Wednesday, April 22, 2015

Is Testosterone Replacement Therapy "Feeding the Fire" of Prostate Cancer?

Testosterone replacement therapy (TRT) is the administration of testosterone to men with abnormally low testosterone, termed hypogonadism, or "low T," Men with symptoms of low testosterone, can often benefit from TRT. Common symptoms of hypogonadism in post-pubertal men commonly include decreased muscle mass, decreased energy, depressed mood, decreased libido, decreased spontaneous erections, and erectile dysfunction [Wang et al., 2008, Basaria, 2014].

While TRT has been used for decades the last decade has seen a dramatic increase in the use of TRT. The percentage of men in the Unites States over 40 years of age prescribed TRT increased from less than 1% in 2001 to nearly 3% in 2011 [Baillargeon et al., 2013]. The increase in TRT and lack of data from large, long term randomized controlled trials (RCT) has raised concern for unrecognized adverse health risks, including potential increases in cardiovascular disease and prostate cancer (PC).

Changes in androgen use over time. From Baillargeon et al., 2013.

There is large body of both historic and modern data supporting a role for androgens in PC pathogenesis and progression.

In 1941, Huggins and Hodges proposed that PC growth was driven by androgens, after observing benefits of castration in PC patients [Huggins et al., 1941]. Current laboratory data demonstrate that many PC cell lines depend on testosterone for growth and spread.  [Kyprianou et al., 1990, Webber et al., 1996, Schwab et al., 2000]. In animal models, testosterone promotes PC tumor growth [Bladou et al., 1996, Ahmad et al., 2008].

The data supporting the androgen hypothesis has led to the dogma that TRT in PC patients is like "feeding the fire." Historically, there is data supporting this concept. In 1982 Fowler et al. reported on 52 men with metastatic PC patients who recieved testosterone. 38% of men had elevations in prostatic acid phosphatase (a blood test used to monitor PC), 2 men had measurable metastatic progression, and ther were 4 deaths [Fowler et al., 1982]. Importantly, these patients had advanced disease, and many had prior androgen deprivation [Fowler et al., 1982]. Thus, it would not be appropriate to apply these observations to men with clinically localized disease who receive early primary treatment and PSA monitoring.


There is currently no reliable data indicating an increase in PC in men without PC undergoing TRT.

The majority of studies on TRT and PC are small, and to date, there have been no prospective studies on TRT with sufficient patient numbers to determine increased PC risk. By one estimate, 6,000 patients receiving 5 years of TRT would be needed to detect a 30% increase in PC incidence [Bhasin et al., 2003]. In a systematic review of 40 prospective studies, there was no study which demonstrated an association between TRT and PC risk in men without prior PC. In addition, a meta-analysis of 19 studies, there was no significant increase in PC or significant PSA increases necessitating prostate biopsy. [Calof et al., 2005].


TRT in patients with localized PC appears safe, based on limited data

Using Medicare data, Kaplan and colleagues reported on 149,354 men, including 1,181 men who received TRT after a diagnosis with PC. Overall, TRT was not associated with PC deaths [Kaplan et al., 2014]. Similarly, Pastuszak and colleagues reported on 103 men who after prostatectomy were treated with TRT. There was an overall increase serum PSA, but no evidence of increased cancer recurrence over 36 months [Pastuszak et al., 2013]. In a smaller study, Morgentaler et al. examined 13 patients with untreated PC, enrolled in an active surveillence program and receiving TRT. After a median follow-up of 2.5 years, 2 men had worse pathology on subsequent biopsy, but no cases of disease or PSA progression were seen [Morgentaler et al., 2011].



Overall, there remains no clear answer to the question "Does testosterone promote prostate cancer development in humans?" Thus, TRT in men with prostate cancer remains controversial. There is clear evidence that androgens can promote PC in animal models. It is clear that the influence of testosterone on PC disease progression is of paramount importance to both patients and providers as they weight the potential benefits of TRT. Currently, there is a growing amount of evidence that TRT is safe in well-selected men with clinically localized PC. However, these results are based on TRT in a small number of patients. Furthermore, the heterogeneity in PC progression and aggressiveness may give rise to heterogeneity in the responsiveness of tumors to TRT. Thus, until the results of future RCTs are available, TRT should only be offered to select patients who are carefully monitored and well-informed about the potential risks and benefits.


This blog was written by Jason E. Michaud M.D., Ph.D., urology resident at the Brady Urological Institute, currently in his laboratory research year.



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