| name | icsm-consider-tt-active-surveillance-shared-understanding |
| description | This skill advises that testosterone therapy may be reasonable for men on active surveillance for prostate cancer who have hypogonadism when both clinician and patient acknowledge the paucity of long-term safety data. It is triggered when a clinician manages a man on cancer surveillance with hypogonadism and questions whether it is okay to use testosterone while monitoring the cancer, and both clinician and patient accept the uncertainty. |
Consider testosterone therapy in active surveillance with shared understanding of limitations
STEP 1 — Gather Information
Confirm active surveillance for prostate cancer (stable PSA, imaging, biopsy criteria). Document hypogonadism: symptoms (e.g., low libido, fatigue) plus two morning total testosterone measurements <12 nmol/L (350 ng/dL). Review contraindications: untreated prostate abnormality, hematocrit ≥54%, desire for fertility. Discuss shared decision-making goals, emphasizing limited long-term safety data on testosterone therapy in this setting.
STEP 2 — Rule In / Rule Out
Is the patient on active surveillance for prostate cancer with biochemically confirmed hypogonadism? If YES, proceed to Step 3. If NO, testosterone therapy is not indicated in this context; manage hypogonadism per standard guidelines without active surveillance considerations.
STEP 3 — Classify or Stratify
Assess mutual understanding and willingness to accept unknown risk of prostate cancer progression. If both clinician and patient explicitly acknowledge the lack of long-term safety data and are willing to accept possible risks, classify as “shared understanding present.” If either party declines or is uncertain, classify as “shared understanding absent.”
STEP 4 — Decide
If shared understanding present: discuss testosterone therapy options (e.g., gel, injectable), obtain informed consent, initiate therapy with baseline and ongoing monitoring (testosterone, hematocrit, PSA, DRE per guideline). If shared understanding absent: defer testosterone therapy, continue active surveillance, and revisit discussion if circumstances change.
Clinical Guardrails / Mimics / Pitfalls
Do not offer testosterone therapy if patient or clinician is unwilling to accept uncertainty about long-term prostate cancer safety. Do not initiate therapy without confirming hypogonadism via two low testosterone measurements. Avoid using testosterone as monotherapy for erectile dysfunction in this population. Do not ignore hematocrit monitoring (≥54% warrants dose adjustment or cessation). Do not overlook the need for baseline PSA and DRE before starting therapy.
Concrete Clinical Example
A 62-year-old man on active surveillance for Gleason 3+4 prostate cancer (PSA 1.2 ng/mL, stable imaging) presents with low libido and fatigue. Two morning total testosterone levels are 8 nmol/L and 9 nmol/L. Clinician explains the limited long‑term safety data on testosterone therapy in active surveillance; patient expresses willingness to accept the uncertainty. They agree to a trial of testosterone gel 5 mg daily, with follow‑up testosterone, hematocrit, PSA, and DRE at 3, 6, and 12 months.
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
