Why is cancer a contraindication in Testosterone (T) replacement therapy?

From the Guidelines

Cancer is not an absolute contraindication in testosterone replacement therapy (TRT), but it requires careful consideration and monitoring, particularly for men with a history of prostate cancer. The relationship between testosterone and cancer, especially prostate cancer, has been a topic of debate. While it is true that testosterone can stimulate the growth of hormone-sensitive cancers, the evidence suggests that the risk of developing prostate cancer due to TRT is low 1. In fact, a compilation of prospective studies revealed only 5 cases of prostate cancer among 461 men (1.1 percent) followed for 6 to 36 months, a prevalence rate similar to that in the general population 1.

Key Considerations

• Men with active prostate cancer or breast cancer should not receive TRT as testosterone may accelerate tumor growth in these conditions.
• For men with a history of prostate cancer who are in remission, TRT requires careful consideration and is often avoided until they have been cancer-free for a significant period (typically 3-5 years) and show no evidence of recurrence.
• The decision to use TRT in patients with other types of cancer should be individualized based on the specific cancer type, its hormone sensitivity, and consultation with an oncologist.
• Regular monitoring of PSA levels and prostate examinations are essential for men on TRT to detect any potential cancer development early.

Recent Guidelines and Recommendations

The 2015 update of the Endocrine Society clinical practice guidelines for male hypogonadism emphasizes the need for prospective trials addressing men who have been diagnosed as having or having been treated for prostate cancer and their outcomes after TRT 1. This highlights the importance of ongoing research and careful consideration in the management of hypogonadal men with a history of cancer.

Monitoring and Screening

Before initiating TRT, patients should undergo screening including digital rectal examination and PSA testing to rule out existing prostate cancer. This approach allows for the early detection of prostate cancer and the potential for cure if cancer is identified. Regular monitoring is crucial for men on TRT, as it enables the early detection of any potential cancer development, thereby improving outcomes in terms of morbidity, mortality, and quality of life 1.

From the FDA Drug Label

Men with known carcinoma of the breast or known or suspected carcinoma of the prostate. Testosterone gel is contraindicated in men with carcinoma of the breast or known or suspected carcinoma of the prostate [see Warnings and Precautions (5.1)].

Cancer is contraindicated in testosterone replacement therapy because testosterone may worsen or promote the growth of certain types of cancer, such as prostate cancer. The specific types of cancer that are contraindicated include:

• Breast cancer in men
• Prostate cancer in men, including known or suspected cases 2, 2, 2

From the Research

Cancer and Testosterone Replacement Therapy

• Cancer is a complex disease that can be affected by various factors, including hormone replacement therapy 3, 4.
• Testosterone replacement therapy (TRT) is a treatment option for hypogonadism, a condition characterized by low testosterone levels, which is common among cancer patients and survivors 5, 6.
• The use of TRT in cancer patients is a topic of ongoing debate, with some studies suggesting potential benefits for quality of life and morbidity, while others raise concerns about oncologic risks 3, 7.

Contraindications for TRT in Cancer Patients

• Certain types of cancer, such as breast cancer, endometrial stroma sarcoma, and hormone receptor-positive gastric and bladder cancer, are considered contraindications for TRT due to the potential risk of promoting tumor growth 3.
• Other types of cancer, such as prostate cancer, require careful consideration and monitoring when using TRT, as the relationship between testosterone and prostate cancer is complex and not fully understood 7.
• The decision to use TRT in cancer patients should be made on a case-by-case basis, taking into account the individual's specific medical history, cancer type, and overall health status 3, 7.

Risks and Benefits of TRT in Cancer Patients

• The benefits of TRT in cancer patients include improved quality of life, increased energy, and enhanced libido and sexual function 5, 6.
• However, the potential risks of TRT in cancer patients, such as promoting tumor growth or increasing the risk of recurrence, must be carefully weighed against the benefits 3, 7.
• Further research is needed to fully understand the risks and benefits of TRT in cancer patients and to develop evidence-based guidelines for its use in this population 5, 6.