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8.3 Sex hormones and hormone antagonists in malignant disease

8.3 Sex hormones and hormone antagonists in malignant disease

8.3.1 Oestrogens

AMBER    Diethylstilbestrol tablets 1mg 
GREEN      Ethinylestradiol tablets 1mg


8.3.2 Progestogens

GREEN      Medroxyprogesterone acetate tablets 100mg, 400mg 
GREEN      Megestrol acetate tablets 160mg 
GREEN      Norethisterone tablets 5mg 
 
For further information on the uses of Megestrol please see page 39 of guidelines <<link>> 


8.3.4 Hormone antagonists

8.3.4.1 Breast Cancer

AMBER     Anastrozole tablets 1mg 
AMBER     Exemestane tablets 25mg 
AMBER     Letrozole tablets 2.5mg 
AMBER     Tamoxifen tablets 10mg, 20mg

8.3.4.2 Gonadorelin analogues and gonadotrophin-releasing hormone antagonists 

Metastatic cancer of the prostate usually responds to hormone treatments aimed at androgen depletion. 

Gonadorelin analogues:- 

Goserelin and leuprorelin are recommended for use within their licensed indications, with goserelin recommended as the first line product. Any unlicensed uses (e.g. precocious puberty) should not be transferred to primary care prescribers –prescribing should be retained by secondary care.  There are two shared care protocols in place for the use of goserelin (the preferred LHRH analogue).  One covers the use in gynaecology, the other covers the use in oncology settings (breast & prostate cancer), and they can be accessed online - click here to access them 

First Line 
AMBER with SHARED CARE     Goserelin injection 3.6mg, 10.8mg     
 
Second Line        
AMBER with SHARED CARE     Leuprorelin injection 3.75mg, 11.25mg
(currently no shared care protocols exist for the use of leuprorelin locally as it is a second line agent)


Anti-androgens:-

Anti-androgens may inhibit tumour 'flare' which may occur after adminstration of gonadorelin analogues.
 
AMBER     Generic Bicalutamide tablets 50mg, 150mg 
AMBER     Cyproterone acetate tablets 50mg, 100mg 
AMBER     Flutamide tablets 250mg 
RED           Abiraterone Acetate tablets 250mg 
RED           Enzalutamide 40mg capsules NICE TAG316 (The use of enzalutamide for treating                   metastatic hormone- relapsed prostate cancer previously treated with                                     abiraterone is not covered by this guidance)
RED           Enzalutamide 40mg capsules recommended as an option by NICE for treating                       metastatic hormone relapsed prostate cancer before chemotherpay is                                     indicated. NICE TA377 


Gonadotrophin-releasing hormone antagonists

Degarelix is a gonadotrphin-releasing hormone antagonist used to treat advanced hormone dependent prostate cancer which does not induce a testosterone surge or tumour 'flare'. Anti-androgen therapy is not required when Degarelix is used.                                                                                                                                                                                         CAMET recommends its use ONLY where LHRH analogues or concomittant anti-androgens are contra-indicated.

Degarelix is recommended as an option for treating advanced hormone-dependent prostate cancer in people with spinal metastases NICE TA404 

AMBER    Degarelix injection with diluent 80mg and 120mg          

Click here to access a Prescribing Information Sheet for Degarelix (Firmagon®)                            

8.3.4.3 Somatostatin analogues
NHS England is responsible commissioner for acromegaly, cancer and congenital
hyperinsulinism.  RED Traffic Light
 
RED      Octreotide injection 50 microgram/1ml, 1mg/5ml 
RED      Octreotide depot injection 10mg, 20mg, 30mg
RED      Lanreotide 30mg vial
             60mg, 90mg, 120mg prefilled syringes
 
All other licensed indications are considered AMBER Traffic Light
AMBER      Octreotide injection 50microgram/1ml, 1mg/5ml 
AMBER      Octreotide depot injection 10mg, 20mg, 30mg
AMBER      Lanreotide 
                   30mg vial

                   60mg, 90mg, 120mg prefilled syringes

 



Lanreotide may be prescribed in line with its licensed indications only following recommendation from a specialist centre(NB - Any off license prescribing should not be passed on to primary care prescribers)