Testosterone Therapy on Active Surveillance and Following Definitive Treatment for Prostate Cancer

Current Urology Reports, Jun 2017

Purpose of Review Previously considered an absolute contraindication, the use of testosterone therapy in men with prostate cancer has undergone an important paradigm shift. Recent data has changed the way we approach the treatment of testosterone deficiency in men with prostate cancer. In the current review, we summarize and analyze the literature surrounding effects of testosterone therapy on patients being treated in an active surveillance protocol as well as following definitive treatment for prostate cancer. Recent Findings The conventional notion that defined the relationship between increasing testosterone and prostate cancer growth was based on limited studies and anecdotal case reports. Contemporary evidence suggests testosterone therapy in men with testosterone deficiency does not increase prostate cancer risk or the chances of more aggressive disease at prostate cancer diagnosis. Although the studies are limited, men who received testosterone therapy for localized disease did not have higher rates of recurrences or worse clinical outcomes. Current review of the literature has not identified adverse progression events for patients receiving testosterone therapy while on active surveillance/watchful waiting or definitive therapies. Summary The importance of negative effects of testosterone deficiency on health and health-related quality of life measures has pushed urologists to re-evaluate the role testosterone plays in prostate cancer. This led to a paradigm shift that testosterone therapy might in fact be a viable option for a select group of men with testosterone deficiency and a concurrent diagnosis of prostate cancer.

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Testosterone Therapy on Active Surveillance and Following Definitive Treatment for Prostate Cancer

Curr Urol Rep Testosterone Therapy on Active Surveillance and Following Definitive Treatment for Prostate Cancer Vishnukamal Golla Alan L. Kaplan Alan L. Kaplan Purpose of Review Previously considered an absolute contraindication, the use of testosterone therapy in men with prostate cancer has undergone an important paradigm shift. Recent data has changed the way we approach the treatment of testosterone deficiency in men with prostate cancer. In the current review, we summarize and analyze the literature surrounding effects of testosterone therapy on patients being treated in an active surveillance protocol as well as following definitive treatment for prostate cancer. Recent Findings The conventional notion that defined the relationship between increasing testosterone and prostate cancer growth was based on limited studies and anecdotal case reports. Contemporary evidence suggests testosterone therapy in men with testosterone deficiency does not increase prostate cancer risk or the chances of more aggressive disease at prostate cancer diagnosis. Although the studies are limited, men who received testosterone therapy for localized disease did not have higher rates of recurrences or worse clinical outcomes. Current review of the literature has not identified adverse progression events for patients receiving testosterone therapy while on active surveillance/watchful waiting or definitive therapies. Prostate cancer; Testosterone replacement therapy; Hypogonadism; Active surveillance; Testosterone; Testosterone deficiency - Dr. Charles Huggins described the relationship between serum testosterone and prostate cancer more than 70 years ago [1]. It is estimated that testosterone deficiency (TD) affects up to 25% of men over 40 with prevalence increasing significantly with age. Treatment for testosterone deficiency primarily involves exogenous testosterone supplementation via topical gels or liquids, implantable pellets, or injectable preparation. Testosterone therapy affords symptomatic benefits (e.g., increased energy and libido) as well reductions in body mass index (BMI), improved glycemic control and lipid profile, and improvement in bone mineralization and cardiovascular outcomes [2]. Despite growing awareness of the potential health benefits of testosterone therapy for men with TD, those with concurrent or historical prostate cancer are frequently denied exogenous testosterone therapy. Until recently, conventional thinking dictated that testosterone therapy is an absolute contraindication in men with prostate cancer. However, a preponderance of new data has shed light on the significant benefits of testosterone on quality of life and the function of multiple organ systems. As a result, urologists are re-examining these historical assumptions regarding the effect of exogenous androgen on the prostate, especially in men diagnosed with prostate cancer. New data published within the past decade has raised serious doubts about the risk of cancer progression among men with prostate cancer treated with testosterone therapy. However, physicians continue to have deep-seated fears that testosterone therapy can lead to prostate cancer recurrence or even rapid progression in men despite definitive treatment. There are fears that testosterone therapy can even unmask occult prostate cancer. Prostate cancer is the most commonly diagnosed malignancy in men after skin cancer with about 161, 000 new cases every year [3]. At the same time, the propensity for active surveillance has increased in the past decade with surveillance rates quoted as high as 64% at some urological practices [4]. Therefore, it is paramount that we critically evaluate the data on testosterone therapy and prostate cancer. Material and Method We conducted a Medline and PubMed search from 1935 to 2017 to identify all publications related to the use of testosterone in men with prostate cancer, treated or otherwise. Original studies and review articles were included. Key words used for the search were “prostate cancer,” “testosterone replacement therapy,” “hypogonadism,” “active surveillance,” “testosterone,” “testosterone deficiency,” “testosterone therapy,” “radical prostatectomy,” and “radiation therapy.” These historical assumptions date back to the 1940s based on the clinical observations by Dr. Huggins and Dr. Hodges that prostate cancer was androgen dependent and that androgen deprivation resulted in the regression of prostate cancer with a concurrent drop in prostate-specific antigen (PSA). It was their seminal research in men with metastatic prostatic cancer that established the androgen hypothesis: that there is a direct correlation between androgen activity in the body and prostate cancer growth and development. This conclusion led to axiomatic teaching that administration of exogenous testosterone to men with prostate cancer would promote malignant prostate cell proliferation and progression. In a 1935 research study, Kutscher and Wo (...truncated)


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Vishnukamal Golla, Alan L. Kaplan. Testosterone Therapy on Active Surveillance and Following Definitive Treatment for Prostate Cancer, Current Urology Reports, 2017, pp. 49, Volume 18, Issue 7, DOI: 10.1007/s11934-017-0695-6