Treatment

Second line hormone therapy and further treatment options

If you are on hormone therapy and your PSA starts to rise, this may mean that your hormone therapy is no longer working as well as it was.

The first hormone therapy you have may keep your cancer under control for several months or years. However, over time, the behaviour of your cancer cells may change and your cancer may start to grow again.

Although the prostate cancer is no longer responding as well to one type of hormone therapy, it may still respond to other types of hormone therapy. This is sometimes called second-line hormone therapy. You cancer may also respond to a combination of other treatments. The aim of treatments is to control your cancer and delay or manage any symptoms such as pain and urinary problems.

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More hormone therapy 

You will normally keep having your original hormone therapy even if your PSA has started to rise. It may still help to keep the amount of testosterone in your body low.

You may also start taking another type of hormone therapy, called an anti-androgen, as your cancer may respond to this different type of hormone treatment. Some health professionals call this combined or maximum androgen blockade.

If you have been having both injections and anti-androgen tablets and your PSA is rising, your doctor may suggest that you stop the anti-androgen treatment for a little while. This may cause your PSA level to fall. You may hear this called a 'withdrawal response'.

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Steroids

Steroids can help to stop other parts of the body producing as much testosterone. A small amount of testosterone is produced by the adrenal glands. These are two glands which sit above your kidneys. Some cancer cells may also start to produce their own testosterone.

Steroids you may take include:

  • dexamethasone
  • prednisolone or prednisone
  • hydrocortisone.

Steroids may also help improve your appetite and energy levels, and can treat pain. You might also have steroids in combination with other treatments, including chemotherapy and abiraterone.

Like all medicines, steroids can cause some side effects, such as indigestion, weight gain and and water retention. These will depend on the dose you are taking and the length of time you are on them. Steroids are given in a low dose to treat prostate cancer, so most men do not get many side effects.

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Oestrogens

Diethylstilbestrol (Stilboestrol®) is a tablet that is similar to the hormone oestrogen. Oestrogen is a hormone found in both men and women, but women usually produce more. Diethylstilbestrol is sometimes used to treat prostate cancer that is no longer responding to other types of hormone therapy.

Diethylstilbestrol can cause similar side effects to other types of hormone therapy. It can also increase your risk of circulation problems, such as blood clots. You will usually take drugs such as aspirin or warfarin to reduce the risk of blood clots. You may not be able to take diethylstilbestrol if you have a history of high blood pressure, heart disease or strokes.

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Ketoconazole

Ketoconazole is a type of anti-fungal treatment that may also help treat prostate cancer It can help reduce testosterone production from the adrenal glands and cancer cells. It is not used very often, but you may have it if you are not fit enough for treatments such as chemotherapy.

Your doctor or nurse will need to monitor how well your liver is working because ketoconazole can cause liver problems. If there are any problems, you can stop taking the drug and your liver will return to normal. Ketoconazole can also cause a dry mouth and make some people feel very tired.

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Chemotherapy

Chemotherapy uses drugs to kill cancer cells wherever they are in the body.

In the UK, docetaxel (Taxotere®) is the standard chemotherapy treatment for men with advanced prostate cancer that is no longer responding to hormone therapy.

If you have already had treatment with docetaxel and your cancer has started to grow again, you may be able to take a newer chemotherapy drug called cabazitaxel (Jevtana®).

Docetaxel and cabazitaxel may help some men to live longer. They can also help to improve symptoms such as pain.

Chemotherapy may not be suitable for everyone as the side effects are sometimes difficult to cope with. Your doctor will first check your general health to make sure you are fit enough for chemotherapy.

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Abiraterone

Abiraterone (Zytiga®) is a new type of hormone therapy for men with advanced prostate cancer that has stopped responding to other hormone therapy. It is suitable for men who have already had docetaxel chemotherapy and whose cancer has started to grow again. Abiraterone may help some men to live longer. It can also help control symptoms.

Abiraterone is taken as a tablet and works by stopping the production of testosterone.

