Testosterone replacement in young male cancer survivors: A 6-month double-blind randomised placebo-controlled trial

The relationship between hematologic malignancies on male hypogonadism: a scoping review

INTRODUCTION

The associated symptoms of hypogonadism have been reported in patients with various types of cancer. However, the prevalence and significance of hypogonadism among certain hematologic malignancies have not been completely summarized in recent literature.

OBJECTIVE

In this review we aimed to examine the current literature on hypogonadism in patients with hematologic malignancies, with emphasis on leukemias, lymphomas, and multiple myeloma (MM).

METHODS

This review included relevant studies published before July 2023 that were retrieved through a search of PubMed using the keywords "hematologic cancer," "hematologic malignancy," blood cancer," "leukemia," "lymphoma," "hypogonadism," "multiple myeloma," and "testosterone."

RESULTS

The search yielded 214 studies, of which 21 met the inclusion criteria. Commonly reported findings were that patients who had received hematopoietic stem cell therapy for acute lymphoblastic leukemia and acute myelogenous leukemia as children had laboratory-confirmed hypogonadism as adults. However, the impact of these diseases on hypogonadal symptoms was variable in these studies.Studies reporting on lymphoma and hypogonadism had mixed results, with some studies finding that the degree of cytotoxic chemotherapy was associated with hypogonadism, while others showed no correlation. Regardless, multiple studies found that hypogonadism secondary to lymphoma treatment and symptoms of hypogonadism had no apparent association.The most comprehensive assessment of the frequency of hypogonadism in an MM cohort found that 74% of 561 MM patients were classified as hypogonadal compared to 33% of patients in a control population. Testosterone supplementation was found to lower interleukin-6 levels, which could potentially help manage some of the adverse effects of MM, including decreased bone mineral density.

CONCLUSION

There is a relationship between hematologic malignancies and hypogonadism, which is likely multifactorial. In this review we established that the most plausible factors are related to the secondary effects of gonadotoxic treatments and/or systemic inflammatory responses to the diseases.

Cardiovascular safety of testosterone replacement therapy in men: an updated systematic review and meta-analysis

INTRODUCTION

The cardiovascular (CV) safety of testosterone (T) replacement therapy (TRT) is still conflicting. Recent data suggested a TRT-related increased risk of atrial fibrillation (AF). The aim of this study was to systematic review and meta-analyze CV risk related to TRT as derived from placebo controlled randomized trials (RCTs).

AREAS COVERED

An extensive Medline, Embase, and Cochrane search was performed. All placebo-controlled RCTs reporting data on TRT-related CV safety were considered. To better analyze the role of T on AF, population-based studies investigating the relationship between endogenous circulating T levels and AF incidence were also included and analyzed.

EXPERT OPINION

Out of 3.615, 106 studies were considered, including 8.126 subjects treated with TRT and 7.310 patients allocated to placebo. No difference between TRT and placebo was observed when major adverse CV events were considered. Whereas the incidence of non-fatal arrhythmias and AF was increased in the only trial considering CV safety as the primary endpoint, this was not confirmed when all other studies were considered (MH-OR 1.61[0.84;3.08] and 1.44[0.46;4.46]). Similarly, no relationship between endogenous T levels and AF incidence was observed after the adjustment for confounders Available data confirm that TRT is safe and it is not related to an increased CV risk.

Insulin-like Factor 3, Basal and Human Chorionic Gonadotropin-Stimulated Testosterone as Biomarkers to Predict the Effect of Testosterone Replacement in Testicular Cancer Survivors With Mild Leydig Cell Insufficiency

INTRODUCTION

Mild Leydig cell insufficiency affects a substantial proportion of testicular cancer survivors. Previous studies have not shown a beneficial effect of testosterone replacement therapy, however, with a pronounced interindividual effect. Thus, biomarkers identifying the subgroups that might benefit are wanted. We aimed to determine if insulin-like factor 3 (INSL3), basal and human chorionic gonadotropin (hCG)-stimulated testosterone can predict the effect of testosterone replacement therapy in testicular cancer survivors with mild Leydig cell insufficiency.

