The Effect of Finasteride on Prostate Specific Antigen: Review of Available Data

Treatment Algorithm for Management of Benign Prostatic Obstruction: An Overview of Current Techniques

The management of benign prostatic obstruction (BPO) should involve a treatment algorithm that takes into account prostate size, and patient's symptoms and preference with the aim of helping with urinary symptoms and enhance quality of life. The diagnostic assessment for men with lower urinary tract symptoms (LUTS) should be comprehensive to help choose the best management strategy. Strategies from lifestyle modifications to medical treatment with alpha blockers and/or 5-alpha-reductase inhibitors to surgical procedures can all be used in the management algorithm. Surgical management ranges from transurethral resection of prostate (TURP) to minimally invasive surgical therapies (MIST) including laser therapies such as Holmium laser enucleation (HoLEP) and photoselective vaporisation (PVP), aquablation, Rezūm system, prostate artery embolisation (PAE), prostatic urethral lift (PUL), temporary implantable nitinol device (iTind) and Optilume BPH catheter system. BPO is a common urological condition that has a significant impact on quality of life and economic burden globally and is likely to become increasingly prevalent with an ageing population. Selecting the most appropriate treatment modality will depend on the individual patient preferences, availability of resources, cost, anatomical factors and the goals of treatment.

A prospective evaluation of the effect of finasteride on prostate health index (phi)

PURPOSE

5-alpha reductase inhibitor (5ARI) reduces prostate-specific antigen (PSA) by half but its effect on prostate health index (phi) is unknown. This study aims to investigate this effect and to enable accurate interpretation of phi in men with elevated PSA and on 5ARI.

METHODS

This is a prospective study evaluating the effect of finasteride on PSA, free PSA (fPSA), [ - 2]proPSA (p2PSA) and phi at 6 and 12 moths in men with PSA 4-20 ng/mL, no prior 5ARI use, and one negative prostate biopsy within 6 months before recruitment. The 5ARI Finasteride (5 mg/day) for 1 year was offered if International Prostatic Symptom Score (IPSS) was ≥ 8 at baseline. 5ARI group included patients taking finasteride, while control group included patients not on finasteride. The blood results were compared with t-test between baseline and different time points in each group and between groups at 1 year.

RESULTS

164 men fit the inclusion criteria and 150 were analyzed. In 5ARI group (n = 100) at 1 year, mean PSA reduced by 51.4% from 8.9(± SD 3.7) to 4.4(± SD 2.8)ng/mL (paired t-test, p < 0.001), fPSA reduced by 52.4% from 1.6(± 0.6) to 0.8(± 0.4)ng/mL (p < 0.001), p2PSA reduced by 55.3% from 18.4(± 8.8) to 8.3(± 5.6)pg/mL (p < 0.001), and phi reduced by 34.2% from 33.7(± 11.9) to 22.4(± 12.5) (p < 0.001). PSA and phi values in the control group remained static over 1 year and significantly higher than those in 5ARI group.

CONCLUSION

This study demonstrated p2PSA and phi are reduced by about 55% and 34% in men on 5ARI. A conversion factor of division by 0.66 is needed for phi in men on finasteride to allow the interpretation and use of phi in men on 5ARI.

A machine learning approach to predict progression on active surveillance for prostate cancer

PURPOSE

Robust prediction of progression on active surveillance (AS) for prostate cancer can allow for risk-adapted protocols. To date, models predicting progression on AS have invariably used traditional statistical approaches. We sought to evaluate whether a machine learning (ML) approach could improve prediction of progression on AS.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients diagnosed with very-low or low-risk prostate cancer between 1997 and 2016 and managed with AS at our institution. In the training set, we trained a traditional logistic regression (T-LR) classifier, and alternate ML classifiers (support vector machine, random forest, a fully connected artificial neural network, and ML-LR) to predict grade-progression. We evaluated model performance in the test set. The primary performance metric was the F1 score.

RESULTS

Our cohort included 790 patients. With a median follow-up of 6.29 years, 234 developed grade-progression. In descending order, the F1 scores were: support vector machine 0.586 (95% CI 0.579 - 0.591), ML-LR 0.522 (95% CI 0.513 - 0.526), artificial neural network 0.392 (95% CI 0.379 - 0.396), random forest 0.376 (95% CI 0.364 - 0.380), and T-LR 0.182 (95% CI 0.151 - 0.185). All alternate ML models had a significantly higher F1 score than the T-LR model (all p <0.001).

CONCLUSION

In our study, ML methods significantly outperformed T-LR in predicting progression on AS for prostate cancer. While our specific models require further validation, we anticipate that a ML approach will help produce robust prediction models that will facilitate individualized risk-stratification in prostate cancer AS.

Prostate-Specific Antigen Concentrations in Response to Testosterone Treatment of Severely Hypogonadal Men

Context

Clinical guidelines recommend measurement of the serum prostate-specific antigen (PSA) concentration during testosterone treatment of hypogonadal men to determine whether the increase is sufficiently high to warrant urologic referral. Prior studies of the effect of testosterone treatment on PSA concentrations have been conducted in men who were mildly to moderately hypogonadal.

Objective

The objective of this work is to determine the PSA response to testosterone treatment of men who are severely hypogonadal.

Design and Setting

This retrospective cohort study was conducted at a single academic medical center.

Participants

Eighty-five men participated who were severely hypogonadal as a result hypothalamic-pituitary or testicular disease.

Main Outcome Measure

Changes in serum PSA concentrations were measured during testosterone treatment for up to 18 months.

Results

Testosterone treatment increased the median serum testosterone concentration from 36 ng/dL (interquartile range [IQR], 20-91 ng/dL) at baseline to 395 ng/dL (IQR, 266-542 ng/dL) at 6 to 18 months. This treatment resulted in a median increment in PSA above baseline of 0.70 ng/mL (IQR, 0.10-1.85 ng/mL) at 6 to 18 months. Apropos current Endocrine Society clinical guidelines, 31% of the men experienced a PSA increase above baseline greater than 1.4 ng/mL, and 13% reached an absolute PSA concentration of greater than 4.0 ng/mL. Four men were diagnosed with prostate cancer.

Conclusions

The PSA response to testosterone replacement in men who are severely hypogonadal as a result of pituitary or testicular disease is greater than that previously reported in men with mild to moderate hypogonadism. These results suggest the magnitude of the PSA response to testosterone replacement is related to the degree of hypogonadism.

Prostate-Specific Antigen Levels During Testosterone Treatment of Hypogonadal Older Men: Data from a Controlled Trial

CONTEXT

Prostate-specific antigen (PSA) changes during testosterone treatment of older hypogonadal men have not been rigorously evaluated.

DESIGN

Double-blinded, placebo-controlled trial.

