Turning conventional wisdom upside-down

Cancer Stage, Treatment, and Survival Among Transgender Patients in the United States

Background

Transgender persons face many barriers to health care that may delay cancer diagnosis and treatment, possibly resulting in decreased survival. Yet, data on cancer in this population are limited. We examined cancer stage at diagnosis, treatment, and survival among transgender patients compared with cisgender patients in the National Cancer Database (NCDB).

Methods

Gender (male, female, or transgender) was extracted from medical records from patients diagnosed with cancer between 2003 and 2016. Logistic regression estimated odds ratios (ORs) for the associations between gender and stage at diagnosis and treatment receipt. Cox proportional hazards regression estimated hazard ratios (HRs) for associations between gender and all-cause survival.

Results

Among 11 776 699 persons with cancer in NCDB, 589 were transgender. Compared with cisgender patients, transgender patients may be more likely to be diagnosed with advanced stage lung cancer (OR = 1.76, 95% confidence interval [CI] = 0.95 to 3.28); be less likely to receive treatment for kidney (OR = 0.19, 95% CI = 0.08 to 0.47) and pancreas (OR = 0.33, 95% CI = 0.11 to 0.95) cancers; and have poorer survival after diagnosis with non-Hodgkin lymphoma (HR = 2.34, 95% CI = 1.51 to 3.63), prostate (HR = 1.91, 95% CI = 1.06 to 3.45), and bladder cancers (HR = 2.86, 95% CI = 1.36 to 6.00). Similar associations were found for other cancer sites, although not statistically significant.

Conclusion

Transgender patients may be diagnosed at later stages, be less likely to receive treatment, and have worse survival for many cancer types. Small sample size hampered our ability to detect statistically significant differences for some cancer sites. There is a need for transgender-focused cancer research as the population ages and grows.

Low serum testosterone is a predictor of high-grade disease in patients with prostate cancer

OBJECTIVE

To evaluate the relation between serum total testosterone (TT) and prostate cancer (PCa) grade and the effect of race and demographic characteristics on such association.

METHOD

We analyzed 695 patients undergoing radical prostatectomy (RP), of whom 423 had serum TT collected. Patients were classified as having hypogonadism or eugonadism based on two thresholds of testosterone: threshold 1 (300 ng/dL) and threshold 2 (250 ng/dL). We evaluated the relation between TT levels and a Gleason score (GS) ≥ 7 in RP specimens. Outcomes were evaluated using univariate and multivariate analyses, accounting for race and other demographic predictors.

RESULTS

Out of 423 patients, 37.8% had hypogonadism based on the threshold 1 and 23.9% based on the threshold 2. Patients with hypogonadism, in both thresholds, had a higher chance of GS ≥ 7 (OR 1.79, p=0.02 and OR 2.08, p=0.012, respectively). In the multivariate analysis, adjusted for age, TT, body mass index (BMI) and race, low TT (p=0.023) and age (p=0.002) were found to be independent risk factors for GS ≥ 7. Among Black individuals, low serum TT was a stronger predictor of high-grade disease compared to White men (p=0.02).

CONCLUSION

Hypogonadism is independently associated to higher GS in localized PCa. The effect of this association is significantly more pronounced among Black men and could partly explain aggressive characteristics of PCa found in this race.

Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency

INTRODUCTION

Testosterone (T) deficiency (TD; hypogonadism) has deleterious effects on men's health; negatively affects glycometabolic and cardiometabolic functions, body composition, and bone mineral density; contributes to anemia and sexual dysfunction; and lowers quality of life. T therapy (TTh) has been used for the past 8 decades to treat TD, with positive effects on signs and symptoms of TD.

AIM

To summarize the health benefits of TTh in men with TD.

METHODS

A comprehensive literature search was carried out using PubMed, articles relevant to TTh were accessed and evaluated, and a comprehensive summary was synthesized.

MAIN OUTCOME MEASURES

Improvements in signs and symptoms of TD reported in observational studies, registries, clinical trials, and meta-analyses were reviewed and summarized.

