Prostate Cancer: Management

A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
A. Tamoxifen
B. Lansoprazole
C. Allopurinol
D. Cyproterone acetate
E. Tamsulosin

Answer:
D. Cyproterone acetate

Discussion: Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels. The British National Formulary (BNF) advises starting cyproterone acetate 3 days before the gonadorelin analogue.

Prostate Cancer: Management

Localised prostate cancer (T1/T2) : Treatment depends on life expectancy and patient choice. Options include:
 conservative: active monitoring & watchful waiting
 radical prostatectomy
 radiotherapy: external beam and brachytherapy

 Localised advanced prostate cancer (T3/T4) : Options include:
 hormonal therapy: see below
 radical prostatectomy
 radiotherapy: external beam and brachytherapy

Metastatic prostate cancer disease
- Synthetic GnRH agonist
 e.g. Goserelin (Zoladex)
 cover initially with anti-androgen to prevent rise in testosterone
- Anti-androgen
 cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes
- Orchidectomy