Matters of Survivorship: Fighting Back on ADT
ADT will try to affect your overall health, but here’s the good news: you can fight back, says PCF-funded medical oncologist Alicia Morgans, M.D., M.P.H., soon to be Medical Director of Cancer Survivorship at Dana Farber. Arm yourself with what it might do, and you will be better able to protect yourself against its tactics.
So here, in no particular order, are some of the things ADT might affect, and countermeasures you can take:
Bone health: Prostate cancer can affect your bones, and so can ADT, in different ways. Treating prostate cancer in the bones not only protects them, it can improve survival! ADT raises your risk of osteoporosis – but not only is this treatable, it’s not a “done deal” that every man on ADT will develop it! For specific advice on keeping your bones strong, from Harvard medical oncologist Matthew Smith, M.D., Ph.D., click here. “Avoiding fractures is so important,” says Morgans. “Men who have fragility fractures (due to osteoporosis) can lose their mobility and independence, and can have some major changes in their lives until those fractures are repaired. If we simply follow the guidelines we already have on how to care for bone and prevent osteoporosis, we can improve those outcomes pretty dramatically.
“A lot of the complications associated with ADT are absolutely things that we can address head on, try to prevent and to reverse; for instance, we have effective therapies to counteract bone thinning and lower the risk of fracture and complications from weak bones. Many of the known side effects of ADT are not necessarily inevitable.”
Your risk of cardiovascular disease: Here’s some good news: A new drug, Orgovyx (relugolix), was approved in December 2020 by the FDA for men with advanced prostate cancer, based on results of the Phase 3 HERO study. It lowers testosterone, but it works in a different way. It’s also administered differently – a once-daily pill instead of a shot – and it has a significantly lower risk of major adverse cardiovascular events compared to Lupron (leuprolide). If you have cardiovascular risk factors, such as high blood pressure, high cholesterol, a family history of cardiovascular disease, diabetes or pre-diabetes, if you’re overweight or if you smoke: heart disease needs to be on your radar, because ADT can make it worse. “Multiple studies have shown that men who have cardiovascular risk factors, particularly if they are not addressed, have higher rates of complications and even death on ADT,” says Morgans. But treating these risk factors with diet, exercise, and medication if needed, can “improve overall survival and also quality of life. When your body is healthier, you feel better.”
Note: For just about every category on this list, exercise is one of the answers. Men on ADT who exercise lower their risk of having cardiovascular and cognitive effects, developing insulin resistance, diabetes or pre-diabetes, obesity, and high blood pressure. “All of these are modifiable risk factors,” says Morgans, who tells patients on ADT to remember “A,B,C,D, and E,” which stand for:
Awareness: recognize the risks of complications, and fight back with diet, exercise and lifestyle changes.
Blood pressure: keeping your blood pressure healthy lowers the risk of heart attack and stroke.
Cigarette smoking: if you stop, your risk of dying of prostate cancer instantly begins to get lower.
Diet and Diabetes. You can lower your risk of insulin resistance with diet; particularly, trying to limit your carbohydrates. PCF has a wealth of good information on diet; click here to download our guide, The Science of Living Well, Beyond Cancer.
Exercise. It can help keep your bones strong, your weight down, improve your blood pressure, and also improve your mood. Speaking of mood:
Depression: “Depression is highly treatable,” says Morgans. “This is important, because evidence suggests that men treated with ADT do have higher rates of depression than men who have prostate cancer but are not receiving ADT.” But depression is underdiagnosed and undertreated in men on ADT, she adds, “perhaps because of reticence to ask for help, or a perceived stigma with mental illness,” or perhaps because it has crept up, and the patient hasn’t recognized that there’s a problem. This is where friends, family and caregivers can help. Depression can affect sleep, appetite, and memory, as well.
Cognitive changes: ADT can cause cognitive decline and dementia. However, this is more complicated than it sounds, Morgans notes. For one thing, symptoms of depression can be mistaken for cognitive decline, and can improve with antidepressants and exercise. For another, there are multiple forms of dementia, including vascular dementia. “If that risk is increased because of ADT, then a medicine that reduces the risk of major adverse vascular events could feasibly lower the risk of dementia, as well,” although this remains to be proven in large-scale studies. In general, “what’s good for the heart is good for the brain,” and taking steps to improve your cardiovascular health will help protect your cognitive function, too. “We also have strategies and mental tricks to help improve memory, and even medicines that may slow the progress of Alzheimer’s.” The key is to tell your doctor, and get further evaluation and help if needed. “The choice of therapies may help, as well,” Morgans notes. “In multiple ongoing studies, some really interesting MRI data suggests that there may be differences in some distribution of blood flow in the brain” between androgen-targeted medicines, “including one study with darolutamide that has just launched.”
Hot flashes: “At is basic level, ADT is lowering testosterone, which keeps men’s bodies functioning in a way they’re used to,” says Morgans. “Just as we see when women go through menopause, there are widespread changes. The constellation of symptoms is much broader than just the effects of ADT on the prostate cancer cells themselves.”
Among the most annoying and persistent – and undertreated – are hot flashes, which “can affect mood, sleep, and cognition,” says Morgans. A novel approach on the horizon is a “wearable,” she adds. It’s like an Apple watch, and can be linked to your phone. The basic idea is to stimulate the autonomic nerves on the wrist, with a cool sensation. “PCF is actively engaged in supporting work that can potentially improve quality of life and reduce hot flashes in men on ADT. This is an area with much room for improvement, where attention is needed, and pharmacologic therapies aren’t as effective as we wish.”
For now, treatment with antidepressants may help; so can exercise. Many men seek relief of symptoms with holistic treatments, including relaxation therapy, hypnosis, cognitive-behavioral therapy, and acupuncture.