Advancing Prostate Cancer Care: Integrating Guideline Updates and Patient Preferences for Optimal ADT Management of Advanced Prostate Cancer

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Dr. Dorff: 
This is CME on ReachMD, and I'm Dr. Tanya Dorff. In this brief lecture, I'll discuss the importance of monitoring testosterone levels and how changes in testosterone levels impact quality of life in our patients with advanced prostate cancer.

So traditionally, we use either injections or, today, we have also an oral agent available to lower testosterone in order to effectively treat prostate cancer. But we haven't always emphasized the need to monitor whether we are actually achieving a low testosterone level in these patients. We often have just followed PSA as an indicator that treatment is working. However, there are occasionally patients whose testosterone levels will not be adequately suppressed, and so we won't know that unless we also measure the testosterone level together with the PSA.

While we don't have any prospective trial data to suggest that, should we detect the patient in whom the testosterone level is not adequately suppressed, there is something specific we can do that will then improve outcomes, there certainly are retrospective data that show men whose testosterone levels are not suppressed below 20 don't have as good prostate cancer outcomes as those who register testosterone levels consistently below 20 during their course of androgen deprivation therapy. So we know that suppressing testosterone is important. We don't yet know what to do about it, but certainly, most of us would consider switching agents or adding a second agent on top of our testosterone-suppressing drug if we notice that the testosterone levels are too high in a patient who's actively receiving ADT.

Now when it comes to a rising PSA, without checking a testosterone level, we don't know whether the rise in PSA is occurring because of failure of testosterone suppression or whether it indicates castration resistance. Since castration resistance is literally defined as a rising PSA with a testosterone less than 50, which is the standard definition, without that testosterone level we can't appropriately or accurately categorize what our patient is experiencing.

So when I stop a testosterone suppression drug in my patients, I do warn them what to expect, because sometimes the side effects don't get better right away. And in fact, things like hot flashes can actually flare up as testosterone goes from low back up to high. So when a patient is experiencing more hot flashes or ongoing symptomatology after I've stopped androgen deprivation therapy, checking that testosterone level really helps me inform them where they are in the recovery trajectory and what to expect.

Furthermore, there were some recent data analyzing RTOG or NRG trials where radiation was given together with androgen deprivation of varying lengths. And these data indicated that a large percentage of men may not recover their testosterone. Now these were done with our traditional longer-acting depot formulations of LHRH agonists, and so we haven't seen whether this holds true in patients treated with the shorter-acting antagonist medications. But until we know we really have to prepare our patients that the duration of testosterone suppression might actually be longer than what we're prescribing and that there's some chance that the testosterone won't recover in a patient who's going to get a longer-term ADT course.

So regardless, when we start testosterone suppression, we need to warn patients about side effects and actively work to mitigate them in order to maintain their overall health and their quality of life. Referrals to urology for sexual function, referrals to psychology or social work for coping with the changes in the body and in the way they feel, emotional changes, and then our usual supportive interventions for monitoring blood pressure, cholesterol, diabetes, all those things that we do to take care of our patients on ADT remain critically important, regardless of which agents we're using to suppress testosterone and really how long a patient will be on them.

Thank you for tuning in to this brief lecture. I hope this information will be helpful for you.

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