Palliative care or comfort care is the treatment undertaken to prevent or reduce the symptoms of a life-threatening illness like cancer. It is usually indicated for cases where other therapeutic options have either failed to “cure” the cancer and the case has advanced to the point where any further treatments aimed at “cure” would be fruitless and drastically reduce the patient’s quality of life. Palliative care is therefore for symptomatic relief.
Bone Pain in Prostate Cancer
Many advanced prostate cancer patients often suffer from bone pain that adversely affect quality of life. The management of pain or other cancer related functional impairment is integral part of palliative care. Palliative management can include analgesics, glucocorticoids, palliative chemotherapy, radioisotopes or radiotherapy.
Radioisotopes (like phosphorus-32, strontium-89) that selectively concentrate in bone lesions are approved for the palliative treatment of painful bone metastases. The treatment is of more value in patients with multiple metastases (cancer spread to several sites). The radioisotopes have been found to reduce the need for opioid painkillers (analgesics) in such patients.
EBRT is effective in painful bone lesions in advanced prostate cancer patients but not an ideal option if there are multiple lesions at different sites. The lesions in multiple sites will progress after EBRT in one site and pain will reappear in a short time afterwards, unless other systemic therapies are initiated to control the disease process. Read more on EBRT under prostate cancer treatments.
Androgen Deprivation Therapy for Palliative Care
Androgen deprivation therapy or ADT is the treatment that reduces the androgenic stimulation of prostate cancer cells by different approaches. Androgenic stimulation means the hormonal factors that promote cancer growth.
The various approaches in ADT include :
- Androgen lowering surgery with orchiectomy
- Luteinising hormone releasing hormone (LHRH) agonists
- Steroids like cyproterone acetate
- Non steroids like bicalutamide and flutamide
- Estrogens like diethylstilbesterol
An approach with early ADT or deferring ADT till progression is still debatable and usually depends on the patient preference or often left to the discretion of the attending physician. There is cancer-specific survival benefit with early ADT, but the overall survivals in both approaches have been found to be similar. The cardiovascular risk assessment should also be done before ADT is commenced as ADT is known to increase risk for cardiovascular events.
ADT may be used as neoadjuvant treatment option before definitive primary treatment or used concurrently with it. It may also be used as adjuvant therapeutic agent following radiotherapy or prostatectomy. Patients with recurrence after surgery or radiation may be considered for ADT if they are not suitable for local therapy. ADT may be considered a therapeutic option in patients with high-risk limited disease along in combination with radiotherapy or surgery.
ADT is the standard of care in patients with metastatic prostatic cancer. The options available in advanced cancer include bilateral orchiectomy, LHRH analogues and anti-androgens. The surgical approach in this set up is less preferred by most patients now.
Several LHRH agonists are approved for advanced prostate cancer and are equally effective in reducing the testosterone to castration levels.
The anti-androgens binds to the androgen receptors and blocks its activation by androgens. When anti-androgens are used as monotherapy, there can be increased testosterone levels due to stimulating feedback from the blocked receptors.
Estrogens were found to be associated with serious adverse effects than other LHRH agonists and are now reserved only for secondary hormone therapy.