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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
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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)