Innovations in Testosterone Therapy in Men Treated for Prostate Cancer

[madman]

Urology Times® is celebrating its 50th anniversary in 2022. To mark the occasion, we are highlighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, Amy Pearlman, MD, interviews Mohit Khera, MD, MBA, MPH on how advancements in testosterone therapy have changed treatment modalities across urology, providing patients with more efficacious, individualized care. Khera is a professor of urology and director of the Laboratory for Andrology Research, and director of the Executive Health Program at the McNair Medical Institute at Baylor College of Medicine in Houston, Texas. Pearlman is a clinical assistant professor of urology and the director of the Men’s Health Program at the Carver College of Medicine at the University of Iowa Health Care in Iowa City, Iowa.

 

[Ozzieville]

Madman - thanks very much for sharing this.

I'm sort of a poster child for (1) being diagnosed with prostate cancer and (2) going on testosterone replacement therapy. Even though my T levels are quite high (over 1500), my PSA (a marker of prostate cancer) has hardly budged during the three years since my diagnosis, suggesting that the cancer is staying quiet (I'm also getting regular MRIs and biopsies as needed). So for now I'm just on "active surveillance" and avoiding treatment.

While I don't expect TRT to "cure" my cancer, the latest evidence suggests it's not going to fuel the cancer either. And meanwhile I get to enjoy the enhanced life benefits that TRT offers.

Ozzie

 

[Nelson Vergel]

While I don't expect TRT to "cure" my cancer, the latest evidence suggests it's not going to fuel the cancer either. And meanwhile I get to enjoy the enhanced life benefits that TRT offers.

Ozzie

Great news!

 

[toddao]

Urology Times® is celebrating its 50th anniversary in 2022. To mark the occasion, we are highlighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, Amy Pearlman, MD, interviews Mohit Khera, MD, MBA, MPH on how advancements in testosterone therapy have changed treatment modalities across urology, providing patients with more efficacious, individualized care. Khera is a professor of urology and director of the Laboratory for Andrology Research, and director of the Executive Health Program at the McNair Medical Institute at Baylor College of Medicine in Houston, Texas. Pearlman is a clinical assistant professor of urology and the director of the Men’s Health Program at the Carver College of Medicine at the University of Iowa Health Care in Iowa City, Iowa.

As a person with prostate cancer , very low testosterone, I can tell you as of 2/2022 and for the last 3 years the urologist and the family doctors are only interested in what ever treatment is acceptable to the Florida licensing board, and using testosterone is not ok. We need the drug companies to promote their products for new uses.

 

[Jed Dorsey]

Madman - thanks very much for sharing this.

I'm sort of a poster child for (1) being diagnosed with prostate cancer and (2) going on testosterone replacement therapy. Even though my T levels are quite high (over 1500), my PSA (a marker of prostate cancer) has hardly budged during the three years since my diagnosis, suggesting that the cancer is staying quiet (I'm also getting regular MRIs and biopsies as needed). So for now I'm just on "active surveillance" and avoiding treatment.

While I don't expect TRT to "cure" my cancer, the latest evidence suggests it's not going to fuel the cancer either. And meanwhile I get to enjoy the enhanced life benefits that TRT offers.

Ozzie

Ozzie happy for you brother I to have returned to TRT after about a year and a half stopping it because of fear of progression. I restarted TRT about two years ago after much research and putting faith in two very good doctors named Dr. Mark Schulz and Dr. Abraham Morgantaler both men have done over 40 years incredible research in the field of prostate cancer and how it responds to testosterone.
I too have had multiple biopsies and MRI and has yet to progress. I am Gleason 6 (very low grade) and on active surveillance. What’s your PCa type?

 

[Ozzieville]

Hey Jed - we certainly must be brothers! Dr. Scholz is my oncologist, and I did a Zoom consultation with Dr. Morgentaler.

I'm a Gleason 7, but with a small percentage of pattern 4. You're very lucky to be Gleason 6, which some doctors hardly regard as true cancer (never becomes metastatic). But of course if TRT is "pouring fuel on the fire," heaven help us. Personally, I'm placing my bet on TRT not only promoting a better quality of life, but being anti-cancer as well.

 

[Jed Dorsey]

Good luck to you brother these are the types of discussion on PCa/Testosterone we need to be having so other men here can learn from our experiences. When I was first diagnosed I didn’t know there were different types of PCa.
-Gleason 6 (very low grade)
-G 7 3+4 (Low grade)
-G 7 4+3 (Intermediate grade 1)

TRT still not approved for the types below due to its aggression type nature
-G 8 (Intermediate grade 2)
-G 9 (Aggressive)
-G 10 (Very Agressive)

 

[Ozzieville]

The nice thing is that it’s pretty easy to get on TRT outside the usual medical channels, with the ready availability of online clinics.

I really wonder whether it makes sense to say that any diagnosis of prostate cancer, however high the Gleason score, means TRT is off limits. Either testosterone promotes prostate cancer or it doesn’t. The latest research seems to say it doesn’t, or could even have anti-cancer effects (per the book “The New Testosterone Treatment” by Dr. Edward Friedman). So if TRT doesn’t add fuel to the fire of prostate cancer, the Gleason score should be irrelevant.

 

[madman]

The nice thing is that it’s pretty easy to get on TRT outside the usual medical channels, with the ready availability of online clinics.

