Testosterone Treatment and Prostate Cancer Risk

Educational Objectives

The goal of this program is to improve the management of testosterone deficiency (TD) in men using testosterone therapy (TT) without the risk for prostate cancer (PC). After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the absence of risk for aggressive PC with TT.

Summary

Introduction: there is a concern about the long-term sequelae of testosterone therapy (TT); the speaker believes that TT for patients with hypogonadism or testosterone deficiency (TD) should not be considered a risk factor for prostate cancer (PC); the need to counsel patients about the potential risk for PC associated with TT remains unclear

The American Urological Association statement: TT is an appropriate treatment for patients with clinically significant TD (low free and total testosterone with symptoms), after a full discussion of its risks (potential adverse effects) and benefits

Effects of TT: randomized controlled trials (RCTs) demonstrate clear benefits of testosterone replacement in men with TD; it has good effects on the brain, muscle, and bone strength; however, the prostate is a hormonally sensitive organ; depriving men of testosterone has been proven to be an effective treatment for metastatic PC; however, this led to concerns that TT could cause or promote PC; early RCTs found that the incidence of PC among patients receiving TT was significantly higher; however, RCTs cannot definitively determine whether TT causes PC; meta-analysis data indicate that men on testosterone are screened more for PC and biopsied more, increasing detection of PC

The Veteran’s Affairs TT study (Walsh et al [2018]): this was a pharmacoepidemiologic study of men 40 to 89 yr of age treated with TT and followed up for ≈10 yr; they investigated whether exogenous testosterone (ET) increases the risk for aggressive PC (ie, if it initiates, promotes, or increases the likelihood of diagnosis); men detected to have low testosterone by guidelines were included; men at risk, ie, those with a history of PC, elevated prostate-specific antigen, or inadequate PC screening, were excluded from the study

Results: ≈33% of the ≈150,000 participants were treated with various forms of testosterone; >60% were treated with intramuscular (IM) testosterone; TT vs untreated groups — comorbidities were similar across treatment groups; IM testosterone administration resulted in the most significant increase in testosterone levels; no increased risk for aggressive PC or any PC was found in men receiving TT; time-varying dose analysis — revealed no increased risk (for aggressive PC or any PC) and potential protective effects of TT with long-term use; topical vs nontopical testosterone — no significantly increased risk for aggressive or any PC was found based on the route of administration and time-varying cumulative dose (TVCD) comparisons

Conclusion: the use of testosterone does not appear to increase the risk for aggressive PC or any PC; the results were consistent for “ever-never” (ie, solitary testosterone exposure vs no exposure), TVCD, and route of administration

Readings

Debruyne FM, Behre HM, Roehrborn CG, et al. Testosterone treatment is not associated with increased risk of prostate cancer or worsening of lower urinary tract symptoms: Prostate health outcomes in the Registry of Hypogonadism in Men. BJU Int. 2017;119(2):216-224. doi:10.1111/bju.13578; Mulhall JP, Trost LW, Brannigan RE, et al. Evaluation and management of testosterone deficiency: AUA Guideline. J Urol. 2018;200(2):423-432. doi:10.1016/j.juro.2018.03.115; Walsh TJ, Shores MM, Krakauer CA, et al. Testosterone treatment and the risk of aggressive prostate cancer in men with low testosterone levels. PLoS One. 2018;13(6):e0199194. Published 2018 Jun 22. doi:10.1371/journal.pone.0199194.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Walsh is a consultant for Biote, Boston Scientific, and Coloplast, has received grant/research support from Boston Scientific, Coloplast, and Endo, and is on the Advisory Board for Progyny. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Walsh was recorded at the 43rd Annual Ralph E. Hopkins Urology Seminar, held January 31 to February 3, 2024, in Jackson Hole, WY, and presented by Grand Rounds in Urology. For information on upcoming CME activities from this presenter, please visit jacksonholeseminars.com. Audio Digest thanks the speakers and Grand Rounds in Urology for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

UR472301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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