Hormonal therapy evaluation

The role of combined hormonal therapy, also referred to as maximal androgen deprivation or total androgen blockade, continues to be evaluated. 

Bispecific monoclonal antibodies are being evaluated in phase I and II studies in a variety of malignant diseases in the fields of hematooncology and solid tumors. It is likely that in the next decade immunotherapy using bispecific monoclonal antibodies will have a place, complementary to the current modalities such as surgery, chemotherapy, hormone therapy, and radiation, in the treatment of malignancies. 

While numerous studies have evaluated the effect of oral contraceptives and postmenopausal hormone replacement on drug clearance, many were flawed by poor study design. Table 21.1 lists studies that were of crossover or sequential design such that each subject was evaluated in the contraceptive phase and placebo phase. These study designs minimize the effect of interindividual variability. In most studies there was no effect of hormonal therapy on drug metabolism, but in some there were interactions that inhibited or increased the metabolism of concurrently administered drugs. 

HPI BB is a 76-year ld man with metKtatic prostate cancer. He was diagnosed 4 years ago and underwent a radical prostatectomy but ejected to delay other treatment because he was asymptomatic. Today he presents to evaluate treatment options because he is experiencing bone pain from hb metastases. He b very opposed to orchiectomy, but b willing to try hormonal therapy to control hb disease. He b in otherwise good health. 

Evaluation of each individual woman is essential in determining the appropriateness of perimenopausal and postmenopausal hormone therapy, and collaboration between a woman and her primary care provider in the decision-making process is essential. The benefits and risks of hormone therapy should be reassessed annually. 

Each patient should be evaluated for the presence of indications (i.e., menopausal symptoms such as hot flushes or vaginal dryness) and possible contraindications. The risks and benefits of hormone therapy should be discussed with the patient so that she can weigh the risks and benefits versus alternatives and make a rational decision about whether to use hormone therapy. 

Annual follow-up should include assessment of hormone therapy compliance and evaluation for signs and symptoms of associated endocrine disorders. ... 

The role of ERP/PRP in the management of other hormone-dependent cancers has been well established. Patients with melanomas are currently treated with hormonal therapy. In a preliminary evaluation (F6), the hormone binding ability of melanomas was demonstrated through the assay of ERP in cytosol preparations. This study was undertaken to verify if some melanomas are hormone dependent and to determine the usefulness of such findings in the treatment of melanomas. About 50% of the patients were positive for ERP. ERP receptors also have been observed in patients with prostatic cancer (F7). 

Laboratory tests indicate elevated TSH (11 mlU/ml) and low levels of free T4 (0.6 ng/dL). The physical and laboratory findings are consistent with a diagnosis of hypothyroidism. Her physician wants to treat the hypothyroidism with hormone replaoement therapy. Evaluate the given structures for use in this case. 

A 74-year-old woman, who was referred for evaluation of pain and persistently abnormal exposure of jaw bone after extraction of teeth, had been using weekly oral alendronate for osteoporosis for about 5 years. She had the clinical features of bisphosphonate-associated osteonecrosis of the mandible, which was precipitated by extraction of teeth 14 months before she was referred for assessment. She had multiple susceptibility factors for osteonecrosis of the jaw, including older age, type 2 diabetes mellitus, and a long duration of bisphosphonate therapy. The mandibular lesions did not improve despite repeated operations over 14 months. Bisphosphonate therapy was withdrawn and parathyroid hormone therapy was started after 2 months the oral mucosa had healed, after 4 months the pain had completely subsided, and after 6 months the patient s eating and drinking habits had returned. The serum concentration of osteocalcin, a marker of bone formation, which was initially suppressed, increased by 174% from baseline after 6 months of treatment with parathyroid hormone. 

The standard of care in evaluation and treatment of these patients must include nutritional, electrolyte, hormone, and structural considerations that should be properly balanced, while social and family history, familial support structures, and secondary gain issues should be investigated. Nutritional supplements, replacement hormone therapy, and surgical interventions should be considered as a matter of course in an appropriate sequence dictated by standard of care. 

Explain how to evaluate a patient for the appropriate use of hormone-replacement therapy. 

Finally, therapeutic sequencing of different hormonal agents is fast becoming a common clinical practice, and fulvestrant is a good treatment choice to extend the opportunity for using endocrine therapies before reliance upon cytotoxic chemotherapy is necessary. Further research is required in order to evaluate the optimal sequence, both in clinical practice as well as in the laboratory, to choose the correct treatment of breast cancer in each person after the appearance of tamoxifen-induced drug resistance (Robertson 2004 Osipo et al. 2004 Johnston 2004 Robertson et al. 2005). 

---