SETTING

Twelve US academic medical centers.

PARTICIPANTS

Seven hundred ninety hypogonadal men ≥65 years of age with average testosterone levels ≤275 ng/dL. Men at high risk for prostate cancer were excluded.

INTERVENTIONS

Testosterone or placebo gel for 12 months.

MAIN OUTCOMES

Percentile changes in PSA during testosterone treatment of 12 months.

RESULTS

Testosterone treatment that increased testosterone levels from 232 ± 63 ng/dL to midnormal was associated with a small but substantially greater increase (P < 0.001) in PSA levels than placebo treatment. Serum PSA levels increased from 1.14 ± 0.86 ng/mL (mean ± SD) at baseline by 0.47 ± 1.1 ng/mL at 12 months in the testosterone group and from 1.25 ± 0.86 ng/mL by 0.06 ± 0.72 ng/mL in the placebo group. Five percent of men treated with testosterone had an increase ≥1.7 ng/mL and 2.5% of men had an increase of ≥3.4 ng/mL. A confirmed absolute PSA >4.0 ng/mL at 12 months was observed in 1.9% of men in the testosterone group and 0.3% in the placebo group. Four men were diagnosed with prostate cancer; two were Gleason 8.

CONCLUSIONS

When hypogonadal older men with normal baseline PSA are treated with testosterone, 5% had an increase in PSA ≥1.7 ng/mL, and 2.5% had an increase ≥3.4 ng/mL.

Meta-analysis of the efficacy and safety of combination of tamsulosin plus dutasteride compared with tamsulosin monotherapy in treating benign prostatic hyperplasia

Background

We performed a meta-analysis to confirm the efficacy and safety of the combination of tamsulosin plus dutasteride compared with tamsulosin monotherapy in treating benign prostatic hyperplasia (BPH) during a treatment cycle of at least 1 year.

Methods

Randomized controlled trials were searched by using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. The data was evaluated and statistically analyzed by using RevMan version 5.3.0.

Results

Five studies including 4348 patients were studied. The analysis found that the combination group was significantly greater effect in international prostate symptom score (mean difference [MD], − 1.43; 95% confidence interval [CI], − 2.20 to − 0.66; P = 0.0003), prostate volume (MD, − 10.13; 95% CI, − 12.38 to − 7.88; P < 0.00001), transitional zone volume (MD, − 3.18; 95% CI, − 3.57 to − 2.79; P<0.0001), maximum urine flow rate (MD, 1.05; 95% CI, 0.82 to 1.29; P < 0.00001), prostate specific antigen (MD, − 0.54; 95% CI, − 0.80 to − 0.29; P < 0.0001) and post-void residual volume (MD, − 3.85; 95% CI, − 4.95 to − 2.76; P < 0.00001) compared with the tamsulosin group. In terms of safety, including adverse events (odds ratio [OR], 2.06; 95% CI, 1.34 to 3.17; P = 0.001), erectile dysfunction (OR, 2.24; 95% CI, 1.73 to 2.92; P < 0.00001), ejaculation disorder (OR, 3.37; 95% CI, 1.97 to 5.79; P < 0.0001), retrograde ejaculation (OR, 2.30; 95% CI, 1.08 to 4.93; P = 0.03), decreased libido (OR, 2.25; 95% CI, 1.53 to 3.31; P < 0.0001) and loss of libido (OR, 3.38; 95% CI, 1.94 to 5.88; P<0.0001), the combination group showed poor tolerance than the tamsulosin group with the exception of dizziness (OR, 1.16; 95% CI, 0.75 to 1.80; P = 0.50). The combination group significantly reduced the risk of clinical progression than the tamsulosin group especially in incidence of BPH-related symptom progression (OR, 0.56; 95% CI, 0.46 to 0.67; P < 0.00001) and acute urinary retention (OR, 0.61; 95% CI, 0.38 to 0.98; P = 0.04).

Conclusion

The combination of tamsulosin plus dutasteride provides a preferable therapeutic effect for BPH with a higher incidence of sexual side effects, but combination-therapy can markedly reduce risk of BPH-related symptom progression and acute urinary retention relative to tamsulosin monotherapy.

The use of 5-alpha reductase inhibitors in the treatment of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is characterized by an enlarged prostate, lower urinary tract symptoms (LUTS), and a decreased urinary flow rate. Common in older men, BPH is a progressive disease that can eventually lead to complications including acute urinary retention (AUR) and the need for BPH-related surgery. Both normal and abnormal prostate growth is driven by the androgen dihydrotestosterone (DHT), which is formed from testosterone under the influence of 5-alpha reductase. Thus, 5-alpha reductase inhibitors (5-ARIs) effectively reduce the serum and intraprostatic concentration of DHT, causing an involution of prostate tissue. Two 5-ARIs are currently available for the treatment of BPH—finasteride and dutasteride. Both have been demonstrated to decrease prostate volume, improve LUTS and urinary flow rates, which ultimately reduces the risk of AUR and BPH-related surgery. Therefore, either alone or in combination with other BPH medications, 5-ARIs are a mainstay of BPH management.

A Four-kallikrein Panel and β-Microseminoprotein in Predicting High-grade Prostate Cancer on Biopsy: An Independent Replication from the Finnish Section of the European Randomized Study of Screening for Prostate Cancer

BACKGROUND

A panel of four kallikrein markers (total, free, and intact prostate-specific antigen [PSA] and human kallikrein-related peptidase 2 [hK2]) improves predictive accuracy for Gleason score ≥7 (high-grade) prostate cancer among men biopsied for elevated PSA. A four-kallikrein panel model was originally developed and validated by the Dutch center of the European Randomized Study of Screening for Prostate Cancer (ERSPC). The kallikrein panel is now commercially available as 4Kscore™.

OBJECTIVE

To assess whether these findings could be replicated among participants in the Finnish section of ERSPC (FinRSPC) and whether β-microseminoprotein (MSP), a candidate prostate cancer biomarker, adds predictive value.

DESIGN, SETTING, AND PARTICIPANTS

Among 4861 biopsied screening-positive participants in the first three screening rounds of FinRSPC, a case-control subset was selected that included 1632 biopsy-positive cases matched by age at biopsy to biopsy-negative controls.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The predictive accuracy of prespecified prediction models was compared with biopsy outcomes.

RESULTS AND LIMITATIONS

Among men with PSA of 4.0-25ng/ml, 1111 had prostate cancer, 318 of whom had high-grade disease. Total PSA and age predicted high-grade cancer with an area under the curve of 0.648 (95% confidence interval [CI] 0.614-0.681) and the four-kallikrein panel increased discrimination to 0.746 (95% CI 0.717-0.774). Adding MSP to the four-kallikrein panel led to a significant (Wald test; p=0.015) but small increase (0.003) in discrimination. Limitations include a risk of verification bias among men with PSA of 3.0-3.99ng/ml and the absence of digital rectal examination results.

