Testosterone Replacement Therapy and Prostate Risks: Where’s the Beef?

Abraham Morgentaler, MD
Division of Urology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts, USA

It has been over 60 years since Huggins published his landmark work showing that castration caused regression of metastatic prostate cancer, linking forever the issues of prostate cancer and testosterone (T). 1 The recognition that prostate cancer is largely androgen-dependent has resulted in a reluctance, and in some quarters even a strong antipathy, to treat hypogonadal men with testosterone replacement therapy (TRT). After all, castration or pharmacologic lowering of serum T to castrate levels continues to be a mainstay of treatment for advanced prostate cancer to this day. If lowering testosterone makes prostate cancer cells die, then it should follow that raising testosterone should make prostate cancer cells grow.

Nevertheless, there is growing recognition in the medical community that hypogonadism is a significant and treatable condition of men that becomes increasingly common with aging. Moreover, the benefits of TRT have been well documented, including improvement in libido, erectile dysfunction, mood, cognition, lean body mass, and bone density. 2 How then does one reconcile the benefits of TRT in the hypogonadal man with the potential risk that TRT may cause an occult cancer to grow?

Curiously, after all these years of testosterone usage and awareness of the androgendependence of prostate cancer, there remains no compelling evidence that TRT does, in fact, represent a true risk for prostate cancer growth. Below, I present a summary of the data regarding TRT and prostate cancer.