Testosterone Therapy in Men With Prostate Cancer

Abstract

Context The use of testosterone therapy in men with prostate cancer was previously contraindicated, although recent data challenge this axiom. Over the past 2 decades, there has been a dramatic paradigm shift in beliefs, attitude, and treatment of testosterone deficiency in men with prostate cancer. Objective To summarize and analyze current literature regarding the effect of testosterone replacement in men with prostate cancer. Evidence acquisition We conducted a Medline search to identify all publications related to testosterone therapy in both treated and untreated prostate cancer. Evidence synthesis The historical notion that increasing testosterone was responsible for prostate cancer growth was based on elegant yet limited studies from the 1940s and anecdotal case reports. Current evidence reveals that high endogenous androgen levels do not increase the risk of a prostate cancer diagnosis. Similarly, testosterone therapy in men with testosterone deficiency does not appear to increase prostate cancer risk or the likelihood of a more aggressive disease at prostate cancer diagnosis. Androgen receptor saturation (the saturation model) appears to account for this phenomenon. Men who received testosterone therapy after treatment for localized prostate cancer do not appear to suffer higher rates of recurrence or worse outcomes; although studies to date are limited. Early reports of men on active surveillance/watchful waiting treated with testosterone have not identified adverse progression events. Conclusions An improved understanding of the negative effects of testosterone deficiency on health and health-related quality of life—and the ability of testosterone therapy to mitigate these effects—has triggered a re-evaluation of the role testosterone plays in prostate cancer. An important paradigm shift has occurred within the field, in which testosterone therapy may now be regarded as a viable option for selected men with prostate cancer suffering from testosterone deficiency. Patient summary In this article, we review and summarize the existing literature surrounding the use of testosterone therapy in men with prostate cancer. Historically, testosterone was contraindicated in men with a history of prostate cancer. We show that this contraindication is unfounded and, with careful monitoring, its use is safe in that regard.

Testosterone Therapy in Patients with Treated and Untreated Prostate Cancer: Impact on Oncologic Outcomes

“…These findings are similar to what is seen in literature currently, and are explained by the saturation model proposed by Morgentaler & Traish 18,28 . While our rates of BCR were lower than clinical norms, our trial design doesn’t allow comment on causative factors.…”

“…The prostatic androgen receptors become saturated with a serum T concentration of around 240-250 ng/dl (8-8.7 nmol/L) 18 . Below this saturation point, PSA is seen to increase in a linear fashion with increasing testosterone, but the relationship becomes uncoupled after this point 19 .…”

“…The saturation hypothesis is supported by basic science research going back to 1968 24 . A 2015 review summarizes over a dozen studies in support of TT 18 . This paper includes men with RP, XRT, and AS who have all received TT without worse outcomes.…”

Testosterone therapy and prostate cancer

“…A 2016 review concluded that although the data on using TTh in men on AS are limited, preliminary studies show no, or minimal, increased risk compared to the quality of life improvements seen with treatment of hypogonadism (98). Conversely, a 2011 study following 25 men with CaP reported highly variable outcomes after starting TTh.…”

“…Conversely, a 2011 study following 25 men with CaP reported highly variable outcomes after starting TTh. The authors urged caution in treating these patients and concluded that an international registry to collect more data would be the only way to address whether TTh was safe in men with CaP (98,99). While the preliminary studies of TTh in the setting of AS appear to demonstrate the relatively safety of treating hypogonadism with TTh in this setting, it is important to note that none of these studies were randomized or controlled and that more work must be done before unequivocally determining the safety of such treatment.…”