CONCLUSIONS

These findings provide additional evidence that kallikrein markers can be used to inform biopsy decision-making. Further studies are needed to define the role of MSP.

PATIENT SUMMARY

Four kallikrein markers and β-microseminoprotein in blood improve discrimination of high-grade prostate cancer at biopsy in men with elevated prostate-specific antigen.

Androgenetic Alopecia: An Update of Treatment Options

Androgenetic alopecia (AGA) is characterized by a non-scarring progressive miniaturization of the hair follicle in predisposed men and women with a pattern distribution. Although AGA is a very prevalent condition, approved therapeutic options are limited. This article discusses the current treatment alternatives including their efficacy, safety profile, and quality of evidence. Finasteride and minoxidil for male androgenetic alopecia and minoxidil for female androgenetic alopecia still are the therapeutic options with the highest level evidence. The role of antiandrogens for female patients, the importance of adjuvant therapies, as well as new drugs and procedures are also addressed.

The new insight of prostate-specific antigen reduction during finasteride therapy in aging men

OBJECTIVE

To evaluate the effect of finasteride on prostate-specific antigen (PSA) in Chinese population.

MATERIALS AND METHODS

From Feb 2011 to Jan 2012, 83 benign prostatic hyperplasia (BPH) patients with prostate volume (PV) >30 mL were enrolled in our study. All the patients were older than 50 years and all of them received combined therapy (finasteride + doxazosin). All the patients were required for 1-year follow-up. PSA level and PV was measured at the start, 6 and 12 months, respectively.

RESULTS

79 patients completed the follow up. PSA level reduced by approximately 40 % during finasteride therapy. We defined baseline PSA as PSA1, PSA at 6 months as PSA2, PSA at 12 months as PSA3. PSA1 was significantly correlated with PSA2/PSA1 and PSA3/PSA1. However, prostate volume was not correlated with PSA1. We divided the patients into three groups according to PSA level. Groups 1, 2, 3 represented the patients with PSA less than 2 ng/mL, between 2 and 4 ng/mL and greater than 4 ng/mL, respectively. Both the PSA2/PSA1 and the PSA3/PSA1 had significant difference among three groups. Furthermore, group 1 and group 2 both showed the fairly large data variance.

CONCLUSIONS

When baseline PSA level was greater than 4 ng/mL, the doubling rule could be used for screening. When baseline PSA level was less than 4 ng/Ml, the doubling rule might not be an accurate predictor. We can use the PSA rise from nadir or proPSA to predict prostate cancer.

Treatment of hormone-refractory prostate cancer

Objective. An increasing number of patients with prostate cancer develop hormone-refractory disease after standard treatment modalities. In these patients, early clinical trials with chemotherapy produced disappointing response rates. However, clinical trials that employ response criteria such as prostate-specific antigen (PSA) and clinical benefit response have produced encouraging responses. This article reviews current and future treatment options for the management of hormone-refractory prostate cancer.

Data Sources. A MEDLINE search for the years 1978 to 1998 was completed. The following terms were used in our search: prostate cancer, hormone-refractory, treatment, and chemotherapy. Relevant articles referenced in the literature obtained in our MEDLINE search were reviewed.

Study Selection. Randomized and nonrandomized clinical trials were used in our review. Clinical trials using prostate-specific antigen or a palliation of symptoms as primary criteria for response were given priority.

Data Synthesis. Several genetic alterations, including the overexpression of bcl-2 or mutations in p53, may lead to the development of hormone-refractory prostate cancer. Agents such as estramustine and taxanes, which affect microtubule function and potentially modulate bcl-2, appear to be particularly active in the treatment of hormone-refractory prostate cancer. In addition, mitoxantrone as well as other agents has been shown to be beneficial in improving the quality of life in patients with hormone-refractory prostate cancer.

Conclusion. Hormone-refractory prostate cancer is not a chemotherapy-resistant disease as once believed; significant progress in the treatment of hormone-refractory prostate cancer has been made with new combinations of chemotherapy agents. Promising new treatments are currently under evaluation to assess their potential benefit over the standard treatment modalities that are currently available.

Prevalence of the HOXB13 G84E mutation in Danish men undergoing radical prostatectomy and its correlations with prostate cancer risk and aggressiveness

OBJECTIVES

To determine the prevalence of the HOXB13 G84E mutation (rs138213197) in Danish men with or without prostate cancer (PCa) and to investigate possible correlations between HOXB13 mutation status and clinicopathological characteristics associated with tumour aggressiveness.

MATERIALS AND METHODS

We conducted a case-control study including 995 men with PCa (cases) who underwent radical prostatectomy (RP) between 1997 and 2011 at the Department of Urology, Aarhus University Hospital, Denmark. As controls, we used 1622 healthy men with a normal prostate specific antigen (PSA) level.

RESULTS

The HOXB13 G84E mutation was identified in 0.49% of controls and in 2.51% of PCa cases. The mutation was associated with a 5.12-fold increased relative risk (RR) of PCa (95% confidence interval [CI] 2.26-13.38; P = 13 × 10(-6) ). Furthermore, carriers of the risk allele were significantly more likely to have a higher PSA level at diagnosis (mean PSA 19.9 vs 13.6 ng/mL; P = 0.032), a pathological Gleason score ≥7 (83.3 vs 60.9%; P = 0.032), and positive surgical margins (56.0 vs 28.5%; P = 0.006) than non-carriers. Risk allele carriers were also more likely to have aggressive disease (54.2 vs 28.6%; P = 0.011), as defined by a preoperative PSA ≥20 ng/mL, pathological Gleason score ≥ (4+3) and/or presence of regional/distant disease. At a mean follow-up of 7 months, we found no significant association between HOXB13 mutation status and biochemical recurrence in this cohort of men who underwent RP.

CONCLUSIONS

This is the first study to investigate the HOXB13 G84E mutation in Danish men. The mutation was detected in 0.49% of controls and in 2.51% of cases, and was associated with 5.12-fold increased RR of being diagnosed with PCa. In our RP cohort, HOXB13 mutation carriers were more likely to develop aggressive PCa. Further studies are needed to assess the potential of HOXB13 for future targeted screening approaches.

Resveratrol reduces the levels of circulating androgen precursors but has no effect on, testosterone, dihydrotestosterone, PSA levels or prostate volume. A 4-month randomised trial in middle-aged men

BACKGROUND

Resveratrol is a naturally occurring polyphenol with purported inhibitory effects on prostate growth and cancer development. A number of studies have demonstrated that resveratrol reduces prostate growth in animal models and reduces prostate cell growth in vitro. Based on these pre-clinical findings, interest in resveratrol is increasing in relation to the management of benign prostate hyperplasia (BPH) and prostate cancer. So far, no human trials have evaluated the effects of resveratrol on circulating androgens, prostate size, or biochemical markers of prostate size.

