The Consumer’s Guide to Androgen Deprivation Therapy for Advanced Prostate Cancer

ADT can be done with surgery (surgical castration) or medication (medical or chemical castration), says Andrew Armstrong, MD, a professor of pharmacology, cancer biology, and urology at Duke University School of Medicine in Durham, North Carolina.

While surgery to remove the testicles (an orchiectomy) is the most cost-effective way to lower testosterone levels, most men opt for medication, because it is reversible, says Dr. Armstrong. ADT includes medications that affect the production of LHRH: LHRH agonists and LHRH antagonists.

One difference between the medications is that LHRH agonists cause an initial surge of testosterone in the body. That can cause you to experience what’s known as a “testosterone flare,” resulting in symptoms such as bone pain and trouble urinating.

Doctors can give LHRH agonists alongside other medications called antiandrogens, such as bicalutamide, that block testosterone activity for a few weeks. “That lets the testosterone surge pass, and it protects our patients from the side effects [of an LHRH agonist],” says Dr. Siddiqui.

LHRH antagonists don’t cause a testosterone flare. Since they shut down testosterone production quickly, they’re a good option for people who may be in the hospital with cancer that is already causing symptoms, says Armstrong.

LHRH antagonists include:

• degarelix (Firmagon)
• relugolix (Orgovyx)

Degarelix, which has been approved by the U.S. Food and Drug Administration (FDA) since 2008, is given by injection every 28 days. Relugolix, which was approved in 2020, is taken as a pill once a day.

LHRH agonists have been approved by the FDA for about 30 years to treat prostate cancer. These include:

• leuprolide (Lupron Depot, Eligard, Camcevi)
• goserelin (Zoladex)
• triptorelin (Trelstar)

LHRH agonists, which are injected or placed as small implants under the skin, are given anywhere from once a month to once every six months. “The main advantage to using the agonists is that they can be given on a less frequent basis,” says Siddiqui.

In the past, ADT was often the only treatment for prostate cancer, says Siddiqui. But that changed about 15 years ago, when studies started showing that people who used ADT along with other therapies, such as antiandrogens and chemotherapy, experienced less disease progression, he says.

Antiandrogens, as the name suggests, are medications that block androgen hormones, including testosterone, from stimulating the growth of prostate cancer cells. Chemotherapy is another drug treatment that can kill cancer cells.

“In many patients, intensifying their treatment early on seems to lead to improved outcomes,” says Siddiqui.

“ADT is a life-prolonging treatment,” says Siddiqui, “but it’s not curative.” The treatment can temporarily starve the cancer, causing it to recede, but the cancer will eventually return and become resistant to the medication, he says.

When hormone therapy stops working, the cancer is said to be “castration resistant.” On average, it takes about two years for prostate cancer to become resistant to hormone therapy, says Siddiqui. Once men develop metastatic castration-resistant prostate cancer, the average survival rate is just over two years.

ADT suppresses testosterone levels, so many people who take an ADT drug experience hormone-related side effects, including fatigue, hot flashes, night sweats, mood swings, muscle loss, and bone thinning, says Siddiqui. “The way I describe it to my patients is, they undergo a form of male menopause,” he says.

Side effects can vary from person to person, including their intensity. “I have some patients who sail right through it and other patients whose symptoms are really intolerable,” says Siddiqui.