The scientific name for removing the testes is surgical debulking, a form of endocrine therapy in which both testes are removed simultaneously to reduce testosterone levels (the main androgen) to debulking levels (less than 50ng/dl or less than 1.7nmol/L), which “starves” most prostate cancer cells. This is due to the androgen-dependent nature of most prostate cancer cells.
The current application of this surgical debulking approach is also diminishing, and we speak in two parts.
Is debulking only surgical debulking?
No.
With advances in technology, there is an additional means of debridement, a pharmaceutical debridement. The overall effect of debridement is exactly the same as surgical debridement, and intermittent debridement (intermittent endocrine therapy) can be achieved to improve the quality of life of the patient.
Does all prostate cancer require denervation?
Neither.
We broadly classify each prostate cancer according to its degree of progression into early-stage prostate cancer and late-stage prostate cancer (this classification is not quite standardized, so for the sake of explanation and ease of understanding, let’s divide it this way for now). The treatment strategy for early-stage prostate cancer is by and large focused on completely curing the tumor (some patients may choose to be actively observed), while late-stage prostate cancer is focused on controlling the tumor, improving the patient’s life treatment, and The main goal is to prolong patient survival.
When a patient is diagnosed with prostate cancer by puncture, the physician will assess the patient’s risk of tumor progression and distant metastasis using several aspects: PSA levels, rectal exam and imaging findings, and the score of the puncture pathology, and will classify different patients into low, intermediate, and high risk.
Low-risk patients may not require any treatment or may be controlled by surgery or radiation therapy without debulking
Low-risk patients are arguably more fortunate, and some low-risk patients may first choose to follow up with regular monitoring of PSA, imaging, and repeat punctures until abnormalities in these indicators are detected before considering aggressive treatment. Most low-risk patients can also effectively control tumor progression early with radical radiation therapy, surgery, or even focal therapy.
So for low-risk patients, there is no need to worry too much about whether to remove the testicle.
Medical debulking is an option for intermediate- and high-risk patients
Medium- and high-risk patients without distant metastases can also have their tumors removed by radical surgery or radiation therapy and then be considered for a period of adjuvant endocrine therapy based on several evaluation criteria or postoperative pathology, the main tool being denervation.
But this does not necessarily mean that the testes must be removed either, because suppression of testosterone synthesis in the body by subcutaneous or intramuscular injections of a class of drugs called LHRH-α (luteinizing hormone-releasing hormone analog) can achieve hormone levels similar to those of surgically removed testes in 2 to 4 weeks, which is what is referred to as pharmacologic debulking. Thereafter, adjuvant endocrine therapy after radical treatment can be completed by maintenance injections every 1 month (some agents can be injected every 2, 3, or 6 months).
And for patients who have developed distant metastases, surgery or radiation therapy can only be used as a means of tumor reduction therapy, with endocrine therapy becoming the treatment of choice.
Destructive therapy is the most important component of endocrine therapy, and it was demonstrated as early as 1941 that destructive therapy was effective in slowing the progression of metastatic prostate cancer by surgical removal of the testes.
However, since 1985, when the first synthetic LHRH-α drug leuprolide became available, drug depot has begun to gain popularity among urologists. Its most important advantages are that it avoids the psychological impact of the irreversibility of testicular resection, while allowing flexible adjustment of treatment regimens, reducing treatment costs through intermittent endocrine therapy, and potentially prolonging tumor progression to a hormone-non-dependent stage. Therefore, pharmacologic debulking has gradually become the first option to consider for debulking treatment.
Since pharmacologic debulking is essentially equivalent to surgical debulking in terms of efficacy, does this mean that surgical debulking can be eliminated?
No.
Of course not.
First of all, the overall cost of long-term pharmacologic debulking (either alone or in combination with antiandrogenic drugs) is much higher than bilateral orchiectomy based on economic considerations. Depot treatment is supposed to be cost-effective and result in the best quality of life for the patient, and prolonged LHRH-α maintenance therapy clearly increases the financial burden on the patient, so orchiectomy may be considered for patients with a longer life expectancy or limited financial means for endocrine therapy.
Second, because of the relatively long onset of effect of pharmacologic depot at the initial LHRH-α injection, there is a transient rise in testosterone followed by a gradual decline. This process can cause exacerbation, and an additional class of antiandrogen drugs often needs to be given to counteract this starting 2 weeks or the day before dosing, so surgical removal of the testes is a better option for some patients who need rapid reduction in testosterone levels, such as those presenting with spinal cord compression of bone metastases.
In addition, patients with metastatic prostate cancer often progress to castration resistant prostate cancer (CRPC) after a median remission time of 18 to 24 months on endocrine therapy, but treatment continues at this time to maintain depressed testosterone levels. It has been suggested that surgical removal of the testes can effectively lower testosterone levels if serum testosterone does not reach destructive levels in the presence of drug destructive resistance, thereby achieving some tumor control.
In summary, not all patients need to opt for surgical removal of the testicles immediately after the diagnosis of prostate cancer. The doctor will need to evaluate the patient’s condition, his or her wishes, the needs of the disease, and financial factors to choose the most appropriate treatment option for the patient.
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