THE "NEW" PROSTATE CANCER INFOLINK

A new paper just published in the Journal of Urology addresses (again) the controversial issue of whether the use of testosterone replacement therapy (TRT) is appropriate as a management strategy after first-line treatment for hypogonadal patients. As will be well known to many readers of this news blog, the reason that TRT is considered to be controversial in men with a history of prostate cancer is because of the concern that it may stimulate re-growth of the cancer.

Pastuszak et al. have carried out a retrospective review of data from 152 patients managed at their center who fell into one or other of two groups:

• Hypogonadal men who were diagnosed with prostate cancer, treated  by radical prostatectomy, and subsequently treated with testosterone supplementation (Group A, n = 103)
• Non-hypogonadal men who were diagnosed with prostate cancer, treated by prostatectomy, but not subsequently treated with testosterone supplementation (Group B, n = 49)

So that we are quite clear, “hypogonadism” in men is a condition in which the body doesn’t produce enough testosterone, the hormone that plays a key role in masculine growth and development during puberty and that profoundly affects things like vigor, libido, muscle mass, and other factors in males later in life.

The “normal” lower limit of serum T that is used to define hypogonadism is 300 to 375 ng/dl. However, in this particular study the authors included patients who had clear sympotms of hypogonadims, even if their serum T level was > 300 ng/dl. (The highest serum T level of any of the patients defined as hypogonadal in this study was actually 513 ng/dl.)

All patients evaluated in either Group A or Group B had to have one or more “undetectable” levels of PSA post-surgery. The patients were all, also, classified into two risk groups:

• A “non-high” risk group
  • 77 men in Group A were of “non-high” risk.
  • 34 men in Group B were of “non-high” risk.
• A “high” risk group (including men with one or more of the following: pathologic Gleason score ≥ 8, positive surgical margins, or positive lymph nodes)
  • 26 men in Group A were at “high” risk
  • 15 men in Group B were “high” risk

Here are the key results of the retrospective analysis:

• Median follow-up from TRT initiation among men in Group A was 27.5 months (range, 6.2 to 189.3 months).
• Median follow-up after surgery among men in Group B was 16.5 months (range, 1.7 to 77 months).
• There were no significant differences between non-high risk and high risk men in Group A with respect to PSA levels or any serum hormone levels.
• There was a higher occurrence of pT3b tumors among men in Group B compared to men in Group A.
• Among men in Group A
  • There were significant increases in serum T levels at almost all follow-up time points
  • There was a small but statistically significant increase in PSA levels among non-high risk and high risk men at 18-24 months after initiation of TRT.
  • Median PSA velocity was 0.002 ng/ml/yr (range, 0.001 to 0.003 ng/ml/yr).
  • Biochemical disease recurrence was observed in 4/103 patients (3.9 percent).
• Among men in Group B
  • There were no significant increases in PSA levels.
  • Median PSA velocity was 0.0002 ng/ml/yr (range, –0.001 to +0.010 ng/ml/yr).
  • Biochemical disease recurrence was observed in 8/49 patients (16.3 percent).
• All biochemical recurrences occurred among men in the high risk patient subgroups.

The authors are careful, to note that, “the median duration of our follow-up period remains relatively short in the context of the natural history of prostate cancer, and these data may not be representative of longer-term trends.”

The “New” Prostate Cancer InfoLink recognizes that there is a gradually increasing body of evidence to suggest that  TRT may well be safe in the management of carefully selected men previously treated with prostate cancer who have undetectable PSA levels post-treatment. However, we concur with Pastuszak et al. when they point out that:

• Reported global experience with TRT among men treated for prostate cancer is small, with only about 600 patients (many treated in very different ways) evaluated to date.
• At this time, the use of TRT in many with any history of prostate cancer should be conducted under a very rigorous surveillance protocol.

Filed under: Living with Prostate Cancer, Management, Treatment | Tagged: hypogonadism, radical prostatectomy, replacement, risk, surgery, testosterone, TRT |