Table 3.

Summary of adverse effects of prostate cancer endocrine therapy and their management

COMPLICATION	SUMMARY OF EVENTS	MANAGEMENT
Cardiovascular disease	Increased risk of cardiac events Increased risk of stroke Increased risk of DVT/PE	Lifestyle changes to promote healthy diet and weight Smoking cessation Exercise therapy Monitoring and medical optimization of blood glucose, blood pressure, lipid profiles Consider use of GnRH antagonist in patients with significant cardiac comorbidities Consider referral to cardiac oncology
Change in body composition	Increased BMI Increased percentage body fat Decreased muscle mass	Lifestyle changes to promote healthy diet and weight Exercise therapy Monitoring and medical optimization of blood glucose, blood pressure, lipid profiles
Change in metabolic parameters	Insulin resistance/glucose intolerance Increased risk for incident diabetes Worse glycemic control Altered lipid profiles Increased risk for metabolic syndrome	Lifestyle changes to promote healthy diet and weight Exercise therapy Monitoring and medical optimization of blood glucose, blood pressure, lipid profiles
Bone health	Decreased BMD Increased risk for osteoporosis Increased risk for clinical fractures	Smoking and alcohol cessation Adequate calcium intake (1200 mg/d) and vitamin D supplementation (800-1000 IU/d) Exercise therapy Pharmacologic therapy with a bisphosphonate or denosumab for men with risk factors for bone fracture (ie, previous history of low trauma fracture, diagnosis of osteoporosis, moderate or high 10-year fracture risk)
Hot flashes	NA	Avoidance of triggers Pharmacologic therapy Consider acupuncture Consider intermittent ADT
Breast events	Gynecomastia Mastodynia	Treatment with tamoxifen or low-dose RT (tamoxifen preferred) Surgical management for select patients
Cognitive function	Concentration Memory Dementia Depression	Evidence for causality is weak Appropriate patient education and monitoring of symptoms
Fatigue and anemia	NA	Exercise therapy for fatigue Workup secondary causes of anemia and referral to hematology when indicated
Impaired sexual function	Decreased penile and testicular size Loss of libido Decreased sensitivity to sexual stimulation Erectile dysfunction	Appropriate pretreatment counseling Sex therapy PDE5 inhibitor and other ED therapies where appropriate Consider intermittent ADT
Quality of life	Multiple domains	Exercise therapy Consider intermittent ADT

ADT—androgen deprivation therapy, BMD—bone mineral density, BMI—body mass index, DVT—deep-vein thrombosis, ED—erectile dysfunction, GnRH—gonadotropin-releasing hormone, NA—not applicable, PDE5—phosphodiesterase 5, PE—pulmonary embolism, RT—radiation therapy.