RESULTS

A large body of evidence provides significant valuable information pertaining to the therapeutic value of TTh in men with TD. TTh in men with TD provides real health benefits for bone mineral density, anemia, sexual function, glycometabolic and cardiometabolic function, and improvements in body composition, anthropometric parameters, and quality of life.

CONCLUSION

TTh in the physiologic range for men with TD is a safe and effective therapeutic modality and imparts great benefits on men's health and quality of life. Traish AM. Benefits and Health Implications of Testosterone Therapy in Men With Testosterone Deficiency. Sex Med Rev 2018;6:86-105.

Risk of Testosterone Flare in the Era of the Saturation Model: One More Historical Myth

CONTEXT

When luteinizing hormone-releasing hormone (LHRH) agonists were introduced in the 1980s, it was universally believed that the initial transient rise in serum testosterone (T), termed T flare, caused rapid prostate cancer (PCa) growth and led to disease progression, complications, and death. It became routine to offer antiandrogens (AAs) to prevent these risks. However, over the last decade, it has become recognized that androgens have a finite ability to stimulate PCa growth (the saturation model), providing a theoretical challenge to the risks of T flare.

OBJECTIVE

To review evidence for the risks associated with T flare from a modern perspective, specifically prostate-specific antigen (PSA) flare, disease progression, and spinal cord compression.

EVIDENCE ACQUISITION

An Ovid Medline database search was conducted to identify articles related to "testosterone flare", "disease flare", and "PSA flare" associated with LHRH agonists. The literature review included papers published from May 1, 1980 through May 1, 2016. Key search terms included, luteinizing hormone-releasing hormone, gonadotropin-releasing hormone, and antiandrogens.

EVIDENCE SYNTHESIS

Initial administration of LHRH agonists uniformly results in peak increases in serum T by 40-100% on days 2-3, returning to baseline by days 7-8, after which T declines to castrate levels by approximately 2-3 wk. Of six LHRH agonist studies reporting PSA during the period of T flare, five showed no significant rise in PSA despite the presence of advanced disease with mean baseline PSA as high as ≥500ng/ml. Evidence for disease flare was limited to one report of greater bone pain with LHRH agonists alone versus LHRH agonists with AAs. Three other RCTs reported no disease flare. Rates of spinal cord compression were no greater for LHRH agonists alone compared with castration or estrogen treatment. We identified no studies of men treated with LHRH agonists versus placebo/no treatment to assess the effects of LHRH agonists compared with the natural history of advanced PCa.

CONCLUSIONS

Although T flare has been considered risky for 30 yr, a modern review of the evidence collected primarily in the 1980s and 1990s fails to support this view. Specifically, T flare does not appear to be associated with significantly increased PSA, disease progression, or adverse events, even in men with widely metastatic disease. These results are consistent with the saturation model, first introduced in 2006. There seems little value in adding AA to LHRH agonists, except possibly for men with extensive vertebral metastases and serum T concentrations well below the saturation point of approximately 250ng/dl (8.7nmol/l).

PATIENT SUMMARY

A review of the literature reveals no evidence for increased risks associated with testosterone flare from the initiation of luteinizing hormone-releasing hormone (LHRH) agonists. This appears to be an unsupported belief from an earlier era when our understanding of testosterone's relationship to prostate cancer was less sophisticated. Except in rare instances, there appears to be no need to use an androgen blocker when beginning treatment with LHRH agonists.

