LHRH modalities: What's best for the patient?

Scottsdale, AZ-While luteinizing hormone-releasing hormone agonist injections offer patients advantages like flexibility and regular physician contact, LHRH implants can provide the convenience of once-yearly visits, as well as lower overhead for urologists. So said experts in a presentation pitting LHRH implants versus injections at the Perspectives in Urology: Point-Counterpoint meeting held here.

"The question is: Which one is most appropriate for the individual patient?"

Six to 12 months after treatment, some patients still experience hot flashes and reduced sexual desire, he explained.

"Some patients don't get their testosterone levels back."

Furthermore, some evidence shows that the longer men have been on LHRH agonists, the longer it takes for their testosterone levels to recover.

"Some of that is a duration effect," he said. "But the longer durations are due to higher doses. So it may be a dosage effect rather than a duration effect."

Accordingly, some oncologists now provide long-term therapy only through a series of monthly injections, said Dr. Morgentaler.

Injection flexibility

LHRH injections' advantages ovan implant include a more flexible treatment schedule. LHRH injections also provide an opportunity to bring patients to the physician's office regularly, perhaps for a physical exam and PSA check as well.

"The gentlemen feel well taken care of," Dr. Morgentaler said. "A lot of what we do in medicine, especially with cancer patients, is not just science. The art is how we interact with patients."

Conversely, he said patients might feel abandoned if a physician tells them to come back in a year, as might happen with some LHRH implants. Perhaps more important, such implants occasionally fail. Dr. Morgentaler said that after switching one of his patients who had been doing well with LHRH injections to a year-long implant, the patient's PSA quickly rose from 0.9 to 2.3 ng/mL over 5 months. It turned out that his testosterone was 212 ng/dL and was no longer suppressed. Worried that there had been nothing in the implant, Dr. Morgentaler called its manufacturer.

"The company said that in rare cases, the medication extrudes too quickly, resulting in only transient suppression of testosterone," he said.

The lesson is that testosterone levels should be checked if a man's PSA is rising rapidly while on LHRH therapy.

Additional implant drawbacks include the need for surgical procedures, plus office space and time for performing them, which usually requires a physician, rather than a nurse. They also don't offer the discretion of an injection.

"Implants are palpable and frequently visible," Dr. Morgentaler said. "For the purposes of this debate, I'm happy to point out the relative merits of injections over implants, but actually I use both modalities: injections early in the course of treatment or for shorter-term testosterone suppression; implants for longer-term treatment."