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The "Consensus of Chinese Experts on the Management of Testosterone in Prostate Cancer" was first published in 2017.
Based on the current status of clinical application of testosterone management in China, combined with recent updates of guidelines, consensus and literature evidence in various countries, the Chinese Medical Association Urology Branch (CUA), China The Anti-Cancer Association Urology and Male Reproductive System Professional Committee (CACA-GU) and the Chinese Medical Doctor Association Urology Branch (CUDA) jointly organized an expert group to update the 2021 version of the consensus
.
Androgen deprivation therapy (ADT) is one of the most important basic treatments for prostate cancer.
Its main goal is to reduce and stably maintain serum testosterone below the castrated level
.
Testosterone management for prostate cancer refers to the selection of clinical diagnosis and treatment strategies for prostate cancer through regular testosterone detection and result analysis.
It is an important part of the diagnosis and treatment of prostate cancer
.
In recent years, prostate cancer-related research has continuously brought new ideas to testosterone management.
The content involves the definition of testosterone castration levels, the comparison of different detection methods, and the reasonable frequency of monitoring
.
In the 1990s, "<50ng/d" was often used as the standard for castration of testosterone
.
In 2013, the results of a study confirmed for the first time that controlling testosterone to a lower level (≤32ng/dl) can significantly delay the appearance of castration-resistant prostate cancer
.
Based on relevant research, the 2014-2020 editions of the European Association of Urology (EAU) prostate cancer guidelines all proposed that "control of stable testosterone levels <20ng/dl can be used as a more appropriate value for judging the level of castration
.
The
2018 edition of "Recurrent and Metastatic Prostate Cancer in Canada" The "Consensus on Testosterone Suppression Therapy" also regards "<20ng/dl" as the new castration standard
.
Testosterone metabolism and influencing factors The physiological functions of adult testosterone include maintaining muscle volume and muscle strength, bone density and strength, and maintaining normal libido and sexual function
.
Most of the testosterone in the blood exists in the bound form, 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 reduced directly or by 5α The enzyme action is converted into dihydrotestosterone to activate the androgen receptor, and then play a role in regulating the growth and function of the prostate
.
Common factors that affect testosterone levels include: 1 As age increases, serum total testosterone decreases slowly, but FT decreases more significantly.
It is generally believed that the highest level is 20-29 years old, and it drops significantly after 40 years old, and reaches the lowest level at 70-80.
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 can lead to increased testosterone; zinc deficiency reduces testosterone levels
.
Clinical recommendations for testosterone management 1.
It is emphasized that testosterone management must 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 among patients and their families to obtain cooperation
.
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 needs to be tested as a baseline value for subsequent diagnosis and treatment Provide reference
.
3.
During ADT of prostate cancer and when CRPC is diagnosed, the testosterone level is still less than 50ng/dl (1.
735nmol/L) as the standard of castration; but the deep ketone reduction during ADT is to suppress the testosterone level to less than 20ng/dl (0.
694nmol/L) ), which can be used as a reference indicator for better clinical prognosis and adjustment of treatment
.
4.
It is recommended to test testosterone regularly before the start of ADT and within 8 months of treatment; in the initial stage of using LHRHa drugs, androgen receptor antagonists should be used to avoid the potential risk of disease progression caused by pharmacological testosterone "flashing"; When the condition enters a stable state, the testosterone test interval can be extended to once every 3 to 6 months; or the testosterone test and PSA test should be performed simultaneously
.
5.
When it is found that testosterone escapes, it can be replaced with other drugs that inhibit testosterone production or switch to surgical castration
.
6.
After CRPC is diagnosed, it is still necessary to maintain testosterone at the castrated level
.
7.
In the initial clinical application of new long-acting ADT preparations or new endocrine therapy drugs, care should be taken to ensure the frequency of testosterone testing to ensure the effect of testosterone control and reduce the rate of loss to follow-up
.
Standardized flow chart of testosterone monitoring and management during ADT treatment Conclusion and outlook Testosterone management is an important part of the entire management of prostate cancer
.
After testosterone reaches the castrated level, reducing testosterone to a lower level (<20ng/dl) can be used as a reference standard for judging a better prognosis and adjusting treatment for prostate cancer patients.
In the future, more prospective studies are needed to further explore the testosterone during its application.
Long-term clinical benefits of standardized management and lower testosterone levels
.
In recent years, a variety of new endocrine drugs have entered the domestic market, and they have been superimposed with traditional ADT in the earlier stage of prostate cancer patients.
This will bring more new problems to the management of testosterone
.
Theoretically, androgen synthesis inhibitors represented by abiraterone can lower serum testosterone; drugs such as enzalutamide and apatamide, which are non-steroidal androgen receptor antagonists, can increase testosterone through negative feedback regulation
.
In view of the short clinical application time of new endocrine drugs in China, the standardized management strategy of testosterone during its application still needs to be further explored and supplemented
.
Source: Chinese Medical Association Urology Branch, Chinese Anti-Cancer Association Urinary and Male Genital Tumor Professional Committee, Chinese Medical Doctor Association Urology Branch.
