[Criticisms to patient selection in active surveillance in prostate cancer]. / Criticas a la selección de pacientes en vigilancia activa en cancer de prostata.

OBJECTIVES: Active treatment in localized prostate cancer, in its various types, is assumed as a valid alternative. The effect of the possible overtreatment has raised that options such as active surveillance are offered as an alternative to active treatments, without evidence about its validity in many points. The objective of this study is to analyze the current controversies to define candidates to this alternative, follow up criteria, impact on quality of life and evidence bases to do it. METHODS: We perform an analysis updating the Medline search with the terms localized prostate cancer and active surveillance, analyzing the articles and their evidence, as well as guidelines recommendations. RESULTS: Selection criteria for candidates to active surveillance are heterogeneous, without evidence of uniformity. Likewise, follow up and its criteria or progression are not well defined. The impact on progression, or delay in decision-making, have not been analyzed and we lack of studies of highest evidence including comparative studies for cancer specific or global survival results. CONCLUSIONS: Although AS seems to be a reasonable alternative in many patients with localized prostate cancer, we still need to define many features of inclusion and decision-making. Comparative studies are needed to better define selection and validity of active surveillance.

Críticas a la selección de pacientes en vigilancia activa en cáncer de próstata / Criticisms to patient selection in active surveillance in prostate cancer

OBJETIVO: El tratamiento activo del cáncer de próstata localizado, en sus diferentes formas, es asumido como una alternativa válida. El efecto del posible sobretratamiento ha planteado que opciones como la vigilancia activa se oferte como alternativa a los tratamientos activos, sin en muchos puntos evidencias importantes sobre su validez. El objetivo de este estudio es analizar las controversias actuales para definir candidatos a esta alternativa, criterios de seguimiento, impacto en calidad de vida y bases de evidencia para ello. MÉTODO: Realizamos un análisis actualizando con la búsqueda en medlinede términos cáncer de próstata localizado y active surveillance-vigilancia activa "VA", analizando los diferentes trabajos y sus evidencias, así como recomendaciones en guías clínicas. RESULTADOS: Los criterios de selección de los pacientes candidatos a seguimiento activo son heterogéneos, sin una evidencia de uniformidad. El seguimiento y criterios del mismo o progresión igualmente están mal definidos. El impacto en la progresión o retraso en la toma de decisiones no está analizado y carecemos de estudios de máxima evidencia sobre estudios comparativos para resultados de supervivencia cáncer específica o global. CONCLUSIONES: Aunque la VA parece una alternativa razonable en muchos pacientes con CPL, la inclusión y toma de decisiones, todavía necesitan de muchas aspectos por definir, siendo necesarios estudios comparativos que puedan definir mejor la selección y validez de seguimiento activo

OBJECTIVES: Active treatment in localized prostate cancer, in its various types, is assumed as a valid alternative. The effect of the possible overtreatment has raised that options such as active surveillance are offered as an alternative to active treatments, without evidence about its validity in many points. The objective of this study is to analyze the current controversies to define candidates to this alternative, follow up criteria, impact on quality of life and evidence bases to do it. METHODS: We perform an analysis updating the Medline search with the terms localized prostate cancer and active surveillance, analyzing the articles and their evidence, as well as guidelines recommendations. RESULTS: Selection criteria for candidates to active surveillance are heterogeneous, without evidence of uniformity. Likewise, follow up and its criteria or progression are not well defined. The impact on progression, or delay in decision-making, have not been analyzed and we lack of studies of highest evidence including comparative studies for cancer specific or global survival results. CONCLUSIONS: Although AS seems to be a reasonable alternative in many patients with localized prostate cancer, we still need to define many features of inclusion and decision-making. Comparative studies are needed to better define selection and validity of active surveillance

[Testosterone deficit syndrome in the old male]. / Síndrome de deficit de testosterona en el anciano.

