Can testosterone therapy be used in a patient with a history of testicular cancer?

Testosterone Therapy in Patients with History of Testicular Cancer

Testosterone therapy can be safely administered to patients with a history of testicular cancer who demonstrate symptoms of hypogonadism, particularly after the completion of cancer treatment and when there is no evidence of recurrence. 1, 2

Assessment of Hypogonadism in Testicular Cancer Survivors

• Patients with a history of testicular cancer have a higher risk of developing hypogonadism due to:

  • Leydig cell dysfunction, even in the contralateral testis 1
  • Orchidectomy and subsequent treatment effects 1
  • 12-16% of long-term testicular cancer survivors are classified as hypogonadal by laboratory standards 1

• Before initiating testosterone therapy:

  • Monitor for signs and symptoms of hypogonadism 1
  • Measure morning serum testosterone levels if symptoms are present 1
  • Evaluate cardiovascular risk factors 2
  • Measure hemoglobin/hematocrit (testosterone therapy may increase these values) 2

Timing of Testosterone Therapy

• The risk of hypogonadism is greatest at 6-12 months after testicular cancer treatment 1
• There may be some improvement in Leydig cell function after treatment 1
• It is reasonable to delay initiation of testosterone therapy until the patient shows continuous signs or symptoms of testosterone deficiency 1

Monitoring During Testosterone Therapy

• Regular monitoring of:
  • Serum testosterone levels
  • Hemoglobin/hematocrit (intervention required if hematocrit exceeds 54%) 2
  • Cardiovascular risk factors 1
  • Signs of disease recurrence

Benefits and Considerations

• Testosterone therapy may improve:

  • Erectile function
  • Sex drive
  • Bone mineral density
  • Lean body mass
  • Anemia
  • Depressive symptoms 2

• Important considerations:

  • Testosterone therapy can suppress spermatogenesis and may impact fertility 2
  • Patients should be informed about potential fertility implications
  • Sperm cryopreservation should be considered before initiating therapy if fertility is desired 1

Clinical Evidence

• Studies show no evidence that testosterone therapy increases the risk of testicular cancer recurrence 2
• A 2022 randomized double-blind trial showed that testosterone replacement therapy did not significantly improve anxiety, depression, sexual function, fatigue, or overall quality of life in patients with mild Leydig cell insufficiency compared to placebo 3
• However, this study focused on mild cases, and patients with more severe hypogonadism may benefit from therapy

Practical Approach

1. Confirm hypogonadism with morning testosterone levels and presence of symptoms
2. Ensure patient has completed cancer treatment with no evidence of recurrence
3. Discuss fertility implications and consider sperm preservation if relevant
4. Start with standard testosterone replacement dosing as indicated for hypogonadism
5. Monitor for symptom improvement and potential side effects
6. Continue regular testicular cancer surveillance as recommended 1

Caveats

• Testosterone therapy is indicated for replacement therapy in conditions associated with symptoms of deficiency or absence of endogenous testosterone 4, 5
• Patients with testicular cancer history should be monitored for cardiovascular disease risk factors, as they have an elevated risk 1
• The decision to initiate testosterone therapy should be made after ensuring there is no evidence of active disease