"Chinese Expert Consensus on Prostate Cancer Testosterone Management (2021 Edition)" update key interpretation: standardize testosterone management throughout the entire process of prostate cancer diagnosis and treatment!

Doctor Daily News (Rong Media reporter Qiu Jia) Worldwide, the incidence of prostate cancer ranks second in male malignant tumors, second only to lung cancer
.

Compared with European and American countries, China's prostate cancer has the characteristics of low incidence (10.
23 per 100,000 male population), late stage at the time of diagnosis of the disease, and rapid increase in incidence in recent years
.

Androgen deprivation therapy (ADT) is one of the most important basic treatments for prostate cancer, and the management of testosterone for prostate cancer is an important part of the diagnosis and treatment of prostate cancer
.

In 2017, China issued the "Chinese Expert Consensus on the Management of Testosterone in Prostate Cancer" for the first time
.

In recent years, prostate cancer-related research has continuously brought new ideas to testosterone management, and national guidelines or consensus have also been revised and recommended
.

To this end, in April this year, the Chinese Medical Association Urology Branch (CUA), the Chinese Anti-Cancer Association Urology and Male Reproductive Tumor Professional Committee (CACA-GU), the Chinese Medical Doctor Association Urology Branch (CUDA), China's three major urological fields Authoritative societies jointly issued the "Chinese Expert Consensus on Prostate Cancer Testosterone Management (2021 Edition)"
.

In order to better understand the updated points of the new version of the consensus, taking the opportunity of this CUDA annual meeting, "Physician Daily" invited the corresponding author of the consensus, the president of the Urology Branch of the Chinese Medical Doctor Association, the National Cancer Center, and the Chinese Academy of Medical Sciences Oncology Professor Xing Nianzeng, Director of the Department of Urology of the Hospital, and Honorary President of the Urology Branch of the Chinese Medical Doctor Association who participated in the compilation of this consensus, Professor Zhou Liqun of the Department of Urology, Peking University First Hospital, Vice President of the Urology Branch of the Chinese Medical Doctor Association, and Urology of West China Hospital of Sichuan University Professor Wei Qiang, the director of surgery, brought a detailed interpretation to everyone
.

Testosterone management runs through multiple processes of prostate cancer diagnosis and treatment.
ADT is the cornerstone of prostate cancer treatment, and has been unanimously recommended by domestic and foreign guidelines and consensus
.

The main goal of ADT is to reduce testosterone and maintain it stably below castrate levels
.

Testosterone management runs through multiple processes of prostate cancer diagnosis, evaluation, treatment and prognosis evaluation, and has important clinical significance for patients at different stages of the disease
.

Testosterone is a steroid hormone, 95% of which is synthesized in testicular stromal cells.
Its main physiological function is to maintain muscle volume and muscle strength, bone density and strength, libido and sexual function
.

Testosterone mostly exists in a combined form, only 1%~3% exists in a free form, and the two maintain a dynamic balance
.

Free testosterone (FT) is the main substance that exerts biological activity
.

Testosterone synthesis is regulated by the hypothalamic-pituitary-gonadal axis (HPGA)
.

The secretion of testosterone has a circadian rhythm, reaching a peak in the morning and dropping to a low point in the evening; testosterone levels are also regulated by pulsed secretion of luteinizing hormone (LH), which fluctuates rhythmically every 90 minutes
.

Since puberty, with age, the phenomenon of rhythmic secretion of testosterone gradually weakens, but clinical monitoring of testosterone should still pay attention to the impact of its fluctuations
.

The detection methods of serum testosterone include radioimmunoassay (RIAs), a common detection method for total testosterone; chemiluminescence immunoassay (CLIA), which has a high degree of automation, a long shelf life of reagents, and no radioactive contamination.
It is more popular in clinical practice.
However, the detection sensitivity and accuracy need to be improved; liquid chromatography-mass spectrometry (LC/MS) has better sensitivity, accuracy and stability, especially suitable for lower testosterone levels (<20ng/dl) Accurate detection
.

Five highlights of the new version of the testosterone management consensus 01 Highlights 1 More emphasis on testosterone management throughout the entire process of prostate cancer diagnosis and treatment The new version of the consensus proposes that baseline serum testosterone levels are related to the risk of prostate cancer and disease outcome
.

It is emphasized that testosterone management needs to run through the entire process of diagnosis, evaluation, treatment, and efficacy evaluation of prostate cancer patients.
It is an important part of disease management, and the significance of testosterone management should be popularized to patients and their families to obtain cooperation
.

Studies have shown that people with low serum FT levels have a lower risk of prostate cancer (OR=0.
77)
.

Low FT level (<6.
5 ng/dl) before radical surgery is an independent risk factor for biochemical recurrence (OR=0.
564)
.

In patients with early prostate cancer, high baseline total testosterone (TT) (>403 ng/dl) is positively correlated with higher pathological grades, high risk of recurrence, and positive postoperative margins after radical resection
.

Patients with low TT levels (<300ng/dl) before radical resection have a significantly shorter survival without biochemical recurrence
.

