Alexander Pastuszak, MD, PhD: Is hormone therapy safe after prostate cancer radiotherapy?

In an interview with Urology Times during the American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting in Washington, DC, this week, Alexander Pastuszak, MD, PhD, assistant professor of surgery and urology in the department of surgery at The University of Utah School of Medicine, discussed the evolving understanding and clinical implications of testosterone therapy in patients with prostate cancer who received radiotherapy.

Though testosterone therapy has been historically marked for its increased risk of androgen-dependent tumors in patients, emerging data has shown its benefit in measures including bone density, cardiovascular health and overall patient quality of life.

“We know that it's optimized for insulin responses, for body habitus, for libido, and to some extent, energy levels, and then other aspects...such as better sleep and mental clarity—some of these symptoms that may not be fully and well defined, since the symptoms of hypogonadism are fairly nonspecific, but nevertheless, that you see improvements in men with when you give them testosterone,” Pastuszak said.

At the same time, patients face risks including erythrocytosis, increased estrogen levels, risk of infertility, liver damage, sleep apnea, and even prostate cancer.

“A big part of the reason that patients come and see doctors like me after or even before... surgery or radiation therapy for prostate cancer, is really to help them mitigate the negative outcomes, right?” Pastuszak said. “And it's a process of shared decision making. A lot of men are told what the negative side effects of their therapy are going to be before they undergo therapy, but if you query those men after therapy, a lot of them will not remember, right? And they'll come back and say, 'Wow, this is not what I expected,' or 'This is worse than I expected.'”

A proactive approach to planning testosterone therapy post-prostate cancer radiotherapy could include Pastuszak and colleagues helping to design a penile rehabilitation program for either before or right after treatment. Specialists can also help assure what effect the treatment should have on domains including sexual function and physical rehabilitation. Additionally, they can provide perspective on the evolution of understanding around radiotherapy that may address misconceptions borne from data now nearly a century old.

“A lot of the concerns that were raised with this initial study in 1941 by Huggins and Hodges have been, to a large extent, put to bed,” Pastuszak said. “The urological community has successfully treated men with low, intermediate and even high risk prostate cancer...with hormone therapy without necessarily seeing an increase in either prostate cancer incidence, recurrence or progression. And while that doesn't satisfy the question of, is hormone therapy safe in the context of these treated and/or untreated men, it does allay a lot of concerns.”

References

1. ^{Pastuszak A. Testosterone Replacement Therapy (TRT) Following Radiation Treatment for Prostate Cancer: Are We Doing a Disservice or Providing a Benefit? Session presented at: American Society for Radiation Oncology (ASTRO) 2024 Annual Meeting. Washington, DC. September 29 – October 2, 2024.}
2. ^{HUGGINS C, STEVENS RE, HODGES CV. STUDIES ON PROSTATIC CANCER: II. THE EFFECTS OF CASTRATION ON ADVANCED CARCINOMA OF THE PROSTATE GLAND. Arch Surg. 1941;43(2):209–223. doi:10.1001/archsurg.1941.01210140043004}