Endocrine Abstracts

Title – Testosterone replacement Therapy (TRT) and prostate cancer Hypogonadism is a condition with low serum testosterone level, which can manifest as depression, lack of libido, decreased bone mineral density and muscle weakness In patients with hypogonadism returning serum testosterone to normal levels results in improvement in cognition, mood, sexual function, physical performance, normalises bone density and erythropoiesis.

Case

We describe the case of 64-year-old man who was diagnosed with primary testosterone deficiency in the year 2008. His past medical history also includes essential hypertension, asthma, obesity and fatty liver. He does not have a family history of malignancy. He started on Testosterone replacement Therapy (TRT) in the form of Testogel and it was titrated to achieve and maintain optimum testosterone level. In October 2019, we noticed PSA (Prostate specific Antigen) raise to 5.2 mg/l and patient was referred to urology team. At that time, he did not have lower urinary tract symptoms; he had good erectile function on testosterone supplement, in urology he had a MRI of prostate and Trans perineal biopsy which came back as prostate adenocarcinoma which was of intermediate risk. Testosterone replacement was stopped; Following a Multidisciplinary team meeting Oncologists managed him for his Prostate cancer. He received Brachytherapy and Radiotherapy with good response. Oncologists suggested to us that testosterone replacement therapy can be restarted not earlier than 18 months and only if PSA level will remain within the normal range.

Key learning

There is no proven correlation between normal or high serum testosterone levels and prostate cancer. However, regular checking of PSA level helps to diagnose prostate cancer early. In this case, the patient was referred to urology department immediately after the abnormal test result and had a good outcome Some studies showed that ~ 15% of hypogonadial men with PSA lower than 4.0 mg/l will have prostate biopsy showing cancer. Men with low testosterone levels have also shown to have worse prognoses in prostate cancer with higher grade, more aggressive cancer while men with normal or higher testosterone level would more likely to have less advanced forms of cancer. The possible explanation is that lower levels of testosterone would not activate the androgen response elements in the PSA promoter, so these patients will be diagnosed much later. PSA can raise shortly after initiation of TRT but overall there is no proven increased risk of developing prostate cancer while on TRT.