| name | icsm-consider-tt-active-surveillance-accept-risk |
| description | Considers offering testosterone therapy to men on active surveillance for low-grade prostate cancer when both clinician and patient acknowledge the limited data on cancer progression risk. Triggered when managing a man with low-grade prostate cancer and low testosterone who questions whether testosterone can be used while monitoring the cancer. |
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
