Prostate cancer is the most common cancer in men. Across the UK over 47,500 men are diagnosed each year with a 10-year survivorship of approximately 80% (Prostate Cancer UK, 2022). It is estimated that more than 400,000 men in the UK are living with and beyond prostate cancer (Prostate Cancer UK, 2022). Many of these men are receiving androgen deprivation therapy (ADT) for non-localised prostate cancer. Side-effects of hormone therapy treatment may significantly impact quality of life (Ng et al, 2012; Meng et al, 2022). At Prostate Cancer UK, we know that patients’ knowledge of hormone therapy and management strategies is poor and that healthcare professionals play a significant role in supporting and educating men in managing these side-effects. 

The purpose of ADT is to reduce the levels of androgens; the hormone responsible for stimulating prostate cancer cell growth. However, blocking the production of testosterone is associated with a plethora of side-effects and metabolic changes, for example, cardiovascular disease, non-insulin dependent diabetes and osteoporosis (Wibowo et al, 2019). These are often referred to as ‘the unseen side-effects of hormone therapy’. Thus, close monitoring of patients is pertinent in managing metabolic changes. Hormone therapy is also associated with physical and psychological changes, which include obesity, sexual dysfunction, hot flushes, and cognitive symptoms (Wibowo et al, 2019; Shim et al, 2022).

MANAGING METABOLIC CHANGES — THE UNSEEN 


Regularly monitoring a man’s weight and any metabolic changes can help to reduce their risk. Literature observes that frequent exercise and a good, heart-healthy diet are all good strategies (Segal et al, 2017; Reale et al, 2021). ADT reduces muscle mass and increases body fat; particularly around the waist within the first year of starting this drug. It is important to monitor cholesterol and blood sugar levels, including preassessment weight, repeating at six and 12 months. In addition, starting a regular cardio and gentle resistant training programme is beneficial in controlling weight and reducing the risk of metabolic changes. Comparison studies have shown that men who follow a regular exercise programme while on ADT fared better in comparison to men who did not (Ussing et al, 2022). Furthermore, they experienced fewer physical side-effects with better psychological wellbeing. Bone mineral density loss of approximately 5–10% also occurs in the first year of ADT (Brown et al, 2020). Resistant training helps to maintain good bone health and reduces the risk of osteoporosis. Similarly, calcium and vitamin D also help.

HOT FLUSHES


Approximately 80% of men experience hot flushes (Elkins et al, 2014). The cause is a decline in oestradiol, which is made directly from testosterone. The intensity of hot flushes can vary and be a potential source of distress for men. There are pharmacological and non-pharmacological approaches in managing this. The National Institute for Health and Care Excellence (NICE, 2019) recommends medroxyprogesterone as first-line treatment to alleviate and reduce symptoms. Other medicines are cyproterone, gabapentin and venlafaxine. Incorporating lifestyle changes, such as exercise, reducing spicy foods, alcohol intake and smoking will help (Edmunds et al, 2020). Furthermore, regularly practising breath work, such as abdominal breathing, is thought to help with reducing hot flushes and a good relaxation technique for men (Wassersug et al, 2021).

PSYCHOLOGICAL AND COGNITIVE WELLBEING 


Literature has postulated a link between psychological and cognitive function. ADT, mainly LHRH agonists (luteinising hormone-releasing hormone), cross the brain barrier. Numerous neural centres in the brain have androgen and oestradiol receptors and are involved in learning and memory. Thus, ADT may impair cognitive processes (Mitsiades et al, 2008; Wu et al, 2013). However, the available research uses a small population sample size which limits statistical power. Moreover, side-effects of ADT, such as fatigue, insomnia and hot flushes, may be a cause of mood and cognitive issues alone. Nonetheless, anecdotal evidence highlights that low mood memory and cognitive issues are a real worry for men. So much so, that some men consider stopping treatment altogether. 
Maintaining an active lifestyle is pertinent in managing low mood. Using problem-solving solutions such as a calendar, written reminders and routine planning are helpful strategies. Consider self-assessment screening for reported low mood or depression. Acknowledgement of how one is feeling and, if appropriate, exploring counselling options or support groups is also helpful. Prostate Cancer UK has an excellent wellbeing hub full of support and information for men who are struggling with side-effects of prostate cancer (https://prostatecanceruk.org/prostate-information/wellbeing-hub). 
Lacking knowledge of ADT, its side-effects and management strategies may contribute to a significant decrease in a man’s quality of life and impact compliance to treatment. Thus, it is vital that healthcare professionals assess patients’ knowledge and understanding of ADT. Asking questions, taking a person-centred approach and being aware of the seen and unseen side-effects of ADT is paramount. In the author’s opinion, healthcare professionals are in a prime position to monitor and educate men on the side-effects of ADT and discuss strategies to help manage them, which in turn, can improve their quality of life.

