Table 1:

Recommendations for screening and therapy for male-specific late effects in HCT adult patients

Potential late effects	Screening Recommendations	Therapeutic Implications	Quality of Evidence	Strength of Recommendation	Comments
Genital chronic GvHD	- Screening for symptoms (change in appearance of genitalia, a new burning sensation or painful intercourse) at each visit 27 - Genital exam, yearly 31 - Biopsy not required but can be done to exclude (pre-)malignant changes and infections	Topical therapy (e.g. high-potency topical corticosteroids [0.05%] or calcineurin inhibitors [0.1%]) and, if necessary, systemic immunosuppression	Low	Strong	- Consider multidisciplinary evaluation by the HCT provider, urologist and dermatologist for suspected genital GvHD - The occurrence of subsequent genital skin cancer remains a concern and patients should be educated on self-examination and symptoms
		Circumcision for complete phimosis	Low	Strong
		Surgical interventions for meatal stenosis	Low	Strong
Hypogonadism	- Screening for symptoms at each visit (lack of libido or erectile dysfunction, lack of motivation, reduced muscle mass and increased fat mass) 44 - Hormonal testing (testosterone, FSH, LH), ideally done in fasting patients, first thing in the morning in patients with symptoms 31 - Low testosterone should be confirmed by a repeat test 44, 47 - Annual screening for bone loss in allogeneic HCT recipients and patients at risk of bone loss 31, 55 - DEXA scan and fracture risk evaluation at 3 months for patients without pre-transplant evaluation or if patient received high dose steroids early post-transplant	Testosterone therapy in hypogonadal men to correct symptoms of testosterone deficiency 44	Low	Weak	- Consider referral to an endocrinologist or urologist to discuss the potential risks and benefits of testosterone therapy - Consider toxicities of testosterone therapy: screening for polycythemia and prostate cancer before initiating treatment, and close monitoring during treatment
Sexual dysfunction	- Screen for sexual health regularly through the survivorship process (loss of sexual interest, concerns related to perceived attractiveness, problems obtaining erection, ejaculation or orgasm) 85	Treatment of hormonal deficiencies, psychoeducation, referral to specialist in sexual health	Moderate	Strong	- Adapt interventions based on patient priorities - Consider referral to a psychologist for individual or couples-based interventions to address psychological contributors to sexual dysfunction
		Sildenafil treatment, vacuum erectile device, medicated urethral system for erection, or intra-cavernous injection for erectile dysfunction	Low	Weak
Infertility	- Pre-transplant counseling about risk of infertility and fertility preservation (sperm banking offered to all adult male patients undergoing HCT) depending on the type of pretransplant therapy and the conditioning 92 - Post-transplant counseling and consideration of semen analysis	Pre-transplant fertility preservation (sperm banking)	Moderate	Strong	- Consider discussion about alternative options for fatherhood - Consider referral to appropriate specialists for patients having difficulties conceiving 31 Contraception counseling if fertile or fertility status not known
		Referral to reproductive health specialist for patients with infertility	Moderate	Strong
Subsequent malignancies - Cancers only affecting men - Cancers more prevalent in men than in women	- Cancers which affect only men (Prostate, testis and penile cancers) follow guidelines for the general population - Patients with ongoing chronic GvHD or a history of chronic GvHD should have regular full skin examination, including genitalia - Counsel patients about risk of subsequent cancers, including ones in which men are at higher risk and ones that only affect men	Follow the guidelines for the general population	Low	Strong	- Special attention to screening for symptoms of squamous cell cancers of the skin, oral cavity and genitalia

GvHD: graft-versus-host disease; HCT, hematopoietic cell transplantation; FSH, follicle stimulating hormone; LH, luteinizing hormone; DEXA, dual energy X-ray absorptiometry