Is there a protective role of testosterone against high-grade prostate cancer? Incidence and severity of prostate cancer in 553 patients who underwent prostate biopsy: a prospective data register

This study investigated the role of testosterone replacement therapy (TRT) in prostate safety and cancer progression. A cohort of 553 patients, 42 treated and 162 untreated hypogonadal men, and 349 eugonadal men were included. Pathological analysis of prostate biopsies examining the incidence and severity of PCa revealed that: 16.7% of treated hypogonadal men had a positive biopsy, a Gleason score of ≤6 in 71.4% and >6 in 28.6% of men, a predominant score of 3 and tumour staging of II in 85.7% men; 51.9% of untreated hypogonadal men had a positive biopsy, a Gleason score of ≤6 in 40.5% and >6 in 59.5% men, a predominant score of 3 (77.4%) and tumour staging of II (41.7%) or III (40.5%); 37.8% of eugonadal men had a positive biopsy, a Gleason score of ≤6 in 42.4% and >6 in 57.6% of men, a predominant score of 3 (82.6%) and tumour staging of II (44.7%) or III (47.7%). The incidence of positive prostate biopsies was lowest in hypogonadal men receiving TRT, with significantly lower severity of PCa in terms of staging and grading in the same group. These results suggest that TRT might have a protective effect against high-grade PCa.

Low serum testosterone is associated with tumor aggressiveness and poor prognosis in prostate cancer

Serum testosterone is a potential marker to distinguish between indolent and aggressive prostate cancer (PCa). The present study aimed to investigate whether low levels of total serum testosterone at diagnosis were associated with aggressive PCa and poor clinical outcomes. In total, 762 non-Hispanic Caucasian men with previously untreated PCa were recruited from The University of Texas MD Anderson Cancer Center (Houston, TX, USA). Patients were categorized into three groups based on their total serum testosterone levels according to clinical guidelines [low (<230 ng/dl), intermediate (230-350 ng/dl) and normal (>350 ng/dl)]. PCa aggressiveness (low-, intermediate- or high-risk, or metastatic) was compared using multinomial logistic regression. Rates of disease progression, mortality from any cause and PCa-specific mortality were compared using the multivariate Cox proportional hazards model. Testosterone levels significantly decreased as PCa aggressiveness increased (P<0.001). Compared with the normal testosterone group, the low testosterone group had 2.9-fold (OR, 2.92; 95% CI, 1.74-4.90; P<0.001), 5.6-fold (OR, 5.63; 95% CI, 3.14-10.12; P<0.001) and 72.4-fold (OR, 72.40; 95% CI, 20.89-250.89; P<0.001) increased risks of having intermediate-risk, high-risk and metastatic PCa, respectively. Furthermore, low levels of testosterone were significantly associated with a 10.7-fold (HR, 10.68; 95% CI, 1.35-84.44; P=0.03) increased risk of PCa-specific mortality. The results of the present study indicate that low levels of total serum testosterone at diagnosis are associated with aggressive PCa and predict poor PCa-specific survival.

Current opinion on the role of testosterone in the development of prostate cancer: a dynamic model

BACKGROUND

Since the landmark study conducted by Huggins and Hodges in 1941, a failure to distinguish between the role of testosterone in prostate cancer development and progression has led to the prevailing opinion that high levels of testosterone increase the risk of prostate cancer. To date, this claim remains unproven.

PRESENTATION OF THE HYPOTHESIS

We present a novel dynamic mode of the relationship between testosterone and prostate cancer by hypothesizing that the magnitude of age-related declines in testosterone, rather than a static level of testosterone measured at a single point, may trigger and promote the development of prostate cancer.

TESTING THE HYPOTHESIS

Although not easily testable currently, prospective cohort studies with population-representative samples and repeated measurements of testosterone or retrospective cohorts with stored blood samples from different ages are warranted in future to test the hypothesis.

IMPLICATIONS OF THE HYPOTHESIS

Our dynamic model can satisfactorily explain the observed age patterns of prostate cancer incidence, the apparent conflicts in epidemiological findings on testosterone and risk of prostate cancer, racial disparities in prostate cancer incidence, risk factors associated with prostate cancer, and the role of testosterone in prostate cancer progression. Our dynamic model may also have implications for testosterone replacement therapy.

Racial Differences in Age-Related Variations of Testosterone Levels Among US Males: Potential Implications for Prostate Cancer and Personalized Medication

AIM

The magnitude of the age-related declines in testosterone rather than levels measured at single point in time may be related to the genesis of prostate cancer (PCa). We examined age-related variations of testosterone levels among black and white males, which may provide important insights into racial disparities in PCa incidence and mortality.

