loss of bone density, which leaves bones more brittle and easy to break.
What’s the point of going through this early, when ultimately it’s not going to work any better than if a man waits to start hormone therapy until he develops symptoms of advanced disease?
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