METHODS

In a randomized placebo controlled clinical study using two doses of resveratrol (150 mg or 1,000 mg resveratrol daily) for 4 months, we evaluated the effects on prostate size, prostate specific antigen (PSA) and sex steroid hormones in 66 middle-aged men suffering from the metabolic syndrome(MetS).

RESULTS

At baseline, prostate size and PSA were positively correlated (R = 0.34, P < 0.007) as was prostate size and age (R = 0.37, P < 0.003). Prostate size did not correlate with testosterone, free testosterone, dihydrotestosterone (DHT), or any other androgen precursor at baseline. The highest dose of resveratrol lowered the serum level of androstenedione 24% (P = 0.052), dehydroepiandrosterone (DHEA) 41% (P < 0.01), and dehydroepiandrosterone-sulphate (DHEAS) 50% (p<0.001), compared to the control group. However, prostate size and levels of PSA, testosterone, free testosterone and DHT remained unchanged.

CONCLUSION

In this population of middle-aged men suffering from MetS, high dose resveratrol (1,000 mg daily) administration for 4 months significantly lowered serum levels of the androgen precursors androstenedione, DHEA and DHEAS, whereas prostate size and circulating levels of PSA, testosterone, free testosterone, and dihydrotestosterone were unaffected. The present study suggests that resveratrol does not affect prostate volume in healthy middle-aged men as measured by PSA levels and CT acquired prostate volumes. Consequently, we find no support for the use of resveratrol in the treatment of benign prostate hyperplasia.

Clinical effects of discontinuing 5-alpha reductase inhibitor in patients with benign prostatic hyperplasia

PURPOSE

To assess changes in lower urinary tract symptoms (LUTS), prostate volume, and serum prostate-specific antigen (PSA) after discontinuation of 5-alpha reductase inhibitor (5ARI) combination therapy in patients with benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

From December 2003 to December 2012, data were collected retrospectively from 81 men more than 40 years of age with moderate to severe BPH symptoms (International Prostate Symptom Score [IPSS]≥8). The men were classified into group 1 (n=42) and group 2 (n=39) according to the use of 5ARI therapy. A combination of dutasteride 0.5 mg with tamsulosin 0.2 mg was given daily to all patients for 1 year. For the next 1 year, group 1 (n=42) received the combination therapy and group 2 (n=39) received tamsulosin 0.2 mg monotherapy only. The IPSS, prostate volume, and PSA level were measured at baseline and at 12 and 24 months according to the use of dutasteride.

RESULTS

Discontinuation of dutasteride led to significant deterioration of LUTS, increased prostate volume, and increased PSA level. The repeated-measures analysis of variance showed that the changes in IPSS, prostate volume, and PSA level over time also differed significantly between groups 1 and 2 (p<0.001).

CONCLUSIONS

Withdrawal of 5ARI during combination therapy resulted in prostate regrowth and deterioration of LUTS. The PSA level is also affected by the use of 5ARI. Therefore, regular check-up of the IPSS and PSA level may be helpful for all patients who either continue or discontinue the use of 5ARI.

Impact of treatment with statins on prostate-specific antigen and prostate volume in patients with benign prostatic hyperplasia

Purpose

We investigated the impact on prostate-specific antigen (PSA) and prostate volume (PV) of statin medication for 1 year in patients with benign prostatic hyperplasia (BPH).

Materials and Methods

We retrospectively investigated 791 patients in whom BPH was diagnosed. For analysis, the patients were divided into four groups according to their medications: group A, α-blocker; group B, α-blocker+statin; group C, α-blocker+dutasteride; group D, α-blockers+statin+dutasteride. To investigate changes in serum PSA, PV, and total cholesterol, we analyzed the data at the time of initial treatment and after 1 year of medication.

Results

After 1 year, group A showed a 1.3% increase in PSA and a 1.0% increase in PV. Group B showed a 4.3% decrease in PSA and a 1.8% decrease in PV. The difference in PV reduction between groups A and B was statistically significant (p<0.001). Group C showed a 49.1% reduction in PSA and a 22.9% reduction in PV. Group D showed a 51.6% reduction in PSA and a 24.5% reduction in PV. The difference in PV reduction between groups C and D was not statistically significant (p=0.762). By use of a multivariate logistic regression model, we found that the probability of PV reduction after 1 year was more than 14.8 times in statin users than in statin nonusers (95% confidence interval, 5.8% to 37.6%; p<0.001).

Conclusions

Statin administration reduced PSA and PV in BPH patients. This finding may imply the improvement of lower urinary tract symptoms and prevention of cardiovascular disease and chemoprevention of prostate cancer with statin treatment.

Screening for prostate cancer: an updated review

Prostate cancer is the most frequently diagnosed malignancy in men and its incidence has been increasing in the last decades. Diagnosis and treatment of prostate cancer were radically improved after the discovery of prostatic-specific antigen. Early detection rates increased, especially in asymptomatic individuals, confirmed by recent published randomized trials. The impact of screening in overdiagnosis and overtreatments is discussed, since benefits in overall mortality rates were not clearly demonstrated. Perhaps younger patients with a longer life expectancy would be the ones with the most benefits from screening. This study presents an update of the most important screening methods for prostate cancer as well as the recent recommendations for screening.

Prostate biopsy in response to a change in nadir prostate specific antigen of 0.4 ng/ml after treatment with 5α-reductase inhibitors markedly enhances the detection rate of prostate cancer

PURPOSE

We examined the effect of 5α-reductase inhibitor therapy on prostate cancer detection in men with persistently increased or fluctuating prostate specific antigen and prior negative prostate cancer biopsy.

MATERIALS AND METHODS

A total of 276 men with prostate specific antigen greater than 4 ng/ml (208) or a prostate specific antigen velocity change of 0.75 ng/ml (68) and a normal digital rectal examination who had previously undergone biopsy a minimum of 2 times with prostate cancer not detected were given 5 mg finasteride (154) or dutasteride (122) daily. In phase 1, 97 patients had prostate specific antigen measured at 6 and 12 months with repeat transrectal ultrasonography and biopsy (12 cores) performed at 1 year. In phase 2, 179 patients underwent biopsy triggered by a change in nadir prostate specific antigen of more than 0.4 ng/ml.

