Radiotherapy with hormones for prostate cancer: an expert’s guide

In recent years a combination of radiation and hormone therapy to treat prostate cancer has become increasingly popular. The question is, how effective is this? Leading clinical oncologist Dr Albert Edwards explains everything you need to know.

Is it possible to do radiation and hormone therapy at the same time for prostate cancer?

Yes, it is entirely possible to do radiation and hormone therapy at the same time for prostate cancer. In fact, giving hormones before, during, and after radiotherapy to the prostate has been shown to improve cancer outcomes. As a result, almost everybody who is undergoing external beam radiotherapy to their prostate will have hormones not only during and after radiation but before the therapy as well.

How successful is combining hormone therapy and radiation for prostate cancer?

A large European study comparing men who were having radiotherapy alone to men who were having hormone treatment before, during, and after their radiotherapy demonstrated great success for those who had the combined treatment. Since this study was conducted, combined treatment has been adopted as a standard of care.

How long can prostate cancer be treated with hormones and radiation?

The length of time focusing on this combined treatment depends on each individual case. With curable prostate cancer, we normally divide each patient into low, intermediate, and high-risk patients according to three particular features; the initial PSA blood test value, the stage of the prostate cancer and the grade on their biopsy.

These three pieces of information allow us to assign the patient to the appropriate category. For example, for patients who are in the high-risk category, I would typically offer them two to three years of hormone treatment in total, whereas the most of the patients in the intermediate category would have six months of hormone treatment.

With regard to the majority of the patients in the low-risk category, we often don't offer treatment. In some cases we watch them for years, namely active surveillance.

Who is the ideal candidate for combined hormone and radiation therapy for prostate cancer?

We can treat most patients with localised prostate cancer with hormones and radiotherapy. We need to consider avoiding using hormones and radiotherapy for some patients, if possible, because it may be unsuitable for them. These patients are normally younger patients, around the age of 60 or 65, who have very curable disease.

It is important to note that there is a very small theoretical risk of secondary malignancy when using external beam radiotherapy. The prostate will get a very high dose, but in order to get that radiation dose to the prostate, the x-ray beams will travel through the rest of the organs in the patient's pelvis, in order to get to the prostate and go out of the body.

The area of the pelvis which will receive the lower or medium radiation dose could be thought of as being at a tiny risk of developing, new cancers in the decades after the treatment. There is no association of risk with brachytherapy or prostate surgery, therefore for patients who don't have high risk disease, it's generally felt that it's not worth taking, running the very small additional risk that isn't associated with the other two treat modalities.

Are there any side effects of treating prostate cancer with hormone and radiation therapy?

Hormone treatment has its own side effects or endocrine effects. Effectively, hormone treatment switches off the patient's production of testosterone from the testicles, which tends to drive prostate cancer. Side effects can include hot flushes and sweats, feeling tired and putting weight around the tummy. Additionally, it can particularly push up the blood sugar levels and in the long term, can affect blood pressure.

Many people feel that prolonged hormone therapy is linked to increased risk of cardiovascular problems. Side effects of radiotherapy can be divided into two categories; ones that occur during the course of radiation and for a few weeks afterwards.

These acute side effects have an impact on the waterworks because the urethra, which carries the urine, runs right through the middle of the prostate. It is difficult to prevent this happening from happening with external beam radiotherapy and as a result, patients can experience a burning sensation while peeing, similar to the sensation of a UTI They may also need to pee more frequently and urgently.    

Furthermore, there is a very small risk of swelling in the prostate due to the radiation treatment. However, it is extremely rare for it to swell to the extent that it interferes with their ability to enter their bladder. This occurs in fewer than 5% of patients during the course of their external beam radiotherapy. If this were to happen, we would not want to interrupt the radiotherapy and we would put a catheter in for the remainder of the treatment.

Of course the bladder sits on top of the prostate and can be affected by the radiation, but is mainly concentrated in the prostate below, and can give some irritative urinary symptoms. The rectum sits behind the prostate. As all of prostates cancer patients will know, when the urologist initially examined them, they could feel the back of their prostate gland through the front of the wall of the rectum.

On a digital rectal examination, the bowel being affected by the radiation in the short term during the radiotherapy can lead to, flatulence, looser stools, more frequent opening of the bowels, a sensation that they need to open the bowels, but there's nothing there, which we call tenesmus.

For patients who are sensitive to radiation, they may pass mucus or sees some traces of blood, when they're opening their baths. There's also, a degree of fatigue, which cab be related to the hormone treatment and perhaps, an effect of the radiation.

In addition, there are later side effects which may be permanent, in a small number of patients. These can affect the waterworks, the bowel and erectile function. There is also a small risk of thinning of the bones, of the pelvis being compounded by the radiation that has gone through during the treatment, causing, fractures in the future in a very small number of patients.

It is essential that patients are fully informed about side effects so that they can come to an informed decision when they decide to proceed with hormone therapy and radiotherapies for their prostate cancer.

If you would like to book a consultation with Dr Albert Edwards, simply visit his Top Doctors profile today.