When Standard Hormones Fail

When the ‘first line’ hormone drugs referred to above lose their effectiveness, there are other, newer drugs which have been shown to work on many patients. These ‘second line’ drugs are often used in combination with the first line hormone drugs. You may find this chart helpful.

Abiraterone Acetate (Zytiga)

This has done well for many patients with advanced cancers that have become resistant to hormone treatments. Abiraterone is currently authorised for use in the NHS as a treatment before or after chemotherapy. It is highly effective in improving survival of some types of prostate cancer, but not all, so it doesn’t work for every patient. Some men have to be taken off the drug when an adverse reaction in the liver is found.

Enzalutamide (Xtandi)

This is an advanced anti-androgen that is showing outstanding results, similar to Abiraterone. It is approved by NICE before or after chemotherapy (see below). However, it cannot currently be given after Abiraterone, unless Abiraterone has caused toxicity problems within the first three months of it being given.

Both these drugs are generally well tolerated. Tiredness is the most common side effect associated with them.


Steroids have been in use for many years and have proved to be effective, though only for a limited period of time. These include Dexamethasone and Prednisolone. These drugs stop the adrenal glands from producing other male hormones. A recent trial has shown Dexamethasone to be twice as effective as Prednisolone; so Dexamthasone should now be considered the preferred option. The main side effect of steroids is an increased appetite.

Bone pain

For bone pain a radioisotope called Strontium 89 may be used. Given as an intravenous infusion, it is taken up by the affected bones. Most men feel the benefit within a few weeks, although for some the pain may get slightly worse before it gets better. It is now rarely used, as it can damage surrounding healthy tissue.

Radium-223 (Xofigo)

Formerly known as Alpharadin, Radium-223 is proving an excellent treatment for bone metastases associated with advanced prostate cancer. This is a much safer treatment, as it only targets the cancerous areas. It is very similar to calcium and, when injected into the bloodstream, is rapidly taken up in the bone. It emits very high-energy alpha particles that cause lethal damage to adjacent tumour cells and has undergone a trial with nearly 1,000 patients with hormone relapsed prostate cancer. The results show that Radium-223 improves survival by a similar amount to Abiraterone or Enzalutamide and is now a standard treatment for men with hormone resistant prostate cancer and bone metastases. It has been approved by NICE for all patients who need it.