Urology
Written by Larry I Lipshultz MD Written by Nannan Thirumavalavan MD
The authors of this work presented a nice abstract demonstrating that testosterone therapy may improve outcomes in patients with low-risk prostate cancer after radical prostatectomy. The traditional teaching has been that patients with any history of prostate cancer cannot have testosterone therapy, as therapy could “worsen” prostate cancer. However, recent trends have questioned this “dogma” and documented that it is safe to treat hypogonadal patients with a history of prostate cancer.1-3 This work by Dr. Ahlering is the first to suggest an oncologic benefit for these patients.
The authors, from University of California, Irvine, performed a retrospective chart review of 9 years of patients receiving radical prostatectomy, for a total of 834 patients. Overall, 152 patients who had “low-risk” disease and were hypogonadal were treated with testosterone therapy, and PSA was periodically measured after surgery (median 3.1 years). Biochemical recurrence occurred in approximately 5% of the patients treated with testosterone, whereas 15% of men not on testosterone therapy had a recurrence. Overall, therapy delayed recurrence by 1.5 years.
Though these data are promising, future prospective data are required to validate these findings. Should they be confirmed, radical changes to how we approach testosterone therapy for hypogonadal men with prostate cancer may be warranted.
References
1.Pastuszak AW, Pearlman AM, Lai WS, et al. Testosterone replacement therapy in patients with prostate cancer after radical prostatectomy. J Urol. 2013;190(2):639-644. auajournals.org/doi/10.1016...
2.Pastuszak AW, Khanna A, Badhiwala N, et al. Testosterone therapy after radiation therapy for low, intermediate and high risk prostate cancer. J Urol. 2015;194(5):1271-1276. auajournals.org/doi/10.1016...
3.Dupree JM, Langille GM, Khera M, Lipshultz LI. The safety of testosterone supplementation therapy in prostate cancer. Nat Rev Urol. 2014;11(9):526-530. nature.com/articles/nrurol....
March 18, 2019—Barcelona, Spain—Testosterone replacement has been found to slow recurrence of low-risk prostate cancer.
This finding of a retrospective review covering a 9-year period was reported at the 34th Annual Congress of the European Association of Urology (EAU), from March 15 – 19.
Thomas Ahlering, MD, of the University of California, Irvine, noted that this finding was surprising because it was not the initial topic of investigation. Testosterone replacement did not increase recurrence, and in fact, it lowered recurrence rates.
According to Dr. Ahlering, the testosterone is not curing the cancer, but is slowing its growth, resulting in an average of 1.5 additional years before cancer can be detected. This is an additional benefit of testosterone, which is known to improve muscle mass, cholesterol and triglyceride levels, and sexual activity.
Dr. Ahlering noted that this is the largest study to suggest that testosterone may not be dangerous for select patients. Although changes to treatment methods are not currently suggested, the taboo against the use of testosterone in low-risk patients following radical prostatectomy should be questioned. The oncology/urology community should consider reviewing the use of testosterone.
Testosterone has long been regarded testosterone as promoting prostate cancer. The dramatic impact of testosterone reduction on prostate cancer was first reported in 1941. Since then, anti-testosterone therapy has become a standard option for a vast number of patients.
In the late 1990s to 2000s, it was discovered that though men on long term anti-testosterone treatments were not dying from prostate cancer, they were dying prematurely of cardiovascular disease.
It seemed that, though anti-testosterone therapies were treating prostate cancer, extremely low testosterone levels were worsening metabolic complications such as elevated blood sugar, diabetes, elevated cholesterol, and mid-abdomen visceral fat significantly.
Low testosterone also caused a loss of sexual function in many men receiving anti-androgen treatment. This led to the suggestion of testosterone treatment in some low-risk men after radiation or surgery.
In 2008, Dr. Ahlering and colleagues began to carefully select patients for testosterone replacement after robotic radical prostatectomy in hopes of improving their recovery of sexual function.
The team worked with 834 patients undergoing radical prostatectomy. They treated 152 low-risk patients with no evidence of disease with testosterone replacement therapy.
After a median of 3.1 years following surgery, they tested patients for biochemical recurrence, as indicated by measurement of the Prostate Specific Antigen (PSA) levels.
They found that the cancer had recurred in only approximately 5% of treated patients. Cancer had recurred in 15% of patients who did not receive testosterone. Overall, after accounting for differences between groups, a nearly a threefold reduction was found.
Francesco Montorsi, MD, of the University Vita-Salute San Raffaele, Milan, noted that these results highlight the importance of evaluating testosterone levels in the management of patients with sexual disorders after radical prostatectomy. If confirmed, immediate quality of life benefits may be realized in optimally selected patients, with an additional possibility of reducing mortality. Larger studies are needed.
Published in Advanced Prostate Cancer and
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