Good News for Low-Risk Prostate Cancer Patients from a Study Changing Views on Testosterone

The almost 80-year-old conventional view that testosterone is the most important driver of prostate cancer cells has taken a serious blow from a study showing that testosterone replacement therapy (TRT) significantly improved outcomes for some men undergoing robot-assisted radical prostatectomy.

This information comes from a study of patients undergoing radical prostatectomy as their main prostate cancer treatment, involving 824 patients. A group with low preoperative free testosterone levels, consisting of 152 patients, received testosterone replacement therapy (TRT) to improve sexual function after surgery.

To their surprise, researchers found that this group had less biochemical disease recurrence within 1 year after surgery (an increase inPSA ). Moreover, compared with standard treatment, testosterone use delayed cancer recurrence (return) and progression (worsening).

The findings directly contradict a dogma dating back to the 1940s: "You do not give testosterone to men with prostate cancer!"

The concern has been that testosterone accelerates prostate cancer cell growth; standard prostate cancer treatment, in fact, aims to lower testosterone through “chemical castration” by suppressing androgens.

Study researcher Maxwell Towe “We need to expand the growing evidence that testosterone replacement is safe and probably beneficial for patients whose testosterone levels were low before surgery,” said.

Clearly, for the idea of testosterone replacement therapy, selecting the right patients is vital, but if confirmed, it could have substantial quality-of-life benefits. The possibility of reducing mortality would be an unexpected bonus.

The study was presented at the European Association of Urology (EAU) 2019 Congress.

In an interview before the meeting, Prof. Dr. Thomas Ahlering explained the rationale for the study:

"It all began when we realized that the sexual lives of the patients I was seeing were very poor. I began investigating why, and from 2009 onward, measuring everyone’s total and free testosterone." he said.

Ahlering explained that free testosterone is the bioactive form of the hormone. He and colleagues also demonstrated that low free testosterone is an independent risk factor for high-grade prostate cancer.

Reduce Testosterone or Keep It at Normal Levels?

Giving testosterone to men with prostate cancer was, according to Dr. Huggins, pioneer of hormonal therapy for prostate cancer and recipient of the 1975 Nobel Prize in Physiology or Medicine, like pouring gasoline on a fire .

However, in recent years Ahlering and his team and other researchers have found evidence suggesting that testosterone replacement may be safe for some men, particularly those who are hypogonadal and have low-risk disease at surgery. Advocates say it is more than safe: it is beneficial, increasing muscle mass, improving lipid profiles, and enhancing libido and sexual performance. Ahlering "This looks like a win-win." said. 

• Related Topic: 5 Things Cancer Patients and Their Partners Should Know About Sexuality

Study Details

Researchers followed 824 patients undergoing robotic radical prostatectomy as the main treatment for prostate cancer. Preoperative testosterone and sex hormone-binding globulin levels were determined for all patients; free testosterone levels were followed prospectively (forward-looking).

Approximately one-fifth of these men (152 patients, %18) had low free testosterone before surgery and received testosterone to improve postoperative sexual function. They remained in the testosterone replacement group throughout follow-up or until biochemical recurrence (a PSA rise).

After a median follow-up of 3.1 years, researchers reported a result that surprised them greatly: those receiving testosterone had a relative biochemical recurrence risk that was %53 lower .

In addition, in a secondary analysis of time to biochemical recurrence, testosterone treatment prolonged the time to cancer recurrence by a median of 1.5 years.

Towe said, “Our hope is to take this into a randomized clinical trial so that we can effectively test the hypothesis that testosterone replacement therapy will help men with prostate cancer.” he said.

A urological surgeon not involved in the study said the findings reflected what he had seen in his patients: “We have seen that patients with hypogonadism (low testosterone levels) have a worse cancer prognosis (disease course) because they have high-grade cancers, and prospectively, patients with a poor prognosis have more biochemical recurrences,” he said.

• Related Topic: Testosterone Deficiency: Symptoms, Treatment, Andropause, and Prostate Cancer

Comment

In conclusion, for a disease such as prostate cancer, in which most patients are now diagnosed early and 5-year survival rates reach %95, quality of life and sexual function cannot be ignored. Although testosterone acts as a growth factor for prostate cancer cells and male hormone-suppressing treatments hold an important place in prostate cancer care, patients with low testosterone at diagnosis may be appropriate candidates for testosterone replacement after primary treatment to improve quality of life.