From the Guidelines
Testosterone Replacement Therapy (TRT) is not absolutely contraindicated in all patients with a history of prostate cancer, though it requires careful consideration. When considering TRT in patients with a history of prostate cancer, it is essential to weigh the potential benefits against the risks, prioritizing morbidity, mortality, and quality of life as outcomes. According to the study by 1, there is no compelling evidence that testosterone has a causative role in prostate cancer, and proper monitoring with measurement of PSA and digital rectal examination can promote early diagnosis and potential cure of most "unmasked" prostate cancers identified during testosterone treatment.
Key considerations for TRT in patients with a history of prostate cancer include:
- A waiting period of 1-2 years following treatment with no evidence of recurrence
- Normal PSA level before initiating TRT
- Close monitoring with regular PSA testing every 3-6 months and digital rectal examinations
- Shared decision-making between the patient and healthcare providers, including both a urologist and endocrinologist
- Selecting patients who have been successfully treated for prostate cancer and are in remission
TRT options for these patients may include:
- Injectable testosterone cypionate or enanthate (50-200mg every 1-2 weeks)
- Daily transdermal gels (50-100mg)
- Testosterone pellets (implanted every 3-6 months)
It is crucial to note that the historical concern about testosterone accelerating prostate cancer growth was based on observations that androgen deprivation therapy slows prostate cancer progression. However, more recent evidence, as discussed in 1, suggests that physiologic testosterone levels may not promote cancer recurrence in properly selected patients who have been effectively treated, though caution is still warranted in high-risk cases or with aggressive cancer histories.
From the Research
Testosterone Replacement Therapy (TRT) in Prostate Cancer Patients
- TRT has historically been contraindicated in men with a history of prostate cancer due to the theoretical risk of progression based on the dogma of hormone-dependent prostate cancer 2, 3.
- However, recent evidence suggests that there is minimal or no prostate cancer growth in the setting of TRT administration in men definitively treated for non-metastatic prostate cancer 4, 3.
- Studies have shown that TRT does not pose any increased risk of prostate cancer growth in men with or without prior treatment, and that severely hypogonadal levels of testosterone may lead to worse oncological outcomes 4, 2.
Safety and Efficacy of TRT in Prostate Cancer Patients
- Available literature provides evidence for the safe application of TRT in patients previously treated for prostate cancer with either radical prostatectomy or radiotherapy 4.
- TRT likely has a role in improved erectile function and other quality-of-life concerns in patients developing testosterone deficiency after being treated for prostate cancer 4, 5.
- Monitoring with prostate-specific antigen (PSA) and digital rectal examination at regular intervals is recommended for patients receiving TRT after prostate cancer treatment 2, 6.
Current Recommendations and Future Directions
- TRT should be offered to select hypogonadal patients who have a history of definitively treated prostate cancer, with careful monitoring and consideration of individual patient risk factors 4, 3.
- Adequately designed randomized controlled trials are necessary to confirm the safety and efficacy of TRT in this population 4, 6.
- The optimal population eligible for TRT after prostate cancer treatment is still being determined, and further research is needed to fully understand the benefits and risks of TRT in prostate cancer patients 5.