The Effect Of Testosterone Replacement Therapy On Psa
Currently available data suggests that even hypogonadal men without prostate cancer will exhibit detectable increases in PSA during testosterone therapy. Patients with large PSA changes should be evaluated for the development of prostate cancer. Current practice guidelines suggest that hypogonadal patients with normal PSA levels should have their PSA rechecked at three months, one year, and every 6 to 12 months thereafter while on testosterone replacement. If the PSA is less than 4.0 ng/ml but rises by 1.5 ng/ml or more in a year, or 0.75 ng/ml per year over two years, further evaluation for prostate cancer including biopsy should be discussed. The role of PSA velocity as an indication for prostate biopsy is still controversial. Data from the Prostate Cancer Prevention Trial indicated an increased sensitivity when PSA velocity was used as an indication for biopsy. However, using a PSA velocity as an indication reduces sensitivity and increases the number of unnecessary biopsies. Finally, biopsies should be offered to any patient with a PSA level above 4.0 ng/ml.
Treating Advanced Prostate Cancer
If the cancer has reached an advanced stage, it’s no longer possible to cure it. But it may be possible to slow its progression, prolong your life and relieve symptoms.
Treatment options include:
- hormone treatment
If the cancer has spread to your bones, medicines called bisphosphonates may be used. Bisphosphonates help reduce bone pain and bone loss.
Relationship Of Testosterone And Prostate Cancer
Huggins and Hodges demonstrated in 1941 that reducing testosterone levels by castration caused regression of metastatic prostate cancer and that administering testosterone promoted the growth of prostate cancers. To this day, however, there is no conclusive evidence of a clear-cut correlation between high serum testosterone levels and prostate cancer risk.
Since prostate cancer is known to be androgen-dependent, there is concern that small, previously undetected tumors may progress to overt disease in the presence of exogenous testosterone or even under the influence of high levels of endogenous testosterone. The question of whether testosterone stimulates the development of prostate cancer remains controversial.
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What Is Hormonal Therapy For Prostate Cancer
Hormonal therapy for prostate cancer is a treatment to lower the levels of the hormone testosterone in the body. Prostate cancer needs testosterone to grow. Testosterone is mainly made by the testicles. Hormonal therapies reduce the amount of testosterone in the body, or stop it reaching the prostate cancer cells.
Testosterone is important for:
- muscle development and bone strength.
Hormonal therapies are drugs that can be given as injections or as tablets.
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Symptomatic treatment of an enlarged prostate usually involves a combination of medication and lifestyle changes. A diet rich in fruits and vegetables may be the best option if you suffer from chronic urination. It will help the body adjust to the increased size of the prostate. Also, taking regular urination intervals will help retrain the bladder to function properly. Inactivity also contributes to urine retention, and cold temperatures can increase the urge to urinate.
Invasive treatment of enlarged prostate includes medication that relieves the pressure on the urethra and bladder. However, if the condition is severe, it may require surgical intervention. If treatment is not successful, the enlarged prostate can become a potentially life-threatening disease. As the hormone levels in the body change, the enlarged prostate can lead to various complications, including urinary retention and even cancer. This is why it is critical to see a doctor for further evaluation.
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Prostate Cancer In Men Receiving Exogenous Testosterone
To date no study or review has documented any direct evidence that testosterone therapy increases incident prostate cancer risk. However, it is still difficult to argue that androgen replacement is safe since no long-term studies have been completed in large populations receiving exogenous androgens over many years. The question of whether androgen replacement increases prostate cancer incidence in an aging population has yet to be answered. The Institute of Medicine, recognizing the need for additional clinical trials to clarify the risks and benefits of testosterone replacement therapy , formed a committee to evaluate the present status of TRT in 2003. This was the most recent statement on the issue of TRT from the Institute of Medicine.
Even studies of TRT in men with high risk for incident prostate cancer because of preexisting prostatic intraepithelial neoplasia did not show an increased risk of prostate cancer. There has been one small study examining the risk of TRT in men with high-grade PIN. These men should presumably be at higher risk for prostate cancer development. After a year of TRT, only one patient with previous high-grade PIN had a detected prostate cancer. The study included 70 men overall 20 with high-grade PIN and 50 controls. This study suggests that TRT does not significantly increase the risk of incident cancer even in an already high-risk population.
What To Expect During Hormone Therapy
As you go through hormone deprivation therapy, youâll have follow-up visits with your cancer doctor. Theyâll ask about side effects and check your PSA levels.
Doctors donât know how long hormone therapy works to keep prostate cancer in check. So, while you take it, your doctor will regularly draw blood to check your PSA levels. Undetectable or low PSA levels usually mean that the treatment is working. If your PSA levels go up, itâs a sign that the cancer has started growing again. If this happens, your cancer is considered castrate-resistant, and hormone deprivation therapy is no longer an effective treatment.
