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Dr. Dorff:
Hi. This is CME on ReachMD. I'm Dr. Tanya Dorff. Our discussion today will focus on managing adverse events of oral and injectable androgen deprivation therapy in advanced prostate cancer.

Many patients come in to see me with preconceived notions and really negative impressions of ADT based on their internet searches or conversations with people who have gone through treatment. So I really try to start out on a positive note that most of my patients on ADT are living their lives similarly to how they did before. That means working full-time, raising their grandkids, traveling, etc. And that's not to say they don't have side effects. Maybe they can't ride their bicycle as far as they used to or work as long a day as they used to. Maybe sometimes they need a nap at the end of the day. But overall, they are able to do the things that are important to them and lead a relatively good quality of life.

Then I broach the specifics, like hot flashes, which are very common but have a spectrum of severity. For mild hot flashes, most patients will just learn to live with them. But in severe cases, we do have multiple supportive interventions that can be employed, which have been shown to reduce the frequency and severity of hot flashes. And I usually choose among these based on what other types of side effects I'm trying to work on. So for instance, if someone is also having some emotional change, then an SSRI approach might be preferable. If they're having also some difficulty with sleep, then a nerve agent like a gabapentin-type approach, which can be a little sedating, especially if the hot flashes are worse at night, can be very helpful there.

For weight gain, which can be a struggle, I definitely proactively talk to patients about diet and exercise. These are things that they can do to mitigate this side effect. And I often counsel patients to include not only cardiovascular exercise, but also muscle-focused exercise, particularly resistance training, in order to try to maintain their muscle mass.

In terms of specific agents for androgen deprivation or testosterone lowering, there aren't really many differences, whether you're doing an oral agent or an injection, agonist or antagonist, in terms of what the patients feel day to day; the spectrum of side effects is really the same. The one major exception is with degarelix. There can be injection site reactions, and we do need to warn patients about those since they can almost look like an infection or a cellulitis. So we proactively tell our patients to do some ice on the area, to take Tylenol as needed. There can be some mild fever, and setting expectations helps reduce that surprise which could lead to unnecessary concern or worry on the part of the patient. And if these injection site reactions are quite severe, we will often talk about switching to a different agent.

In terms of the other big side effect that my patients worry about, those are cardiovascular risk factors. So the impact of the androgen deprivation on things like developing diabetes or controlling blood pressure and cholesterol. So patients don't feel these but they do worry about them. And although it’s possible there are some differences between agonist agents and antagonists here, there are conflicting datasets. The HERO trial was a prospective randomized trial that did suggest a lower risk of cardiovascular morbidity in patients with preexisting cardiovascular disease compared to the LHRH agonist in that study. So for a patient in whom this is very important, we can share the data from the HERO trial and discuss that as part of our decision-making about which agent to use to lower testosterone. But to me, the most important thing we can tell our patients about cardiovascular risk is that they should continue to actively monitor blood pressure, cholesterol, and glucose. We can do that in our clinic, but ideally it's done in conjunction with their primary care physician, and that we can manage these even if it takes additional medications in order to mitigate their risk.

So overall, androgen deprivation therapy certainly impacts our patients. There are side effects that can be challenging to live with, especially over a longer period of time. So some of our patients are on these drugs for years, and it makes it all the more important that we address them, that we acknowledge them, that we utilize all of our available strategies to help our patients stay on therapy so that we can control their prostate cancer and help give them the optimal longevity in cancer control.

Thanks for your attention. I hope this information was useful.

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