02Highlights 2: Deep ketone reduction (<20 ng/dl) can be used as a reference indicator for better clinical prognosis and adjustment of treatment.
National guidelines recommend that during ADT, testosterone should reach and stabilize below the castration level (<50 ng/dl)
.

The new version of the testosterone management consensus recommends for the first time that testosterone drops to a lower level during ADT (20 ng/dl, that is, deep ketone reduction), which is related to a better prognosis and outcome of the disease
.

Studies have shown that if testosterone is suppressed to <20 ng/dl, the rate of testosterone escape will be significantly reduced, the time for patients to progress to castration-resistant prostate cancer (CRPC) is significantly prolonged, the risk of progressing to CRPC is significantly reduced, and the risk of death from prostate cancer Smaller
.

During ADT treatment, the lower the testosterone level, the longer the survival time of patients
.

03 Highlight 3 Focus on new endocrine drugs and LHRHa long-acting dosage form of testosterone testing frequency Currently commonly used drugs for ADT include luteinizing hormone releasing hormone agonists (LHRHa, such as triptorelin) and luteinizing hormone releasing hormone antagonists
.

LHRHa is more widely used clinically in China
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The new consensus points out that LHRHa drugs reduce testosterone levels differently
.

Studies have shown that among the three commonly used LHRHa drugs triptorelin, goserelin and leuprorelin, the March dosage form of triptorelin can help 100% of patients with T<20 ng/dl during treatment, triptorelin The proportion of patients with dosage form T<10 ng/dl in March was significantly higher than that of leuprolide and goserelin
.

But it still needs to be further confirmed by prospective studies
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The new version of the consensus pointed out that compared with the traditional single-month dosage form, the longer-acting LHRHa dosage form has gradually gained clinical approval
.

The dosage form in March is easy to use, can reduce the frequency of injections, simplify the nursing process, improve the quality of life of patients, reduce the number of visits, and reduce overall costs
.

It is reported that the June sustained-release dosage form of LHRHa will be launched in China in 2022
.

In the initial clinical application of new long-acting ADT preparations or new endocrine therapy drugs, attention should be paid to ensuring the frequency of testosterone testing, ensuring the effect of testosterone control and reducing the rate of loss to follow-up
.

In recent years, a variety of new endocrine drugs have entered the domestic market one after another, and superimposed application with traditional ADT in the earlier stage of the disease of prostate cancer patients, which will bring more new problems to the management of testosterone
.

It is necessary to improve the standardization of testosterone management in the treatment of new endocrine drugs
.

04 Highlights Four: Pay attention to the frequency of testosterone monitoring, and implement the new consensus recommendation in synchronization with PSA, at the starting point of important disease stages (diagnosis, recurrence, new onset, metastasis, CRPC, etc.
) and treatment switching points (curative treatment, ADT method changes, chemotherapy Such as the initiation of other treatments, etc.
) Testosterone needs to be tested as a baseline value to provide a reference for subsequent diagnosis and treatment
.

It is recommended to test testosterone on a monthly basis before the start of ADT and within 6 months of treatment
.

As the condition becomes stable, the testosterone test interval can be extended to once every 3 to 6 months, or the testosterone test and PSA test can be performed simultaneously
.

CRPC is a characteristic disease stage of prostate cancer, and it is also an important time node for switching clinical treatment strategies
.

Testosterone below the castration level is a necessary condition for the diagnosis of CRPC, and it must be maintained in the follow-up treatment of CRPC
.

05 Highlight 5 Formulate a standardized flow chart for testosterone management during ADT In view of the important clinical value of testosterone management during ADT, experts have formulated the following process (Figure 1) to facilitate rapid understanding and convenient application by clinicians
.

Fig.
1 Standardized flow chart of testosterone monitoring and management during ADT treatment Han Sujun, deputy chief physician of the Department of Urology, Cancer Hospital, Chinese Academy of Medical Sciences, July 17, "Chinese Expert Consensus on Prostate Cancer Testosterone Management (2021 Edition)" Key Interpretation Special Session will be held in 2021 by Chinese physicians During the annual meeting of the Association of Urologists Branch (CUDA), Han Sujun, deputy chief physician of the Department of Urology, Cancer Hospital of the Chinese Academy of Medical Sciences, interpreted the consensus on the spot
.

There is still a long way to go to improve the cognition of standardized testosterone management.
Finally, experts have said that domestic doctors and patients’ cognition of testosterone management needs to be improved, while establishing a scientific testosterone management model to improve the overall survival level of prostate cancer patients in China
.

In the future, through the new version of the consensus tour, testosterone management excellence center teaching and training, testosterone management multidisciplinary cooperation, testosterone management excellent case cloud sharing and comments, etc.
, promote the consensus to be better used in clinical practice
.

Typesetting: Huang Lingling Editor: Huang Lingling Review: Qiu Jia For more content, please click: Chinese Urology: The goal of 2035 is to lead in Asia and be world-class! Currently 1130000+ doctors have been following to join us