The Myeloma Beacon yesterday published a news article summarizing results of a study investigating testos­terone levels in people recently diag­nosed with multiple myeloma ^[1]. The study, which was conducted at Ohio State University, found that almost three quarters of recently diag­nosed myeloma patients have testos­terone levels that are low for their gender and age.

To understand more about the study and its implications for people with multiple myeloma, The Beacon contacted Dr. Craig Hofmeister, a myeloma specialist and one of the study’s co-authors, to get his feed­back on a number of questions related to the study.

Dr. Hofmeister was at Ohio State’s James Cancer Center when collection of the data for the testos­terone study started. Now, however, he is based at the Winship Cancer Institute at Emory University in Atlanta. The questions The Beacon had for him, and his replies, follow.

Q: Do myeloma patients typically have their testos­terone levels tested? If not, in what cir­cum­stances would you recommend a myeloma patient have their testos­terone level tested?

Dr. Hofmeister: At Ohio State during the time period of this retrospective review, we did test testos­terone levels when you were a new patient to the system. We did not think that there was a sig­nif­i­cant hormonal influence in myeloma, but instead was likely a reflection of the inflam­ma­tory state of myeloma.

I think the time of initial diag­nosis is generally not a reasonable time to check testos­terone, nor is up to 6 months after au­tol­o­gous trans­plant. Testosterone levels will be low during these times, and it’s not plausible that the benefits of replacement will outweigh risks.

I would con­sider checking testos­terone levels in men who wish to im­prove libido or sexual function, and who would con­sider testos­terone replacement if the level was low. I don’t think the data to im­prove bone density or muscle mass is yet ‘ready’ for patients with myeloma, meaning I think the risks should be thought of at least equivalent to the benefits for now.

Q: What are the implications of the sort of lowered testos­terone levels you observed in your study, in terms of their impact on the day-to-day lives and quality of life of myeloma patients? Is the impact different between men and women?

Dr. Hofmeister: I believe that testos­terone in the setting of myeloma is a reflection of the inflam­ma­tory nature of myeloma. I think the myeloma is the driver, and testos­terone is a reflection of it. The impact of just lowered testos­terone levels on quality of life has not yet been reported to my knowledge.

Q: Should patients with low testos­terone levels undergo any kind of treat­ment or procedure to increase the testos­terone levels? If so, when should such treat­ment be con­sidered?

Dr. Hofmeister: For men who have clin­i­cal symp­toms and signs con­sis­tent with testos­terone defi­ciency and a subnormal morning (8 to 10 a.m.) serum testos­terone concentration on two separate occasions, I suggest testos­terone replacement ther­apy.

Currently testos­terone replacement im­proves libido and sexual function in patients with ‘low’ testos­terone. Even the question of what is low is based on whether you test free testos­terone or total testos­terone. Nevertheless replacement is thought to im­prove libido and sexual function. Testosterone replacement does im­prove bone density but that has not yet been studied in the setting of myeloma bone density to my knowledge. There are studies that testos­terone would im­prove muscle strength in men 19-47 years old with low testos­terone, but I ex­pec­t the benefits to be smaller and more indi­vid­u­al­ized in patients with myeloma, as these patients are older and sicker on average. The commercials for testos­terone replacement ther­apy suggest that it will provide addi­tional benefits, but those claims have been false to date.

Q: What form of testos­terone replacement ther­apy do you typically recommend, when you do prescribe it for patients?

Dr. Hofmeister: I usually suggest transdermal testos­terone to most men, especially a gel, because of convenience. No surprise, the newest preparations (the gels) cost the most, the patch costs some­what less, and injectable testos­terone cost the least. I test patients within 2-3 months of starting treat­ment to assess testos­terone concentration and the possibility of undesirable side effects. Before starting patients, I screen patients for prostate cancer, test PSA 3 months after starting replacement, then yearly.

Q: If a patient has low testos­terone levels, will that effect what myeloma treat­ments they should pursue?

Dr. Hofmeister: The risks of replacement are not zero and it is yet another medication added to the patient’s mix. Testosterone increases the risk of prostate cancer, blood clots, and maybe stroke/heart attack. That said, I have not changed myeloma treat­ment based on testos­terone replacement or status to date.

Q: Is there any evi­dence that lower testos­terone levels are correlated with a patient’s survival prognosis?

Dr. Hofmeister: Not to my knowledge, but I wouldn’t be surprised if in a larger study lower testos­terone levels correlated with worsened over­all survival. I would be surprised if low testos­terone, in a multivariable testing, individually increased risk of death. Patients with low testos­terone and myeloma are likely just sicker.