Gerald Chodak, MD


December 27, 2017

Hello. I'm Dr Gerald Chodak for Medscape. Today's topic is the potential risk [for prostate cancer] in men who [receive] hormone replacement for hormone deficiency. In a poster, Haider and colleagues[1] recently reported on a cohort of 776 [hypogonadal] men who were followed for a median of 8 years. About half of them chose to receive hormone replacement and the others chose not to.

All men had a prostate-specific antigen (PSA), digital rectal exam, and prostate ultrasound performed at the beginning of their initiation and periodically during follow-up. At median follow-up, prostate cancer was detected in 2.3% of the men who received hormone replacement; it was three times higher, at 6.9%, in the men who had not received any hormone replacement. Overall, the researchers found that of the nine men who were diagnosed with prostate cancer in the treated group, all of them had stage T2 disease after a radical prostatectomy. None of them had primary Gleason grade 4. Eight out of the nine had a Gleason score ≤ 6.

In the control group, however, they found something different. [Twenty-five] out of the 26 men had a pathologic stage of T3. Overall, they had a greater risk of having high-grade disease, with all of them having Gleason scores > 6.

This study is provocative to say the least, but it is consistent with other studies[2,3] that have shown that administering hormone replacement in men who are hypogonadal has not increased their risk for prostate cancer. What is somewhat surprising, however, is, why administering testosterone should lower a man's risk to even a lower value than might occur if he had normal testosterone and never received any therapy.

There are some concerns about the trial because it is not a randomized study. For example, there were differences in the PSA at the time the study began, with it being about twice as high in the control group compared with the treated group. The authors do not address that. Also, because the men were being followed more often with testing in the treated group, this could have had some impact on diagnosis.

At the end of the day, we can say that administering testosterone replacement to men who are hypogonadal does not appear to raise their risk of getting prostate cancer. We must ask ourselves why it should appear to lower the risk of having more aggressive disease. Another question is, why should men who are untreated when they are hypogonadal have a higher risk from their cancer? Curiously, we reported with some other authors many years ago on men who were being diagnosed and treated for metastatic prostate cancer. We found that lower testosterone conveyed a worse survival compared with men with higher testosterone levels.[4]

There is something going on here with testosterone levels in men and their risks for prostate cancer and aggressive disease. More data are needed to sort this out. Hopefully, those studies will be forthcoming. The bottom line is: It does appear to be safe to administer hormone replacement to hypogonadal men without significantly raising the risk for prostate cancer.

I look forward to your comments. Thank you.


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