RESULTS

In phase 1 at 1 year prostate specific antigen had decreased by 2.4 ng/ml (-46.7%), and prostate volume had decreased 7.1 ml (-17.9%). Prostate cancer was detected in 27 of 97 (27.8%) patients and the mean minimum prostate specific antigen velocity from a nadir of 0.4 ng/ml was 0.6 ng/ml. In phase 2, 48 of 179 (26.8%) men underwent repeat biopsy at a mean of 14.6 months. Of these 48 men 26 (54.1%) were found to have prostate cancer. Of the 26 men in whom prostate cancer was detected 20 (76.9%) were found to have Gleason score 7 or greater disease.

CONCLUSIONS

The magnitude of change in serum prostate specific antigen after 5α-reductase inhibitor therapy may be useful in diagnosing prostate cancer in patients with persistently increased or fluctuating prostate specific antigen and prior negative prostate biopsy.

A Review on the Clinical Utility of PSA in Cancer Prostate

Prostate cancer has come to share the oncological centrestage among male cancers. The availability of Serum Prostate Specific Antigen, PSA, as a marker has encouraged it's use to diagnose both cancer and cancer recurrence. Some clarity is required about its precise role in clinical practice. The available literature on Prostate Specific Antigen was reviewed; Articles were reviewed for content, applicability to the problem at hand, availability of data about sensitivity and specificity of values, refinements in measurements and finally for impact of screening programmes using these values on survival and quality of life. The data in the literature was critically re-evaluated and analysed to draw reasonable conclusions. Serum PSA measurements show variable reliability when it comes to diagnosis of Prostate cancer, given the dynamics of PSA physiology. Surrogate measures like PSA density, PSA velocity, free-to-complexed PSA ratio, percentage Pro-PSA, etc., have been used to improve the predictive utility of this assay for Prostate cancer. The ability of PSA to detect those cancers that will cost life, and thereby permit early curative treatment, is as yet unclear. It's most definitive role appears to be in diagnosing recurrences after adequate surgical treatment, and in evaluating response to treatment.

Changes in sexual function in benign prostatic hyperplasia patients taking dutasteride: 1-year follow-up results

Purpose

Sexual adverse events (AEs), a major cause for discontinuing 5α-reductase inhibitor (5ARI) therapy for benign prostatic hyperplasia (BPH), are known to occur most frequently early in therapy and appear to decline over time. The aim of this study was to investigate the changes in sexual function occurring with dutasteride treatment during a 1-year follow-up period in Korean men.

Materials and Methods

Using the International Index of Erectile Function, we prospectively evaluated, after 1, 3, 6, 9, and 12 months of treatment, the changes in sexual function of 55 outpatients (mean age 62.3±7.2 years) with BPH (mean volume 48.9±16.0 g) who had relatively good erectile function (EF) and were treated with dutasteride for at least 1 year.

Results

EF scores showed the most significant decrease at 1 month (p<0.01). Function gradually recovered thereafter but was still significantly decreased after 12 months of treatment (p<0.05). The scores for orgasmic function and sexual desire also showed the most significant reduction at 1 month but were restored to the baseline level at 6 months. No significant correlation was observed between changes in sexual function and prostate-specific antigen level, prostate volume, or International Prostate Symptom Scores.

Conclusions

After 1 month of treatment, dutasteride therapy resulted in a significant reduction in all investigated sexual functions. Overall, recovery in sexual function was noted at 3 months, and orgasmic function and sexual desire were restored to baseline levels at 6 months. However, EF was still significantly reduced at 12 months.

The effects of 5α-reductase inhibition on benign prostatic hyperplasia treated by photoselective vaporization prostatectomy with the 120 Watt GreenLight HPS laser system

BACKGROUND

We sought to determine whether the efficacy and efficiency of 120W GreenLight HPS (American Medical Systems, Inc) laser photoselective vaporization prostatectomy (PVP) is compromised in patients on chronic 5α-reductase inhibitor (RI) therapy.

STUDY DESIGN

Our GreenLight HPS laser PVP experience in patients with and without long-term 5αRI was evaluated. American Urological Association Symptom Score (AUASS), quality of life (QoL) score, maximum urinary flow rate (Qmax), and postvoid residual (PVR) were measured preoperatively and at 1 and 4 weeks and at 3, 6, 12, 18, and 24 months postsurgery. PSA values and transrectal ultrasonography (TRUS) prostate volumes were determined preoperatively and at 3 months postsurgery.

RESULTS

Fifty-seven patients were on either dutasteride or finasteride (5αRI+) and 124 were not (5αRI-). Mean prostate volumes were 67.1 ± 35.3 mL and 69.2 ± 41.9 mL (p = 0.646) and mean PSA values were 2.2 ± 2.4 ng/mL and 2.7 ± 2.6 ng/ml (p = 0.289), respectively. There were no significant differences in the parameters of laser use (13.6 ± 9.2 minutes and 13.4 ± 10.4 minutes, p = 0.965) and energy usage (87.1 ± 62.4 kJ and 91.8 ± 69.6 kJ, p = 0.623). The majority of patients were catheter-free at discharge for this wholly outpatient procedure. AUASS, QoL, and Qmax values showed significant improvement within each group (p < 0.05). Compared with baseline, PVR values improved in both groups but did not decrease significantly in 5αRI+ (p > 0.05). There was no significant difference in the degree of improvement between the 2 groups in all parameters (AUASS, QoL, Qmax, PVR, PSA, and TRUS volume).

CONCLUSIONS

The efficacy and efficiency of PVP with the GreenLight HPS laser are not negatively affected in patients on chronic 5αRI therapy.

Effect of finasteride on serum prostate-specific antigen (PSA) and on prostate of hamster Mesocricetus auratus (hMa)

PURPOSE

Evaluate the effects of finasteride on the serum PSA and on the prostate of hamster-Mesocricetus auratus(hMa).

METHODS

Twenty hMa male adults were split in groups control and experimental (n=10). Animals of the experimental group received 7.14ng/mL of finasteride, subcutaneously (SC) on the back three times per week, during 90 days. The finasteride dose was equivalent to 5.0mg administered to a 70kg man. At the end of the experiment the mean age for the animals in the control group was 15.2 + or - 1.13 months and for the experimental group was 17.7 + or - 0.67 months. There was a statistically significant difference between mean ages of both groups (t value=5.98; p=0.001). The animals of the control group weighted 129.0 + or - 18.8g and the experimental group weighted 145.0 + or - 15.5g, t=1.88 e p=0.0514. The serum PSA was assessed through ELISA method. Prostates of those animals were collected and processed to histology and morphometry: the diameter of the acinous glands and the acinous epithelium, apoptosis, AgNORs and cellularity were assessed in both groups.

