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Testosterone Replacement, Low T, HCG, & Beyond
Prostate Related Issues
Case deliberations: To treat or not to treat with testosterone therapy?
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<blockquote data-quote="madman" data-source="post: 150792" data-attributes="member: 13851"><p><a href="https://eaucongress.uroweb.org/case-deliberations-to-treat-or-not-to-treat-with-testosterone-therapy/" target="_blank">[ATTACH=full]7606[/ATTACH]https://eaucongress.uroweb.org/case-deliberations-to-treat-or-not-to-treat-with-testosterone-therapy/</a> </p><p></p><p></p><p><span style="font-size: 26px"><strong>Case deliberations: To treat or not to treat with testosterone therapy?</strong></span></p><p><strong><span style="color: rgb(184, 49, 47)">18 </span>March <span style="color: rgb(184, 49, 47)">2019</span></strong></p><p></p><p></p><p><strong>Testosterone therapy (TTH) as a plausible treatment for a patient was examined during <span style="color: rgb(184, 49, 47)">“Plenary Session 06: The role of the urologist in sexual and fertility issues of cancer survivorship”</span>, which was chaired by Dr. Maarten Albersen (BE) and Prof. Jens Sønksen (DK).</strong></p><p></p><p><strong>Moderator Assoc. Prof. Ege Can Şerefoğlu (TR) defined the patient case scenario and set the stage for the deliberations.</strong></p><p></p><p></p><p></p><p></p><p></p><p></p><p><strong>The case</strong></p><p><strong><span style="color: rgb(184, 49, 47)">The patient is a</span> <span style="color: rgb(184, 49, 47)">58-year old male suffering from prostate cancer (PCa) with a PSA level of 7.6 ng/mL. </span><span style="color: rgb(44, 130, 201)">He underwent transrectal ultrasound (TRUS) guided biopsy</span>, <span style="color: rgb(184, 49, 47)">which revealed that he had a Gleason score of 3 + 3 PCa. </span>At that time, he reported no erectile dysfunction (ED).</strong></p><p></p><p><strong><span style="color: rgb(44, 130, 201)">The patient underwent</span> <span style="color: rgb(44, 130, 201)">robotic-assisted radical prostatectomy (RARP) with bilateral nerve-sparing (BNS). </span><span style="color: rgb(184, 49, 47)">The pathology revealed that he has a Gleason score of 4 + 3 PCa.</span> He was taking a daily dose of 5mg of Tadalafil.</strong></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">During a follow-up three months after the operation, his PSA was undetectable (< 0.1 ng/mL)</span> and the patient was suffering from ED despite the Tadalafil. <span style="color: rgb(184, 49, 47)">On the sixth-month, his PSA was still undetectable </span>and he still suffered from ED. He was still taking Tadalafil. <span style="color: rgb(26, 188, 156)">This time, the patient reported depressive thoughts, fatigue and loss of libido.</span></strong></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">When his testosterone (T) levels were checked, they were at 7.6 nmol/L (8-12 nmol/L) which is lower than the normal range. </span><span style="color: rgb(26, 188, 156)">Two weeks later, his T levels were at 7.2 nmol/L (8-12 nmol/L).</span></strong></p><p></p><p></p><p><strong>Pro: Patient is a candidate for TTH</strong></p><p><strong><span style="color: rgb(184, 49, 47)">“If the patient is highly symptomatic, testosterone therapy (TTH) should be seriously considered.</span><span style="color: rgb(44, 130, 201)"> The comorbidities associated with low T level may be more likely to kill him rather than his prostate cancer,” </span>said Prof. John Mulhall (US), who gave the caveat to use TTH term instead of testosterone replacement therapy (TRT).</strong></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">Prof. Mulhall stated that the risk of poor nerve recovery is a concern and should be communicated to the patient prior to the decision of whether or not to forego TTH.</span><span style="color: rgb(44, 130, 201)"> He added, “I believe the Saturation Model is valid because I’ve shown vivo data on PSA’s response to testosterone. The only issue is at what T level is the patient’s androgen receptor fully saturated?”