Testosterone vs Prostate Cancer: Malpractice or Act of God?

Given yesterday's diatribe regarding defensive medicine, I thought it useful to return to an older review article published exactly 3 years ago in the Journal of the National Cancer Institute with the corresponding press release stating clearly that "Sex Hormones [Are] Unrelated to Prostate Cancer Risk".

Why?  Most clinicians are so overworked that keeping up with the literature is an impossibility.  Thus, they still ascribe to their medical school teachings as published by Huggins in 1941 concluding that because removal of testosterone decreased prostate cancer mortality, then testosterone must be the root cause of prostate cancer.

By definition, most of us describe the practice of defensive medicine as ordering unwarranted tests or prescribing unnecessary antibiotics.  However, another definition of defensive medicine is avoiding performance of procedures & interventions out of fear of potential litigation.  Keeping this in mind, think about these clinicians who haven't read about the strong association between higher testosterone and lower mortality or about the fact that androgen deprivation therapy for prostate cancer leads to higher all-cause mortality in those with heart disease.  They're practicing defensive medicine when they refuse to offer testosterone supplementation to clinically hypogonadal men simply because their testosterone is just above the lower limit of normal and therefore is good enough for their age.  After all, they don't want to cause prostate cancer, right?

Even without the above studies, a simple analysis of human demographics should demonstrate clearly that testosterone, in and of itself, does not cause prostate cancer.  Why?  If high testosterone caused prostate cancer, then prostate cancer should be a disease of teenage boys and college-age males.  Instead, we know that prostate cancer is a disease of old(er) men, typically with testosterone levels substantially lower than in their prime or youth.

Now, don't get me wrong.  I'm not advocating that we put testosterone in the water or give it out indiscriminately. However, I think that rather than saying "no" with a closed mind, we should have a thorough discussion with our clinically symptomatic patient (and ideally, their family & loved ones, too) about the potential risks and benefits of testosterone supplementation after a thorough physical exam and review of the laboratory results.

And patients and their family & loved ones must understand that should they develop or be diagnosed with prostate cancer after testosterone supplementation, said supplementation was not malpractice and did not lead to or cause the cancer.  It was just an act of God.  Until we reach that level of trust and understanding, we will never be able to fully treat hypogonadism.