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Randomized Controlled Trial
. 2023 Dec 1;6(12):e2348692.
doi: 10.1001/jamanetworkopen.2023.48692.

Prostate Safety Events During Testosterone Replacement Therapy in Men With Hypogonadism: A Randomized Clinical Trial

Shalender Bhasin  1 , Thomas G Travison  2 , Karol M Pencina  1 , Michael O'Leary  1 , Glenn R Cunningham  3 , A Michael Lincoff  4 , Steven E Nissen  4 , M Scott Lucia  5 , Mark A Preston  6 , Mohit Khera  3 , Nader Khan  7 , Michael C Snabes  7 , Xue Li  7 , Catherine M Tangen  8 , Kevin A Buhr  9 , Ian M Thompson Jr  10
Affiliations
Randomized Controlled Trial

Prostate Safety Events During Testosterone Replacement Therapy in Men With Hypogonadism: A Randomized Clinical Trial

Shalender Bhasin et al. JAMA Netw Open. .

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 2596 [0.19%] in the TRT group vs 3 of 2602 [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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bhasin reported receiving grants from Metri International Biotech and Function Promoting Therapies and consulting fees from OPKO and Versanis outside the submitted work; in addition, Dr Bhasin holds a patent as a co-inventor of a method for free testosterone measurement. Dr Lincoff reported receiving grants from Esperion, Commonwealth Serum Laboratories, Ltd., Novartis, and AstraZeneca; personal fees from Eli Lilly as a trial steering committee member; personal fees from Novo Nordisk as a trial steering committee member and consultant; consulting fees from Recor, Ardelyz, GlaxoSmithKline, Akebia, Endologix, Fibrogen, Provention, Becton Dickson, and Medtronic outside the submitted work. Dr Khera reported receiving personal fees from Tolmar, AbbVie Inc, Halozyme, Marius, and Endo Pharmaceuticals outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. CONSORT Flow Diagram
Figure 2.
Figure 2.. Incidence of Primary (High-Grade Prostate Cancer) and Secondary Prostate Safety End Points
Discrete-time proportional hazards model estimates of hazard ratios (95% CIs) quantifying differential risk in testosterone replacement therapy (TRT) relative to placebo are shown in the forest plot. The hazard ratios are the hazard in the TRT group over the hazard in the placebo group, so a value greater than 1 indicates an excess of prostate events in the TRT group. BPH indicates benign prostate hyperplasia.
Figure 3.
Figure 3.. Estimated Cumulative Incidences of Primary and Secondary Event-Based Outcomes as a Function of Time From Baseline
Aalen-Johansen estimates of cumulative incidence with death as a competing risk, together with pointwise 95% CIs, are shown. Hazard ratios (HRs) and associated 95% CIs and P values based on the discrete proportional hazards model are also shown. Between-group differences are not statistically significant. BPH indicates benign prostatic hyperplasia; HR, hazard ratio; and TRT, testosterone replacement therapy.
Figure 4.
Figure 4.. Changes in Lower Urinary Tract Symptoms Over Time
The lower urinary tract symptoms were evaluated using the International Prostate Symptom Score (IPSS). TRT indicates testosterone replacement therapy.
See this image and copyright information in PMC

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