Testosterone Replacement Therapy in Patients with Prostate Cancer After Radical Prostatectomy

Abstract

Purpose Testosterone replacement therapy in men with prostate cancer is controversial, with concern that testosterone can stimulate cancer growth. We evaluated the safety and efficacy of testosterone in hypogonadal men with prostate cancer treated with radical prostatectomy. Materials and Methods We performed a review of 103 hypogonadal men with prostate cancer treated with testosterone after prostatectomy (treatment group) and 49 nonhypogonadal men with cancer treated with prostatectomy (reference group). There were 77 men with low/intermediate (nonhigh) risk cancer and 26 with high risk cancer included in the analysis. All men were treated with transdermal testosterone, and serum hormone, hemoglobin, hematocrit and prostate specific antigen were evaluated for more than 36 months. Results Median (IQR) patient age in the treatment group was 61.0 years (55.0–67.0), and initial laboratory results included testosterone 261.0 ng/dl (213.0–302.0), prostate specific antigen 0.004 ng/ml (0.002–0.007), hemoglobin 14.7 gm/dl (13.3–15.5) and hematocrit 45.2% (40.4–46.1). Median followup was 27.5 months, at which time a significant increase in testosterone was observed in the treatment group. A significant increase in prostate specific antigen was observed in the high risk and nonhigh risk treatment groups with no increase in the reference group. Overall 4 and 8 cases of cancer recurrence were observed in treatment and reference groups, respectively. Conclusions Thus, testosterone therapy is effective and, while followed by an increase in prostate specific antigen, does not appear to increase cancer recurrence rates, even in men with high risk prostate cancer. However, given the retrospective nature of this and prior studies, testosterone therapy in men with history of prostate cancer should be performed with a vigorous surveillance protocol.

A survey of Canadian urologists’ opinions and prescribing patterns of testosterone replacement therapy in men on active surveillance for low-risk prostate cancer

“…[5][6][7][8][9][10][11] An important question is whether these observations are substantial enough to impact the clinical management of hypogonadism in men under active surveillance for low-stage/grade PCa. The evidence specifically pertaining to active surveillance Canadian opinions about testosterone replacement is even more limited, but the results of our survey reveal that 65% of a representative sample of Canadian urologists believe that this practice is safe.…”

“…Two separate studies that examined a total of 17 men with a history of radical prostatectomy and who were treated with TRT for TDS found no recurrence of cancer. 5,6 A 2013 study by Pastuszak et al examined 152 men who underwent total prostatectomy for PCa, 7 103 hypogonadal men treated with TRT (26 of whom were "highrisk"), and a reference group of 49 non-hypogonadal men. They found an increase in prostate-specific antigen (PSA) in the treatment group, but only four of these men had cancer recurrence, compared to eight in the reference group.…”

Update on Testosterone Replacement Therapy in Hypogonadal Men

“…In a newer retrospective review of 103 hypogonadal men after prostatectomy, Pastuszak found that, while TRT may increase PSA, it did not increase the rate of prostate cancer (4 recurrences on TRT, 8 recurrences in reference group) at a median follow-up of 27.5 months. In fact, the study further stratified these men by risk category and found that of the 23 high-risk men (Gleason 8-10 or positive margins or lymph nodes), there were no recurrences while on TRT, suggesting that TRT can be safe regardless of risk [75].…”

Testosterone deficiency and replacement: Myths and realities

“…Among both groups, all biochemical recurrences were Testosterone deficiency and replacement: Myths and realities seen in men with high-risk features (Gleason score 8 or higher, positive surgical margins or lymph nodes), suggesting that the characteristics of the cancer themselves drive recurrences versus testosterone levels or replacement. 28 In a study of 13 hypogonadal men with untreated prostate cancer undergoing active surveillance, TRT for a median of 30 months was not associated with increased PSA levels or prostate cancer progression. 29 Many healthcare providers hesitate to initiate men on TRT due to the belief that these treatments increase the risk of cardiovascular (CV) events.…”