From the Guidelines
Testosterone replacement therapy may be considered in men with low-grade prostate cancer, but only under close monitoring and after a thorough discussion of risks and benefits, as there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy in these patients. For men with low-grade, localized prostate cancer who have severe hypogonadism symptoms, a typical regimen might involve:
- Testosterone gel 1% applied daily (50-100 mg)
- Or testosterone cypionate injections 100-200 mg every 1-2 weeks Therapy should only be initiated after a thorough discussion of risks/benefits, as stated by the American Urological Association (AUA) guideline 1. Patients require regular follow-up with PSA testing every 3-6 months and prostate exams, as recommended by the AUA guideline for PSA monitoring 1. Treatment should be discontinued if there are signs of cancer progression. The rationale is that low-grade prostate cancers are often slow-growing and may not be significantly stimulated by testosterone, as suggested by the AUA guideline 1. However, this remains an area of ongoing research and debate in the medical community, and any testosterone use in prostate cancer patients should be approached cautiously on a case-by-case basis.
The AUA guideline recommends that clinicians inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer 1, and that patients with testosterone deficiency and a history of prostate cancer should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy 1. Additionally, the guideline suggests that the decision to commence testosterone therapy in men with in-situ prostate cancer on active surveillance or previously treated prostate cancer should be made with caution 1.
In terms of monitoring, the AUA guideline recommends that prostate cancer patients on testosterone therapy should have their PSA levels monitored on the same schedule as men without testosterone deficiency, but clinicians may choose to increase the frequency of testing 1. PSA recurrence in men on testosterone therapy should be evaluated in the same fashion as untreated men, and a discussion regarding the benefit of stopping testosterone therapy should include the possibility of a decline in PSA 1.
From the Research
Evidence Supporting Testosterone Therapy in Men with Low-Grade Prostate Cancer
- The use of testosterone therapy in men with prostate cancer is no longer considered an absolute contraindication, as recent evidence suggests that it may be safe in select patients 2, 3, 4, 5, 6.
- Studies have shown that testosterone replacement therapy can provide important symptomatic and overall health benefits for men with prostate cancer who have testosterone deficiency, including improved erectile function and quality of life 2, 4, 6.
- The saturation model suggests that high endogenous androgen levels do not increase the risk of prostate cancer diagnosis, and 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 6.
- Men who received testosterone therapy after treatment for localized prostate cancer do not appear to suffer higher rates of recurrence or worse outcomes, although more studies are needed to confirm these findings 2, 5, 6.
- Testosterone therapy may be a viable option for selected men with prostate cancer suffering from testosterone deficiency, particularly those with low-risk disease or who have been successfully treated for prostate cancer 3, 4, 6.
Key Considerations
- The decision to use testosterone therapy in men with prostate cancer should be made on a case-by-case basis, taking into account individual circumstances and the potential benefits and risks 3, 4.
- Competent initial assessment and follow-up are mandatory to ensure safe use of testosterone therapy in men with prostate cancer 3.
- More research is needed to fully understand the safety and efficacy of testosterone therapy in men with prostate cancer, particularly in those with intermediate or high-risk disease 2, 3, 5.