</span></strong></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">While larger, longer analyses are required, </span><span style="color: rgb(44, 130, 201)">there is a signal that testosterone therapy is safe in a man with this </span></strong><span style="color: rgb(44, 130, 201)"><strong>patient’s pathology (Gleason 7 or organ-confined).</strong></span></p><p></p><p><strong><span style="color: rgb(44, 130, 201)">“I encourage all of the oncologists in the room to not be so PSA-centric and </span><span style="color: rgb(184, 49, 47)">to focus on quality of life and overall holistic help of the patient. </span><span style="color: rgb(26, 188, 156)">In my opinion, until we have data demonstrating that TTH is unsafe in the prostate cancer population, which we do not have, I believe that choosing the scientific approach should lead us to prescribe TTH if the patient so wishes.”</span></strong></p><p></p><p><strong>Con: “I would be reluctant to give this man TRT”</strong></p><p><strong><span style="color: rgb(26, 188, 156)">Prof. Bertrand Tombal (BE) stated that he would be reluctant to give the patient TRT because evidence is “weak” and the risk of recurrence is not negligible</span>. <span style="color: rgb(184, 49, 47)">He asserted that the T levels of the patient should have been measured before the prostatectomy and that the patient should have given a questionnaire to check for preliminary signs of androgen-deficiency.</span></strong></p><p></p><p><strong><span style="color: rgb(44, 130, 201)">Prof. Tombal discussed the Coffey Paradox: </span><span style="color: rgb(184, 49, 47)">If PCa cells retaining Androgen Receptor (AR) expression, TRT-induced AR signalling up-regulates c-Myc translation and protein stability to stimulate malignant growth. Thus in AR expressing PCa cells, AR signalling is converted from a growth suppressor to an oncogene.</span></strong></p><p></p><p><strong><span style="color: rgb(184, 49, 47)">He underlined that 5 alpha-reductase inhibitors reduce the risk of progression, and provided data that show testosterone made the PCa more aggressive.</span></strong></p><p></p><p><strong>Poll results</strong></p><p><strong>After the debate, Prof. Şerefoğlu asked the audience <span style="color: rgb(184, 49, 47)">“Would you consider TRT for this hypogonadal PCa patient?”</span> The audience keyed in their answers via the EAU Events App. <span style="color: rgb(44, 130, 201)">About 83% voted “Yes” </span><span style="color: rgb(26, 188, 156)">and the 17% voted “No”</span></strong></p></blockquote><p></p>
[QUOTE="madman, post: 150792, member: 13851"] [URL='https://eaucongress.uroweb.org/case-deliberations-to-treat-or-not-to-treat-with-testosterone-therapy/'][ATTACH=full]7606[/ATTACH]https://eaucongress.uroweb.org/case-deliberations-to-treat-or-not-to-treat-with-testosterone-therapy/[/URL] [SIZE=26px][B]Case deliberations: To treat or not to treat with testosterone therapy?[/B][/SIZE] [B][COLOR=rgb(184, 49, 47)]18 [/COLOR]March [COLOR=rgb(184, 49, 47)]2019[/COLOR][/B] [B]Testosterone therapy (TTH) as a plausible treatment for a patient was examined during [COLOR=rgb(184, 49, 47)]“Plenary Session 06: The role of the urologist in sexual and fertility issues of cancer survivorship”[/COLOR], which was chaired by Dr. Maarten Albersen (BE) and Prof. Jens Sønksen (DK).[/B] [B]Moderator Assoc. Prof. Ege Can Şerefoğlu (TR) defined the patient case scenario and set the stage for the deliberations.[/B] [B]The case [COLOR=rgb(184, 49, 47)]The patient is a[/COLOR] [COLOR=rgb(184, 49, 47)]58-year old male suffering from prostate cancer (PCa) with a PSA level of 7.6 ng/mL. [/COLOR][COLOR=rgb(44, 130, 201)]He underwent transrectal ultrasound (TRUS) guided biopsy[/COLOR], [COLOR=rgb(184, 49, 47)]which revealed that he had a Gleason score of 3 + 3 PCa. [/COLOR]At that time, he reported no erectile dysfunction (ED).[/B] [B][COLOR=rgb(44, 130, 201)]The patient underwent[/COLOR] [COLOR=rgb(44, 130, 201)]robotic-assisted radical prostatectomy (RARP) with bilateral nerve-sparing (BNS). [/COLOR][COLOR=rgb(184, 49, 47)]The pathology revealed that he has a Gleason score of 4 + 3 PCa.