COMMENTARY

Prostate Cancer Diagnoses Delayed for Patients on 5-alpha Reductase Inhibitors

Gerald Chodak, MD

Disclosures

July 09, 2019

This transcript has been edited for clarity.

Hello. I'm Dr Gerald Chodak for Medscape. Today's topic is the use of 5-alpha reductase inhibitors (5-ARIs) and the possible implications for the diagnosis of prostate cancer.

Sarkar and colleagues[1] used the Veterans Affairs database and the National Death Index to analyze results of 81,000 men who were diagnosed with prostate cancer between the years 2001 and 2015. They examined four endpoints, with a median follow-up of 6 years. Endpoints included all-cause and cancer-specific mortality; the time from an elevated PSA > 4 ng/mL until a diagnostic biopsy; and finally, clinical stage and grade at the time of diagnosis.

After adjusting the PSA for the men who were taking a 5-ARI, they found the following: First, the time from an elevated PSA until the diagnosis of prostate cancer was significantly longer—by more than 2 years—in the men taking a 5-ARI. Second, men who were taking one of these drugs had a greater incidence of stage T3 or T4 disease, node-positive disease, and metastatic disease; most important, their all-cause and prostate cancer mortality was significantly higher. The median PSA at diagnosis was 13.5 ng/mL in the men taking the drug, compared with 6.4 ng/mL in non-users.

These results have important implications. A large, randomized study[2] previously showed that 5-ARIs can reduce the risk for prostate cancer found on biopsy, but in that study, the PSA was adjusted carefully so that a diagnosis of prostate cancer was not being missed. Now, in an uncontrolled situation we see that many physicians are not following the guidelines that are in the FDA insert for these drugs, which say that the PSA should be adjusted by 50% higher when a 5-ARI is being used, in order to avoid missing cancer. Going forward, it's clear that something needs to be done to improve the awareness of clinicians who are prescribing these drugs, otherwise they are clearly placing their patients in harm's way.

I look forward to your comments. Thank you.

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