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Testosterone Supplementation Contraindicated after Prostate Cancer: Presented at ICPC

By Robert H. Carlson

PARIS, FRANCE -- July 10, 2002 -- A history of prostate cancer is an absolute medical contraindication to testosterone supplementation, according to an international consensus committee.

The guideline, issued by a subcommittee during the 3^rd International Consultation on Prostate Cancer here this week, would seem to be intuitive, given that prostate cancer thrives on testosterone, and blockade with drugs or castration is standard treatment for men with advanced disease.

But what about men who have been treated and are presumably cured of prostate cancer? Such men are typically older than 70 years and are often faced with hypogonadism, muscle atrophy, and declining sexual potency. Older men are increasingly asking their physicians about testosterone supplementation, just as women for years have considered estrogen replacement therapy after menopause.

There are no data showing that men with normal testosterone levels who have not had natural prostate cancer are at any higher risk for developing the disease than men with lower testosterone levels. And there are no studies in humans on testosterone supplementation after treatment for prostate cancer.

Claude Schulman, MD, chair of the department of urology, University Clinics, Brussels, Belgium, was chair of the Committee on Supplementary Hormone Treatment, one of 10 committees reporting consensus guidelines on all phases of prostate cancer care at this meeting. He said the committee's recommendation against testosterone replacement therapy is based on the current data available and that the recommendation applies to men after any stage of prostate cancer.

"If there are any cancer cells remaining after treatment -- and this can happen after radiation or after surgery -- testosterone supplementation could stimulate those tumours to grow," Dr. Schulman said.

But the data are complex and sometimes contradictory, physicians on the panel admitted. And their patients, meanwhile, are asking for the supplements.

Dr. Schulman recommended that physicians tell these men of the consensus panel's warning, and then leave the decision up to the patient.

"What the patient decides to do then is up to him," he said.

Some physicians privately believe that supplementation is reasonable in men who have low testosterone levels after prostate cancer, whether from the disease or the treatment (both unlikely) or from the aging process.

They reason that men with normal testosterone levels after successful cancer treatment would not have their testosterone lowered to castrate levels, as might be done when the cancer is incurable; therefore, there is no reason not to bring testosterone levels back into to the normal range after curative therapy has been completed.

But doctors are hesitant to go on record advocating that treatment plan, and one good reason is the threat of a medical malpractice suit. Michael Brawer, MD, professor, University of Washington, and director, Northwest Prostate Institute, Seattle, said a lawsuit is a strong possibility against a physician who advises testosterone supplementation to a prostate cancer patient whose disease recurs. Proving in court that the recurrence was not due to the supplementation might be difficult, if not impossible.

Another specialist in attendance, Claus Roehrborn, MD, chairman, department of urology, University of Texas Southwestern Medical Center, Dallas, noted that inaccuracies in testing complicate the issue. A man's testosterone levels normally vary widely throughout the day, usually highest in the morning but not always, so testosterone assay values are highly dependent on the time of testing. The expertise of laboratory personnel is also highly variable.

"There needs to be a consensus on how to check testosterone levels properly before solid studies of supplementation can be undertaken," he said, suggesting that the data now in the literature on testosterone and cancer might change if tests were redone using modern technology.

Meanwhile, the unofficial consensus in the audience was that many patients will do what they want in order to improve their quality of life, regardless of their physician's official recommendation.

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