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Testosterone replacement therapy: Safe and maybe even protective

Presented by
Prof. Thomas Ahlering, Dr Maxwell Towe, Ribeiro Morgado
EAU 2019
There was an exciting plenary debate on the safety of testosterone therapy after curative treatment of prostate cancer between Dr John Mulhall (Memorial Sloan Kettering Cancer Center, USA) and Prof. Bertrand Tombal (Catholic University Leuven, Belgium). The final conclusion from both speakers was that testosterone therapy is probably safe to give to certain patients with confirmed signs and symptoms of hypogonadism, even if they have been treated for prostate cancer with curative intent.

In the largest such study so far undertaken, Prof. Thomas Ahlering (University of California at Irvine, USA) presented a study where patients were selected for testosterone replacement after primary treatment of prostate cancer with robotic radical prostatectomy, in hopes of improving recovery of sexual function. You can watch Prof. Ahlering perform this surgery, streamed live on 29 January 2019 [online 1]. Patients (n=834) undergoing radical prostatectomy were included; a subset of 152 low-risk patients with no evidence of disease were treated with testosterone replacement therapy. After a median of 3.1 years following surgery, they tested the patients for biochemical recurrence of the cancer, as indicated by measurement of the Prostate Specific Antigen levels. They found that the cancer had recurred in only approximately 5% of treated patients, whereas the cancer had recurred in 15% of the patients who did not receive testosterone. Overall, after accounting for differences between the groups, they found nearly a 3-fold reduction by 3 years. Dr Maxwell Towe (University of California at Irvine, USA) followed up with his data that in hypogonadal men, treatment with testosterone was associated with longer time to recurrence and delayed disease progression compared with standard management.

Prof. Ahlering commented, “This is not what we set out to prove, so it was a big surprise: not only did testosterone replacement not increase recurrence, but it actually lowered recurrence rates. While the testosterone is not curing the cancer per se, it is slowing the growth of the cancer, giving an average of an extra 1.5 years before traces of cancer can be found. We already know that testosterone can help with physiological markers such as muscle mass, better cholesterol and triglyceride levels, and increased sexual activity, so this seems to be a win-win”.

The abstract from Ribeiro Morgado et al. (Centro Hospitalar de São João, Portugal) examined the cost-effectiveness of screening for testosterone deficiency which is now done step-wise. Their analysis conclusively showed that omitting this step-wise approach and performing a full-screening of the hormonal axis at the very beginning when you have a symptomatic patient is more cost-effective; this study is expected to lead to a change in the EAU Guidelines recommendations.

Figure: Ball and stick model of the testosterone molecule

  1. https://www.broadcastmed.com/urology/8834/videos/robot-assisted-radical-prostatectomy-rarp

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