From the Guidelines
Testosterone Replacement Therapy (TRT) does not appear to exacerbate prostate cancer growth in most cases, contrary to previous medical beliefs. Current evidence suggests that men with a history of prostate cancer who have undergone successful treatment may safely use TRT under careful monitoring 1. For men considering TRT after prostate cancer treatment, it's typically recommended to wait until PSA levels have remained stable for at least 1-2 years post-treatment. Common TRT formulations include testosterone cypionate or enanthate injections (50-200mg every 1-2 weeks), transdermal gels (AndroGel, Testim, 50-100mg daily), or pellets (implanted every 3-6 months). Regular monitoring is essential, including PSA testing every 3-6 months and digital rectal exams 1. The biological reasoning behind this updated understanding is that prostate cancer growth appears to reach a saturation point with normal testosterone levels, meaning additional testosterone doesn't necessarily fuel further growth. However, each case should be individually assessed, as some high-risk or aggressive cancers may still be sensitive to testosterone. Men with active, untreated prostate cancer should generally avoid TRT until their cancer is adequately treated.
Some key points to consider when monitoring men on TRT include:
- Baseline blood tests to measure PSA and hematocrit or hemoglobin level, and a digital rectal examination 1
- Follow-up visits at 1-2 months to assess efficacy of treatment, and subsequent monitoring visits at 3-6 month intervals for the first year and yearly thereafter 1
- Assessment of symptomatic response to treatment, voiding symptoms, and sleep apnea at each visit 1
- Physical examination, including digital rectal examination, and blood tests to measure serum testosterone and PSA levels and hematocrit or hemoglobin level at each visit 1
It's also important to note that there is no universal agreement regarding target levels of replacement therapy, although many experienced clinicians aim for the mid- to upper-normal range in order to optimize the response to treatment 1. Treatment to raise levels above the physiologic range is discouraged, although it should be recognized that peak serum testosterone levels generally do rise transiently above the upper limit of normal with standard injection-therapy dosages 1.
In terms of monitoring for prostate cancer, men who present with an abnormal result on digital rectal examination or elevated PSA level should have a documented negative result from a prostate biopsy before testosterone-replacement therapy is initiated 1. For men with normal digital rectal examinations and PSA levels, there are various approaches to monitoring, including reserving prostate biopsy for those who have an abnormal digital rectal examination or a PSA level above 4.0 ng per milliliter during the course of treatment, or monitoring for a rapid rise in PSA levels, even at levels below 4.0 ng per milliliter, which may be associated with prostate cancer 1.
From the FDA Drug Label
Men with carcinoma of the breast or known or suspected prostate cancer. (4,5.1) The FDA drug label does not answer the question.
From the Research
Testosterone Replacement Therapy and Prostate Cancer Growth
- The relationship between Testosterone Replacement Therapy (TRT) and prostate cancer growth is a topic of ongoing debate, with some studies suggesting that TRT may not pose an increased risk of prostate cancer growth 2, 3, 4.
- A study published in 2006 found that TRT does not appear to increase the risk of prostate cancer growth in men with or without a prior history of prostate cancer, with a cancer rate of approximately 1% in TRT trials 2.
- Another study published in 2006 noted that while there is a theoretical association between TRT and the initiation, progression, and aggressiveness of prostate cancer, the link has not been uniformly studied and any results have been contradictory and nonconclusive 3.
- A 2020 case report found that six patients with high-risk prostate cancer who received TRT after high dose-rate brachytherapy and androgen deprivation therapy did not experience disease recurrence or progression during TRT, with slight increases in PSA within the normal range 5.
- A 2009 review of the literature found that numerous smaller clinical trials and population-based longitudinal studies consistently fail to support the idea that T therapy poses an increased risk of prostate cancer or exacerbation of symptoms due to benign prostatic hyperplasia, and that low serum T is associated with greater prostate cancer risk 4.
- A 2003 study found that men with high-grade prostatic intraepithelial neoplasia (PIN) who received TRT for 1 year did not have a greater increase in PSA or a significantly increased risk of cancer than men without PIN 6.
Key Findings
- TRT may not increase the risk of prostate cancer growth in men with or without a prior history of prostate cancer 2, 4.
- The link between TRT and prostate cancer growth is not uniformly studied and results have been contradictory and nonconclusive 3.
- Regular monitoring for prostate cancer is recommended for men undergoing TRT 2, 4.
- TRT may be beneficial and safe for men with high-risk prostate cancer who have undergone high dose-rate brachytherapy and androgen deprivation therapy 5.