METHOD

We analyzed data from the 1999-2004 National Health and Nutritional Examination Survey to compare age-related variations in the testosterone levels of 355 black and 631 white males.

RESULT

Overall, between the ages of 12 and 15, black males had lower testosterone levels than white males. Testosterone levels increased rapidly with age and reached higher and earlier peak levels in black males compared to white males at 20-30 years of age. After reaching a peak level, testosterone levels declined earlier in blacks than in whites. Further analyses showed that black males had considerably higher levels of testosterone compared to white males aged 20-39 years after adjusting for covariates, including age, body mass index, cigarette smoking, physical activity, and waist circumference; however, no statistically significant differences were observed between the groups at any other age.

CONCLUSION

Our study revealed that testosterone levels in black males decrease substantially with increasing age compared to those in white males. This rapid drop in testosterone levels may contribute to racial disparities in PCa. Our findings also suggest that personalized medication for hormone replacement therapy may be necessary to avoid sudden drops in testosterone levels, particularly for black males.

Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8-10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer

What's known on the subject? and What does the study add? Previous data from clinically localized prostate cancer (PCa) series treated with radical prostatectomy (RP) have suggested that low preoperative serum total testosterone level is associated with more aggressive PCa; however, the definition of low preoperative total testosterone level varied among these studies (from 220 ng/dL to 387 ng/dL). Moreover, no relevant data exist in the literature regarding ethnic Chinese patients. The study shows that the most widely used threshold for low pretreatment total testosterone level (total testosterone < 300 ng/dL) is not appropriate for ethnic Chinese patients, because it could not distinguish patients with more aggressive PCa from those with less aggressive disease. Setting the threshold at the level of total testosterone < 250 ng/dL works better, because pretreatment total testosterone < 250 ng/dL is associated with a significantly higher incidence of Gleason score 8-10 disease in RP specimens.

OBJECTIVE

• To investigate the relationship between preoperative serum total testosterone level and prognostic factors of Chinese patients with clinically localized prostate cancer (PCa).

PATIENTS AND METHODS

• A total of 110 patients with localized PCa, treated by radical prostatectomy (RP), were included in this prospective study. • Clinical and pathological data from each patient were collected. Total testosterone was measured on the morning of surgery. • Total testosterone levels for each patient were compared using two thresholds: threshold 1 (total testosterone <300 ng/dL vs total testosterone ≥ 300 ng/dL) and threshold 2 (total testosterone <250 ng/dL vs total testosterone ≥ 250 ng/dL).

RESULTS

• The median preoperative total testosterone level was 346 ng/dL. Gleason scores of ≤ 6, 7 and ≥ 8 were found in the RP specimens from 21 (19.1%), 67 (60.9%) and 22 (20.0%) patients, respectively. • Compared with those with low grade disease, patients with high grade disease (Gleason score ≥ 8) in RP specimens had a significantly lower preoperative total testosterone. • When comparing 35 patients with hypogonadism with 75 patients with eugonadism, classified by threshold 1, no significant relationships were found. • When comparing 18 patients with hypogonadism with 92 patients with eugonadism, classified by threshold 2, pathological Gleason score ≥ 8 tumours were more common in patients with hypogonadism.

CONCLUSION

• Setting the threshold for hypogonadism at the level of pretreatment serum total testosterone <250 ng/dL is appropriate for ethnic Chinese patients with localized PCa, because patients with pretreatment total testosterone <250 ng/dL are associated with a higher incidence of Gleason score 8-10 disease in RP specimens.

Red wine and component flavonoids inhibit UGT2B17 in vitro

Background

The metabolism and excretion of the anabolic steroid testosterone occurs by glucuronidation to the conjugate testosterone glucuronide which is then excreted in urine. Alterations in UGT glucuronidation enzyme activity could alter the rate of testosterone excretion and thus its bioavailability. The aim of this study is to investigate if red wine, a common dietary substance, has an inhibitory effect on UGT2B17.

