Androgen Deprivation Therapy Its impact and the nursing role. Jane Thacker Uro-Oncology Nurse Specialist

Transcription

1 Androgen Deprivation Therapy Its impact and the nursing role Jane Thacker Uro-Oncology Nurse Specialist

2 Overview of content To gain an understanding of ADT (androgendeprivation therapy) and why and how it is used To review side effects of ADT and their management To review the metabolic effects of ADT including the evidence and their management (cardiovascular risks and bone health) To review the nursing role in the care of men on ADT (keyworker, support, information, treatment monitoring, side effect management) To examine how to support patients on ADT To review the evidence of the patient experience on ADT

3 How do they work GnRH agonists and antagonists exhibit different mechanisms of action. Agonists bind to GnRH receptors and produce an initial intense stimulation. This causes marked increases in LH, FSH and testosterone. Sustained pituitary overstimulation will eventually down-regulate/desensitize GnRH receptors with a consequent decrease in hormone levels. In contrast, antagonists block receptors, immediately stopping LH secretion, producing rapid testosterone suppression without the initial LH and testosterone surge.

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5 Why use hormone therapy It works Safe Ease of administration Generally acceptable side effects No age limit

6 Indications Life expectancy less than 10 years Patient preference Drug of choice in locally advanced or metastatic disease Significant urinary tract symptoms in relation to volume of tumour Assess risk in patients with osteoporosis, hypertension, depression or diabetes

7 Types LHRH agonists (Gonadorelin analogues) goserelin (Zoladex), triptorelin (Decapeptyl), leuprorelin (Prostap), buserelin (Suprefact) also histrelin(vantas) ongoing or intermittent GnRH antagonist degarelix (Firmagon) Anti-androgens bicalutamide (Casodex), cyproterone acetate, flutamide Oestrogens stilboestrol (Diethylstilbestrol) Abiraterone Enzalutamide Consider sub-capsular orchidectomy

8 Common side effects Hot flushes Weight gain Fatigue Mood swings and more emotional Depression Osteoporosis Possible increased risk heart disease and diabetes Gynaecomastia Loss lean muscle mass Loss of libido Erectile dysfunction Reduction in size of penis and testicles Change to ejaculation and orgasm Loss of body hair Memory and concentration Headaches

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10 Hot Flushes Life style triggers clothing, alcohol, diet Herbal remedies Evening primrose, sage extract, red clover Cyproterone Acetate mgs OD Megestrol 20mgs BD Acupuncture Cognitive behavioural therapy (CBT) Hypnotherapy

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12 Weight, mood, fatigue Supportive partner, family etc Diet varied diet, portion control, immune boosting Exercise weight, mood and fatigue Pace yourself Rest during the day Keep active and busy new hobby

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14 Reduced libido & erectile dysfunction Libido little medically Discuss before commencing treatment history including medication, health and sexual activity Oral medication Cialis, Levitra and Viagra Vacuum pump, muse, injection therapy Intermittent hormone therapy/monotherapy

15 Intermittent androgen deprivation Clear PSA response < 4 or 0.5 in relapsing patients PSA and assessment 3 monthly Resume clinical progression or PSA rises to 4 in non-metastatic or 10/15 in metastatic

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17 Gynaecomastia and mastalgia Incidence 13% - LHRH agonist and 70% anti-androgen NICE recommend prophylactic radiotherapy single # 8Gy Tamoxifen daily 10mgs or weekly 20mgs Surgery adenomammectomy or liposuction

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19 Bone health Assess risk pre treatment General advice diet and exercise Dexa scan at initiation & 2 yearly Biphosphonates, calcium and Vitamin D

20 Cardiovascular risk Loss of lean muscle mass Increase of fat mass especially abdominal Increase in triglyceride Total cholesterol increased Increase in fasting insulin and diminishing sensitivity to insulin Possible overall increased risk of cardiac event

21 Evidence Keating et al 2006 GnHR agonist Jespersen 2013 large Danish study Albertsen pooled data from 6, phase 3 trials 31% increase in MI and 16% increase risk stroke Observational studies needs to be a trial setting Orchidectomy does not increase risk of cardiac event

22 Diabetes Decrease in insulin sensitivity among non-diabetic men occur within 12 weeks Worsening of diabetic control among men with diabetes increase in HbA1c levels despite the use of additional diabetic medication

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24 Plan Manage adverse effects Be selective when commencing ADT Do not withhold in high risk and locally advanced disease Avoid in patients with low risk of micrometastases Weigh up risk versus benefit in high risk cardiovascular patients

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26 Future Personalised nutrition genotype likely influences how we metabolise our food affects health Assess impact statin therapy on progression of PCA? More research needed REALITY Yo et al 2014 Use of metformin shown to decrease all cancer mortality Tailored exercise and dietary programmes Margel et al

27 Nurses Role Listen patient s agenda Empathise Offer advice as appropriate Support just being there Reassure appropriately Be honest and realistic Don t offer what you can t deliver Signpost Information

28 Thank you