RESULTS

Serum PSA decreased in the experimental group, 0.003ng/mL versus 0.763ng/mL, H= 7.982 e p= 0.0047. Decrease in the acinous area occurred in animals that received finasteride, 238.000 + or - 24.600 microm(2) versus 398.600 + or - 55.320 microm(2); t= 2.653; p= 0.0122. A remarkable decrease in the area of the acinous epithelium occurred in the animals that received finasteride, 111.900 + or -12.820 microm(2) versus 160.400 + or - 18.430 microm(2) t= 2.162; p= 0.0361. AgNORs were less expressed in finasteride treated animals, 2.846 + or - 0.877 versus 3.68 + or - 1.07 argyrophilic clusters for microm(2), p= < 0.0001. Apoptosis was more intense in the experimental group, 53.62 + or - 1.389 than in controls, 14.76 + or - 2.137, p= 0.0408. However, there was no statistical difference in the cellularity between both groups, 74.75 + or - 5.5 cells, in controls versus 65.07 + or - 13.24, in treated animals, p=0.5105.

CONCLUSIONS

Use of finasteride decreased serum PSA and several histological parameters of the Hamster's prostate, such as lumen area, acinous and epithelium area, and AgNORs expression. Finasteride increased apoptosis in the prostate acinous cells although no significant difference in the cellularity could be found between the two groups of animals under study.

Current status of 5alpha-reductase inhibitors in the management of lower urinary tract symptoms and BPH

PURPOSE

Benign prostatic hyperplasia (BPH) is a progressive disease that is commonly associated with bothersome lower urinary tract symptoms (LUTS) and might result in complications, such as acute urinary retention and BPH-related surgery. Therefore, the goals of therapy for BPH are not only to improve LUTS in terms of symptoms and urinary flow, but also to identify those patients at a risk of unfavorable disease progression and to optimize their management. This article reviews the current status of therapy with 5alpha-reductase inhibitors (5ARIs), namely fiasteride and dutasteride, for men with LUTS and BPH.

METHOD

Data from key randomized controlled trials (Oxford level 1b) on the use of 5ARIs are analyzed.

RESULTS

The efficacy of 5ARIs either as monotherapy or in combination with alpha(1)-adrenoceptor antagonists in the management of LUTS and the impact of monotherapy and combined therapy on BPH progression are discussed. Further promises, including the withdrawal of the alpha-blocker from the combined medical treatment and the potential clinical implications from the use of 5ARIs for prostate cancer chemoprevention in patients receiving 5ARIs for symptomatic BPH are highlighted.

CONCLUSIONS

Current evidence shows that 5ARIs are effective in treating LUTS and preventing disease progression and represent a recommended option in treatment guidelines for men who have moderate to severe LUTS and enlarged prostates.

Postoperative PSA and PSA velocity identify presence of prostate cancer after various surgical interventions for benign prostatic hyperplasia

OBJECTIVES

To determine whether prostate-specific antigen (PSA) values can distinguish those with prostate cancer (CaP) from those with histologic benign prostatic hyperplasia (BPH) only after surgical intervention. Prostatic adenoma inevitably remains after BPH surgery; therefore, patients remain at risk of developing CaP. Although the PSA level can be used for CaP screening in this population, it might be influenced by the efficacies of different BPH procedures.

METHODS

We performed a review of patients who had undergone transurethral resection of the prostate (TURP; n = 343), holmium laser resection of the prostate (HoLRP; n = 54), or open prostatectomy (OP; n = 68). The PSA and PSA velocity values were collected at regular intervals both pre- and postoperatively for all patients. Only patients with histologic BPH and those with incidental CaP who underwent a watchful waiting strategy were included.

RESULTS

The average preoperative PSA values were significantly different between the TURP, HoLRP, and OP groups. Only 1 patient had incidental CaP in the HoLRP group. No differences were present between the preoperative PSA values for patients with histologic BPH and those with incidental CaP undergoing a watchful waiting strategy (P > .05). However, the postoperative PSA values were increased in the patients with CaP (watchful waiting compared with the patient with BPH only (2.4 vs 1.7 ng/mL TURP and 4.1 vs 1.1 ng/mL OP). Similarly, patients with incidental CaP had a significantly elevated postoperative mean PSA velocity compared with patients without CaP (0.38 vs 0.06 ng/mL/y TURP and 0.47 vs -0.13 ng/mL/y OP; P < .05).

CONCLUSIONS

Postoperative PSA and PSA velocity measurements can be used to distinguish patients with CaP from those with histologic BPH only.

Can effect of finasteride on prostate-specific antigen be used to decrease repeat prostate biopsy?

OBJECTIVES

Patients often undergo multiple prostate biopsies for persistently elevated prostate-specific antigen (PSA) levels. Finasteride decreases serum PSA by approximately 50%. We performed a pilot study to examine the correlation among finasteride, PSA, and PSA density (PSAD) to identify patients who could be excluded from repeat prostate biopsy.

METHODS

We performed a prospective study from 2001 to 2002 on 25 men with elevated PSA levels. These patients had prior negative prostate biopsy findings. At study onset, the patients' PSA level and PSAD were measured. Patients were instructed to take finasteride 5 mg for 6 months. PSA and PSAD determination and prostate biopsies were repeated at 6 months and the findings compared with the initial results.

RESULTS

The mean patient age was 67.2 years (median 62). The median PSA level was 8.3 ng/dL at study entry (mean 9.34) and 4.6 ng/dL (mean 5.09) at 6 months. The median PSAD was 0.18 (mean 0.20) at study entry and 0.09 (mean 0.12) at 6 months. Of the 23 patients who completed the study, 6 (26%) were diagnosed with prostate cancer. At study entry, the median PSA level in those with prostate cancer was 9.6 ng/dL and was 5.8 ng/dL at 6 months. Patients without prostate cancer on repeat biopsy had a 44% decrease in PSAD. Patients with prostate cancer had a 5% decrease in PSAD.

CONCLUSIONS

The results of our study have demonstrated that patients without prostate cancer have a greater decrease in PSAD when taking finasteride than those with prostate cancer. This pilot study had a small population with limited power, and a repeat prospective study with a larger population is warranted.

Drug Insight: 5alpha-reductase inhibitors for the treatment of benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a common problem among older men, which is characterized by an enlarged prostate, lower urinary tract symptoms, and decreased flow of urine. It is a progressive disease that can lead to complications such as acute urinary retention (AUR) or a need for BPH-related surgery in some men. Dihydrotestosterone is the primary androgen involved in both normal and abnormal prostate growth and 5alpha-reductase inhibitors (5ARIs) inhibit the conversion of testosterone to dihydrotestosterone. There are two 5ARIs licensed for the treatment of BPH; dutasteride, which inhibits both type 1 and type 2 isoenzymes of 5alpha reductase, and finasteride, which inhibits the type 2 isoenzyme. Both 5ARIs have been shown to decrease prostate volume, improve urinary flow and lower urinary tract symptoms and reduce the risk of AUR and BPH-related surgery. The prevention of disease progression, by treating the underlying cause, and the alleviation of symptoms are important aims of BPH therapy. 5ARIs are the only currently available medical therapy that can reduce the risk of AUR and BPH-related surgery while providing long-term symptom control. This provides a mandate for their use in men with enlarged prostates (volume >or=30 ml), who are at increased risk of disease progression.