Youâll also get other blood tests to see if the cancer is affecting other parts of your body like your liver, kidneys, or bones. Scans will show how well your cancer is responding to hormone therapy.
To lessen the side effects of hormone therapy drugs, researchers suggest that you take them for just a set amount of time or until your PSA drops to a low level. If the cancer comes back or gets worse, you may need to start treatment again.
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Testosterone Supplementation After Prostate Cancer
Two experts examine the pros and cons of this controversial practice
At some point in their 40s, mens testosterone production begins to slow. By some estimates, levels of this hormone drop by about 1% a year. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone. These include reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, lower muscle mass and bone density, and anemia. When severe, these signs and symptoms characterize a condition called hypogonadism.
Researchers estimate that hypogonadism affects two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment, according to the FDA. Deciding which patients should receive testosterone supplementation has proved tricky, however. For example, little consensus exists on what constitutes low testosterone. In addition, some men may have low blood levels of testosterone but not experience any symptoms. And few large, randomized studies on the long-term risks or benefits of testosterone supplementation have been completed.
Testosterone Laboratory Blood Testing
Blood tests are a factor that is used to determine whether testosterone replacement is needed. If you are having your testosterone level checked with a home test or at a laboratory as ordered by your doctor, your results might not be clear-cut.
Issues that affect blood levels of testosterone:
- Testosterone blood levels are higher in the morning and lower in the evening. A test drawn at 4 pm that was low may simply be outside the normal range due to the time of day the blood was taken.
- There are two types of testosterone tests: total testosterone and free testosterone. Most routine tests only measure total testosterone. However, free testosterone is a much more accurate measure of the physiologic activity of testosterone.
Making a decision about your need for testosterone therapy is not based solely on the level of testosterone in your blood. It is equally important to consider your symptoms and whether they are indicative of low testosterone levels.
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Optimum Testosterone Level In The Treatment Of Prostate Cancer
Normal serum testosterone ranges are 300 to 1000 ng/dL for men aged 17 years and older. Due to intra-assay variability, a deviation of about 7% should be accounted for when interpreting testosterone values. A total serum testosterone level of lower than 200 ng/dL or lower than 300 ng/dL is associated with hypogonadism and warrants further workup in an otherwise normal adult.34 Free testosterone is sometimes used in the evaluation of hypogonadism as elevated or decreased sex hormone-binding globulin changes the bioavailability of the free form of testosterone. As an example, obesity is characterized by a reduced total testosterone with normal free testosterone due to reduced protein binding. Serum SHBG concentrations increase with age. With increasing age, less of the total testosterone is free or biologically active, as SHBG binds testosterone with high affinity.35
There is clearly no defined answer to the optimum level of testosterone that should be achieved in the treatment of prostate cancer. Traditional definitions are based on the so-called castrate levels of testosterone. However, what the castrate level actually is depends on the therapeutic intervention: less than 20 ng/dL has been routinely reported for surgical orchiectomy and less than 50 ng/dL has been reported with LHRH therapy.
Staging Of Prostate Cancer
Doctors will use the results of your prostate examination, biopsy and scans to identify the stage of your prostate cancer .
The stage of the cancer will determine which types of treatments will be necessary.
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.
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Treatment To Lower Testicular Androgen Levels
Androgen deprivation therapy, also called ADT, uses surgery or medicines to lower the levels of androgens made by the testicles.
Orchiectomy
Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where most of the androgens are made. This causes most prostate cancers to stop growing or shrink for a time.
This is done as an outpatient procedure. It is probably the least expensive and simplest form of hormone therapy. But unlike some of the other treatments, it is permanent, and many men have trouble accepting the removal of their testicles. Because of this, they may choose treatment with drugs that lower hormone levels instead.
Some men having this surgery are concerned about how it will look afterward. If wanted, artificial testicles that look much like normal ones can be inserted into the scrotum.
LHRH agonists
Luteinizing hormone-releasing hormone agonists are drugs that lower the amount of testosterone made by the testicles. Treatment with these drugs is sometimes called medical castration because they lower androgen levels just as well as orchiectomy.
With these drugs, the testicles stay in place, but they will shrink over time, and they may even become too small to feel.
- Leuprolide mesylate
LHRH antagonists
Possible side effects
Many side effects of hormone therapy can be prevented or treated. For example:
Good Prostate Cancer Care
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.
You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.
You should also be told about any clinical trials you may be eligible for.
If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.
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Does Estrogen Cause Prostate Cancer
Estrogen as a cause of prostate cancer is gaining lots of attention. At least in rats, experts know that testosterone plus estrogen are necessary for the development of prostate cancer. In men, however, the research findings thus far have been mixed, with a few studies indicating an association between estrogens and chronically high estrogens and an increased risk of cancer, but others showing the opposite.
