Surgical Castration. Why is it uncommon?

[pjoshea13]

I received the following circuitously from Richard Wassersug.

-Patrick

"What is known about the psychological distress of surgical castration versus long term androgen suppression with LHRH agonists or antagonists drugs?

I share with Patrick O'Shea an interest in what is in the medical literature as the peer-reviewed literature is usually built upon larger samples than N=1 personally impressions.

What surprised me is that many—perhaps most—of the public, including MDs treating prostate cancer patients, assume that surgical castration is psychologically more traumatic than chemical castration. I saw that presumption in a paper by a Harvard MD some years ago and more recently in a paper by Itty and Getzenberg. Here's the recent reference:

Asian J Androl. 2020 Jan 21. doi: 10.4103/aja.aja_139_19. [Epub ahead of print]

How do we define "castration" in men on androgen deprivation therapy?

Itty S, Getzenberg RH.

A claim made in that paper is perhaps typical of the popular presumption. So, for example, those authors assert that an orchiectomy for prostate cancer treatment "carries a psychological impact". They support that claim with one citation, but it turns out that citation is about "unilateral orchiectomy for a testicular tumor". That is a very different patient population from the advance prostate cancer population.

My impression is that the MDs, who assume that an orchiectomy is more traumatic than repeated depot injections of LHRH drugs, haven't read the literature and are projecting their own feelings upon their patient population.

So, what does the literature say?

Well, the paper that Patrick used to start this thread states:

The results of our present study have shown that bilateral orchidectomy was associated with better HRQoL and global health status with a lesser symptoms score than patients who used degarelix. The reason for a better HRQoL in the case of bilateral orchidectomy is uncertain, but this may be attributed to the lower testosterone castration level, which could reflect better disease control. Although concerns about psychological insult with surgical castration is always raised, patients that choose bilateral orchidectomy may experience less worry and concern about cancer control than patients receiving monthly degarelix injections.

It turns out that the author speculation that "patients that choose bilateral orchidectomy may experience less worry and concern about cancer control..." has already been explored in comparison to the LHRH agonists drugs. Here's the reference and the abstract:

Quality-of-Life Outcomes After Primary Androgen Deprivation Therapy: Results From the Prostate Cancer Outcomes Study

Arnold L. Potosky , Kevin Knopf , Limin X. Clegg , Peter C. Albertsen , Janet L. Stanford , Ann S. Hamilton.

J Clin Oncol. 2001 Sep 1;19(17):3750-7.

Abstract

PURPOSE: To compare health-related quality-of-life outcomes after primary androgen deprivation (AD) therapy with orchiectomy versus luteinizing hormone-releasing hormone (LHRH) agonists for patients with prostate cancer.

PATIENTS AND METHODS: Men (n = 431) newly diagnosed with all stages of prostate cancer from six geographic regions who participated in the Prostate Cancer Outcomes Study and who received primary AD therapy but no other treatments within 12 months of initial diagnosis were included in a study of health outcomes. Comparisons were statistically adjusted for patient sociodemographic and clinical characteristics, timing of therapy, and use of combined androgen blockade.

RESULTS: More than half of the patients receiving primary AD therapy had been initially diagnosed with clinically localized prostate cancer. Among these patients, almost two thirds were at high risk of progression on the basis of prognostic factors. Sexual function outcomes were similar by treatment group both before and after implementation of AD therapy. LHRH patients reported more breast swelling than did orchiectomy patients (24.9% v 9.7%, P < .01). LHRH patients reported more physical discomfort and worry because of cancer or its treatment than did orchiectomy patients. LHRH patients assessed their overall health as fair or poor more frequently than did orchiectomy patients (35.4% v 28.1%, P = .01) and also were less likely to consider themselves free of prostate cancer after treatment.

CONCLUSION: Most endocrine-related health outcomes are similar after surgical versus medical primary hormonal therapy. Stage at diagnosis had little effect on outcomes. These results provide representative information comparing surgical and medical AD therapy that may be used by physicians and patients to inform treatment decisions.

Note—What I highlighted above. It is consistant with what is now reported for degarelix.

The issues also gets raised about the irreversibility of a surgical castration. But that also doesn't apply to the advanced prostate cancer patient with metastatic disease, who is likely to be on some androgen suppressing medications for the rest of his life.

However, suppose a patient with castrate levels of testosterone want to go back on testosterone perhaps because he can't stand androgen suppression or is adventurous and wants to explore "bipolar androgen therapy". My view is that taking testosterone as a topical gel is far easier than having to get regular depot injection of LHRH drugs.

