Is it safe for men with a history of prostate cancer to take testosterone supplements?

Testosterone Supplements and Prostate Cancer

Testosterone therapy can be considered in men with a history of prostate cancer who have been appropriately treated, though caution is warranted and decisions should be made on a case-by-case basis with careful monitoring. 1

Safety of Testosterone Therapy in Men with Prostate Cancer History

Current Evidence

• There is no compelling evidence that testosterone therapy increases the risk of developing prostate cancer in men without a history of the disease 1
• Men who have been treated for prostate cancer and are considered "cured" may be candidates for testosterone therapy, though this remains an area of active debate 1
• The 2024 European Association of Urology guidelines state that men who received radical curative therapy for prostate cancer do not have worse outcomes when receiving testosterone supplementation 1

Recommendations Based on Treatment Status

Post-Radical Prostatectomy

• Testosterone therapy can be considered in men who have undergone radical prostatectomy with favorable pathology (negative margins, negative seminal vesicles, negative lymph nodes) and who have undetectable PSA postoperatively 1
• Limited data show no significant increases in prostate cancer recurrence in men treated with testosterone compared to controls 1, 2

Post-Radiation Therapy

• Studies evaluating testosterone therapy in men treated with radiation therapy suggest that patients do not experience recurrence or progression of prostate cancer 1
• These patients typically experience either a steady decline in PSA values to <0.1 ng/mL or non-significant changes in PSA 1

Active Surveillance

• Limited data exist on men on active surveillance who receive testosterone therapy 1
• Available literature indicates that patients with and without high-grade prostatic intraepithelial neoplasia on testosterone therapy did not experience significant increases in PSA or subsequent cancer diagnosis compared to men not receiving testosterone 1, 3

Monitoring Recommendations

PSA Monitoring

• Prostate cancer patients on testosterone therapy should have their PSA levels monitored on the same schedule as men without testosterone deficiency 1
• Clinicians may choose to increase the frequency of testing in these patients 1
• PSA recurrence should be evaluated in the same fashion as in untreated men 1

Baseline and Follow-up Evaluations

• Before starting therapy: Perform digital rectal examination, PSA testing, and determine baseline voiding history 1
• Follow-up: Monitor every 3-6 months for the first year and annually thereafter 1
• Perform prostate biopsy if digital rectal examination shows change or if there is a substantial increase in PSA 1

Important Caveats and Limitations

• The FDA labels testosterone as contraindicated in men with known or suspected prostate cancer 4
• Currently available studies are underpowered and of too short duration to definitively establish long-term safety 1
• Testosterone therapy in men with locally advanced or metastatic disease remains poorly understood and should ideally be performed under research settings 1
• Patients should be informed that there is inadequate evidence to quantify the risk-benefit ratio of testosterone therapy in men with a history of prostate cancer 1

Decision Algorithm for Testosterone Therapy in Men with Prostate Cancer History

1. Assess cancer status and treatment history:

   • Radical prostatectomy with favorable pathology and undetectable PSA: May consider therapy 1
   • Radiation therapy with stable or declining PSA: May consider therapy 1
   • Active surveillance for low-risk cancer: Consider with extreme caution 1
   • Locally advanced or metastatic disease: Not recommended outside research settings 1

2. Before initiating therapy:

   • Perform digital rectal examination 1
   • Measure baseline PSA 1
   • If PSA is elevated or DRE is abnormal, perform prostate biopsy before considering testosterone 1

3. During therapy:

   • Monitor PSA and perform DRE every 3-6 months for the first year, then annually 1
   • Consider more frequent monitoring in men with history of prostate cancer 1
   • If PSA rises significantly or DRE changes, consider stopping therapy and perform prostate biopsy 1

4. Patient counseling:

   • Discuss the limited evidence regarding safety 1
   • Explain that the decision involves weighing potential benefits against theoretical risks 1
   • Emphasize the importance of regular monitoring 1