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Prostate Cancer Risk and Testosterone Supplements -
Prepared by Harvard Health Publications' editors, this page report describes the causes and treatment of prostate diseases and provides practical advice for coping with troubling side effects. Get weekly health information and advice from the experts at Harvard Medical School. Learn more about this site in a welcome video from Dr.
Marc Garnick, editor in chief. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone. These include reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, lower muscle mass and bone density, and anemia. When severe, these signs and symptoms characterize a condition called hypogonadism.
Researchers estimate that hypogonadism affects two to six million men in the United States. Deciding which patients should receive testosterone supplementation has proved tricky, however. For example, little consensus exists on what constitutes low testosterone. In addition, some men may have low blood levels of testosterone but not experience any symptoms. And few large, randomized studies on the long-term risks or benefits of testosterone supplementation have been completed.
One of the most heated debates centers on whether testosterone fuels prostate cancer. Others point to the fact that many men with prostate cancer, especially those with advanced or metastatic cancers, take hormone therapy that nearly stops the production of testosterone to tamp down the disease.
Under the influence of hormone therapy, tumors regress. Testosterone and Prostate Cancer: An Historical Perspective on a Modern Myth. He also argues in the book, an excerpt of which follows, that some men who have had prostate cancer can take testosterone without upping their risk of cancer recurrence.
Many well-respected experts advocate a more conservative approach: One is Ian Thompson, M. The oldest and most strongly held prohibition against testosterone therapy is its use in men previously diagnosed with prostate cancer. The fear has been that even in men who have been successfully treated for prostate cancer, raising testosterone levels will potentially make dormant, or sleeping, cancer cells wake up and start growing at a rapid rate.
Thus, the FDA requires all testosterone products to include the warning that T [testosterone] therapy is contraindicated in men with a prior history of prostate cancer. However, attitudes about this are changing — and changing rapidly — over just the last few years.
The reasons for this are several, including the ongoing re-evaluation of the old belief that raising the concentration of testosterone is to prostate cancer like pouring gasoline on a fire or feeding a hungry tumor. A major push for consideration of T therapy in symptomatic men with a history of prostate cancer has come from the large population of men who have been treated for prostate cancer over the last 25 years. Many of these men had small or low-grade cancers and, after treatment, were assured that they were cured and had no trace of any remaining cancer in their body.
Despite having been given a clean bill of health, they were then told that they could not receive T therapy. As these prostate cancer survivors have questioned the basis for the T therapy prohibition, many physicians have been forced to reconsider whether the old arguments learned from their former teachers still make sense.
The first people to publish their experience with doing this were Drs. In this article, Drs. Kaufman and Graydon described their experience in treating seven men with T therapy some time after these men had undergone radical prostatectomy as treatment for prostate cancer, with the longest follow-up being 12 years.
None of the men had developed a recurrence of his cancer. Soon afterward, there was another paper by a group from Case Western Reserve University School of Medicine describing a similar experience in 10 men with an average follow-up of approximately 19 months. Then another group from Baylor College of Medicine reported the same results in 21 men. In all these reports, not a single man out of the 38 treated with testosterone developed a cancer recurrence.
It is important to emphasize that all these reports included only men who were considered good candidates because they were at low risk of recurrence anyway. And in some cases, the duration of time the men received T therapy was relatively short. But it was reassuring that none of the 38 men who had suffered from prostate cancer in the past and who were treated for years with testosterone had developed a recurrence of prostate cancer.
This reassuring experience was bolstered by the published experience of Dr. Michael Sarosdy, who reported the results of T therapy in a group of 31 men who had received prostate cancer treatment in the form of radioactive seeds, called brachytherapy. This less-invasive form of treatment does not remove the prostate, so theoretically there is the possibility that a spot of residual cancer might still be present. With an average of five years of follow-up in these men, none of the 31 men had evidence of cancer recurrence.
