July 8, 2008 -- One in four elderly U.S. men with early prostate cancer undergoes hormone therapy -- but it's more likely to harm than help.
Surgery to remove the prostate -- radical prostatectomy -- is too risky for most men in their 70s and 80s. When such men are found to have early prostate cancer, they have three options.
They can wait and see whether this usually slow-moving cancer becomes a problem (called conservative therapy or watchful waiting). They can undergo radiation therapy and suffer its side effects. Or they can undergo androgen-deprivation therapy: hormonal drugs (Lupron, Viadur, Eligard, or Zoladex) or surgery (orchiectomy) that cut off production of male hormones.
In the U.S., older men often opt for stand-alone hormone therapy, even though there's no proof that it really helps. Hormone therapy's most obvious side effect is sexual dysfunction. Of greater concern are several recent studies linking androgen deprivation therapies to diabetes, heart disease, bone fractures, and reduced muscle mass.
Now a new study strongly suggests that hormone therapy offers older men no benefit to justify these serious risks.
Grace L. Lu-Yao, PhD, MPH, of the University of Medicine & Dentistry of New Jersey, and colleagues collected data on more than 19,000 men diagnosed with early-stage prostate cancer at an average age of 77. None of the men underwent surgery or radiation treatment for early prostate cancer. Nearly 8,000 of the men opted for androgen deprivation therapy.
"Use of hormone therapy does not improve survival," Lu-Yao tells WebMD. "The reason patients want this is they want something that will improve their quality of life or their survival. But hormone therapy has a detrimental effect on quality of life. And we cannot find any survival benefit for these men in their 70s with very early-stage cancer."
Why have so many U.S. men undergone an unproven treatment that now seems to do more harm than good?
"It's an American phenomenon," Otis Brawley, MD, chief medical officer for the American Cancer Society, tells WebMD. "The problem is that if a U.S. man has early-stage prostate cancer, both patients and doctors culturally feel that you have to do something. The end result is a number of men who should get conservative therapy get some kind of intervention."
Lu-Yao and Brawley suggest that these older men would have done just as well if their cancers had never been detected. Brawley notes that many of these men likely underwent continued prostate cancer screening with PSA tests. Others probably had possible prostate abnormalities detected by a urologist.
Regardless of how they got there, all these older men must have agreed to undergo prostate biopsies. And that may not have been the result of a fully informed decision, says Simon Hall, MD, head of urology at New York's Mount Sinai School of Medicine.
"You have to have a discussion with an older man before he has a prostate biopsy. You have to ask, 'Do you really want to open Pandora's Box?'" Hall tells WebMD. "Most patients with localized prostate cancer are not going to die from their disease in the first 10 years anyway. It is a legitimate question whether to screen patients this old, and whether urologists should biopsy older patients based on just a knee-jerk reaction."
Hall says there are very few men he would treat with hormone therapy alone.
"A lot of these older men are at low risk and don't need any treatment at all," he says. "It doesn't seem hormone therapy would make a difference, so why put them through the significant side effects and the cost?"
All of the experts who spoke with WebMD noted that the current study findings do not apply to younger men who might receive androgen-deprivation therapy in combination with surgery or radiation. Such men may benefit from hormone therapy.
Lu-Yao and colleagues report their findings in the July 9 issue of The Journal of the American Medical Association.