Prostate Cancer Patients Can Still Take Their Testosterone Therapy!

While doing some research looking for studies on testosterone, I stumbled upon a gem, a diamond in the rough, really, that was published online last month in the Journal of Urology, in which the authors concluded that in patients with untreated prostate cancer, testosterone supplementation does not lead to cancer progression.

This is quite an amazing turnaround in thinking in a very short amount of time if you follow medical literature.  If you'll recall, Huggins received the Nobel Prize in Medicine for discovering that castration (surgically reducing testosterone levels) would allow men w/metastatic prostate cancer to live just a bit longer.  Thus, we all concluded that testosterone had to be the cause of prostate cancer, ignoring the obvious fact that testosterone levels are highest in adolescence whereas prostate cancer is a condition of the aged when testosterone reaches a nadir.

Only recently has literature been published concluding that testosterone is not the cause of prostate cancer and that perhaps, there might be another reason for this malignancy.  And last year, the AHA, ACS & AUA came together in a statement to address the cardiovascular risk associated with (hormonal) androgen deprivation therapy.

We used to think of the prostate simply as analogous to charcoal briquets fresh from the store w/testosterone equivalent to the lighter fluid.  In essence, we were waiting for a spark to ignite a conflagration, analogous to trying to find the (still unknown) factor that converts normal prostate into cancerous prostate.

Now, we have a more complicated picture, the saturation model, whereby a prostate cancer needs a fixed amount of testosterone, albeit very low, such that (surgical or chemical) castration might be beneficial by completely depriving the prostate of any and all testosterone.  However, any more testosterone above that level means nothing to the cancer.

And in fact, that's what the authors found in 13 hypogonadal men (average age 59 years old) who chose active surveillance for their Gleason score 6 (in twelve and 7 in one) and elected testosterone therapy that almost tripled their baseline total testosterone from 238ng/dL up to 664ng/dL on average without any statistically significant change in PSA over 1-8 years of follow up.  Amazingly enough, no cancer was found in half the patients upon repeat biopsy.  There was no progression of disease in any of these men, neither local or distant during the time observed.

Let's be clear.  I'm not advocating that all men w/prostate cancer receive testosterone therapy.  But rather than routinely withhold therapy that can provide clinical benefit, we now have the basis to have an intelligent conversation about risk vs benefit.  In some men with low grade, localized disease who are clinically symptomatic of low testosterone, supplementation might make sense if they are interested in active surveillance anyway.