Most patients treated for advanced metastatic prostate cancer can expect to go on and stay on ADT for the remainder of their lives. One way to achieve sustained androgen suppression is with the standard LHRH drugs, like Lupron, Eligard and Zoladex. But another way is with a surgical castration (i.e., removal of the testicles), more formally known as an orchiectomy.
Research from more than a decade ago suggests that patients who elect a surgical castration are less anxious compared to those who must repeatedly receive depot injections of an LHRH drug. It is also known that after two years of androgen deprivation, the surgical procedure is less costly than repeated ADT depot injections.
So why aren’t more men with advanced metastatic prostate cancer electing to have a surgical castration? A group of urologists in Iowa were curious to know if advanced prostate cancer patients on ADT drugs had ever been offered an orchiectomy as an alternative to repeated depot injections. They surveyed 68 patients on ADT about whether they had been told about the surgical option. They also asked the men whether they would consider surgical castration now that they knew of the option.
Only a third of the men recalled any discussion about an orchiectomy with their treating physicians. However, 40% said that they were interested in the procedure as an alternative to repeated ADT depot injections, once they knew about it.
The authors acknowledged that they “described orchiectomy in a mostly favourable light, specifically as a 30-minute outpatient procedure with minimal side effects…” and one that resulted in a comparable outcome in terms of appearance of the genitals (similar to genital appearance after long-term use of ADT).
It isn’t clear whether the men were told that an orchiectomy is the same as “surgical castration.” It is already known that the language used to discuss androgen deprivation is emotionally charged (Cushman at al. 2010). We don’t know, for instance, if the men knew of Sigmund Freud’s concept of “castration anxiety,” or if this may have contributed to their view of orchiectomy.
This paper raises many questions about what patients understand ‘androgen deprivation therapy’ to be. Some men define castration specifically as a surgical procedure; as such, they don’t consider themselves castrated if androgen suppression is achieved with ADT medications. A standard sales pitch for the ADT drugs is that the effects are reversible. However, this is irrelevant for metastatic patients, who need to have their testosterone suppressed for the remainder of their lives.
It would be intriguing to know what the physicians themselves think about having an orchiectomy. If they personally envision it as an irreversible body modification and find it unappealing for themselves (ala Freud), they may assume that their patients have the same view.
While this study showed that patients are not well informed about surgical castration, it doesn’t answer an important question: Why don’t all physicians inform patients with advanced prostate cancer about this ADT treatment option?
To read the study abstracts, see:
Knowledge and Attitudes Regarding Surgical Castration in Men Receiving Androgen Deprivation Therapy for Metastatic Prostate Cancer and Their Relationship to Health-Related Quality of Life: https://pubmed.ncbi.nlm.nih.gov/33971188/
The language of emasculation: Implications for cancer patients: https://web.p.ebscohost.com/abstract?site=ehost&scope=site&jrnl=15326306&asa=Y&AN=49867926&h=Ge4apJ2j9iSUudS%2baYRt96YapLjhKaxHkhLP%2b9jM74onukLNoH4ruS9BUOdVeIc2721lI33Gnysi73csZTHP1Q%3d%3d&crl=c&resultLocal=ErrCrlNoResults&resultNs=Ehost&crlhashurl=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler%26jrnl%3d15326306%26asa%3dY%26AN%3d49867926
References:
Schubbe ME, Gellhaus PT, Tobert CM, Mott SL, Garje R, Erickson BA. Knowledge and Attitudes Regarding Surgical Castration in Men Receiving Androgen Deprivation Therapy for Metastatic Prostate Cancer and Their Relationship to Health-Related Quality of Life. Urology. 2021;155:179-185. doi:10.1016/j.urology.2021.04.027
Cushman MA, Phillips JL, Wassersug RJ. The language of emasculation: Implications for cancer patients. International journal of Men's Health. 2010;9(1).