Useful links…


Resources for health professionals — risk campaign: https://prostatecanceruk.org/for-health-professionals/resources/risk-campaign  

Education programme for men on or starting hormone therapy for prostate cancer — Life on ADT: www.lifeonadt.com/ 

How hormone therapy affects you: https://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/how-hormone-therapy-affects-you  
Sexual support service: https://prostatecanceruk.org/prostate-information

Diet and physical activity: https://prostatecanceruk.org/prostate-information/living-with-prostate-cancer/your-diet-and-physical-activity

Stamina — lifestyle change in prostate cancer: www.stamina.org.uk/projects

Penny Brohn UK living well with cancer: www.pennybrohn.org.uk/  
 
 
Lisa O’Sullivan is a specialist nurse at Prostate Cancer UK.

References

Brown JE, Handforth C, Compston JE (2020) Guidance for the assessment and management of prostate cancer treatment-induced bone loss. A consensus position statement from an expert group. J Bone Oncol 25: 100311

Edmunds K, Tuffaha H, Scuffham P, Galvão DA, Newton RU (2020) The role of GPN exercise in the management of adverse effects of androgen deprivation therapy for prostate cancer: a rapid review. Support Care Cancer 28(12): 5661–71

Elkins GR, Kendrick C, Koep L (2014) Hypnotic relaxation therapy for treatment of hot flashes following prostate cancer surgery: a case study. Int J Clin Exp Hypn 62(3): 251–9

Ng, E, Woo HH, Turner S, et al (2012) The influence of testosterone suppression and recovery on sexual function in men with prostate cancer: observations from a prospective study in men undergoing Intermittent androgen suppression. J Urol 187(6): 2162-6

Meng MV, Grossfield GD, Sadetsky N, et al (2022) Contemporary patterns of Androgen deprivation therapy use in newly diagnosed prostate cancer. Urology 60(3 Suppl 1): 7–11

Mitsiades N, Correa D, Gross CP, Hurria A, Solvin SF (2008) Cognitive effects problems in patients on androgen deprivation therapy in older adults. Semin Oncol 35: 569–81

National Institute for Health and Care Excellence (2019) Prostate cancer: diagnosis and management. Last updated 2021. NICE, London. Available online: www.nice.org.uk/guidance/ng131/chapter/recommendations Prostate Cancer UK (2022) Facts and figures. Available online: https://prostatecanceruk.org/prostate-information/about-prostate-cancer

Reale S, Turner RR, Sutton E, et al (2021) Embedding supervised exercise training for men on androgen deprivation therapy into standard prostate cancer care: a feasibility and acceptability study (the STAMINA trial). Sci Rep 11: 12470

Segal R, Zwaal C, Green E, et al (2017) Exercise for people with cancer: a clinical practice guideline. Curr Oncol 24: 40–6

Shim M, Bang WJ, Oh CY, Lee YS, Cho JS (2022) Androgen deprivation therapy and risk of cognitive dysfunction in men with prostate cancer: is there a possible link? Prostate Int 10(1): 68–74

Ussing A, Mikkelsen MLK, Villumsen BR, et al (2022) Supervised exercise therapy compared with no exercise therapy to reverse debilitating effects of androgen deprivation therapy in patients with prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 25: 491–506

Wassersug RJ, Walker LM, Robinson JW (2021) Androgen deprivation therapy: An essential guide for prostate cancer patients and their loved ones. 2nd edn

Wibowo E, Wassersug RJ, Robinson JW, et al (2019) How are patients with prostate cancer managing androgen deprivation therapy side effects? Clin Genitourin Cancer 17(3): e408–e419

Wu LM, Dienfenbach MA, Gordon WA, Cantor JB, Cherrier MM (2013) Cognitive problems in patients on androgen deprivation therapy: a qualitive pilot study. Urol Oncol 31: 1533–38
 
This piece was first published in the Journal of General Practice Nursing. To cite this article use: O’Sullivan L (2022) Let’s educate men about the seen and unseen side-effects of ADT. J Gen Pract Nurs 8(4): 16–1


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