TRT After Prostate Cancer: Is Testosterone Therapy Safe for Hypogonadal Men?
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madman
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MODERN RESEARCH AND RISK ASSESSMENT OF TRT BY PATIENT GROUP
1. Men with no history of prostate cancer
1) TRT in men with potential precursors
2. Men with prostate cancer
1) Men on active surveillance
Summary
Current evidence suggests that TRT may be safely administered to hypogonadal men on AS for prostate cancer, with consistently no indication of increased disease progression or the need for definitive treatment across existing studies. However, the data remains limited, with small sample sizes, short follow-up periods, and a lack of robust prospective trials. These findings, while encouraging, depend heavily on careful patient selection, frequent PSA monitoring, MRIs, and biopsies to detect early signs of progression. Observational and retrospective studies provide valuable insights but need further validation from well-designed prospective research. Theoretical models such as the saturation model offer a plausible biological basis for these findings, supporting the cautious use of TRT within structured AS protocols. Nonetheless, clinicians should approach TRT in this population with care, acknowledging the need for more comprehensive data to confirm long-term safety.
2) Men after radical prostatectomy
Summary
Current evidence suggests that TRT is oncologically safe for hypogonadal men following RP, with no significant increases in BCR rates and PSA levels remaining within acceptable ranges across studies. In low- to intermediate-risk patients, the data is reassuring, supporting TRT as a viable option to improve quality of life, including energy, libido, and erectile function. For high-risk patients, some small studies have even shown reduced BCR rates, suggesting potential benefits; however, these findings are limited by very small patient numbers, a lack of robust data, and currently fall outside clinical guidelines. This highlights a critical need for further research to address these gaps in understanding. Increased monitoring remains essential for all patient groups to ensure safety.
3) Men after radiotherapy
Summary
Evidence increasingly supports TRT as a safe and effective option for hypogonadal men postradiotherapy for prostate cancer, with studies showing stable PSA levels and no significant rise in recurrence rates. TRT also improves energy, mood, and sexual function, enhancing quality of life for symptomatic men. However, some studies indicate a slightly higher risk of BCR in men treated with radiotherapy on TRT compared to those who undergo surgery, likely due to the presence of residual prostatic tissue. This underscores the importance of careful, individualized patient selection, limiting TRT to men who are symptomatic and initiating treatment only after achieving a stable PSA nadir. Pre-treatment testosterone levels could also play a vital role in prehabilitation, optimizing overall health and readiness for therapy. Robust monitoring, including regular PSA assessments, remains essential to ensure oncological safety and to promptly identify any early signs of disease progression. MDT input from oncologists, endocrinologists, and urologists is particularly valuable in complex cases, supporting safe, individualized treatment plans. Larger, long-term studies are needed to confirm these findings and further refine the safety profile of TRT in this population.
CARDIOVASCULAR CONCERNS VS BENEFITS
Summary
The cardiovascular effects of TRT have been a topic of considerable debate. Early studies which initially raised the concerns about increased cardiovascular risks, were so significantly flawed in their methodology they cannot be deemed reliable. In contrast, the TRAVERSE trial, a large and well-designed RCT, has provided strong evidence that TRT does not significantly increase the risk of MACE, even in men with pre-existing cardiovascular conditions. Nonetheless, potential risks, such as pulmonary embolism, require careful consideration. On the other hand, TRT may offer cardiovascular benefits by improving metabolic and endothelial dysfunction associated with low testosterone, potentially mitigating cardiovascular risk factors. Clinicians should adopt a personalized approach, carefully balancing the potential risks and benefits of TRT for each individual patient. When appropriate, TRT should be integrated with lifestyle modifications and PDE5Is to enhance overall outcomes and provide a comprehensive strategy for symptom management.
1. Men with no history of prostate cancer
1) TRT in men with potential precursors
2. Men with prostate cancer
1) Men on active surveillance
Summary
Current evidence suggests that TRT may be safely administered to hypogonadal men on AS for prostate cancer, with consistently no indication of increased disease progression or the need for definitive treatment across existing studies. However, the data remains limited, with small sample sizes, short follow-up periods, and a lack of robust prospective trials. These findings, while encouraging, depend heavily on careful patient selection, frequent PSA monitoring, MRIs, and biopsies to detect early signs of progression. Observational and retrospective studies provide valuable insights but need further validation from well-designed prospective research. Theoretical models such as the saturation model offer a plausible biological basis for these findings, supporting the cautious use of TRT within structured AS protocols. Nonetheless, clinicians should approach TRT in this population with care, acknowledging the need for more comprehensive data to confirm long-term safety.
2) Men after radical prostatectomy
Summary
Current evidence suggests that TRT is oncologically safe for hypogonadal men following RP, with no significant increases in BCR rates and PSA levels remaining within acceptable ranges across studies. In low- to intermediate-risk patients, the data is reassuring, supporting TRT as a viable option to improve quality of life, including energy, libido, and erectile function. For high-risk patients, some small studies have even shown reduced BCR rates, suggesting potential benefits; however, these findings are limited by very small patient numbers, a lack of robust data, and currently fall outside clinical guidelines. This highlights a critical need for further research to address these gaps in understanding. Increased monitoring remains essential for all patient groups to ensure safety.
3) Men after radiotherapy
Summary
Evidence increasingly supports TRT as a safe and effective option for hypogonadal men postradiotherapy for prostate cancer, with studies showing stable PSA levels and no significant rise in recurrence rates. TRT also improves energy, mood, and sexual function, enhancing quality of life for symptomatic men. However, some studies indicate a slightly higher risk of BCR in men treated with radiotherapy on TRT compared to those who undergo surgery, likely due to the presence of residual prostatic tissue. This underscores the importance of careful, individualized patient selection, limiting TRT to men who are symptomatic and initiating treatment only after achieving a stable PSA nadir. Pre-treatment testosterone levels could also play a vital role in prehabilitation, optimizing overall health and readiness for therapy. Robust monitoring, including regular PSA assessments, remains essential to ensure oncological safety and to promptly identify any early signs of disease progression. MDT input from oncologists, endocrinologists, and urologists is particularly valuable in complex cases, supporting safe, individualized treatment plans. Larger, long-term studies are needed to confirm these findings and further refine the safety profile of TRT in this population.
CARDIOVASCULAR CONCERNS VS BENEFITS
Summary
The cardiovascular effects of TRT have been a topic of considerable debate. Early studies which initially raised the concerns about increased cardiovascular risks, were so significantly flawed in their methodology they cannot be deemed reliable. In contrast, the TRAVERSE trial, a large and well-designed RCT, has provided strong evidence that TRT does not significantly increase the risk of MACE, even in men with pre-existing cardiovascular conditions. Nonetheless, potential risks, such as pulmonary embolism, require careful consideration. On the other hand, TRT may offer cardiovascular benefits by improving metabolic and endothelial dysfunction associated with low testosterone, potentially mitigating cardiovascular risk factors. Clinicians should adopt a personalized approach, carefully balancing the potential risks and benefits of TRT for each individual patient. When appropriate, TRT should be integrated with lifestyle modifications and PDE5Is to enhance overall outcomes and provide a comprehensive strategy for symptom management.
madman
Super Moderator
Great presentation by the leading expert in the field!
Abraham Morgentaler
For 80 years the question has been:
Wrong question
The right question:
Conclusions
Abraham Morgentaler
For 80 years the question has been:
Wrong question
The right question:
Conclusions
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