2. UroToday Home
  3. Conference Highlights
  4. EAU 2019
  5. EAU 2019 Prostate Cancer

EAU 2019

EAU 2019: Case Based Debate: Hypogonadal Prostate Cancer Patient Following Treatment with Curative Intent: Pro versus Con

Barcelona, Spain (UroToday.com) In this debate, Drs. Mulhall and Tombal debated the safety of testosterone replacement therapy in a prostate cancer patient. The index patient was a 58-year-old male with a pre-treatment PSA of 7.6 who, was 6 months status post radical prostatectomy for Gleason 4+3 prostate cancer with negative margins and an undetectable PSA, but symptomatic hypogonadism and erectile dysfunction despite tadalafil 5mg daily.   It was noted that physicians concerns regarding testosterone replacement therapy are worldwide, stemming from the original Huggins and Hodges data that reduction of testosterone to castrate levels caused prostate cancer to regress whereas administration of exogenous testosterone caused prostate cancer to grow. However, more contemporary data shows no strong evidence on testosterone replacement therapy and prostate cancer and current EAU evidence-based guidelines is listed as “weak”.

Dr. Mulhall argued in favor of administering testosterone replacement therapy in the post-prostatectomy patient. Risks of testosterone therapy include polycythemia, gynecomastia, and an absence of long term safety data in prostate cancer population. Benefits include reduction of cardiovascular events, improved glycemic control, bone density, and nerve recovery. Dr. Mulhall then explained the prostate cancer saturation model, where the receptors become saturated at a specific level and added testosterone does no harm. He explained in vitro and in vivo models which support this data. There is also data that supports testosterone as a neurogenic modulator and supports nerve recovery after prostatectomy. He reviewed a 2017 multivariate analysis demonstrating that patients treated with neoadjuvant ADT were 13 times more likely to have severe ED following prostatectomy. Dr. Mulhall also reviewed the newest MSKCC data which will be released at the upcoming 2019 AUA conference, in which 360 patients status post radical prostatectomy for pT2 Gl 6-7 prostate cancer and undetectable PSA were treated with TRT. Only one patient had a biochemical recurrence at a median follow up of 66 months. Dr. Mulhall concluded that a shared decision making is essential and treatment may be necessary depending upon the patient's specific signs and symptoms of testosterone deficiency.

Dr. Tombal argued the contrary: that he would be reluctant to give this patient testosterone replacement. A 2017 multi-institutional study demonstrated that patients with pT2N0 Gl 7 prostate cancer have an approximately 15% and 20% recurrence and 5 and 10 years, respectively. This is also confirmed via MSKCC nomograms. Existing evidence supporting testosterone replacement therapy is very weak, consisting of small retrospective series with short follow up and most of the patients were Gl 6 disease. Furthermore, Dr. Tombal refuted Dr. Mulhall’s analysis of the saturation model, due to the ignoring of the Coffey Paradox, and believe that prostate cancer is an extremely heterogeneous disease. In summary, Dr. Tombal believes that testosterone replacement therapy may add fuel to the fire – proceed with caution.

Presented by: John Mulhall, MD1 and Bertrand Tombal, MD, PhD2
1. Memorial Sloan Kettering Cancer Center, New York, New York
2. Cliniques Universitaires Saint Luc, Brussels, Belgium

Written by: David B. Cahn, DO, MBS @dbcahn Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19, conference in Barcelona, Spain from March 15-19, 2019.