PATIENTS AND METHODS

We randomized adult testicular cancer survivors with mild Leydig cell insufficiency 1:1 to 12 months of transdermal testosterone replacement therapy (Tostran gel 2%) or placebo. INSL3, basal, and hCG-stimulated testosterone were measured at baseline. Outcomes (glucose, insulin, HbA1C, lipids, blood pressure, and body composition) were measured at baseline, 6 and 12 months. We applied a linear mixed-effect model comparing patients receiving testosterone with placebo in subgroups by biomarker.

RESULTS

We included and randomized 69 patients between October 2016 and February 2018. Patients with INSL3 and hCG-stimulated testosterone concentrations below the median had a -1.7 kg (95% CI: -3.1, -0.4) and -2.0 kg (95% CI: -3.5, -0.6) change in fat mass after 12 months of testosterone replacement therapy compared with placebo. This was not the case in patients with INSL3 and hCG-stimulated testosterone above the median. We did not find any effect of these biomarkers on glucose, insulin, HbA1c, or lipids.

CONCLUSION

Patients with INSL3 and hCG-stimulated testosterone concentrations below the median had decreased fat mass after 12 months of testosterone replacement therapy compared with placebo. It should be evaluated in larger trials if these biomarkers can be used as predictive markers identifying testicular cancer patients with mild Leydig cell insufficiency who might benefit from testosterone substitution.

Effect of statins and testosterone replacement therapy on incident cardiovascular disease among male hormone-related cancer survivors

Purpose

Statins and testosterone replacement therapy (TTh) have been previously linked with prostate, colorectal and male breast cancer (hereinafter we will refer as hormone related cancers [HRCa]), and cardiovascular disease (CVD). However, there is a poor understanding about the combined association of statins and TTh with incident CVD among HRCa survivors and a matched cancer-free cohort.

Methods

We identified 44,330 men of whom 22,165 were previously diagnosed with HRCa, and 22,165 were age-and index-matched cancer-free in SEER-Medicare 2007-2015. Pre-diagnostic prescription of statins and TTh prior to CVD development was ascertained for this analysis in the two matched cohorts. Weighted multivariable-adjusted conditional logistic regression models were used to evaluate the independent and combined associations of statins and TTh with CVD.

Results

We found that use of statins (OR = 0.51, 95% CI: 0.46-0.55) and TTh (OR = 0.81, 95% CI: 0.67-0.97) were each independently inversely associated with incident CVD in the overall sample. TTh plus statins was also inversely associated with CVD. Associations were similar in the matched cancer-free cohort. Among HRCa survivors, only statins and combination of TTh plus statins (OR = 0.60, 95% CI: 0.44-0.98) were inversely associated with CVD, but the independent use of TTh was not associated with CVD.

Conclusion

In general, pre-diagnostic use of statins and TTh, prior to CVD development, independently or in combination, were inversely associated with CVD in the overall, cancer-free population, and among HRCa survivors (mainly combination). Independent effects and combination of statins and TTh remained to be confirmed with specific CVD outcomes among HRCa survivors.

Effect of 12-months testosterone replacement therapy on bone mineral density and markers of bone turnover in testicular cancer survivors - results from a randomized double-blind trial

BACKGROUND

Testicular cancer survivors (TCS) are at risk of Leydig cell insufficiency, which is a condition characterized by elevated luteinising hormone (LH) in combination with low levels of testosterone. It has been suggested that this condition is associated with impaired metabolic profile and low bone mineral density (BMD). The primary aim of the randomized double-blind trial NCT02991209 was to evaluate metabolic profile after 12-months testosterone replacement therapy (TRT) in TCS with mild Leydig cell insufficiency. Here we present the secondary outcomes of changes in BMD and markers of bone turnover.

METHODOLOGY

In total, 69 TCS with mild Leydig cell insufficiency were randomized 1:1 to 12 months TRT (n = 35) (Tostran, gel, 2%, applied transdermally, with a maximum daily dose of 40 mg) or placebo (n = 34). BMD and markers of bone turnover were evaluated at baseline, after 6- and 12-months TRT, and 3-months post-treatment. Linear mixed effects models were used to analyse changes in BMD, N-terminal propeptide of type 1 procollagen (P1NP) and C-terminal telopeptide of type I collagen (CTX).

