Active Surveillance and Testosterone Replacement Therapy

The fact that an opinion has been widely held is no evidence whatever that it is not utterly absurd.

– Bertrand Russell

What man over the age of, say, 45 doesn’t look back—perhaps nostalgically—on the lusty days of yore? Somewhere between the ages of eighteen to thirty, men reach a sexual peak in which desire and performance are at an all-time high. During those years, the primary male hormone, testosterone, is in full swing for most men. However, when blood levels of testosterone begin to drop off, the usual suspect is aging. From age 45 onward, about 40% of men begin to have lower levels of testosterone. This is commonly referred to as “low T” and symptoms can be confused with other signs of aging: reduced energy, low-to-no sexual desire, erectile dysfunction, and depression. So if you experience any of these symptoms—or other troubling conditions that persist—it’s important to see a doctor for a professional diagnosis.

For about 70 years, medicine embraced the belief that testosterone fueled prostate cancer. (As it turns out, this widely held opinion may well prove to be “utterly absurd.” See my article on the subject at https://sperlingprostatecenter.com/revisiting-testosterone-prostate-cancer/) More recently, a staunchly dedicated minority of urologic and endocrine (hormone system) researchers are generating evidence that is toppling that myth. This may turn out to be good news for prostate cancer patients who also have low T.

How safe is TRT for prostate cancer patients on active surveillance? I came across an article published by a team from Men’s Health Boston (Brookline, MA) who report their comparison between two groups of prostate cancer patients on active surveillance (Gleason 3 + 3 or Gleason 3 + 4).[i] The group used a slightly modified version of the Epstein criteria[ii] and allowed inclusion of men with one core of low-volume Gleason 3 + 4 PCa):

  • 28 patients with low T who were treated with testosterone replacement therapy (TRT)
  • 96 patients who were given no TRT

The mean follow-up was over three years for both groups, and they were tracked by biopsy, among other measures. The statistical results were quite similar:

  Treated with TRT Not treated with TRT
Number in group 28 96
Mean follow-up 38.9 months 42.4 months
Biopsy progression 7 men (31.8%) 43 (44.7%)
Upgrade to Gleason 3 + 4 3 men (13.6%) 9 men (9.38%)

The authors concluded, “Biopsy progression in men on AS appears unaffected by T therapy over 3 years.” In other words, they suggest that for prostate cancer patients with low T who are on AS, it is safe to offer TRT for symptom relief and quality of life improvement.

I would offer a couple of precautions for those men who have prostate cancer and even those who don’t, but are worried about low T. First, I want to emphasize the importance of not diagnosing yourself. There are many factors, including the effects of job stress, relationship difficulties, financial worries, etc. that lead to syndromes that mimic low T, so it’s very important to see a doctor and have certain tests if you have symptoms that last more than a month or two. Second, be wary of advertised supplements that ask if you suffer from low T or your partner is not satisfied, and then promise a return to “full manhood” with phrases like “rock hard erections” and “hours of performance.” Many of these products have not been rigorously tested. Some have been shown to contain impure ingredients and fillers, while others contain one or two clinically tested ingredients but have otherwise suspicious formulas.

Whether or not you have prostate cancer, you don’t have to endure the effects of low testosterone—but you do have to place yourself in the hands of a reputable expert.


[i] Kacker R, Mariam H, San Francisco IF, Conners WP et al. Can testosterone therapy be offered to men on active surveillance for prostate cancer? Preliminary results. Asian J Androl. 2015 Aug 21. doi: 10.4103/1008-682X.160270.

[ii] For the complete Epstein AS criteria see http://www.urology.jhu.edu/prostate/active_surveillance_selection.php

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