Category: Treatment Information

Osteoporosis (bone loss) is one of several side effects which accompany androgen deprivation (hormonal) therapy (ADT). Fifty (50) percent of men will be affected by their fourth year of treatment, and more than 80 percent will be affected after10 years. The risk of fractures including those of the spine also increases with hormonal therapy treatment for a year or more. This enhanced risk is illustrated by a recent study in The New England Journal of Medicine where it was reported that “among men with prostate cancer who lived for at least five years after their diagnosis, the risk of a fracture was nearly 20 percent among androgen deprivation (hormonal) therapy users, compared with 13 percent for nonusers.” Men treated with hormonal therapy are generally advised to have annual bone density testing.

Medications are also often prescribed to halt bone loss. The well-known bisphosphonates (such as Fosamax) are the first treatments prescribed followed by selective estrogen receptor modulators (SERMs) such as tamoxifem, used in the treatment of breast cancer. For prostate cancer patients, a new alternative, a monoclonal antibody called denosumab (brand names Xgeva or Prolia), is now generating much attention. Denosumab is an injectable monoclonal antibody. Monoclonal antibodies are made to target and destroy only certain cells in the body thereby helping to protect healthy cells from damage. Xgeva is used to prevent bone fractures and other skeletal conditions in people with tumors that have spread to the bone.  Prolia is another brand of denosumab used to treat osteoporosis in postmenopausal women who have high risk of bone fracture. In November 2010, the Food and Drug Administration (FDA) approved Prolia (Xgeva) to help prevent skeletal-related events in prostate cancer patients treated with hormonal therapy whose cancer had already metastasized to bone. The use of this therapy has recently been expanded. On Friday, September 16, 2011, the FDA approved denosumab (Prolia) in prostate cancer patients undergoing androgen deprivation (hormonal) therapy whose cancer had not yet metastasized to bone. Denosumab is also approved by the FDA for additional indications. The brand Prolia was approved by the FDA on June 1, 2010 for the treatment of postmenopausal women with osteoporosis who are considered to be at high-risk for fractures.

For more details, see the Johns Hopkins Health Alerts, “Prostate Cancer: Why You May be at High Risk for Osteoporosis,” Sept. 29^th, 2011; and, “FDA Expands Approval for Denosumab”, NewsPulse from the Prostate Cancer Foundation, Sept. 30^th, 2011;

Provenge (sipuleucel-T) was the first approved prostate cancer therapy which uses a person’s immune system to fight the disease.  Its approval was limited to men with advanced prostate cancer who have not responded to other treatments like hormonal (androgen deprivation) therapy and are experiencing few or no symptoms. Cost and supply remain significant issues hindering its widespread use. A recent article in the Johns Hopkins Health Alerts (September 8^th, 2011) describes on-going studies involving the administration of Provenge under differing conditions. These include: a) combining Provenge with hormonal therapy in patients with earlier stage disease; b) combining Provenge with radiation therapy in hopes that the combination will have a greater effect than either of the two therapies alone (synergism); and, c) Phase 3 studies in men with early-stage, non-metastatic prostate cancer. Other immunotherapies in clinical trials include Prostvac (from the National Cancer Institute, National Institutes of Health) which may be less costly.

In another earlier issue of the Johns Hopkins Health Alerts (August 24th, 2011), the concept of the Gleason score is described. It is defined as a grade assigned to biopsied tumor cells to indicate a tumor’s potential aggressiveness. This tumor grade “reflects how far the cancer cells deviate from normal, healthy cells.” Gleason scores of 5 and 6 are generally classified as low-grade tumors, a Gleason score of 7 as intermediate and Gleason scores of 8, 9 and 10 as high grade, with the least favorable outlook.

 These Johns Hopkins Health Alerts and additional Bulletins written by Dr. Jacek Mostwin and colleagues are invaluable sources of current information for prostate cancer patients.

Benefits and risks accompany virtually every method of treatment. Hormonal therapy for prostate cancer is no exception. Potential risks include osteoporosis and bone fractures, cardiac effects, diabetes, depression, hot flashes and metabolic changes resulting in weight gain. (These issues are discussed on this website under “My Story”, 2009 entries of July 5^th-27^th, September 29^th, October 20^th, November 25^th, and December 6^th, as well as March 12^th, 2010.) I have been on continuous or intermittent hormonal therapy since August, 2006. Fortunately, my side effects have been minimal although I had gained approximately fifteen pounds. I was told by a urologist that it was difficult to lose weight while on hormonal therapy. Eventually however, I was determined to lose these unwanted pounds. It has not been easy but I have lost most of the weight while continuing my therapy. I found that once I made up my mind to lose the weight, it was indeed possible with diet and exercise. Here are some practical tips I learned along the way.

Personally, it helped to make an initial investment and enroll in one of the popular advertised weight loss programs. It did not take long to begin to understand their general principles and one could discontinue enrolling after a month or so thus saving money. The diets in general consisted of very low-fat, low-carbohydrate meals with moderate protein content. I found the following strategies to be helpful.

1) Eat a fairly substantial breakfast of whole-grain cereals, fruits and light soy or low-fat milk; eggs (omelets) can be substituted.

2) Eat about 5 small meals a day and eat less as the day progresses. Mid-morning and mid-afternoon 100-calorie snacks (cheese, yogurt, fruit) were useful in curbing hunger.

3) If possible, eat dinner at mid-day and your usual lunch as the evening meal. Low fat meats such as chicken, turkey, lean beef (ground sirloin, lean roast beef) as well as fish become staples. Bread was limited to 1-2 slices of 40-calorie whole grain bread daily. Fresh vegetables and salads with low-fat dressing are of course encouraged. Low-fat mayonnaise is recommended but I personally found that one could never fully replace the flavor of real mayonnaise, so I used it in moderation.

4) Sip on water during the day; drinking an 8 oz. glass before meals helped me eat less while feeling satisfied. Diet drinks can be used but I found that water alone was best in satisfying my hunger.

5) Exercise is a must. Aerobic and weight-bearing exercises are also good for healthy bones. My wife and I exercise for 60 minutes in a gym three-times a week.

6) Minimize the use of alcohol, although a small glass of wine on occasions can be incorporated.

7) To satisfy my salt craving, pretzels seemed to be lowest in calorie content.

8) Don’t eat within three hours of bedtime except for a small piece of fruit or similar low calorie snacks. Midnight snacks are forbidden.

9) The eventual goal is portion control. I found that after a few weeks, my hunger was fully satisfied with 33% less food than I had previously consumed. Maintaining this level remains my goal.