I really wonder whether it makes sense to say that any diagnosis of prostate cancer, however high the Gleason score, means TRT is off limits. Either testosterone promotes prostate cancer or it doesn’t. The latest research seems to say it doesn’t, or could even have anti-cancer effects (per the book “The New Testosterone Treatment” by Dr. Edward Friedman). So if TRT doesn’t add fuel to the fire of prostate cancer, the Gleason score should be irrelevant.

3:36-4:45

(Amy) And we were told that by adding testosterone to these regimes it's like adding fuel to the fire so when it comes to testosterone and those with prostate cancer really it's turned a 180 completely different no longer harmful but perhaps protective in certain populations.

(Mohit) I agree and I would say that intuitively I believe that but I will tell you that I just want to go back to the AUA Guidelines.

The AUA Guidelines are very clear in 2018 men should be notified that testosterone therapy does not increase the risk of prostate cancer and that is a strong recommendation by the AUA.

However, in men with a history of prostate cancer (radical prostatectomy, radiation), the risk/benefit ratio has not yet been defined in other words we don't know.

So on paper today is inconclusive until we have more trials.

Now I will tell you that if you survey physicians from 2005-2021 many physicians are treating patients with a history of radical prostatectomy and radiation our comfort level has gone up but again I do want to use some caution that we do need a randomized placebo-controlled trial to really assess the true safety.

 

[madman]

post #12

Low Testosterone in Men: Recommendations on the diagnosis, treatment and monitoring

ABSTRACT The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age...

www.excelmale.com

Take-home point:

*Nonetheless, in the absence of large-scale, long-term controlled studies, it is impossible to definitively assert the safety of TTh with regard to PCa.




Recommendations on the diagnosis, treatment, and monitoring of testosterone deficiency in men (2021)

Bruno Lunenfeld, George Mskhalaya, Michael Zitzmann, Giovanni Corona,
Stefan Arver, Svetlana Kalinchenko, Yuliya Tishova & Abraham Morgentaler



PCa

*There is no evidence of increased PCa risk in men on TTh

*Recent evidence fails to support the longstanding fear that T therapy will increase prostate cancer risk or cause rapid growth of occult cancer

*The relationship between testosterone and prostate cancer appears to follow a saturation curve, present in many biological systems, in which growth corresponds with a concentration of a key nutrient until a concentration is reached in which an excess of the nutrient is achieved (Figure 2). Clinical data indicate the saturation point for serum T is approximately 250 ng/dL (8.68 nmol/L)

*There is no evidence that TTh will convert sub-clinical prostatic lesions to clinically detectable PCa

*Nonetheless, in the absence of large-scale, long-term controlled studies, it is impossible to definitively assert the safety of TTh with regard to PCa.

*Therefore, prior to starting TTh, a patient’s risk of PCa must be assessed using, at a minimum measurement of serum prostate-specific antigen (PSA). Pretreatment assessment should include PCa risk predictors such as age, family history of PCa, and ethnicity/race. If suspicion of PCa exists, it may be reasonable to perform a prostate biopsy if warranted by clinical presentation. Testosterone therapy may be initiated in these men if a prostate biopsy is negative

*After initiation of TTh, patients should be monitored for prostate disease with measurement of serum PSA at 3–6 months, 12 months, and at least annually thereafter. In a subject with an increased risk of PCa urologist supervision is required

*An initial increase of prostate-specific antigen (PSA) and prostate volume with TTh is frequently seen over the first 2–6 months because the prostate is an androgen-dependent organ. The increase in PSA will be greatest in men with marked TD and least (or absent) in men with milder degrees of TD. The PSA level at 6 months after initiation of TTh should be used as the new baseline

*Referral to a urologist for prostate evaluation and possible biopsy during TTh should be made with the development of a new palpable prostate abnormality on DRE or with a worrisome rise in PSA. Recommendations regarding what constitutes a concerning rise in PSA include an increase of 1.0 ng/ml over baseline PSA or a PSA velocity greater than 0.35 ng/ml per year

 

[Ozzieville]

Madman: thanks for that additional info. I know that Dr. Morgentaler does prescribe testosterone for men (like me) with diagnosed prostate cancer, and his book "Testosterone for Life" describes case studies. I had a telemed session with Dr. Morgentaler, and he didn't have any concerns about my going on TRT (while admitting there aren't long-term studies in support, per your extracts above).

Dr. Friedman (in "The New Testosterone Treatment") goes further and says that high levels of testosterone can cause apoptosis (death) of prostate cancer cells. He proposes that high levels of estradiol, not testosterone, promote prostate cancer, and therefore advocates use of an aromatase inhibitor such as anastrozole to keep estradiol levels in check (ideally at 15-25 pg/mL).

In my own case, I'll simply monitor my prostate cancer until treatment becomes warranted (if ever). Better treatments with fewer side effects are coming down the pike all the time. Either way, I don't plan to cease TRT.

 

[tcmi]

For whatever it's worth, I was on TRT for 5+ years, was diagnosed with PCa in 2021 (Gleason 7 3+4). I had RP surgery in August 2022 at Memorial Sloan Kettering in NYC. I was asked to stop TRT the week prior to surgery. I was then able to resume TRT after surgery given a clean biopsy report and an undetectible PSA test at six weeks. My surgeon was not concerned about restarting TRT. Of course, we'll continue to do six month PSA tests (maybe forever), but that's not a big deal.