1. Annual General Practitioner Study Day 2012 Men’s Health Workshop Managing side effects of male cancer therapy Dr Conleth Murphy, Consultant Medical Oncologist

2. Prostate cancer therapies Endocrine therapies – ADT: Orchiectomy or LHRH analogues – Anti-androgens: bicalutamide (casodex) Chemotherapy – Docetaxel (Taxotere) – Cabazitaxel Novel therapies – Abiraterone (Zytiga)

3. Androgen Deprivation Therapy Cognitive dysfunction Worsening of diabetes Hot flashes Weight gain Erectile dysfunction Cardiovascular effects Loss of libido Osteoporosis Anaemia Sarcopaenia

4. Side effects of ADT Hot flashes – Acupuncture 1, venlafaxine 2, medroxyprogesterone acetate 2 (20mg/day), cyproterone 2 (androcur), gabapentin. Anaemia – Monitor B12, folate, TIBC. Avoid EPO Metabolic syndrome and cardiovascular health – 50% of men on long term ADT have metabolic syndrome. – Monitor BP, lipids and glucose. – Encourage diet and resistance exercise. – Cardiology review for men with pre-existing IHD 1.Frisk J, Spetz AC, Hjertberg H, Petersson B, Hammar M. Two modes of acupuncture as a treatment for hot flashes in men with prostate cancer—a prospective multicenter study with long-term follow-up. European Urology. 2009;55(1):156–163 2.Irani J, Salomon L, Oba R et al. Efficacy of venlafaxine, medroxyprogesterone acetate, and cyproterone acetate for the treatment of vasomotor hot flushes in men taking gonadotropin-releasing hormone analogues for prostate cancer: a double-blind, randomised trial, The Lancet Oncology, Volume 11, Issue 2, February 2010, Pages 147-154

5. Osteoporosis Osteoporosis is common – ~35% of hormone-naïve men with prostate CA – ~80% after 10 years of ADT Baseline DEXA Repeat at least every 2 years Weight bearing and resistance exercise Calcium 1200mg + Vit D 800 u daily Zoledronic acid 4mg IV yearly Alendronate 70mg weekly orally Denosumab 60mg S/C q6/12 reduced fracture risk. www.nof.org/professionals/clinical-guidelines http://www.shef.ac.uk/FRAX/tool.jsp?country=1

6. Chemotherapy Up to 10 cycles of docetaxel – Febrile neutropaenia: reduced with neulasta – Nail changes: cold gloves can help – Neuropathy: dose reduction, pregabalin – Watery eyes: lubricants, steroid eyedrops, intervention for canal stenosis – Anaemia: correct deficiencies, consider EPO Steroids reduce fluid retention Please call with any concerns Continue LHRH analogue throughout Rx Cabazitaxel: similar but high rates diarrhoea and neutropaenia

7. Abiraterone Novel oral inhibitor of androgen synthesis – Improves survival c/w best supportive care – 4x 250mg tablets daily 2 hrs after food – Prednisolone 10mg daily Oedema Hypertension Abnormal LFTs Hypokalaemia – Check BP, LFTs, U&E every 2 weeks for 3 months