Its widely accepted that a mans testosterone:estrogen ratio should be in balance that is, higher levels of testosterone than of estrogen. Because testosterone can be changed into estrogen via an enzyme called aromatase, the critical point is to adopt habits that help reduce the activity of this enzyme. This includes maintaining a healthy weight, losing excess belly and body fat , limiting or avoiding alcohol , maintaining healthy blood sugar levels, and taking natural supplements.
What Is Hormone Therapy
Hormones occur naturally in your body. They control the growth and activity of normal cells. Testosterone is a male hormone mainly made by the testicles.
Prostate cancer usually depends on testosterone to grow. Hormone therapy blocks or lowers the amount of testosterone in the body.
Hormone therapy on its own doesn’t cure prostate cancer. But it can lower the risk of an early prostate cancer coming back when you have it with other treatments. Or it can shrink an advanced prostate cancer or slow its growth.
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What Is Unique About Receiving Hormone Therapy At Rocky Mountain Cancer Centers
At Rocky Mountain Cancer Centers, your cancer care team will design a personalized cancer treatment plan that provides the ideal combination of therapies for the best possible outcome. Under our care, you will be monitored closely to determine if your hormone therapy is working. This involves regular PSA tests for prostate cancer treatment and regular checkups for breast cancer treatment.
Rest assured, you are in good hands with Rocky Mountain Cancer Centers. We believe in treating the whole person, not just the disease, which is why we will work hard to create the best cancer treatment plan for you.
What Vitamins Can I Take For My Prostate
As with any medical concerns, talk to your doctor before moving forward with any plans to introduce vitamin or mineral supplements to your diet. Its every bit as important to ensure you dont take too much of a vitamin as it is to be certain you arent deficient. However, supplements are necessary for multiple reasons ranging from dietary restrictions to genetic conditions. There are plenty of foods that contain sufficient quantities of the vitamins below, but if the food itself is not enough, prostate supplements are available to help.
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Testosterone Therapy And Prostate Cancer
Testosterone therapy may increase the risk of prostate cancer recurrence for some people.
Some factors that are particularly associated with a high risk of recurrence:
- Extraprostatic extension
- Positive margins
- Gleason scores of 8 or more on biopsy
- Invasion of the seminal vesicles
There are some situations when testosterone therapy would not be harmful and may be beneficial for people who have had prostate cancer.
- Men who have low-grade or benign tumors
- Men who have completed therapy with surgery or radiation and appear to be cured can use testosterone therapy after an appropriate waiting period between two and five years. The risk of cancer recurrence at this point is generally quite low.
- When a man with known prostate cancer has a low testosterone level and severe physical infirmity or very advanced muscle loss that is associated with notable weakness.
Other Evidence To Support Lower Testosterone Levels And Improved Outcomes
The historic investigations known as the Veterans Administration Cooperative Urological Research Group studies formed a basis for the treatment of prostate cancer with DES before the availability of LHRH analogues. Due to higher death rates in the 5-mg DES treatment arm in VACURG I, lower DES doses were studied in VACURG II. Patients were randomized to 3 different dose ranges of DES versus placebo.43 Men receiving 0.2 mg/day of DES had a significantly shorter overall survival than men receiving 5 mg/day. VACURG II showed some survival benefit for hormonal treatment when Kent and associates44 reported that 0.2 mg/day and 1 mg/day of DES failed to consistently suppress testosterone to castrate levels. These data suggest that ineffective androgen suppression may reduce survival in advanced prostate cancer.
Several studies have demonstrated that the addition of an antiandrogen to orchiectomy did not improve overall survival, whereas the addition of an antiandrogen to an LHRH analogue did.4547 Although specific testosterone data are not available, it does suggest that ineffective or inconsistent testosterone suppression by LHRH analogues might be an explanation.
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Can Testosterone Treat Prostate Cancer
A small study found that testosterone may suppress the growth of some advanced prostate cancers and could reverse resistance to testosterone-blocking agents.
Testosterone has been found to suppress the growth of some advanced prostate cancers and may also be able to reverse the resistance to prostate cancer drugs that suppress testosterone production. The findings are surprising, since testosterone is generally known to provide fuel for prostate tumor growth.
The small 16-patient pilot study treated men with asymptomatic metastatic prostate cancer, who had rising prostate-specific antigen levels and evidence of resistance to androgen deprivation therapy , with three 28-day cycles of testosterone and 2 weeks of the chemotherapy etoposide. The patients who had declining PSA levels after three cycles continued to receive testosterone injections alone.
The results of the study were in Science Translational Medicine.
Seven of the men had 30% to 99% decreases in PSA levels. Four of these men stayed on therapy for 1 to 2 years and had steady low PSA levels. Of the remaining nine men, seven had no changes in their PSA levels, one died due to pneumonia and sepsis from the chemotherapy treatment, and one did not complete the study due to prolonged erection from the testosterone.
According to the authors, more studies to test the role of testosterone in CRPC are being planned at Johns Hopkins University and other institutions.
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