So, in sum, for the specific population of advanced prostate cancer patients, voluntary surgical castration has NOT been shown to be more psychologically stressful that androgen suppression with depot injects of LHRH agonist or the antagonist degarelix.

This doesn't mean that I am personally endorsing one treatment over the other. Nor am I willing to assume that what is least stressful for an advanced prostate cancer patient would apply to other populations, such as testicular cancer patients or transsexuals.

---------------------

As a postscript, the Itty and Getzenberg paper has other problems. For example, it is not up to date on the use of transdermal estradiol at an ADT option. Those authors don't cite any of they papers of transdermal estradiol and they don't seem aware of the PATCH study in the UK.

Richard Wassersug

LIFEonADT.com

[Grumpyswife]

Thank you for this. When my husband decided on orchiectomy he was discouraged by his MO who mentioned barbaric. We disliked having to plan our lives and travel around injections. Husband says he has no regret.

[Zetabow]

I had it done in Nov, no issues physical or mental.

MO thought it a better option for me, I was struggling with brutal hot flushes (20+ a day) and very advanced Mets so I didn't hesitate when he suggested. I still have hot flushes, maybe 6-7 a day now.

[Kaliber]

Counter perspective....

OMG nooooooooooooooooooooooo ..... oh hell noooooooooooooooooo yayahahahaya. 😂 they might be shriveled up and climbed up into my abdomen someplace, but I’m not cut . Although I can’t see or find them anymore ... my precious nurdles, or what’s left of them, are still here ( probably ... I’m pretty sure ...

I think they are ) 😂😂😂😂

Just say’in

[Grumpyswife in reply to Kaliber]

Typical male.

[Kaliber in reply to Grumpyswife]

Yayahahahaya ..... you bet’cha. 😉😉😉 yayahahahaya

[alephnull in reply to Grumpyswife]

/sarc

Typical female....

It's like killing your two best friends.

And you would be guilty of their deaths.

/sarc

[Kaliber in reply to alephnull]

I hear you brother 😁😁😁😁😁

[Hidden in reply to alephnull]

I chopped mine Like the poison weeds in any garden . Dead wood..

[oldbeek in reply to Kaliber]

Same here

[addicted2cycling in reply to Kaliber]

JUST SAY'N >>>>

Bilateral Orchiectomy = Best SURGERY this "addicted2cycling" soon to be 70yo ever had

PERIOD!!!!

[Kaliber in reply to addicted2cycling]

Don’t make up your mind up too fast ... you still haven’t given amputations a try yet.

Just say’in 😁😁😁

[addicted2cycling in reply to Kaliber]

Castration was a WIN-WIN !!! bicycling became a LOT MORE COMFORTABLE and had the FASTEST 10 POUND weight loss in my life. 😁

Amputation definitely would lighten me up BUT would slow down my bicycling so I'm gonna pass.

[Kaliber in reply to addicted2cycling]

Yayahahahaya good one , you’d fit right in with the J-O-H-N crowd here. 😂😂😂👍👍👍

Ok ...

1. I can’t consider surgical removal because my surgeon, Dr Ghiggles Bobbitt , is old and has double vision ( not to mention odd personality traits ) and trusting him down there is definitely iffy.

Or ...

2. What 10 pounds ??? ..... well ........ , thats ok .... for people with short legs and small hands, only 10 pounds is OK . It’s all good.

Yayahahahaya 😂😂😂😂

[Hidden in reply to addicted2cycling]

Go no ballers!!

[noahware]

As I've commented previously, I think the irreversibility of a surgical castration is precisely why it can prove to be less stressful for some men: the range of potential ADT decisions (stopping, pausing, switching, etc.) are greatly reduced.

Life is a lot simpler when options are eliminated. When you have no ability to change what you've already done, you have the possibility to be free of the burden of weighing options. That can let you spend more of your life LIVING rather than thinking, worrying and waiting.

[Kaliber in reply to noahware]

Well that’s a strong argument , making life simpler when you are croaking could be a really good thing...... right ? ... let you focus more on the things at hand. Speaking of hand ... why stop there tho, let’s carry that thought further down the road ..... if I had my hands removed, I wouldn’t have to hide my wedding ring when hitting on the ladies or forget to put it back on. I wouldn’t have to worry if I just put my hand in that gob of goo there on that table or bird cage , no worries about sleeve length on that suit or dress shirt any more . Clearly , life would be much simpler too. Wow I can think of lots more ways cutting parts off my body could make life simpler .... never though of it that way before . Eliminating the need for options definitely makes life simpler , doesn’t it ? Yayahahaha 🤪

Peace brother ✌️

[noahware in reply to Kaliber]

Well, you've got to create a similar context of uncertainty, weighing two bad scenarios against each other. Cutting a hand as compared to WHAT, exactly?