RESULTS

After 12 months treatment, TRT was not associated with a statistically significant difference in BMD compared to placebo; total body BMD: 0.01 g/cm2 (95% confidence interval (CI): -0.01 - 0.02), BMD of the lumbar spine: 0.01 g/cm2, (95% CI: -0.01-0.03), BMD of the left femoral neck: 0.00, (95% CI: -0.01-0.02). TRT was associated with a small but statistically significant increase in P1NP: 11.65 µg/L (95% CI: 3.96, 19.35), while there was no difference in CTX.

CONCLUSION

12 months of TRT did not change BMD, while there was as small and clinically irrelevant increase in P1NP compared to placebo in TCS with mild Leydig cell insufficiency. The findings need validation in a larger cohort.

Perioperative substitution testosterone therapy in patients with advanced head and neck squamous cell carcinoma

Testosterone replacement therapy is becoming more and more popular in men as "anti-aging medicine". Testosterone has beneficial effects on body mass and muscle gain, and much research has examined testosterone in palliative cancer therapy for oncology patients. In addition to direct effects on weight gain, testosterone improves mood and self-confidence, strength, libido, muscle mass, bone density, and cognitive functions and reduces the risk of cardiovascular disease. Lower testosterone levels are found in 65% of male patients with progressive tumors compared to only 6% of men in the general population. We hypothesize that perioperative substitution testosterone therapy (PSTT) together with a balanced diet, may be more effective than balanced diet alone in the overall treatment outcome of patients with head and neck squamous cell carcinomas. Therefore, PSTT in combination with a balanced diet should be considered as an additional tool for head and neck carcinoma treatment.

Testosterone Replacement Therapy in the Aged Male: Monitoring Patients’ Quality of Life Utilizing Scoring Systems

Hypogonadism has been associated with significant deterioration of well-being. In the aging male, late-onset hypogonadism affects sexual life, mental health, levels of energy, lower urinary tract symptoms and, therefore, quality of life may be found significantly deteriorated. Testosterone replacement or supplementation therapy has been found efficient to reverse the adverse effects of hypogonadism and improve quality of life. Scales and questionnaires assessing the general health, urinary symptoms, sexual health, and cognition can provide a thorough assessment of the clinical syndrome, optimize treatment, assist the follow-up, and facilitate referrals to other specialties depending on the chief complaint. A systematic assessment might combine several tools, but the optimal ones and the exact usage is unknown. In this narrative review, we are flipping through the literature presenting the available tools per domain for the assessment of quality of life in men on testosterone replacement therapy and we discuss the optimal usage.

Male-specific late effects in adult hematopoietic cell transplantation recipients: a systematic review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GvHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies. They may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT. We provide a systematic review of male-specific late effects in a collaboration between transplant physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research, and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. The systematic review summarizes incidence, risk factors, screening, prevention and treatment of these complications and provides consensus evidence-based recommendations for clinical practice and future research.

Joint association of statins and testosterone replacement therapy with cardiovascular disease among older men with prostate cancer: SEER-Medicare 2007-2015

BACKGROUND

Use of statins and testosterone replacement therapy (TTh) have been independently linked with prostate cancer (PCa) and cardiovascular diseases (CVD). However, there is a research gap about the joint association of statins and TTh with CVD among PCa survivors and a matched cancer-free cohort.

METHODS

In SEER-Medicare 2007-2015 (N = 35,990 men), we identified 17,995 PCa survivors, and 17,995 age- and index-matched cancer-free men. Pre-diagnostic prescription of statins and TTh was ascertained for this analysis and examined in two matched cohorts. Weighted multivariable-adjusted conditional logistic regression models were used to evaluate the independent and joint associations of statins and TTh with CVD.

RESULTS

We found that independently statins (OR = 0.48, 95% CI: 0.44-0.53) and TTh (OR = 0.74, 95% CI: 0.0.61-0.90) were each inversely associated with CVD in the overall sample. TTh plus statins was inversely associated with CVD (OR = 0.50, 95% CI: 0.36-0.70, P_interaction = 0.03). Similar associations were observed among the matched cancer-free cohort. Among PCa survivors, only statins (OR = 0.62, 95% CI: 0.56-0.68) and combination of TTh plus statins (OR = 0.63, 95% CI: 0.44-0.90) were inversely associated with CVD, but not the independent use of TTh.