The interpretation of serum prostate specific antigen in men receiving 5alpha-reductase inhibitors: a review and clinical recommendations

PURPOSE

We reviewed the effects of 5alpha-reductase inhibitors on prostate specific antigen and clarified the adjustments that should be made to compensate for these effects to ensure that the usefulness of prostate specific antigen for detecting prostate cancer is maintained.

MATERIALS AND METHODS

We reviewed articles published in the scientific literature with relevance to the effects of 5alpha-reductase inhibitors on the usefulness of prostate specific antigen for detecting prostate cancer.

RESULTS

A total serum prostate specific antigen of 4.0 ng/ml has traditionally been used as the threshold for triggering prostate biopsy. However, clinical trials of finasteride and dutasteride have shown that 5alpha-reductase inhibitors decrease serum prostate specific antigen in patients with and without prostate cancer. To compensate, the doubling rule has been applied in clinical trials and clinical practice. However, doubling serum prostate specific antigen may overestimate actual prostate specific antigen in some patients receiving 5alpha-reductase inhibitors for up to 6 to 9 months, accurately estimate prostate specific antigen from 1 to 3 years and underestimate it thereafter. An increase in prostate specific antigen of 0.3 ng/ml from nadir as a trigger for biopsy maintains 71% sensitivity for prostate cancer in men receiving dutasteride with 60% specificity, similar to the 4.0 ng/ml prostate specific antigen cutoff using placebo.

CONCLUSIONS

We propose that a prostate specific antigen increase from nadir of 0.3 ng/ml or greater could represent an alternative to the doubling rule for monitoring prostate specific antigen in patients on 5alpha-reductase inhibitors. The prostate specific antigen increase from nadir appears to be a more accurate cancer indicator than a doubled value in some patients.

Blood levels of free-PSA but not complex-PSA significantly correlates to prostate release of PSA in semen in young men, while blood levels of complex-PSA, but not free-PSA increase with age

BACKGROUND

The proportion of free- and complex-prostate specific antigen (PSA) in serum is used for differentiating between benign and malignant prostate disease. To further understand the physiological relationship between PSA in seminal plasma and blood, we have analyzed free-PSA (fPSA) and complex-PSA (cPSA) in blood and PSA in seminal plasma in young healthy men. We also compared age-related changes of PSA-forms in blood from young versus older men.

METHODS

Total-PSA (tPSA), fPSA, and cPSA were measured in (i) blood and semen from 289 male conscripts (mean age 18.1 years) and in (ii) blood from a representative population of 1,389 men (mean age 46.5 years) without diagnosis of prostate cancer (PCa) during long-term follow-up.

RESULTS

fPSA in serum (r = 0.40, P < 0.0001) but not cPSA (r = 0.09, P = 0.11), correlates to PSA in seminal fluid. fPSA levels in blood in young (geometric mean: 0.20 ng/ml) versus middle-aged men (geometric mean: 0.18 ng/ml) was not different (P = 0.06), whereas cPSA in middle-aged men (geometric mean: 0.38 ng/ml) was higher (P < 0.0001) than in young men (geometric mean: 0.28 ng/ml).

CONCLUSIONS

fPSA in blood, but not cPSA, is associated to PSA in semen ( approximately 17% co-variation). In blood cPSA, but not fPSA, increase with age in healthy men, which may reflect an increasing incidence of prostate disease.

Diagnostic value of prostatic specific antigen in hirsute women

Determination of prostatic specific antigen (PSA) in female tissues has become available recently. The expression of PSA gene is under androgenic regulation. Therefore, hyperandrogenemic states, such as polycystic ovary syndrome (PCOS), are expected to be presented with the higher levels of PSA. The current study aimed at evaluating PSA levels in hirsute women presumed to have PCOS or idiopatic hirsutism (IH). Thirty-three patients with PCOS, 40 patients with IH, and 20 healthy control subjects were enrolled in the study. Beside basal hormonal evaluation, total PSA (tPSA), and free PSA (fPSA) were determined in all subjects. Average level of tPSA was the highest in PCOS patients (0.099+/-0.267 ng/ml) when compared with IH and control subjects (p<0.05 and p<0.001, respectively). Besides, mean fPSA levels were found to be significantly higher in patients with PCOS than healthy controls (0.033+/-0.070 vs 0.010+/-0.001 ng/ml; p<0.05). Both total and free PSA levels were found to be higher in 73 hirsute women than in control subjects (p<0.01 and p<0.05, respectively). Women with hyperandrogenemia tended to have higher tPSA than women without hyperandrogenemia (p<0.01). PSA is likely to be used to discriminate hyperandrogenemic hirsutism. If more sensitive assays become available, PSA might be used as a diagnostic criteria for hirsutism and even for some diseases which have hirsutism as a component.

Decreased gene expression of steroid 5 alpha-reductase 2 in human prostate cancer: implications for finasteride therapy of prostate carcinoma

BACKGROUND

Steroid 5alpha-reductase 2 (SRD5A2) catalyzes the conversion of testosterone to the more potent androgen, DHT, in the prostate. The therapeutic influence of SRD5A2 inhibitor finasteride on prostate cancer is currently unknown. The direction and extent of changes in SRD5A2 expression in disease tissues is a relevant issue in this regard.

METHODS

The expression differences of SRD5A2 in tissues representative of normal, benign, and malignant growth in the human prostate were examined in parallel by comparative analysis of relevant microarray gene expression data. Semiquantitative RT-PCR was used to further verify the gene expression differences of SRD5A2.

RESULTS

Consistently decreased expression of SRD5A2 was observed in 25 prostate cancer samples when compared to 25 matched normal samples and nine BPH samples. Expression differences among these samples for six other genes were presented in parallel as indicators of the direction and extent of expression changes. These additional genes include SRD5A1, Hepsin (overexpressed in prostate cancer), AMACR (overexpressed in prostate cancer), Keratin 8 (epithelial marker), smooth muscle actin (stromal marker), Nell2 (overexpressed in BPH). Semiquantitative RT-PCR verified the expression differences for SRD5A2 in six normal, six BPH, and six prostate cancer samples.

CONCLUSIONS

Results from this study, combined with those from previous studies, indicate an association of prostate cancer with reduced 5alpha-reductase enzymatic activity as a result of remarkably decreased expression of the SRD5A2 gene. The implications of this study for finasteride therapy of prostate cancer are discussed.