At a minimum, it is now possible to say that there is evidence from a number of small studies that T therapy in men who have been successfully treated for prostate cancer does not appear to be associated with a substantial risk of cancer recurrence over the first several years of treatment. First, it has become obvious that raising testosterone levels in a man with a history of prostate cancer is not like pouring gasoline on a fire.
In fact, with the important exception of men who have undergone hormonal treatment to bring down their T levels to castrate levels, the limited evidence suggests that raising T levels does very little to the growth of prostate cancer.
Of course, one day new studies may suggest that there is a risk. However, no such study is likely to appear for at least five to 10 years because it takes at least that long to judge whether a treatment has stimulated the growth of a cancer. Until then, we have to make decisions based on the available evidence, supported by logic and experience. Second, it is important to recognize that even if you have low levels of testosterone as well as the symptoms of chronic fatigue, decreased libido, and erectile dysfunction, there is no certainty that raising T levels will alleviate your symptoms.
There may be other reasons you are feeling this way. Moreover, there is no known benefit to T therapy if T levels are not truly low. Thus, the decision about whether to try T therapy requires balancing possible benefits with possible risks. This decision will be different for every man. Third, T therapy is not itself a treatment for prostate cancer. Finally, it is important for any man with a history of prostate cancer to maintain his perspective on what is important to him.
For some, it is enough to be alive and feeling reasonably well despite prostate cancer treatment. Adding a treatment that may stir up anxiety about their cancer may not be worth any benefit they may experience with regard to sex, mood, energy, or vitality. For others, the important thing is to live well. For them, an improved quality of life may be important enough to take on an unknown degree of risk, including a treatment that still lacks approval from the broader medical community.
What concerns do you have about prescribing testosterone to men who have been successfully treated for prostate cancer? Obviously, testosterone supplementation has salutary effects for someone who is hypogonadal and suffering from osteoporosis, muscle loss, erectile dysfunction, and other problems.
Unquestionably, otherwise healthy men given the choice of being on testosterone or being off testosterone would rather be on it. So, why not prescribe testosterone supplements to men who are hypogonadal and have been treated for prostate cancer? Well, imagine two men with prostate cancer.
The cancer can be felt during a digital rectal exam but is confined to the prostate capsule. Both men have undergone treatment. In his case, the risk of testosterone supplementation is low. And that would suggest that testosterone supplementation would increase his risk of disease recurrence. How does that happen? Testosterone could reactivate existing disease. Or, if the patient had external beam radiation, not all of the tissue becomes fibrotic.
Some normal epithelium, the cell layer that lines the prostate, will persist, and that normal epithelium is at risk of becoming cancerous. If you apply that standard, every older man would be clinically hypogonadal.
Where did those numbers come from? And what else is going on in the body? There are differences from one person to the next in how testosterone is used.
And the interactions of other androgens and the androgen receptors are so variable. If I think someone might need it, I refer him to an endocrinologist who will manage his condition. Managing hypogonadism is a very complicated matter. In fact, an endocrinologist who specializes in hypogonadism often will obtain a blood sample every half hour for two hours, pool them, and then run a testosterone level. But what about the man in the middle? My biggest concern is that, with very little data, we are assuming that androgen replacement is safe.
We only have to look at history — hormone replacement in women — to see the error of assuming that hormone replacement is safe and effective. What PSA level suggest a recurrence of prostate cancer?
I had brachial therapy over 22 years ago. My last biopsy Was approximatately 10 years Ago with a Gleason of 6 psa 8. DRE results no tumor felt. I am 78 in perfect health. Constant excercise, excellent Appetite.
Urologist Specializing prostate cancer does not recommend hormone Therapy at this time. Follow up with psa in 6 month Unless Experience sudden Fatigue, loss of appetite etc. Never had hormonal therapy.
Medical facility Cleveland Clinic Weston Fl. Thank you Mel Dubin. I am 75 years old. I had external beam radiation for PC ten years ago. Following the radiation treatment, my PSA scores dropped to the 1. Now, ten years later, they have jumped to in the last two years.