CONCLUSION

Pre-diagnostic use of statins and TTh, independent or in combination, were inversely associated with CVD in the overall and cancer-free populations, but among PCa survivors it was mainly use of statins, not TTh. Greater reduced effects on CVD were observed with statins or in combination with statins, but not with TTh. Future studies need to confirm these associations among older men with aggressive PCa.

Recommendations on the diagnosis, treatment and monitoring of testosterone deficiency in men

The relative proportional increase of the elderly population within many countries will become one of the most significant social transformations of the twenty-first century and, for the first time in history, persons aged 65 or above outnumbered children under five years of age globally. One in four persons living in Europe and Northern America will be aged 65 or over. One of the goals of ISSAM is to raise awareness of the special health needs of older men. Since a significant number of aging men will eventually become testosterone deficient, the Hypogonadism panel of ISSAM updates its guidelines.

Male-specific late effects in adult hematopoietic cell transplantation recipients: a systematic review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

BACKGROUND

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GvHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies, such as prostate, penile, and testicular cancer. They may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT.

OBJECTIVE

Here, we provide a systematic review of male-specific late effects in a collaboration between transplant physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research, and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation.

STUDY DESIGN

We utilized systematic review methodology to summarize incidence, risk factors, screening, prevention and treatment of these complications and provide consensus evidence-based recommendations for clinical practice and future research.

RESULTS

Most of the evidence regarding male GvHD is still based on limited data, precluding strong therapeutic recommendations. We therefore recommend to systematically screen for male genital GvHD regularly and report it to large registries to allow for a better understanding. Future research should also address treatment since little published evidence is available to date. Male-specific endocrine consequences of HCT include hypogonadism which may also affect bone health. Since the evidence is scarce, current recommendations for hormone substitution and/or bone health treatment are based on similar principles as for the general population. Following HCT, sexual health decreases and this topic should be addressed at regular intervals. Future studies should focus on interventional strategies to address sexual dysfunction. Infertility remains prevalent in patients having undergone myeloablative conditioning, which warrants offering sperm preservation in all HCT candidates. Most studies on fertility rely on descriptive registry analysis and surveys, hence the importance of reporting post-HCT conception data to large registries. Although the quality of evidence is low, the development of cancer in male genital organs does not seem more prevalent than in the general population; however, subsequent malignancies in general seem to be more prevalent in males than females, and special attention should be given to skin and oral mucosa.

CONCLUSION

Male-specific late effects, probably more under-reported than female-specific complications, should be systematically considered during the regular follow-up visits of male survivors who have undergone HCT. Care of patients with male-specific late effects warrants close collaboration between transplant physicians and specialists from other involved disciplines. Future research should be directed towards better data collection on male-specific late effects and on studies about the interrelationship between these late effects, to allow the development of evidence based effective management practices.

Late adverse effects and quality of life in survivors of testicular germ cell tumour

Currently, ~95% of patients with testicular germ cell tumour (TGCT) are cured, resulting in an increasing number of TGCT survivors. Although cured, these men face potential late adverse effects and reduced quality of life. Survivors face a twofold increased risk of second malignant neoplasms after chemotherapy and radiotherapy, with evidence of dose-dependent associations. For survivors managed with surveillance or treated with radiotherapy, the risk of cardiovascular disease (CVD) is comparable to the risk in the general population, whereas treatment with chemotherapy increases the risk of life-threatening CVD, especially during treatment and after 10 years of follow-up. Other adverse effects are organ-related toxicities such as neuropathy and ototoxicity. Pulmonary and renal impairment in patients with TGCT treated with chemotherapy is limited. Survivors of TGCT might experience psychosocial distress including anxiety disorders, fear of cancer recurrence and TGCT-specific issues, such as sexual dysfunction. Late adverse effects can be avoided in most patients with stage I disease if followed on a surveillance programme. However, patients with disseminated disease can experience toxicities associated with radiotherapy and chemotherapy, and/or adverse effects related to surgery for residual disease. The severity of adverse effects increases with dose of both chemotherapy and radiotherapy. This Review discusses the most recent data concerning the late adverse effects of today's standard treatments for TGCT.

