Management Guidelines for Androgen Deprivation Therapy

[Euan]

First here is a quick summary of recommendations

Bone Health:

• General preventive and lifestyle measures include regular physical exercise, smoking cessation, and alcohol consumption of < 2 standard drinks per day.
  
• Commence vitamin D supplementation as necessary to achieve a target serum vitamin D level > 75 nmol/L
  
• In men with minimal trauma fracture, commence treatment with an antiresorptive agent such as a bisphosphonate
  
• BMD measurement should be performed yearly during the first 2 years of ADT
  

Metabolic Health:

• Management includes reducing cardiovascular risk factors, and particularly, encouraging smoking cessation. Blood pressure should be < 130/80mmHg, and lipid targets should be LDL-C of <2.0 mmol/L, HDL-C> 1.0 mmol/L and Triglycerides < 1.5 mmol/L
  

Full Articles:

http://www.mja.com.au/public/issues/194 ... 289_fm.pdf

These management guidelines are an extension of the excellent work done at Westmead and it is also worth a read

http://www.mja.com.au/public/issues/184 ... 140_fm.pdf

[Guest]

Thanks Euan,

An interesting article.

My comments to compare with others are:

1. Although my specialist told me there was a risk of loss of bone density I have had no tests in the last 2 years to my knowledge. I take it from the article that this is an x-ray test of some kind. Have all of you had BMD tests?

2. After about a year blood test indicated calcium down a bit & vitamin D on the bottom of normal so I take caltrate with vitamin D now – after I prompted the urologist. My general impression is he did not seem to worried about loss of bone density in my case.

3. I put on no weight when I went on ADT but the effects of radiation I found took off weight – I just did not eat as much. Also I had a kidney removed so with all that I did not gain weight in fact I went from approx 83 kg down to 78kg. Now I am 83 again which is probably too much for me. I do not know what my body mass index is. So for someone to put on weight after radiation must have a very robust constitution. That is my experience anyway.

4. On the scale of men my age I am a heavy exerciser. I go to the pool & gym 3 times a week to run in water for approx 30 mins & pump iron for approx 30 mins – very hard exercise which does make you lose weight if you get your heart rate up. Bottom line is you need your heart rate up to 80% of your max for at least 30 mins if you want to lose weight. If you don’t do that it does not happen for me anyway & observing my fellow travellers it does not happen for them either.

5. I found that after radiation treatment & commencement of ADT my body strength dropped by maybe 30%. Bench pressing, curls, pulling exercises all dropped. It was very deflating. I recovered a little & oscillate up & down but have never recovered the level I was doing before all this happened. I also look flabbier, lost body hair & my muscles didn’t have the same tone – all the effects of no testosterone I am assuming. The urologist said I should not lose muscle strength but I have. Maybe in my case I have put on body fat but that has been masked by muscle loss.

6. Some of this may be due to underlying rheumatoid arthritis. I had a single attack a few years ago of a joint after injury & went on heavy doses of prednisone. Occasionally I get the symptoms back & need a small dose of prednisone. This has affected my hand grip.

So exercise may be good for you but don’t expect miracles. If I have lost bone density I don’t know about it. Time for a test I suspect.

We are in the business of hanging on as much as possible & juggling our various ailments & the effects of aging & our cancer journey & [Moderator] with our gained knowledge. Life was not meant to be easy?

Tony

[Euan]

1. Although my specialist told me there was a risk of loss of bone density I have had no tests in the last 2 years to my knowledge. I take it from the article that this is an x-ray test of some kind. Have all of you had BMD tests?

I have had 3 Dual-emission X-ray absorptiometry (DXA, previously DEXA) scans which I arranged through my GP. You are entitled to one every 12 months funded by Medicare if you have hypogonadism (low testosterone). My radiation oncologist told me that it was not funded by Medicare and was not worth the $125 expense. My DXA scans caused me to research further and enabled me to make changes with my GP to avoid osteoporosis.

2. After about a year blood test indicated calcium down a bit & vitamin D on the bottom of normal so I take caltrate with vitamin D now – after I prompted the urologist. My general impression is he did not seem to worried about loss of bone density in my case.

My urologist told me that my bone loss would return once I came off ADT. This does not agree with what the Westmead article says.

3. I put on no weight when I went on ADT but the effects of radiation I found took off weight – I just did not eat as much. Also I had a kidney removed so with all that I did not gain weight in fact I went from approx 83 kg down to 78kg. Now I am 83 again which is probably too much for me. I do not know what my body mass index is. So for someone to put on weight after radiation must have a very robust constitution. That is my experience anyway.

Some men do loose weight but the majority put on weight in the first year, see attached pdf

4. On the scale of men my age I am a heavy exerciser. I go to the pool & gym 3 times a week to run in water for approx 30 mins & pump iron for approx 30 mins – very hard exercise which does make you lose weight if you get your heart rate up. Bottom line is you need your heart rate up to 80% of your max for at least 30 mins if you want to lose weight. If you don’t do that it does not happen for me anyway & observing my fellow travellers it does not happen for them either.

I agree with this Tony and go to the gym on most days, resistance work on third days. I believe that interval training is better than steady training.

5. I found that after radiation treatment & commencement of ADT my body strength dropped by maybe 30%. Bench pressing, curls, pulling exercises all dropped. It was very deflating. I recovered a little & oscillate up & down but have never recovered the level I was doing before all this happened. I also look flabbier, lost body hair & my muscles didn’t have the same tone – all the effects of no testosterone I am assuming. The urologist said I should not lose muscle strength but I have. Maybe in my case I have put on body fat but that has been masked by muscle loss.

I found that just one session per week was enough to stop muscle loss with me. If I stopped exercising as when I had two heavy colds one after the other muscle loss quite fast and at least twice as fast as normal for me.

6. Some of this may be due to underlying rheumatoid arthritis. I had a single attack a few years ago of a joint after injury & went on heavy doses of prednisone. Occasionally I get the symptoms back & need a small dose of prednisone. This has affected my hand grip.

So exercise may be good for you but don’t expect miracles. If I have lost bone density I don’t know about it. Time for a test I suspect.

Very strongly recommended based on my experience. You might be lucky and not have lost much bone at all. But if you are like me I was loosing 9.3% per year inspite of my exercising and calcium with vit D tablets.

We are in the business of hanging on as much as possible & juggling our various ailments & the effects of aging & our cancer journey & [Moderator] with our gained knowledge. Life was not meant to be easy?

I agree with the moderator we need to guide our doctors. GPs in particular are usually quite happy to order tests for you but less so with drugs when you are also with a specialist.

[Guest]

Hi All, Finally on the Forum site. Euan's comments on management of ADT I think are one of the keys to surviving this disease. My problem is the cumulative impact of 10 chemo sessions has left me breathless and fatigued so that doing anything physical like walking/gym is problematic. I do some light weights. I was better earlier and hopefully will regain some of this now that I've stopped chemo and I can get back to the gym.

I look like joining a restricted trial of Abiraterone + prednisone out of Royal Brisbane but it has a number of restrictions which preclude me at the moment.

I'm seeing my oncologist Rick Abraham on Thursday and my understanding is that while I don't have a rising PSA (Currently sitting on 0.67), I will have to wait. I'm happy to wait 10 years if it wants to stay at 0.67!!

Peter McNally