Population Screening for Prostate Cancer and Emerging Concepts for Young Men

Prostate cancer is the most common malignancy in American men, accounting for > 29% of all diagnosed cancers and approximately 13% of all cancer deaths. Nearly 1 of every 6 men will be diagnosed with the disease at some time in their lives. In 2003 alone, an estimated 221000 men in the United States will be diagnosed with prostate cancer and > 28000 will die of the disease. An elevated level of prostate-specific antigen (PSA) is correlated with the presence of prostate cancer, and since 1989 we have been living in the "PSA era," in which the PSA screening test is widely used in clinical practice. This article summarizes what has been learned about the use of PSA screening, including the intricacies of free PSA, PSA doubling time, and various factors that may affect PSA and confound screening in young men. Although population-based screening for prostate cancer has yet to be definitively proven to affect disease-specific mortality, PSA testing is detecting cancers in younger men and at earlier stages of disease progression and, partly as a result, 5-year cancer-specific survival is increasing. Even though this lead-time effect may not translate into long-term improvement, these changes are very promising and are a necessary prerequisite to effective screening. For patients at high risk with a family history of the disease and for black men, a strategy consisting of an annual PSA blood test and digital rectal examination for men >or=40 years of age appears to be prudent. Use of age- and race-specific reference ranges for PSA based on sensitivity, or maximal cancer detection, is the most appropriate approach in this high-risk group. Specifically among black men 40-49 years of age, those with a PSA value > 2.0 ng/mL should consider further evaluation. Many men at low/average risk aged 40-49 years also request testing and it is reasonable to offer testing and risk assessment to these young men. The exact screening threshold for total PSA in these men is unknown, but 95% of these men will have a PSA < 2.5 ng/mL. Prostate-specific antigen velocity, percentage of free PSA, and perhaps complexed PSA may be used to help determine risk, but further study of young men is needed. In the future, a risk-stratified approach using molecular biomarkers and/or proteomics in young men is anticipated.

Changes in molecular forms of prostate-specific antigen during treatment with finasteride

OBJECTIVE

To study the influence of finasteride treatment on the molecular forms of prostate-specific antigen (PSA) in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Total PSA, free PSA and PSA complexed to alpha1-antichymotrypsin (PSA-alpha1ACT) were measured in plasma and serum from 40 men with BPH and a total PSA of < 20 ng/mL, using in-house and commercial immunoassays, before and during treatment with finasteride (30 men) or placebo (10 men).

RESULTS

The baseline values were not significantly different between the groups, with mean (sd) total plasma PSA levels of 3.6 (4.3) and 4.8 (5.9) ng/mL in the finasteride and placebo groups, respectively. Finasteride, but not placebo, induced a significant reduction in total PSA, free PSA and PSA-alpha1ACT levels in plasma and serum (P < 0.001). However, complexed-to-total (c/t) and free-to-total (f/t) PSA ratios remained constant in both groups, both in plasma and serum, during the follow-up.

CONCLUSION

The decrease in total PSA after finasteride treatment results from a proportional reduction in its two major molecular forms, free PSA and PSA-alpha1ACT, which explains why the c/t and f/tPSA ratios do not change significantly despite treatment. This suggests that routine analysis of molecular forms of PSA could improve the utility of the change in total PSA associated with finasteride for the early diagnosis of prostate cancer. It also suggests that any subsequent change in both ratios, particularly an increase in c/tPSA or a decrease in f/tPSA ratio, could be considered an early sign of neoplastic degeneration rather than a therapeutic consequence.

PSA response to finasteride challenge in men with a serum PSA greater than 4 ng/ml and previous negative prostate biopsy: preliminary study

OBJECTIVES

To determine, in a prospective study, the prostate-specific antigen (PSA) response to finasteride challenge in men with a serum PSA greater than 4 ng/mL who had undergone previous biopsy. Patients with a serum PSA level greater than 4 ng/mL who have undergone repeated prostate biopsy with prostate cancer (CaP) that was not detected present a diagnostic dilemma. The magnitude of PSA reduction after administration of finasteride has been well documented. In addition, doubling of the PSA value after 1 year of finasteride has been touted to be a more useful paradigm for diagnosing CaP than PSA alone.

METHODS

Thirty-eight men with a baseline serum PSA level greater than 4 ng/mL and a normal digital rectal examination who had been previously biopsied a minimum of two times, with CaP not detected, were given 5 mg finasteride daily. The PSA level was measured at 6 and 12 months with repeat transrectal ultrasonography and biopsy (12 cores) performed at 1 year. Changes in prostate volume, serum PSA, PSA density, and the incidence of CaP at 1 year were assessed.

RESULTS

The mean age of the group was 60.5 years (+/-7.6). For the group, the average number of previous biopsies performed was 2.9 (range 2 to 6). The baseline PSA level for the entire group was 6.32 ng/mL (+/-3.2), and the baseline prostate volume was 37.3 cm3 (+/-12.4). At 1 year, the PSA level had decreased to 3.73 ng/mL (-41.0%), and the prostate volume had decreased to 30.4 cm3 (-18.5%). In the 11 men (29%) in whom CaP was detected, the serum PSA decreased from 7.3 to 5.2 ng/mL (-28.8%) and the prostate volume decreased from 37.3 to 32.3 cm3 (-13.4%). CaP was detected in 0 of 10 men with a serum PSA decrease of 50% or higher, in 6 (32%) of 19 men with a PSA decrease between 33% and 50%, and in 5 (56%) of 9 men who had a PSA decrease of less than 33%.

CONCLUSIONS

The data in this preliminary study suggest that the magnitude of change in serum PSA after 1 year of finasteride challenge may be useful in diagnosing CaP in patients with elevated PSA levels and prior negative prostate biopsy.

The future of prostate cancer prevention

The dramatic international variation in prostate cancer mortality rates suggest an environmental influence. This combined with a building understanding of the genetic mechanisms of carcinogenesis encourages a search for ways to prevent it. Androgenic stimulation over a period of time has been suggested a cause of prostate cancer. The corollary to this hypothesis is that lowering androgenic stimulation over time will prevent prostate cancer. Decreasing androgenic stimulation of the prostate with 5-alpha-reductase inhibitors such as finasteride has been shown to decrease prostate size and may prevent prostate cancer. A large, long-term clinical trial is underway using finasteride to determine if it can prevent prostate cancer. Results are expected in 2004. Epidemiologic and laboratory studies also suggest that high selenium and vitamin E intake lowers risk of prostate cancer. Recent serendipitous findings of two randomized clinical trials support the hypothesis that selenium and vitamin administration will decrease prostate cancer risk. A study to assess these compounds is beginning. Other promising, but less developed, interventions in chemoprevention of prostate cancer include vitamin D supplementation and diet modification. All will need to be rigorously evaluated before they can be advocated for prostate cancer prevention.