Chinese Expert Consensus on Prostate Cancer Testosterone Management (2021 Edition).
Based on the current status of clinical application of testosterone management in China, combined with recent updates of guidelines, consensus and literature evidence in various countries, the Chinese Medical Association Urology Branch (CUA), China The Anti-Cancer Association Urology and Male Reproductive System Professional Committee (CACA-GU) and the Chinese Medical Doctor Association Urology Branch (CUDA) jointly organized an expert group to update the 2021 version of the consensus
.
Androgen deprivation therapy (ADT) is one of the most important basic treatments for prostate cancer.
Its main goal is to reduce and stably maintain serum testosterone below the castrated level
.
Testosterone management for prostate cancer refers to the selection of clinical diagnosis and treatment strategies for prostate cancer through regular testosterone detection and result analysis.
It is an important part of the diagnosis and treatment of prostate cancer
.
In recent years, prostate cancer-related research has continuously brought new ideas to testosterone management.
The content involves the definition of testosterone castration levels, the comparison of different detection methods, and the reasonable frequency of monitoring
.
In the 1990s, "<50ng/d" was often used as the standard for castration of testosterone
.
In 2013, the results of a study confirmed for the first time that controlling testosterone to a lower level (≤32ng/dl) can significantly delay the appearance of castration-resistant prostate cancer
.
Based on relevant research, the 2014-2020 editions of the European Association of Urology (EAU) prostate cancer guidelines all proposed that "control of stable testosterone levels <20ng/dl can be used as a more appropriate value for judging the level of castration
.
The
2018 edition of "Recurrent and Metastatic Prostate Cancer in Canada" The "Consensus on Testosterone Suppression Therapy" also regards "<20ng/dl" as the new castration standard
.
Testosterone metabolism and influencing factors The physiological functions of adult testosterone include maintaining muscle volume and muscle strength, bone density and strength, and maintaining normal libido and sexual function
.
Most of the testosterone in the blood exists in the bound form, 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 reduced directly or by 5α The enzyme action is converted into dihydrotestosterone to activate the androgen receptor, and then play a role in regulating the growth and function of the prostate
.
Common factors that affect testosterone levels include: 1 As age increases, serum total testosterone decreases slowly, but FT decreases more significantly.
It is generally believed that the highest level is 20-29 years old, and it drops significantly after 40 years old, and reaches the lowest level at 70-80.
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 can lead to increased testosterone; zinc deficiency reduces testosterone levels
.
Clinical recommendations for testosterone management 1.
It is emphasized that testosterone management must 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 among patients and their families to obtain cooperation
.
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 needs to be tested as a baseline value for subsequent diagnosis and treatment Provide reference
.
3.
During ADT of prostate cancer and when CRPC is diagnosed, the testosterone level is still less than 50ng/dl (1.
735nmol/L) as the standard of castration; but the deep ketone reduction during ADT is to suppress the testosterone level to less than 20ng/dl (0.
694nmol/L) ), which can be used as a reference indicator for better clinical prognosis and adjustment of treatment
.
4.
It is recommended to test testosterone regularly before the start of ADT and within 8 months of treatment; in the initial stage of using LHRHa drugs, androgen receptor antagonists should be used to avoid the potential risk of disease progression caused by pharmacological testosterone "flashing"; When the condition enters a stable state, the testosterone test interval can be extended to once every 3 to 6 months; or the testosterone test and PSA test should be performed simultaneously
.
5.
When it is found that testosterone escapes, it can be replaced with other drugs that inhibit testosterone production or switch to surgical castration
.
6.
After CRPC is diagnosed, it is still necessary to maintain testosterone at the castrated level
.
7.
In the initial clinical application of new long-acting ADT preparations or new endocrine therapy drugs, care should be taken to ensure the frequency of testosterone testing to ensure the effect of testosterone control and reduce the rate of loss to follow-up
.
Standardized flow chart of testosterone monitoring and management during ADT treatment Conclusion and outlook Testosterone management is an important part of the entire management of prostate cancer
.
After testosterone reaches the castrated level, reducing testosterone to a lower level (<20ng/dl) can be used as a reference standard for judging a better prognosis and adjusting treatment for prostate cancer patients.
In the future, more prospective studies are needed to further explore the testosterone during its application.
Long-term clinical benefits of standardized management and lower testosterone levels
.
In recent years, a variety of new endocrine drugs have entered the domestic market, and they have been superimposed with traditional ADT in the earlier stage of prostate cancer patients.
This will bring more new problems to the management of testosterone
.
Theoretically, androgen synthesis inhibitors represented by abiraterone can lower serum testosterone; drugs such as enzalutamide and apatamide, which are non-steroidal androgen receptor antagonists, can increase testosterone through negative feedback regulation
.
In view of the short clinical application time of new endocrine drugs in China, the standardized management strategy of testosterone during its application still needs to be further explored and supplemented
.
Source: Chinese Medical Association Urology Branch, Chinese Anti-Cancer Association Urinary and Male Genital Tumor Professional Committee, Chinese Medical Doctor Association Urology Branch.
Chinese Expert Consensus on Prostate Cancer Testosterone Management (2021 Edition).