[/COLOR] He was taking a daily dose of 5mg of Tadalafil.[/B] [B][COLOR=rgb(184, 49, 47)]During a follow-up three months after the operation, his PSA was undetectable (< 0.1 ng/mL)[/COLOR] and the patient was suffering from ED despite the Tadalafil. [COLOR=rgb(184, 49, 47)]On the sixth-month, his PSA was still undetectable [/COLOR]and he still suffered from ED. He was still taking Tadalafil. [COLOR=rgb(26, 188, 156)]This time, the patient reported depressive thoughts, fatigue and loss of libido.[/COLOR][/B] [B][COLOR=rgb(184, 49, 47)]When his testosterone (T) levels were checked, they were at 7.6 nmol/L (8-12 nmol/L) which is lower than the normal range. [/COLOR][COLOR=rgb(26, 188, 156)]Two weeks later, his T levels were at 7.2 nmol/L (8-12 nmol/L).[/COLOR][/B] [B]Pro: Patient is a candidate for TTH [COLOR=rgb(184, 49, 47)]“If the patient is highly symptomatic, testosterone therapy (TTH) should be seriously considered.[/COLOR][COLOR=rgb(44, 130, 201)] The comorbidities associated with low T level may be more likely to kill him rather than his prostate cancer,” [/COLOR]said Prof. John Mulhall (US), who gave the caveat to use TTH term instead of testosterone replacement therapy (TRT).[/B] [B][COLOR=rgb(184, 49, 47)]Prof. Mulhall stated that the risk of poor nerve recovery is a concern and should be communicated to the patient prior to the decision of whether or not to forego TTH.[/COLOR][COLOR=rgb(44, 130, 201)] He added, “I believe the Saturation Model is valid because I’ve shown vivo data on PSA’s response to testosterone. The only issue is at what T level is the patient’s androgen receptor fully saturated?”[/COLOR][/B] [B][COLOR=rgb(184, 49, 47)]While larger, longer analyses are required, [/COLOR][COLOR=rgb(44, 130, 201)]there is a signal that testosterone therapy is safe in a man with this [/COLOR][/B][COLOR=rgb(44, 130, 201)][B]patient’s pathology (Gleason 7 or organ-confined).[/B][/COLOR] [B][COLOR=rgb(44, 130, 201)]“I encourage all of the oncologists in the room to not be so PSA-centric and [/COLOR][COLOR=rgb(184, 49, 47)]to focus on quality of life and overall holistic help of the patient. [/COLOR][COLOR=rgb(26, 188, 156)]In my opinion, until we have data demonstrating that TTH is unsafe in the prostate cancer population, which we do not have, I believe that choosing the scientific approach should lead us to prescribe TTH if the patient so wishes.”[/COLOR][/B] [B]Con: “I would be reluctant to give this man TRT” [COLOR=rgb(26, 188, 156)]Prof. Bertrand Tombal (BE) stated that he would be reluctant to give the patient TRT because evidence is “weak” and the risk of recurrence is not negligible[/COLOR]. [COLOR=rgb(184, 49, 47)]He asserted that the T levels of the patient should have been measured before the prostatectomy and that the patient should have given a questionnaire to check for preliminary signs of androgen-deficiency.[/COLOR][/B] [B][COLOR=rgb(44, 130, 201)]Prof. Tombal discussed the Coffey Paradox: [/COLOR][COLOR=rgb(184, 49, 47)]If PCa cells retaining Androgen Receptor (AR) expression, TRT-induced AR signalling up-regulates c-Myc translation and protein stability to stimulate malignant growth. Thus in AR expressing PCa cells, AR signalling is converted from a growth suppressor to an oncogene.[/COLOR][/B] [B][COLOR=rgb(184, 49, 47)]He underlined that 5 alpha-reductase inhibitors reduce the risk of progression, and provided data that show testosterone made the PCa more aggressive.[/COLOR][/B] [B]Poll results After the debate, Prof. Şerefoğlu asked the audience [COLOR=rgb(184, 49, 47)]“Would you consider TRT for this hypogonadal PCa patient?”[/COLOR] The audience keyed in their answers via the EAU Events App. [COLOR=rgb(44, 130, 201)]About 83% voted “Yes” [/COLOR][COLOR=rgb(26, 188, 156)]and the 17% voted “No”[/COLOR][/B] [/QUOTE]
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Testosterone Replacement, Low T, HCG, & Beyond
Prostate Related Issues
Case deliberations: To treat or not to treat with testosterone therapy?
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