Icsm Consider Tt Active Surveillance Accept Risk

Consider testosterone therapy in active surveillance if patient and provider accept unknown progression risk

STEP 1 — Gather Information

Confirm active surveillance eligibility (low-grade prostate cancer, e.g., Gleason ≤3+3, low PSA volume, MRI if performed), document symptomatic hypogonadism (total testosterone <12 nmol/L with symptoms such as low libido, fatigue, or erectile dysfunction), obtain baseline PSA and DRE, and discuss patient values regarding uncertainty of cancer progression risk.

STEP 2 — Rule In / Rule Out

Is the patient on active surveillance for low-grade prostate cancer AND has symptomatic hypogonadism? If yes, proceed to discuss risk acceptance; if no, testosterone therapy is not indicated for this scenario.

STEP 3 — Classify or Stratify

Do both the patient and provider accept the unknown risk of prostate cancer progression associated with testosterone therapy? If yes, consider offering testosterone therapy; if no, decline testosterone therapy and continue active surveillance without hormonal intervention.

STEP 4 — Decide

If risk acceptance is shared, initiate testosterone therapy after shared decision‑making, targeting mid‑normal testosterone levels, with monitoring per guideline (PSA and DRE every 3‑6 months initially, then annually); if risk is not accepted, continue active surveillance alone and revisit the discussion if preferences change.

Clinical Guardrails / Mimics / Pitfalls

Do not offer testosterone therapy if either party is unwilling to accept uncertain progression risk; avoid using testosterone as monotherapy for erectile dysfunction in this population; ensure baseline prostate evaluation (PSA, DRE, possibly MRI) to rule out occult cancer; monitor closely for any PSA rise or clinical progression and be prepared to discontinue therapy if progression is suspected.

Concrete Clinical Example

A 61‑year‑old man with Gleason 3+3 prostate cancer on active surveillance (PSA 4.0 ng/mL, MRI‑PIRADS 2) presents with fatigue and low libido; total testosterone is 9 nmol/L. After discussing the limited long‑term data on prostate cancer progression with testosterone, both patient and clinician accept the unknown risk. Testosterone gel is started, with PSA and DRE planned every 6 months; at 12‑month follow‑up PSA remains 4.2 ng/mL and symptoms improve.

Source: Male hypogonadism: recommendations from the Fifth International Consultation on Sexual Medicine (ICSM 2024), International Society for Sexual Medicine, 2025, DOI: 10.1093/sxmrev/qeaf036