From the Guidelines
Testosterone replacement therapy (TRT) can be safe for testicular cancer survivors, but requires careful medical supervision and individualized assessment, as supported by the most recent evidence 1.
Key Considerations
When considering TRT for testicular cancer survivors, several key factors must be taken into account:
- Cancer remission must be confirmed before initiating TRT.
- Survivors should have documented testosterone deficiency with associated symptoms such as fatigue, decreased libido, or depression.
- Comprehensive evaluation including hormone level testing (morning total testosterone, free testosterone, LH, FSH), prostate-specific antigen (PSA) testing, and complete blood count should be performed before starting TRT.
TRT Options and Monitoring
Typical TRT options include:
- Injectable testosterone cypionate or enanthate (50-200mg every 1-2 weeks).
- Daily transdermal gels (AndroGel, Testim 50-100mg).
- Testosterone pellets implanted every 3-6 months. Regular monitoring is essential, with testosterone levels, complete blood count, liver function, and PSA checked at 3,6, and 12 months after starting therapy, then annually, as recommended by 1 and 1.
Contraindications and Precautions
TRT is contraindicated in men with:
- Active prostate cancer.
- Elevated PSA.
- Severe lower urinary tract symptoms.
- Erythrocytosis.
- Unstable cardiovascular disease. Careful consideration of fertility goals is also necessary, as TRT can suppress sperm production, as noted in 1 and 1.
From the FDA Drug Label
INDICATIONS AND USAGE Testosterone cypionate injection is indicated for replacement therapy in the male in conditions associated with symptoms of deficiency or absence of endogenous testosterone. Primary hypogonadism (congenital or acquired)-testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome; or orchidectomy.
PRECAUTIONS General: Patients with benign prostatic hypertrophy may develop acute urethral obstruction.
Carcinogenesis: Animal data Testosterone has been tested by subcutaneous injection and implantation in mice and rats. The implant induced cervical-uterine tumors in mice, which metastasized in some cases.
The FDA drug label does not answer the question.
From the Research
Safety of Testosterone Replacement Therapy in Testicular Cancer Survivors
- The safety of testosterone replacement therapy (TRT) in testicular cancer survivors is a topic of ongoing research, with some studies suggesting that it may be beneficial for certain patients, while others raise concerns about its efficacy and potential risks 2, 3.
- A randomized double-blind trial published in 2022 found that TRT did not improve symptoms of anxiety and depression, sexual function, fatigue, and overall quality of life in testicular cancer survivors with mild Leydig cell insufficiency compared to placebo 2.
- A systematic review published in 2024 found that testosterone replacement may be beneficial in patients with impaired quality of life metrics, metabolic factors, and bone mineral density at baseline, but routine supplementation for all individuals in this patient population lacks efficacy 3.
- Another study published in 2021 found that hypogonadism is prevalent among male cancer patients and survivors, and that TRT may have potential benefits for hypogonadal male cancer survivors and those with advanced cancer, but further studies are needed to elucidate the role of TRT 4.
- A review of clinical considerations for TRT published in 2024 found that the benefits of this therapy outweigh the risks and result in overall increased quality of life and remission of symptoms related to hypogonadism, but carefully designed clinical trials are warranted for the investigation of TRT in symptomatic age-related hypogonadism 5.
- A systematic review and meta-analysis published in 2016 found that standard chemotherapy, non-conventional therapy, and infradiaphragmatic radiotherapy are associated with an increased risk of testosterone deficiency in testicular cancer patients compared to orchiectomy alone 6.
Potential Risks and Benefits
- The potential benefits of TRT in testicular cancer survivors include improved libido, muscle mass, cognition, and quality of life 5.
- The potential risks of TRT include an increased risk of polycythemia, benign prostate hypertrophy, prostate cancer, gynecomastia, testicular atrophy, and infertility 5.
- The risk of testosterone deficiency appears to be highest in patients treated with non-conventional therapy 6.
Current Evidence and Gaps
- The current evidence on the safety and efficacy of TRT in testicular cancer survivors is limited, and further studies are needed to fully understand its potential benefits and risks 2, 3, 4.
- There is a need for carefully designed clinical trials to investigate the role of TRT in symptomatic age-related hypogonadism and to elucidate the potential benefits and risks of TRT in testicular cancer survivors 5.