Hypogonadism in male cancer patients

Prevalence of hypogonadism in men with cancer has been reported between 40% and 90%, which is significantly higher than in the general population. Hypogonadism is likely to affect the quality of life in these patients by contributing to non-specific symptoms, including decreased energy, anorexia, sarcopenia, weight loss, depression, insomnia, fatigue, weakness, and sexual dysfunction. Pathogenesis of hypogonadism in cancer patients is thought to be multi-factorial. Inflammation may play an important role, but leptin, opioids, ghrelin, and high-dose chemotherapy through different mechanisms have all been implicated as the cause. Hypogonadism is also associated with poor survival in cancer patients. Data looking into the treatment of hypogonadal male cancer patients with testosterone are limited. However, improvements in body weight, muscle strength, lean body mass, and quality of life have been shown in hypogonadal men with other chronic diseases on testosterone replacement therapy. Prospective and interventional trials are needed to test the efficacy and safety of testosterone treatment in improving quality of life of these patients.

Low testosterone levels and increased inflammatory markers in patients with cancer and relationship with cachexia

CONTEXT

Male cancer patients suffer from fatigue, sexual dysfunction, and decreased functional performance and muscle mass. These symptoms are seen in men with hypogonadism and/or inflammatory conditions. However, the relative contribution of testosterone and inflammation to symptom burden in cancer has not been well-established.

OBJECTIVE

The aim of this study was to measure testosterone levels in male cancer patients and determine the relationship between testosterone, inflammation, and symptom burden.

DESIGN/SETTING

This cross-sectional study enrolled patients from a tertiary-care center. SUBJECTS/OUTCOME MEASURES: Subjects included males with cancer-cachexia (CC; n = 45) and cancer without cachexia (CNC; n = 50), as well as noncancer controls (CO; n = 45). Total testosterone (TT), bioavailable testosterone, C-reactive protein (CRP), and IL-6 were measured in plasma. Functional performance was assessed by the ECOG (Eastern Cooperative Oncology Group) and KPS (Karnofsky Performance Scales), and sexual function was assessed by the IIEF (International Index of Erectile Function).

RESULTS

Low testosterone levels were seen in more than 70% of CC cases. TT was lower in CC compared to CNC (P < 0.05). Also, CC had lower bioavailable testosterone, grip strength, IIEF scores, appendicular lean body mass, and fat mass and higher IL-6 and CRP compared to controls (P ≤ 0.05). ECOG and KPS were lower in CC and CNC compared to controls (P ≤ 0.05). On multiple regression analysis, TT, albumin, and CRP predicted symptoms differentially in cancer patients.

CONCLUSIONS

CC patients have higher inflammation and lower testosterone, grip strength, functional status, erectile function, fat mass, and appendicular lean body mass. Inflammation, TT, and albumin are associated with heavier symptom burden in this population. Interventional trials are needed to determine whether testosterone replacement and/or antiinflammatory agents benefit cancer patients.

Hypertension and its management in the elderly

Many trials focused on cardiovascular outcomes demonstrate that reduction in blood pressure to levels below 140/90 mm Hg reduce cardiovascular events including stroke and myocardial infarction. There are very few such trials, however, in the elderly cohort, especially among those aged 70 and older. In the few outcome trials that have been completed in this older age group, systolic blood pressures in the range between 140 and 149 mm Hg demonstrate a clear reduction in cardiovascular events. Moreover, among the subgroup that has a vasculature that allows a systolic pressure to go below 140 mm Hg without cognitive side effects, ie, somnolence, memory loss, etc, does even better than those whose blood pressures are in the 140 to 149 mm Hg range. Thus, titration of systolic blood pressure goals in the elderly should strive for a goal of less than 140 mm Hg, and if not achievable without side effects, compromise to below 150 mm Hg.

Glycemic control and cardiovascular disease in chronic kidney disease

Diabetes increases cardiovascular (CV) risk to a similar extent as myocardial infarction. Epidemiologic data support the same concept for the presence of Stage 3 (ie, glomerular filtration rate of < 60 mL/min) or higher nephropathy without diabetes. The most common cause of end-stage kidney disease requiring dialysis is diabetes. Hence, CV risk is highest among those with kidney disease and diabetes. Glycemic control in the context of CV risk reduction among patients with kidney disease has not been the focus of any specific trial; however, secondary analyses of trials, primarily in type 1 diabetes, have looked at this issue. Nevertheless, the outcome data are sparse. What can be said, however, is that failure to achieve reasonable glycemic control (ie, glycated hemoglobin < 7.5%) is associated with a higher risk of CV events and hospitalizations for CV events and infections among those with advanced kidney disease. The impact of poor glycemic control on kidney disease progression has not been well studied and should be the focus of future studies.

Effects of triglycerides, obesity, and starvation on ghrelin transport across the blood-brain barrier

Human ghrelin is transported across the blood-brain barrier (BBB) of normal mice. Here, we studied the effects of triglycerides, obesity, and starvation in retired breeder mice maintained on a high fat diet, mice age-matched to the retired breeders but maintained on normal chow, and 8-week-old mice maintained on breeder chow. The rate of ghrelin transport across the BBB was studied by both the intravenous administration method of multiple-time regression analysis and by the brain perfusion method. We found that (1) obese, aged mice lost the ability to transport intravenously administered ghrelin across the BBB, resulting in an inverse relation between body weight and ghrelin BBB permeability; (2) serum triglycerides promoted transport of intravenously administered ghrelin across the BBB, whereas epinephrine had no effect; (3) fasting tended to promote ghrelin transport across the BBB as most readily shown in brain perfusion studies; (4) evidence suggested that a serum factor promoted ghrelin transport in 8-week-old mice. Overall, these results show that serum factors and physiological states influence the rate at which ghrelin is transported across the blood-brain barrier.