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Clinical Trials

There are a number of clinical trials looking into new treatments for prostate cancer that is no longer responding as well to hormone therapy. There are also trials to find out whether existing treatments work better in new combinations or doses. Clinical trials can be a way of having newer treatments that are not yet available on the NHS.

If you would like to find out about taking part in a clinical trial, ask your doctor or specialist nurse. You can also find out about different trials on the CancerHelp UK clinical trials database.

Personal experience
"Clinical trials gave us hope and my dad felt that he was doing some good too."

You will also take a steroid called prednisone to reduce the risk of side effects. Side effects include:

  • fluid retention
  • high blood pressure
  • liver problems
  • a lower than normal level of potassium in the blood. This could make you feel tired and you may be a risk of a fast irregular heartbeat. You should contact your doctor if you experience this.

You will have your blood pressure checked regularly, and have blood tests to check how well your liver is working.

Abiraterone is also effective in men who have stopped responding to other types of hormone therapy but have not yet had chemotherapy. However it is not widely available in the UK for these men. If your doctor thinks it is suitable for you, they may be able to apply for you to get it.

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Enzalumatide

Enzalutamide is a new type of hormone therapy for men whose prostate cancer has stopped responding to other hormone therapy and chemotherapy treatments.

Enzalutamide is taken as a tablet and works by stopping the hormone testosterone from reaching the prostate cancer cells.

Enzalutamide is not available on the NHS. If you would like more information about it, speak to your doctor or nurse, or call our Specialist Nurses.

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Other treatments

If you have prostate cancer that has spread to the bones or other parts of the body you may develop symptoms such as bone pain or urinary problems. There are treatments to help manage any symptoms. Sometimes these are called palliative treatments because they aim to reduce symptoms.

These types of treatments include:

There is also a new drug to treat bone problems called denosumab (Xgeva®), which is similar to bisphosphonates. However, this is not widely available in the UK. If your doctor thinks it is suitable for you, they may be able to apply for it for you. Speak to your doctor or nurse for more information.

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Where can I get support?

All men are different but if your hormone therapy is no longer controlling your cancer so well you may feel disappointed, angry or worried about the future.

There are different ways to tackle this. Talking to someone or getting support can be useful. Your partner and family may also need support in emotional and practical ways. This information may also be helpful for them.

Friends and family
Some men get all the back-up they need from their family and friends. Get things off your chest by talking to a partner, friend or family. Explaining how you feel can help those close to you understand and give you support if you want it.

Personal experience: "Throughout my journey my partner has been my biggest supporter and long may this continue."

Your doctor or nurse
Talk to your specialist nurse, doctor or other health professionals involved in your care. They should be able to answer any questions or concerns you might have, as well as providing support. You can also speak to one of our Specialist Nurses.

Personal experience: "Ask your doctor or specialist nurse anything, including anything that may seem small. This can save confusion and concerns later."

Counselling
Some people find it easier to talk to someone they do not know. Counsellors are trained to listen and can help you to find your own answers. Your GP may be able to refer you to a counsellor or you can see a private counsellor. There are different types of counselling available. To find out more contact the British Association for Counselling and Psychotherapy.

Talking to someone affected by prostate cancer
Talking to someone with similar experiences often helps. Our support volunteers are all personally affected by prostate cancer. They are trained to listen and offer support over the telephone.

You and your family can join our online community. You can share your experiences with other men and their families. There are also prostate cancer support groups across the country, where you and your family can meet other people affected by prostate cancer.

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Questions to ask your doctor or nurse

Keep a note of any questions you have to take to your next appointment.

  • If my hormone therapy is not working as well as before, what other treatments are available to me?

  • Will I continue to have my original hormone therapy even if it has stopped working as well?

  • What are the possible side effects of my new treatments?

  • Will I see any new health professionals?

  • Are there any clinical trials I could take part in?

  • What treatments are there to manage symptoms (for example pain or tiredness)?

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References

You can find a full list of references used to produce this page in our online fact sheet.