A growing body of case series in the literature suggests that Testosterone Replacement Therapy (TRT) may be reasonable in carefully selected patients that have a low grade prostate cancer and are not currently pursuing active treatment, such as surgery, which is called “active surveillance” or “waiting and watching” as it’s often called. Current expert guidance generally favors using the lowest effective testosterone dose needed to restore physiologic androgen levels, with ongoing monitoring at regular intervals tailored to the route of administration.
Until more definitive data from long-term prospective or placebo-controlled randomized trials are available, men on active surveillance or with a history of prostate cancer should be counseled on the importance of strict adherence to enhanced monitoring, including more frequent assessment of testosterone levels, PSA, and digital rectal examinations. The quality of life improvements from TRT need to be weighed in a risk-benefit discussion with their physician.
Review article from 2021 journal, Androgens: Clinical Research and Therapeutics – Updated Review of Testosterone Replacement Therapy in the Setting of Prostate Cancer. “
1. Kaplan-Marans et al., 2024 — population-based SEER-Medicare
Men on active surveillance: 167 on testosterone vs 6,658 not on testosterone. “TRT did not increase conversion to active treatment and did not worsen prostate-cancer-specific or overall mortality.”
2. Daza et al., 2023 — matched retrospective cohort
24 TRT patients vs 72 controls, median follow-up 5.82 years. Conversion to treatment was 24% vs 21%, not significant; PSA density, not TRT, predicted treatment-free survival. “TRT was not associated with conversion to treatment in this matched analysis among patients with localized prostate cancer on active surveillance.”
3. Applewhite et al., 2025 — single-center AS cohort
Men on active surveillance who later received TRT; PSA/testosterone tracked before and after TRT. “No significant change in PSA level was observed after initiating testosterone therapy, despite an increase in testosterone levels”
4. Morgentaler et al., 2011 — untreated prostate cancer case series
13 symptomatic hypogonadal men with untreated prostate cancer, mostly Gleason 6, TRT median 2.5 years. “Testosterone therapy in men with untreated prostate cancer was not associated with prostate cancer progression in the short to medium term. These results are consistent with the saturation model, ie maximal prostate cancer growth is achieved at low androgen concentrations. The longstanding prohibition against testosterone therapy in men with untreated or low risk prostate cancer or treated prostate cancer without evidence of metastatic or recurrent disease merits reevaluation.”
5. Ory et al., 2016 — treated and untreated prostate cancer
Included a small active-surveillance subgroup, reportedly 8 men on AS. PSA rose in that subgroup, but no Gleason upgrading was seen over median follow-up around 27 months. “our study supports the hypothesis that testosterone therapy may be oncologically safe in hypogonadal men after definitive treatment or in those on active surveillance for prostate cancer.”
6. Golla & Kaplan review, 2017
Review focused on testosterone therapy in men on active surveillance and after definitive prostate-cancer treatment; summarized early AS data as limited but not showing obvious short-term progression signals. “testosterone therapy for men on active surveillance for prostate cancer, testosterone therapy did not increase the risk of conversion to active therapy or worsen mortality.”