Methods

Testosterone glucuronidation was assayed using human UGT2B17 supersomes with quantification of unglucuronidated testosterone over time using HPLC with DAD detection. The selected red wine was analyzed using HPLC; and the inhibitory effects of the wine and phenolic components were tested independently in a screening assay. Further analyses were conducted for the strongest inhibitors at physiologically relevant concentrations. Control experiments were conducted to determine the effects of the ethanol on UGT2B17.

Results

Over the concentration range of 2 to 8%, the red wine sample inhibited the glucuronidation of testosterone by up to 70% over 2 hours. The ethanol content had no significant effect. Three red wine phenolics, identified by HPLC analyses, also inhibited the enzyme by varying amounts in the order of quercetin (72%), caffeic acid (22%) and gallic acid (9%); using a ratio of phenolic:testosterone of 1:2.5. In contrast p-coumaric acid and chlorogenic acid had no effect on the UGT2B17. The most active phenolic was selected for a detailed study at physiologically relevant concentrations, and quercetin maintained inhibitory activity of 20% at 2 μM despite a ten-fold excess of testosterone.

Conclusion

This study reports that in an in vitro supersome-based assay, the key steroid-metabolizing enzyme UGT2B17 is inhibited by a number of phenolic dietary substances and therefore may reduce the rate of testosterone glucuronidation in vivo. These results highlight the potential interactions of a number of common dietary compounds on testosterone metabolism. Considering the variety of foodstuffs that contain flavonoids, it is feasible that diet can elevate levels of circulating testosterone through reduction in urinary excretion. These results warrant further investigation and extension to a human trial to delineate the health implications.

Early detection of high-grade prostate cancer using digital rectal examination (DRE) in men with a prostate-specific antigen level of <2.5 ng/mL and the risk of death

Study Type--Prognosis (inception cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? There is little data on the utility of digital rectal examination (DRE) as a diagnostic tool in the era of prostate-specific antigen (PSA) testing. Using a population-based database, we found that detection of prostate cancer while still localized among men with high-grade PSA-occult disease may result in survival benefit.

OBJECTIVE

• To determine whether detection of high-grade prostate cancer while still clinically localised on digital rectal examination (DRE) can improve survival in men with a normal prostate-specific antigen (PSA) level.

PATIENTS AND METHODS

• From the Surveillance, Epidemiology and End Results database, 166,104 men with prostate cancer diagnosed between 2004 and 2007 were identified. • Logistic regression was used to identify factors associated with the occurrence of palpable, PSA-occult (PSA level of <2.5 ng/mL), Gleason score 8-10 prostate cancer. • Fine and Gray's and Cox multivariable regressions were used to analyse whether demographic, treatment, and clinicopathological factors were associated with the risk of prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM), respectively.

RESULTS

• Both increasing age (adjusted odds ratio [aOR] 1.02, 95% confidence interval (CI) 1.01-1.03; P < 0.001) and White race (aOR 1.26, 95% CI 1.03-1.54; P = 0.027) were associated with palpable, Gleason 8-10 prostate cancer. Of 166,104 men, 685 (0.4%) had this subset of prostate cancer. • Significant factors associated with risk of PCSM included PSA level (adjusted hazard ratio [aHR] 0.71, 95% CI 0.51-0.99; P = 0.04), higher Gleason score (aHR 2.20, 95% CI 1.25-3.87; P = 0.006), and T3-T4 vs T2 disease (aHR 3.11, 95% CI 1.79-5.41; P < 0.001). • Significant factors associated with risk of ACM included age (aHR 1.03, 95% CI 1.01-1.06; P = 0.006), higher Gleason score (aHR 2.05, 95% CI 1.36-3.09; P < 0.001), and T3-T4 vs T2 disease (aHR 2.11, 95% CI 1.38-3.25, P < 0.001)

CONCLUSIONS

• Clinically localised disease on DRE among men with PSA-occult high-grade prostate cancer was associated with improved PCSM and ACM, suggesting that DRE in this cohort (older age and White race) may have the potential to improve survival.