Epidemiological studies have demonstrated that prevalence of hypogonadism in old males increases with every additional decade of life. These males present various symptoms including decrease of sexual function, decrease of cognitive function, altered lipid profile, increased visceral adiposity, changes in bone density and muscular strength secondary to atrophy. Currently, testosterone injections and gel preparations are the most used. Testosterone replacement therapy provides significant symptomatic improvements for men with late start hypogonadism. Long-term benefits and risks of testosterone replacement therapy will be more evident when testosterone effects are studied on all health related parameters over a prolonged period of time. There is a large ongoing multicentric randomized clinical trial sponsored by NIH for testosterone control in old men with low testosterone levels. Its results may give answers to the possible benefits and risks of testosterone replacement in aging males. If an aging male is diagnosed as late-start hypogonadism, the urologist should discuss with the patient potential benefits and risks of testosterone therapy. Aging males with significant erythrocytosis, untreated sleep apnea, prostate cancer and high risk of cardiovascular events must be excluded from testosterone replacement therapy. Currently, there are not enough evidences to clearly state that the benefits of testosterone replacement therapy in aging males are better than the risks of this treatment. A general recommendation cannot be given that testosterone replacement therapy may be applied to all aging males with low testosterone levels independently of significant signs or symptoms.

Síndrome de déficit de testosterona en el anciano / Testosterone deficit syndrome in the old male

Los estudios epidemiológicos han demostrado que la prevalencia de hipogonadismo en los hombres de edad avanzada aumenta con cada década adicional de vida. Estos hombres presentan diversos síntomas que incluyen la disminución de la función sexual, disminución de la función cognitiva, perfil lipídico alterado, aumento de la adiposidad visceral, cambios en la densidad ósea y en la fuerza muscular secundaria a la atrofia. En la actualidad, las inyecciones de testosterona y preparaciones en forma de gel son las más usadas. La terapia de reemplazo de testosterona proporciona mejoras significativas en los síntomas para hombres con hipogonadismo de inicio tardío. Los beneficios a largo plazo y los riesgos del tratamiento con testosterona de reemplazo se harán más evidentes cuando los efectos de la testosterona se estudian en todos los parámetros relacionados con la salud durante un período prolongado de tiempo. Está en curso un gran ensayo multicéntrico aleatorizado patrocinado por NIH para el control de la testosterona en hombres de edad avanzada con niveles bajos de testosterona. Sus resultados pueden dar respuestas a los posibles beneficios y riesgos de reemplazo de testosterona en los hombres que envejecen. Si se produce un envejecimiento masculino se diagnostica como hipogonadismo de inicio tardío, el urólogo debe consensuar con el paciente los beneficios y riesgos potenciales de la terapia con testosterona (AU)

Los hombres ancianos que tienen eritrocitosis significativa, apnea del sueño no tratada, cáncer de próstata, y alto riesgo de eventos cardiovasculares deben ser excluidos de la terapia de reemplazo de testosterona. En la actualidad, no hay pruebas suficientes para afirmar claramente que los beneficios de la terapia de reemplazo de testosterona es mejor que los riesgos de este tratamiento de reemplazo en los hombres que envejecen. No se puede hacer una recomendación generalizada de que esta terapia de reemplazo de testosterona puede ser aplicada a todos los varones ancianos con niveles bajos de testosterona independientes de los signos o síntomas significativos (AU)

Epidemiological studies have demonstrated that prevalence of hypogonadism in old males increases with every additional decade of life. These males present various symptoms including decrease of sexual function, decrease of cognitive function, altered lipid profile, increased visceral adiposity, changes in bone density and muscular strength secondary to atrophy. Currently, testosterone injections and gel preparations are the most used. Testosterone replacement therapy provides significant symptomatic improvements for men with late start hypogonadism. Long-term benefits and risks of testosterone replacement therapy will be more evident when testosterone effects are studied on all health related parameters over a prolonged period of time. There is a large ongoing multicentric randomized clinical trial sponsored by NIH for testosterone control in old men with low testosterone levels. Its results may give answers to the possible benefits and risks of testosterone replacement in aging males. If an aging male is diagnosed as late-start hypogonadism, the urologist should discuss with the patient potential benefits and risks of testosterone therapy. Aging males with significant erythrocytosis, untreated sleep apnea, prostate cancer and high risk of cardiovascular events must be excluded from testosterone replacement therapy. Currently, there are not enough evidences to clearly state that the benefits of testosterone replacement therapy in aging males are better than the risks of this treatment. A general recommendation cannot be given that testosterone replacement therapy may be applied to al aging males with low testosterone levels independently of significant signs or symptoms (AU)