The Evidence-Practice Gap in Testosterone Therapy for Prostate Cancer: A Narrative Review

The contraindication to testosterone replacement therapy (TRT) in men with prostate cancer (PCa) has been progressively challenged by contemporary evidence. Over recent years, increasing data suggest that TRT does not increase biochemical recurrence, disease progression, or PCa-specific mortality in carefully selected men, including those managed by active surveillance and those treated with radical prostatectomy or radiotherapy. Despite this convergence in the evidence, clinical practice has lagged. Major society guidelines continue to describe the available data as inadequate; many clinicians decline TRT in any man with a history of PCa, and symptomatic hypogonadism in survivors remains undertreated. This narrative review synthesises the contemporary evidence and characterises the persistent gap between evidence and clinical practice. It examines the principal drivers of that gap, which include conservative interpretation of guideline language, medico-legal anxiety, concerns surrounding on-treatment biochemical monitoring, the absence of randomised trials in this specific population, multidisciplinary fragmentation, and limited exposure during training. A practical clinical framework for shared decision-making and on-treatment surveillance, relevant to the UK and European practice, is proposed. The review concludes that an absolute contraindication is no longer tenable in men with symptomatic hypogonadism and a history of treated PCa, and that this population deserves a contemporary, evidence-informed conversation about TRT.