Is testosterone treatment good for the prostate? Study of safety during long-term treatment

INTRODUCTION

For men with androgen deficiency on testosterone replacement therapy (TRT), clinical concern relates to the development of prostate cancer (PCa).

AIM

An updated audit of prostate safety from the UK Androgen Study was carried out to analyze the incidence of PCa during long-term TRT.

MAIN OUTCOME MEASURES

Diagnosis of PCa in men receiving TRT, by serum prostate-specific antigen (PSA) testing and digital rectal examination (DRE), and its relation to different testosterone preparations.

METHODS

One thousand three hundred sixty-five men aged 28-87 (mean 55) years with symptomatic androgen deficiency and receiving TRT have been monitored for up to 20 years. All patients were prescreened for PCa by DRE and PSA along with endocrine, biochemical, hematological, and urinary profiles at baseline and every 6 months. Abnormal findings or rising PSA were investigated by transrectal ultrasound and prostate biopsy. The data were compared for the four different testosterone preparations used in TRT, including pellet implants, Restandol, mesterolone, and Testogel.

RESULTS

Fourteen new cases of PCa were diagnosed at one case per 212 years treatment, after 2,966 man-years of treatment (one case per 212 years). Time to diagnosis ranged from 1 to 12 years (mean 6.3 years). All tumors were clinically localized and suitable for potentially curative treatment. Initiating testosterone treatment had no statistically significant effect on total PSA, free PSA or free/total PSA ratio, and any initial PSA change had no predictive relationship to subsequent diagnosis of cancer.

CONCLUSIONS

The incidence of PCa during long-term TRT was equivalent to that expected in the general population. This study adds to the considerable weight of evidence that with proper clinical monitoring, testosterone treatment is safe for the prostate and improves early detection of PCa. Testosterone treatment with regular monitoring of the prostate may be safer for the individual than any alternative without surveillance.

Association between preoperative erectile dysfunction and prostate cancer features--an analysis from the Duke Prostate Center Database

INTRODUCTION

Erectile dysfunction (ED) is related to several co-morbidities including obesity, metabolic syndrome, cigarette smoking, and low testosterone, all of which have been reported to be associated with adverse prostate cancer features.

AIM

To examine whether preoperative ED has a relationship with adverse prostate cancer features in patients who underwent radical prostatectomy (RP).

METHODS

We analyzed data from our institution on 676 patients who underwent RP between 2001 and 2010. Crude and adjusted logistic regression models were used to investigate the association between preoperative ED and several pathological parameters. The log-rank test and multivariate proportional hazards model were conducted to determine the association of preoperative ED with biochemical recurrence (BCR).

MAIN OUTCOME MEASURES

The expanded prostate cancer index composite (EPIC) instrument was used to evaluate preoperative erectile function (EF). Preoperative normal EF was defined as EPIC-SF ≥ 60 points while ED was defined as preoperative EPIC-SF lower than 60 points.

RESULTS

Preoperatively, a total of 343 (50.7%) men had normal EF and 333 (49.3%) men had ED. After adjusting for covariates, preoperative ED was identified a risk factor for positive extracapsular extension (OR 1.57; P = 0.029) and high percentage of tumor involvement (OR 1.56; P = 0.047). In a Kaplan-Meier curve, a trend was identified that patients with ED had higher incidence of BCR than men with normal EF (P = 0.091). Moreover, using a multivariate Cox model, higher preoperative EF was negatively associated with BCR (HR 0.99; P = 0.014).

CONCLUSIONS

These results suggest that the likelihood for adverse pathological outcomes as well as BCR following prostatectomy is higher among men with preoperative ED, though these results require validation in larger datasets. The present study indicates that preoperative ED might be a surrogate for adverse prostate cancer outcomes following RP.