Testosterone Replacement Therapy (TRT) After Prostate Cancer Diagnosis

For nearly 50 years the medical profession has had the opinion that men with prostate cancer or at risk for prostate cancer should avoid testosterone as it was like adding gasoline to a fire. Well, that assumption has been reversed and there are certain men with prostate cancer who have symptoms of low testosterone, such as lethargy, falling asleep after meals, loss of muscle mass, and decreased libido, and who have documented low blood testosterone levels.
Testosterone replacement therapy (TRT) might be suitable for men with hypogonadism who also have a history of prostate cancer, but more research is needed, according to a group of Canadian and American scientists.

Typically, TRT is not considered for this population because exogenous testosterone is believed to stimulate the growth of prostate cancer cells. However, recent research has suggested that TRT might be safe for these men. Still, these studies have been small and the safety of TRT is still questioned.
This study took another look at this issue. Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the researchers examined the prostate cancer-specific outcomes, disease-specific survival, and overall survival information for 149,354 men with prostate cancer. The men’s median age was 73 years. Less than one percent of the men (1,181) underwent TRT after their cancer diagnosis.

Testosterone was administered via injections or subcutaneous pellets. Men on TRT underwent a median of 8 years of follow up; for men who did not take testosterone, the follow-up median was 6 years. TRT was more common among men who had had radical prostatectomy and those who had well-differentiated tumors. TRT was less common among men on watchful waiting or active surveillance protocols.

Overall and cancer-specific mortality rates were higher among men who were not on TRT. Also, TRT was not associated with higher rates of salvage androgen deprivation therapy.
The researchers noted the following:
• TRT did not appear to raise the rates of overall or cancer-specific mortality. In fact, the men taking testosterone had fewer mortality events than those who were not on TRT. The researchers were not certain why this occurred and noted the need for more follow-up.
• The percentage of men using TRT was low and declined over time. In 1992, 1.24% of the men underwent TRT after prostate cancer diagnosis. By 2006, that rate fell to 0.40%. In contrast, the researchers pointed out that the prevalence of hypogonadism, for which TRT is often prescribed, is much higher, ranging from 2.1% to 25%, depending on the parameters used.
• Income and educational status were factors in TRT use. “Seemingly, educated young men of means are more likely to either seek out, be offered, or accept TRT than other men,” wrote the study authors.
They added, “As the effects of hypogonadism intensify with age, and as our understanding of hypogonadism and testosterone deficiency expands, improved access to testosterone replacement will be important for older, low-socioeconomic (SES) men with prostate cancer, should further studies corroborate TRT safety.”
In light of these results, the researchers concluded that TRT could be safe for men after prostate cancer diagnosis. However, they stressed the need for prospective studies to confirm their findings.

The study was published online in January in the Journal of Sexual Medicine.

Bottom Line: There are times when it is necessary to challenge old ideas and assumptions. This certainly applies to testosterone replacement therapy and men with prostate cancer. If a man has a stable PSA after treatment for localized prostate cancer, has symptoms of low testosterone, and a documented decrease in the blood testosterone levels, then hormone replacement therapy may be helpful.

Resources
The Journal of Sexual Medicine
Kaplan, Alan L., MD
“Testosterone Replacement Therapy Following the Diagnosis of Prostate Cancer: Outcomes and Utilization Trends”
(Full-text. First published online: January 21, 2014)
http://onlinelibrary.wiley.com/doi/10.1111/jsm.12429/full

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