ANZUP 2017 – Dr Ada CheungDr Ada Cheung discusses the under-recognised condition of hypogonadism in men following treatment for testicular cancer
Talking Urology podcast transcript
ANZUP 2017 Interviews - Joseph Ischia and Ada Cheung
Joseph Ischia: I’m Joseph Ischia and I’m speaking with Ada Chung. She’s an endocrinologist at the Austin Hospital and the APCR are as well as a researcher at the University of Melbourne. She gave an excellent talk today on the disease state basically of hypogonadism in men that have been treated for testicular cancer. Ada, can you just give us the highlights of your talk from today?
Ada Cheung: Yes, sure. We think that low testosterone levels after treatment for testicular cancer occurs in about 15 per cent of individuals. One of the difficulties is actually ascertaining whether a man actually has low testosterone levels. We do have some surveillance guidelines, so ANZUP have got some testing recommendations. They recommend testing 6 months after orchiectomy and again at 2 years and 5 years and similar recommendation exists in the UK. But testing is really important because the timing of measurement is critical.
Joseph: Yes. And when should we test?
Ada: Testosterone has a circadian rhythm. It’s higher in the morning, lower in the afternoon and so you should always test first thing in the morning early morning fasting levels.
Joseph: Why fasting?
Ada: Because as soon as you eat the testosterone levels drop.
Joseph: Well that’s no good.
Ada: Testosterone is a very sensitive hormone. It will drop with eating. It will lower with any sort of illness, so getting it first thing in the morning in the fasting state is critical.
Joseph: Okay. We hear a lot about these symptoms of hypogonadism, but they’re incredibly difficult to tease out really, aren’t they?
Ada: They are, they are. The tricky thing is, symptoms of hypogonadism or low testosterone is really non-specific. Many men get decreased sexual function, decreased libido, tiredness, fatigue, and depression. There are so many contributing factors when someone’s been diagnosed with cancer that can lead to these symptoms. Working it out based on symptoms and science is really tricky.
Joseph: When would you treat someone based on their symptoms for their testosterone level?
Ada: There is no hard evidence. The evidence, it’s low-quality evidence, but my opinion is that I would generally treat someone if their total testosterone was less than 10 nmol/L and and make sure that it was definitely a fasting early morning level and there wasn’t any reversible cause like any acute illness or drugs affecting it. If it was repeatedly less than 10, I would definitely consider treating. I might consider treating if it’s less than 12 animals per liter if you know in specific individualized circumstances. If they were symptomatic, they had low libido, or if the LH (luteinizing hormone) was very high, which reflects the primary hypogonadism, then I would also consider treating.
Joseph: With testosterone, it sounds wonderful. Why don’t we give it to everyone?
Ada: Exactly. It’s actually been shown to be not the fountain of youth that people thought it was going to be. It affects fertility. These are often young men in their ‘30s. They get testicular cancer and when you give testosterone, it’s a contraceptive, it stops sperm production, so that’s one reason not to. We’re also uncertain about the long-term side effects. Giving testosterone, getting high levels can be associated with increased hematocrit and polycythemia. There’s also some concern about potential cardiovascular risk. You may have heard of the multicenter T trials that have been a coordinated set of randomized controlled trials in older men in America looking at various outcomes to try and answer some of the unanswered questions. Concerningly, after 12 months of treatment, the men on testosterone had increased coronary artery plaque. We don’t know what that means, whether it translates to cardiovascular events, but it’s a concern. I think we should be conservative and only treat those who truly have low testosterone levels who are going to get a benefit.
Joseph: Thank you Ada. It’s been an absolute pleasure having you here at ANZUP and we look forward to seeing you more in the future.
Ada: That’s a pleasure. Thank you for inviting me. Thanks Joe.