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We appreciate the comments by Luh and Eng regarding the use of radiation therapy for the prevention and treatment of gynecomastia and mastalgia. Our article and most of the literature on gynecomastia do not include radiation therapy in the management of gynecomastia because it is very infrequently used in North America and is only relevant in patients with prostate cancer who are receiving androgen-suppressive therapy, a small subset of the patients with gynecomastia that the review was meant to address.
At Mayo Clinic and at most practices in North America, when androgen-suppressive therapy for prostate cancer is indicated, the primary approach is the use of a luteinizing hormone–releasing hormone antagonist (eg, leuprolide or goserelin). Luteinizing hormone–releasing hormone antagonists do not induce gynecomastia or mastalgia, although weight gain may painlessly increase the volume of adipose tissue in the breast. If a nonsteroidal antiandrogen such as bicalutamide (Casodex) is used, it is generally at the relatively low dose of 50 mg/d and in combination with a luteinizing hormone–releasing hormone antagonist for a 4- to 6-month period. The development of gynecomastia and/or mastalgia correlates with both the dose and the duration of bicalutamide therapy and is less common with this approach. In fact, radiation therapy is used to treat one or fewer men annually at Mayo Clinic in Rochester, MN, for this indication.
In Europe, prostate cancer is increasingly treated with nonsteroidal antiandrogen monotherapy,1 typically at a high dosage of 150 mg/d. With this high-dose regimen, gynecomastia and/or mastalgia occur with high frequency. Thus, radiation therapy for prevention or treatment of these symptoms is reasonable. Although this approach is sometimes adopted in the United States,2,3 it is more common in Europe, where the largest randomized trial and much of the literature originate.4