Latest expert consensus: 7 clinical recommendations for testosterone management

Introduction The "Chinese Expert Consensus on Testosterone Management in Prostate Cancer" was first published in 2017.
Based on the current clinical application of testosterone management in China, combined with the update of national guidelines, consensus and literature evidence in recent years, the Chinese Medical Association Urology Branch (CUA), China The Anti-Cancer Association Urology and Male Reproductive Department (CACA-GU) and the Chinese Association of Urological Surgeons (CUDA) jointly organized an expert group to update the 2021 version of the consensus
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Androgen deprivation therapy (ADT) is one of the most important basic treatments for prostate cancer, and its main goal is to reduce serum testosterone and maintain it below castration levels
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Testosterone management of prostate cancer refers to the selection of clinical diagnosis and treatment strategies for prostate cancer through regular testosterone detection and result analysis, and is an important part of prostate cancer diagnosis and treatment
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In recent years, prostate cancer-related research has continuously brought new ideas for testosterone management, including the definition of testosterone castration levels, the comparison of different detection methods, and the reasonable monitoring frequency
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In the 1990s, "<50ng/d" was often used as the castration standard for testosterone
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In 2013, a study showed for the first time that lowering testosterone levels (≤32ng/dl) significantly delayed the onset of castration-resistant prostate cancer
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Based on related studies, the 2014-2020 edition of the European Association of Urology (EAU) prostate cancer guidelines all proposed that “controlling a stable testosterone level <20ng/dl can be a more appropriate value for judging the level of castration
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The
2018 edition of Canadian Recurrent and Metastatic Prostate Cancer The Consensus on Testosterone Suppression Therapy also sets "<20ng/dl" as the new castration standard
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Metabolism and influencing factors of testosterone The physiological functions of adult testosterone include maintaining muscle volume and strength, bone density and strength, and maintaining normal libido and sexual function
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Most of the testosterone in the blood exists in the bound form, and only 1%~3% exists in the free form.
There is a dynamic balance between the two forms.
Free testosterone is the main substance that exerts biological activity.
After serum testosterone enters the prostate, it can be directly or reduced by 5α The enzyme action is converted into dihydrotestosterone to activate androgen receptors, which in turn play a role in regulating prostate growth and function
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Common factors that affect testosterone levels include: 1.
With age, total serum testosterone decreases slowly, but FT decreases more significantly.
It is generally believed that the highest level is at 20-29 years old, and it decreases significantly after 40 years of age, and reaches the minimum at 70-80 years old.
Excessive obesity promotes the conversion of local glucocorticoids, destroys the function of HPGA, and leads to a decrease in testosterone levels; stress and prolonged fast-wave sleep time can lead to elevated testosterone levels; zinc deficiency reduces testosterone levels
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Clinical Recommendations for Testosterone Management 1.
Emphasize that testosterone management needs to run through the whole process of diagnosis, evaluation, treatment and efficacy evaluation of prostate cancer patients, and is an important part of disease management, and to popularize the significance of testosterone management to patients and their families to obtain cooperation
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2.
At the starting point of important disease stages (diagnosis, recurrence, new metastasis, CRPC) and treatment switching points (curative treatment, ADT method change, chemotherapy and other treatment initiation), testosterone should be detected as a baseline value for follow-up diagnosis and treatment.
Provide a reference
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3.
During prostate cancer ADT and when CRPC is diagnosed, testosterone level <50ng/dl (1.
735nmol/L) is still used as castration standard; however, deep ketone reduction during ADT means suppressing testosterone level to <20ng/dl (0.
694nmol/L) ) can be used as a reference index for better clinical prognosis and adjustment of treatment
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4.
It is recommended to test testosterone regularly before the start of ADT and within 8 months of treatment; at the beginning of the use of LHRHa drugs, androgen receptor antagonists should be used to avoid the potential risk of disease progression caused by pharmacological testosterone "flicker"; When the condition has entered a stable state, the testosterone test interval can be extended to once every 3-6 months; and/or testosterone test and PSA test can be carried out simultaneously
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5.
Switch to other testosterone-suppressing drugs or switch to surgical castration when testosterone escape is found
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6.
After the diagnosis of CRPC, it is still necessary to maintain testosterone at castration levels
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7.
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 to ensure the control effect of testosterone and reduce the rate of loss to follow-up
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Standardized flow chart of testosterone monitoring and management during ADT treatment Conclusion and outlook Testosterone management is an important part of the whole management of prostate cancer
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After testosterone reaches the castration level, reducing testosterone to a lower level (<20ng/dl) can be used as a reference standard for judging better prognosis and adjusting treatment in patients with prostate cancer.
In the future, more prospective studies are needed to further explore the testosterone during its application.
Long-term clinical benefit of standardized management and lower testosterone levels
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In recent years, a variety of new endocrine drugs have entered the domestic market one after another, and have been superimposed with traditional ADT in the earlier stages of prostate cancer patients, which will bring more new problems to the management of testosterone
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In theory, androgen synthesis inhibitors represented by abiraterone can reduce serum testosterone; drugs such as enzalutamide and apalutamide are non-steroidal androgen receptor antagonists that can increase testosterone through negative feedback regulation
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In view of the short clinical application time of new endocrine drugs in China, the standardized management strategy of testosterone during their application period still needs to be further explored and supplemented
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Source: Urology Branch of Chinese Medical Association, Urology and Male Genital Oncology Professional Committee of China Anti-Cancer Association, Urology Branch of Chinese Medical Doctor Association.
Chinese expert consensus on testosterone management in prostate cancer (2021 edition).