Prostate safety events during testosterone replacement therapy in men with hypogonadism - a randomized clinical trial

Authors

  • S Bhasin Harvard Medical School
  • TG Travison Harvard Medical School
  • KM Pencina Harvard Medical School
  • M O’Leary Harvard Medical School
  • GR Cunningham Baylor College of Medicine
  • AM Lincoff Cleveland Clinic
  • SE Nissen Cleveland Clinic
  • MS Lucia University of Colorado
  • MA Preston Brigham and Women’s Hospital
  • M Khera Baylor College of Medicine
  • N Khan AbbVie Inc
  • MC Snabes AbbVie Inc
  • X Li AbbVie Inc
  • CM Tangen University of Washington
  • KA Buhr University of Wisconsin
  • IM Thompson Jr The University of Texas Health Science Center

Abstract

Importance: The effect of testosterone replacement therapy (TRT) on the risk of prostate cancer and other adverse prostate events is unknown.

Objective: To compare the effect of TRT vs placebo on the incidences of high-grade prostate cancers (Gleason score >4 + 3), any prostate cancer, acute urinary retention, invasive prostate procedures, and pharmacologic treatment for lower urinary tract symptoms in men with hypogonadism.

Design, setting, and participants: This placebo-controlled, double-blind randomized clinical trial enrolled 5246 men (aged 45-80 years) from 316 US trial sites who had 2 testosterone concentrations less than 300 ng/dL, hypogonadal symptoms, and cardiovascular disease (CVD) or increased CVD risk. Men with prostate-specific antigen (PSA) concentrations greater than 3.0 ng/mL and International Prostate Symptom Score (IPSS) greater than 19 were excluded. Enrollment took place between May 23, 2018, and February 1, 2022, and end-of-study visits were conducted between May 31, 2022, and January 19, 2023.

Intervention: Participants were randomized, with stratification for prior CVD, to topical 1.62% testosterone gel or placebo. Main outcomes and measures: The primary prostate safety end point was the incidence of adjudicated high-grade prostate cancer. Secondary end points included incidence of any adjudicated prostate cancer, acute urinary retention, invasive prostate surgical procedure, prostate biopsy, and new pharmacologic treatment. Intervention effect was analyzed using a discrete-time proportional hazards model.

Results: A total of 5204 men (mean [SD] age, 63.3 [7.9] years) were analyzed. At baseline, the mean (SD) PSA concentration was 0.92 (0.67) ng/mL, and the mean (SD) IPSS was 7.1 (5.6). The mean (SD) treatment duration as 21.8 (14.2) months in the TRT group and 21.6 (14.0) months in the placebo group. During 14 304 person-years of follow-up, the incidence of high-grade prostate cancer (5 of 2 596 [0.19%] in the TRT group vs 3 of 2 602 [0.12%] in the placebo group; hazard ratio, 1.62; 95% CI, 0.39-6.77; p = .51) did not differ significantly between groups; the incidences of any prostate cancer, acute urinary retention, invasive surgical procedures, prostate biopsy, and new pharmacologic treatment also did not differ significantly. Change in IPSS did not differ between groups. The PSA concentrations increased more in testosterone-treated than placebo-treated men.

Conclusions and relevance: In a population of middle-aged and older men with hypogonadism, carefully evaluated to exclude those at high risk of prostate cancer, the incidences of high-grade or any prostate cancer and other prostate events were low and did not differ significantly between testosterone- and placebo-treated men. The study’s findings may facilitate a more informed appraisal of the potential risks of TRT.

Trial registration: ClinicalTrials.gov Identifier: NCT03518034

Author Biographies

S Bhasin, Harvard Medical School

Research Program in Men’s Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

TG Travison, Harvard Medical School

Marcus Institute for Aging Research, Hebrew Senior Life, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

KM Pencina, Harvard Medical School

Research Program in Men’s Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

M O’Leary, Harvard Medical School

Research Program in Men’s Health: Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

GR Cunningham, Baylor College of Medicine

Baylor College of Medicine, Houston, Texas

AM Lincoff, Cleveland Clinic

Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

SE Nissen, Cleveland Clinic

Cleveland Clinic Coordinating Center for Clinical Research (C5Research), Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

MS Lucia, University of Colorado

Department of Pathology, University of Colorado, Aurora

MA Preston, Brigham and Women’s Hospital

Division of Urology, Brigham and Women’s Hospital, Boston, Massachusetts

M Khera, Baylor College of Medicine

Baylor College of Medicine, Houston, Texas

N Khan, AbbVie Inc

AbbVie Inc, North Chicago, Illinois

MC Snabes, AbbVie Inc

AbbVie Inc, North Chicago, Illinois

X Li, AbbVie Inc

AbbVie Inc, North Chicago, Illinois

CM Tangen, University of Washington

Fred Hutchison Cancer Center, University of Washington, Seattle

KA Buhr, University of Wisconsin

Statistical Data Analysis Center, Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison

IM Thompson Jr, The University of Texas Health Science Center

CHRISTUS Santa Rosa Health System and The University of Texas Health Science Center, San Antonio

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Published

2024-07-02

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Original Article