Counseling patients with prostate cancer starting ADT

 All patients with metastatic CSPC should receive ADT, with the addition of other modalities depending on patient-specific factors and the extent of disease.  Choices include orchiectomy, Gnrh agonists or antagonists. Gnrh agonists are commonly administered as monthly, 3 month or 6 month injections.

Relugolix is a GNRH antagonist. Compared to ADT it is associated with less major adverse cardiovascular events. This difference is more pronounced in patients with past hx of a major CV event.

Leuprolide and Eligard are the most commonly used ADT meds. These are given intramuscularly.

ADT is associated with metabolic, cardiovascular, musculoskeletal, cognitive, and neuropsychiatric issues, as well as sexual dysfunction.

1. Osteoporosis prevention: Bisphosphonates do not reduce skeletal related events in newly diagnosed castrate sensitive met prostate cancer based on CALGB 90202 study and STAMPEDE trial. However, a baseline DXA scan is indicated to identify underlying osteoporosis or high risk osteopenia which may worsen with ADT. Calcium and vitamin D supplementation are indicated.

Recommended:

DXA scan

Calcium 1000 mg with vit D3 1000 units daily

If DXA shows  high risk osteopenia ( T score less than neg 2) or osteoporosis ( T less than neg2.5), then will discuss bisphosphonates q 6 m.

2. Sarcopenia and risk of falls : These are well known side effects. I recommended strength training at least 20 min a day 3 days a week along with stretching exercises.

3. Cardiovascular risk factors: The patients cardiac risk factors were evaluated.

No hx of ongoing angina or exertional dyspnea. Can climb 2 flights of stairs without stopping. No CP at rest. No hx of MI or cardiac stents. Has a hx of controlled hypertension being managed by PCP. Current meds include:

He is on aspirin but not on an anticoagulant.

4. Fatigue is also extremely common with ADT. Exercise can help with this.

 Hot flashes and gynecomastia: discussed these side effects. Gabapentin, acupuncture and effexor can help.

5. We will monitor lipid panel annually as well as weight gain since ADT increases risk of metabolic syndrome.

6. Erectile dysfunction is a common side effect. 

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