Because nobody gets his balls cut off just for the hell of it, as an option to a normal life, as in your hand-removal example. Castration is a possible alternative to various courses of ADT (not fun) and to the doubt, worry and decision-making involved in those upcoming treatments (also not fun).

So pick an option:

1) have all fingers surgically removed at once, or...

2) at various random times over a few years, have each finger cut off, one by one...

Now if you interviewed men a year in, do you really think the men who still had two or three fingers yet to be chopped off would be that much happier than the men who were done with the process?

So in that context, YES, I might choose the simplification of one amputation NOW vs. one after the other, again and again. To go "one and done" seems a bit easier.

[Kaliber in reply to noahware]

Yayahahahaya rite on brother Noah .... with a few of us here , me among them, a lot ( most ) of what I post is intended to break up the gloom and doom that permeates this place a lot. Some of it intended to be supportive and uplifting at times if need be as well. For us stage 4 M1 guys that are circling the drain , it’s just fun to toss in some ridiculousness here and there. A few of us have seen over the edge to the drain trap but have managed to remain from getting flushed , so to speak. In the real world , probably all of us would do whatever it took to hang in here .... I doubt that having a few parts removed would cause us to blink ... in the scheme of things. If I need to experience some slicing / dicing or burn ( radiation ) to extend things or relieve unbearable pain ... I’d surely do it in a heart beat.

Hopefully us S4 guys are far beyond politics , confrontation, personal attacks and most social manipulation and all that other crap .... for those of us able to shed denial, manage our grief and “ get it “ .... our world has changed dramatically... including our thought processes. Grief seeps in occasionally and PCa in general isn’t happyville for anyone in the family ... it is what it is tho ...

Messing around some, cracking a few jokes .. even messing with posts lightheartedly, it’s all good.

I doubt you think I’m trying to actually be negative with or about you .. if you are stage 4 , almost certainly you are right here with the rest of us. Still .... it doesn’t hurt to make the standard “ disclaimer “ post , now and then , so everyone understands the nature of this. Lots of group members are in differing head spaces ... just smooths out the bumps ... kinda.

It fun to talk with you brother Noah, this place is all about the rich texture of life !

Peace brother ✌️✌️✌️ 🌸🌼🌻

[noahware in reply to Kaliber]

No problems, I figured you were just busting balls (so to speak).

Funny thing about chopping your balls off to "simplify" life... I can remember when I was (much) younger thinking how much simpler life would be if I didn't have sex on the brain 24/7.

Here's to dirty old men!

[Kaliber in reply to noahware]

Yayahahahaya .... ( edited for Darryl standards )

Busting balls yayahahahaya... great stuff brother 😂😂😂😂

[j-o-h-n in reply to Kaliber]

Rule of Thumb (thumb pun intended).. If you decide to go to a new urologist run like hell if his ten fingers are missing...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/28/2020 5:42 PM EST

[Kaliber in reply to j-o-h-n]

Took me a minute ..... 10 fingers missing ??? ..... then “ ewwwwwwwwwww “ .... had to get up and get some Purell. Yayahahahaya yayahahahaya yikes ....

[j-o-h-n in reply to Kaliber]

If you happen not to notice that his ten fingers are missing you'll be able to know they are when he starts nibbling on you ear during the DRE...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/28/2020 5:55 PM EST

[Hidden in reply to j-o-h-n]

No tongue in the ear though?

[Hidden in reply to noahware]

I agree.

[Northcaptain]

I think this is such an important subject, it should have been researched much more. But alas since big pharmas loose money if someone proceed with orchiectomy, they wont invest in study to prove it right.

I'm sure i'll be placed in the decision in the progression of the disease and i'm more inclined to cut than to keep because for quality of life i want to be on my boat in the middle of the pacific 6 months per year and not live with an injection calendar....(just thinking).

I would like to read more on the subject.

[Kaliber in reply to Northcaptain]

I’d like to keep my boat in the middle of the pacific too, but it doesn’t float anymore since adt started.

Just say’in 😂😂😂😂

[oldbeek]

My dad though his testicles were sexy. He didn't want to remove his old friends. Yes there is a physiological component.

[TFBUNDY]

Bloody hell nooooo. Not again! My consultant mentioned ADT some while back but I was half way down the corridor by the time he finished talking. But chopping my bollocks off.... Noooo.... Just noooo.....! No no no....