Hypogonadism and cancer survivorship

PURPOSE OF REVIEW

Hypogonadism is highly prevalent among not only patients with a history of prior treatment for cancer, but also among those patients with a new oncologic diagnosis who have not yet received any cancer therapy. Hypogonadism can cause a wide array of signs and symptoms including: deceased muscle mass; increased fat mass; decreased energy, mood, and overall sense of well being; diminished bone mineral density; infertility; and impaired libido and sexual function. This purpose of this manuscript is to review the mechanisms by which cancer and oncologic treatment regimens can adversely affect the hypothalamic pituitary gonadal axis, resulting in hypogonadism. Risks and benefits associated with the treatment of testosterone deficiency are also discussed, which are important considerations for clinicians caring for affected patients.

RECENT FINDINGS

Hypogonadism has a high prevalence in the setting of cancer and is an important survivorship issue. Recent randomized controlled trials confirm testosterone's therapeutic benefits in terms of sexual function, mood body composition, and bone health, but the specific benefits in terms of quality of life are less clear.

SUMMARY

More prospective studies are needed to further delineate the risks, benefits, and overall outcomes of testosterone replacement therapy in patients with cancer and cancer survivors.

Glutamate in Male and Female Sexual Behavior: Receptors, Transporters, and Steroid Independence

The survival of animal species predicates on the success of sexual reproduction. Neurotransmitters play an integral role in the expression of these sexual behaviors in the brain. Here, we review the role of glutamate in sexual behavior in rodents and non-rodent species for both males and females. These encompass the release of glutamate and correlations with glutamate receptor expression during sexual behavior. We then present the effects of glutamate on sexual behavior, as well as the effects of antagonists and agonists on different glutamate transporters and receptors. Following that, we discuss the potential role of glutamate on steroid-independent sexual behavior. Finally, we demonstrate the interaction of glutamate with other neurotransmitters to impact sexual behavior. These sexual behavior studies are crucial in the development of novel treatments of sexual dysfunction and in furthering our understanding of the complexity of sexual diversity. In the past decade, we have witnessed the burgeoning of novel techniques to study and manipulate neuron activity, to decode molecular events at the single-cell level, and to analyze behavioral data. They pose exciting avenues to gain further insight into future sexual behavior research. Taken together, this work conveys the essential role of glutamate in sexual behavior.

Low Testosterone in Male Cancer Patients and Survivors

INTRODUCTION

Hypogonadism (HG) is prevalent among patients with ongoing advanced cancer and cancer survivors. The etiology of HG in these patients is multifactorial and can be examined from cancer-related and cancer-treatment perspectives. There is evidence that HG contributes to increased morbidity in male cancer patients. Testosterone replacement therapy (TRT) for cancer survivors and advanced cancer patients is not well studied outside of prostate cancer. Here, we evaluate and summarize the current literature on HG in male cancer patients, including the role of TRT in nonprostate cancer patients.

OBJECTIVE

To summarize and present the literature for the background, etiology, clinical consequences, and treatment for HG in male cancer patients and survivors.

METHODS

A literature review was performed in MEDLINE between 1980 and 2020 using the terms hypogonadism, advanced cancer, testosterone replacement therapy, quality of life, and cancer survivors. Studies including only prostate cancer patients were excluded.

RESULTS

The main outcome measure was to complete a review of peer-reviewed literature. HG is not only prevalent among male cancer patients and survivors but also clinically reduces quality of life and increases morbidity. The etiology of HG in male cancer patients and survivors is multifactorial. There are few studies examining the benefit of TRT in these patient populations. The results of randomized controlled trials show potential benefit for TRT in hypogonadal male cancer survivors and those with advanced cancer.

CONCLUSION

HG affects many male cancer patients and survivors because of a multifactorial etiology. HG in these patients contributes to increased morbidity and reduced quality of life. Treatment of HG in male cancer patients is not well studied, and further studies are needed to elucidate the role of TRT. Xu P, Choi E, White K, et al. Low Testosterone in Male Cancer Patients and Survivors. Sex Med 2021;9:133-142.