[OA] Testosterone Replacement in a Man with Intermediate-risk Prostate Cancer
In brief, a hypogonadal man with successfully treated localized prostate cancer deserves testosterone therapy (TTh) regardless of grade. The evidence is not conclusive but compelling. The story is different for those with intermediate-risk disease who, for a variety of reasons, need TTh but cannot or elect not to have treatment of their primary malignancy, but still desire androgen supplementation.
These cases are few and far between. For them, evidence for the oncological safety of TTh is tenuous, and outcomes are highly variable. A high degree of familiarity with the issues, circumspection, and thoughtfulness by the treating clinician are mandatory.
The scenario under discussion is a man with untreated intermediate-risk prostate cancer (PCa) and significantly symptomatic hypogonadism. The most current guideline defined the features of intermediate-risk PCa as prostate-specific antigen (PSA) of 10–20 ng/ml or Gleason grade group 2–3 or clinical stage T2b–c and, depending on the clinical staging and grade group, as favorable or unfavorable.
For treatment, the guideline provides without ambiguity a strong recommendation (evidence level grade A) for radical prostatectomy (RP) or radiotherapy with androgen deprivation therapy (ADT). For those with favorable intermediate risk, an alternative option is radiation alone (moderate recommendation; evidence level grade B).
Therefore, the first question is why is this man not considered a candidate for curative treatment before testosterone therapy (TTh)?
If he was treated successfully, he may very well be cured of his PCa and he is clearly a candidate for TTh as long as he presents with a clinical picture of testosterone deficiency (TD) that is further supported by an adequate laboratory evaluation confirming low T levels. TTh can be started shortly after completion of his PCa treatment. After RP, it can begin as soon as the PSA level has reached the nadir.
A more complicated situation occurs if the man is not a candidate for curative treatment (personal choice or contraindications) but his hypogonadism is so severe and disabling that TTh is considered important for his wellbeing and quality of life. Under these circumstances, ethical considerations come into play.
Above all, the patient must be given detailed and realistic information of the anticipated benefits and drawbacks of receiving TTh. He must be made aware of the controversial nature of this approach and the lack of consensus regarding its safety. Well-documented informed consent should be obtained.
Once the above conditions have been fulfilled, both the treating physician and the patient assume dual responsibility for adherence to competent and rigorous monitoring
Morales A. Testosterone Replacement in a Man with Intermediate-risk Prostate Cancer. Eur Urol Focus. http://www.eu-focus.europeanurology.com/article/S2405-4569(17)30161-X/fulltext
In brief, a hypogonadal man with successfully treated localized prostate cancer deserves testosterone therapy (TTh) regardless of grade. The evidence is not conclusive but compelling. The story is different for those with intermediate-risk disease who, for a variety of reasons, need TTh but cannot or elect not to have treatment of their primary malignancy, but still desire androgen supplementation.
These cases are few and far between. For them, evidence for the oncological safety of TTh is tenuous, and outcomes are highly variable. A high degree of familiarity with the issues, circumspection, and thoughtfulness by the treating clinician are mandatory.
The scenario under discussion is a man with untreated intermediate-risk prostate cancer (PCa) and significantly symptomatic hypogonadism. The most current guideline defined the features of intermediate-risk PCa as prostate-specific antigen (PSA) of 10–20 ng/ml or Gleason grade group 2–3 or clinical stage T2b–c and, depending on the clinical staging and grade group, as favorable or unfavorable.
For treatment, the guideline provides without ambiguity a strong recommendation (evidence level grade A) for radical prostatectomy (RP) or radiotherapy with androgen deprivation therapy (ADT). For those with favorable intermediate risk, an alternative option is radiation alone (moderate recommendation; evidence level grade B).
Therefore, the first question is why is this man not considered a candidate for curative treatment before testosterone therapy (TTh)?
If he was treated successfully, he may very well be cured of his PCa and he is clearly a candidate for TTh as long as he presents with a clinical picture of testosterone deficiency (TD) that is further supported by an adequate laboratory evaluation confirming low T levels. TTh can be started shortly after completion of his PCa treatment. After RP, it can begin as soon as the PSA level has reached the nadir.
A more complicated situation occurs if the man is not a candidate for curative treatment (personal choice or contraindications) but his hypogonadism is so severe and disabling that TTh is considered important for his wellbeing and quality of life. Under these circumstances, ethical considerations come into play.
Above all, the patient must be given detailed and realistic information of the anticipated benefits and drawbacks of receiving TTh. He must be made aware of the controversial nature of this approach and the lack of consensus regarding its safety. Well-documented informed consent should be obtained.
Once the above conditions have been fulfilled, both the treating physician and the patient assume dual responsibility for adherence to competent and rigorous monitoring
Morales A. Testosterone Replacement in a Man with Intermediate-risk Prostate Cancer. Eur Urol Focus. http://www.eu-focus.europeanurology.com/article/S2405-4569(17)30161-X/fulltext