[TFBUNDY]

Sorry Patrick I failed to answer the question properly. Castration is uncommon because the patient can run faster than the doctor due to an adrenaline surge. Fight or flight....

[Kaliber in reply to TFBUNDY]

Rotflol 😂😂😂

[monte1111 in reply to TFBUNDY]

Sounds like a great reality show.

[Kaliber in reply to monte1111]

Ewwwwwwwwww .... interesting ..... but ewwwwwwww

😂😂😂😂😂

[pjoshea13]

Nala,

Back when Huggins started earning his Nobel, I was just emerging from the womb.

The choices were castration or the synthetic estrogen DES (a pill). Huggins wasn't making $1,000 / month with a Lupron shot. He had no financial interest. Interesting that men would opt for DES over surgery even when the cardio risks became known.

Huggins knew that no form of castration would cure. He was fortunate that men had such a miserable life expectancy back then. (Pension plans were still viable because of that.) With no screening, a late diagnosis and comorbidities, castration offered a good chance of dying with - not of - PCa.

That started to change with OSHA (Nixon, 1970), men giving up smoking, possibly dietary changes, reductions in competing deaths. We live too long now. LOL

The focus on the androgen receptor [AR] axis is a dead-end. The law of diminishing returns demands that BigPharma look elsewhere. IMO

-Patrick

[Muffin2019]

I talked about surgical castration and got a poo poo, at my age they are not serving any real purpose . If necessary I would have no problem losing them, if done I would not receive the lupron every 3 months. The only question is will it cut the hormone enough or would you still have to take pills, did not have an answer on that . So continue the lupron and add pill, he discouraged the cosadex in favor of zytiga which is expensive even with insurance. I disagreed and wanted to start with cosadex first before the expensive stuff. He said another patient had it last only 6 months before moving on to zygtia but everyone is different. Some on here has been on cosadex for years before moving on.

[Grumpyswife in reply to Muffin2019]

You are wise to use Casodex as long as possible. My husband was up to taking 3 Casodex and should have worked it longer. However his new MO at the time likes Xtandi. In retrospect I wish he would have started with Zytiga instead.

[Muffin2019 in reply to Grumpyswife]

What was his dosage of casodex ? Not on it yet, waiting for psa to level off according to dr., will see in may after the next lupron shot.

[Grumpyswife in reply to Muffin2019]

I believe they were 50 mg tabs and he started with one. He went CR rather quickly.

[Muffin2019 in reply to Grumpyswife]

Probably works better depending on the person, ztiga is better than xtandi in the progression .

[MateoBeach]

Thank you for that thoughtful review of this topic. It provides clear perspective for decision making based on available data.

I am still looking for a single individual in this forum to report regretting haven had bilateral orchiectomy for advanced prostate cancer. - Paul

[Kaliber in reply to MateoBeach]

Lol

[monte1111 in reply to MateoBeach]

I'm still looking for those in this forum to report regretting their frontal lobotomies. There are several candidates.

[Kaliber in reply to monte1111]

Hay mannnnnn ... I resemble that remark . I did go in for an evaluation but the docs said my scans showed that my frontals were too shriveled to lobotomise. Maybe a trim job on my occipital‘s instead, dunno.

🤪🤪🤪🤪

[MateoBeach in reply to monte1111]

Good one! As has been said “ I’d rather have a full bottle in front of me than to have a pre-frontal lobotomy “.

[j-o-h-n]

Cause it takes balls to cut off your balls....

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/28/2020 5:04 PM EST

[Kaliber in reply to j-o-h-n]

A razor blade is what “ MEN “ use .... the rest of us run down the hall screaming 😱. ( insert whiny little bixxx sound effect here )

[j-o-h-n in reply to Kaliber]

single or double edge..... oieeeeeeeeeeeeeeeeeeeeeeee

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/28/2020 5:50 PM EST

[Kaliber in reply to j-o-h-n]

🤪🤪🤪😂😂😂😂😂

[Hidden in reply to j-o-h-n]

What balls?

[Zetabow]

I did have some post surgery issues, I got slightly infected and stitches dissolved but the wound still hadn't healed. I went to GP and Nurse monitored my progress until everything healed.

Kinda surreal laying on a bed with a 26 year old Nurse looking at your scrotum saying "They look good today" I never imagined anyone would be gently cleaning my balls saying those words, let alone a cute 26 year old. lol

[Hidden]

I’ve only stopped all meds one month ago but I feel better even if it’s shot lived. Cut them off and that option goes away. Just my 2 cents. Sounds like we have corona virus in Kansas.