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If you have been diagnosed with prostate cancer, chances are you have been told about hormonal therapy.  Nearly 70 years ago, the management of prostate cancer was revolutionized by the discovery that prostate cancer is fueled by the male hormone testosterone.  Prior to this discovery, numerous men languished in hospital beds suffering from the pain of advanced prostate cancer.  After the discovery, men with advanced prostate cancer started undergoing orchiectomy (surgical removal of the testicles).  Because the testicles naturally produce most of the testosterone in men, removing them effectively removes most of the testosterone from the body.  With the “food” gone, the prostate cancer moves much more slowly and sometimes decreases in size.  While not a cure, such hormonal manipulation has led to significantly decreased symptoms for men with advanced prostate cancer.

Hormonal therapy was further advanced about 30 years ago with the development of “medical castration.”  Rather than removing the testicles, doctors could give medicine which would effectively prevent the body from producing testosterone.  This approach was significantly more appealing for most men as it avoided the psychological trauma of castration.  Initially, medical castration or hormonal therapy was used just for men with prostate cancer which had spread to the bones and other distant organs.  Studies demonstrated that the treatment, although not a cure, could allow men with metastatic prostate cancer to live symptom free for many years.  More recently, the use of hormonal therapy has been further expanded to men with localized disease.  Numerous studies demonstrated that hormonal therapy given in combination with radiation therapy for men with locally advanced prostate cancer is superior to radiation alone.  As a result many doctors now give at least a short course of hormonal therapy at the start of radiation therapy while others give hormonal therapy up to 2 years following radiation therapy for men with localized disease.  Other doctors also give early hormonal therapy for men with a PSA recurrence after radical prostatectomy.  With these expanded indications, more and more men are currently treated with hormonal therapy. 

The problem with such widespread use of hormonal therapy is that this treatment modality, like all medicines, is no free lunch.  As more and more men have been treated with hormonal therapy, more and more risks have been discovered.  The risk of osteoporosis, for example, is very well known to urologists and patients alike and is often very carefully monitored and treated.  Recently, however, the very real impact of hormonal therapy on the heart has been demonstrated.  Studies have demonstrated that treatment with hormonal therapy often leads to metabolic changes such as increases in blood sugar and cholesterol.  As a result, a very real increase in heart attacks and heart related deaths have been attributed to the use of hormonal therapy.  While radiation oncologists and urologists are very well trained to evaluate and treat prostate cancer, they are generally not as great at looking at the big picture.  As a result, the treatment of prostate cancer often takes priority over heart health, particularly when a primary care doctor is not part of the decision making process.  The goal of this post is to review the real metabolic consequences of hormonal therapy and the subsequent heart risks that they then create.

With the metabolic changes mentioned above, it probably does not seem surprising that studies have demonstrated that taking hormonal therapy may pose a substantial risk to the heart.  Large studies ( 37,000- 73,000 men) have demonstrated that hormonal therapy results in a 16-19% increased risk of coronary artery disease, an 11-28% increased risk of heart attack, and a 16-35% increased risk of sudden death when compared with men not undergoing the treatment.  Another study demonstrated a 20% increased risk of heart complications within 1 year of starting hormonal therapy.  Not surprisingly, higher risk was seen in older men, with one study demonstrating that men over age 65 undergoing hormonal therapy have over 2 times the risk of heart related death within 5 years of starting therapy (5.5% vs 2%) as compared with those that do not undergo the therapy.

The impact of hormonal therapy for men with preexisting heart disease is even more dramatic.  A recent study published in the Journal of the American Medical Association studied men with localized prostate cancer undergoing 4 months of hormonal therapy in combination with radiation therapy.  The study specifically looked at men with a prior history of a heart attack or heart failure.  In this group, the study found that 26% of men undergoing hormonal therapy died within an average of 5 years as compared to 11% of men who did not undergo the therapy.  That represents TWICE the risk of death for men with prior heart disease who underwent hormonal therapy plus radiation therapy as compared to the men that underwent radiation therapy alone.  Interestingly, the authors of the study did not demonstrate an increased risk of death for those men undergoing hormonal therapy who did not have significant underlying heart disease or risk factors for heart disease. 

So what do we conclude from this worrisome information?  Should hormonal therapy no longer be offered to men with prostate cancer?  Should men already on hormonal therapy stop the treatment?  Of course not.  Hormonal therapy has been vital in the fight against prostate cancer, particularly for men with advanced disease.  Instead, this data should make us rethink who should receive hormonal therapy and what precautions should be taken when the therapy is administered.  The problem with many urologists and radiation oncologists is that they often get caught up with prostate cancer and, sometimes, miss the big picture.  While they see the potential benefits of hormonal therapy in terms of prostate cancer, they don’t pay enough attention to the impacts of this treatment on other vital aspects of a patient’s health.  As a result, as the patient, you need to make sure that a few steps get taken prior to proceeding with hormonal therapy:

As with many other aspects of prostate cancer treatment I have discussed on this blog, hormonal therapy, again, proves that there is no such thing as a free lunch.  While hormonal therapy has been shown to be beneficial for many patients with varying extents of prostate cancer, this benefit does not come without risk.  The development of significant heart disease can negate any prostate cancer benefits in SOME men.  As a result, before agreeing to hormonal therapy, make sure that your doctor weighs the relative risks and benefits in YOUR case.  If you and your doctor conclude that hormonal therapy is right for you, make sure that you put together the right team and plan to manage the potential risks.  As a urologist, I am committed to battling prostate cancer with all the medical and surgical tools available to me.  As a patient, you need to make sure that your doctors keep your overall health in mind while fighting this battle.