Testosterone Therapy After Radical Prostatectomy: Can This Patient Resume?
No, this patient should not resume testosterone therapy at this time because his PSA is detectable (0.04 ng/mL) and rising from a previous level of <0.06 ng/mL, which indicates possible biochemical recurrence and represents an absolute contraindication to testosterone replacement. 1
Critical PSA Considerations
The fundamental requirement for testosterone therapy after radical prostatectomy is an undetectable PSA that remains stable. 1 This patient fails this criterion on two counts:
- His PSA is detectable at 0.04 ng/mL, when it should be undetectable (typically <0.01-0.02 ng/mL depending on assay sensitivity) 1
- His PSA appears to be rising (from <0.06 previously to 0.04 now suggests measurement variability, but any detectable PSA warrants concern) 2
After radical prostatectomy, PSA should become undetectable within 8 weeks post-surgery given the 2-3 day half-life of PSA. 2 Any detectable PSA, particularly 20 years post-surgery, raises concern for:
- Residual benign prostatic tissue at surgical margins (less likely after 20 years)
- Biochemical recurrence of prostate cancer (more concerning)
Biochemical Recurrence Definition
Biochemical failure after radical prostatectomy is defined as PSA ≥0.2 ng/mL confirmed on repeat testing, or PSA ≥0.4 ng/mL at minimum 1 month after surgery confirmed by subsequent rising values. 2 While this patient's PSA of 0.04 ng/mL doesn't yet meet the strict definition of biochemical recurrence, the presence of any detectable PSA disqualifies him from testosterone therapy consideration. 1
Mandatory Prerequisites for Testosterone Therapy
Before any consideration of testosterone therapy in prostate cancer survivors, the following must be documented: 1
- Favorable surgical pathology: negative surgical margins, negative seminal vesicles, negative lymph nodes 1
- Undetectable PSA postoperatively that remains stable 1
- No high-risk features: no high-grade disease, no positive lymph nodes 1
- Adequate time from surgery with documented cure
Monitoring Protocol If PSA Were Undetectable
Even if this patient had an undetectable PSA, the monitoring requirements would be stringent: 1
- PSA monitoring on the same schedule as men without testosterone deficiency, with consideration for more frequent testing 1
- More aggressive biopsy thresholds: PSA increase >1.0 ng/mL in first 6 months or >0.4 ng/mL per year thereafter warrants urologic evaluation 1, 2
- Regular hematocrit monitoring (intervention at >54%) 1
Evidence Quality and Informed Consent
The 2018 AUA Guideline explicitly states that available studies are underpowered and of too short duration to detect effects attributable to testosterone therapy. 1 The evidence base remains insufficient to quantify the true risk-benefit ratio. 1
Patients must be informed that there is inadequate evidence to quantify the risk-benefit ratio, and theoretical concern exists that testosterone may accelerate growth of occult residual cancer cells. 1, 2
Recommended Next Steps
- Repeat PSA measurement using the same assay at the same laboratory to confirm the value and establish trend 2
- Calculate PSA doubling time if serial values show rising trend (requires minimum 3 PSA values over 3 months with ≥4 weeks between measurements) 2
- Refer to urology for evaluation of detectable/rising PSA before any consideration of testosterone therapy 2
- Consider prostate bed imaging (MRI or PET/CT) if PSA continues to rise 2
Common Pitfall to Avoid
Do not assume that a "low" PSA value (like 0.04 ng/mL) is safe for testosterone initiation simply because it's below the 0.2 ng/mL biochemical recurrence threshold. The requirement is undetectable PSA, not just "low" PSA. 1 Any detectable PSA after radical prostatectomy represents either residual disease or recurrence and contraindicates testosterone therapy.