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Is anyone an appropriate candidate for finasteride therapy to prevent prostate cancer today?

Posted Sep 17 2008 1:25am

Given the results of the Prostate Cancer Prevention Trial, which were controversial at the time of their publication, and still give rise to heated discussion in the urology community, it is a fair question to ask whether there are any men who are appropriate candidates for finasteride therapy to prevent prostate cancer today.

Let’s look at the pros and the cons.

On the one hand, we know that long-term daily use of finasteride in men over 55 appears to increase risk for higher grades of prostate cancer in men who actually get diagnosed with prostate cancer.

On the other hand, we have a lot of other information, as follows:

  • Finasteride definitely reduces risk for prostate cancer by nearly 25 percent.
  • Certainly tens of thousands of men have taken finasteride daily to treat benign prostatic hyperplasia or BPH (an enlarged prostate), and there has been no suggestion that these men have demonstrated increased risk for diagnosis with higher grades of prostate cancer in the 15 years since finasteride was first approved.
  • The original authors of the PCPT have themselves suggested sound potential explanations for why there appears to have been an increased risk for high grades of prostate cancer in the PCPT, while suggesting that this may not actually be the case.

Two relatively recent publications have argued this last point with a degree of sincerity.

In the first study, Cohen et al. determined that finasteride reduces the volume of the prostate and therefore increases the likelihood of finding high-grade cancer cells in a biopsy. They further come to the conclusions that finasteride accelerates the detection of high-grade cancer yet may not promote its development.

The second study (published by Scott Lucia et al. ) analyzed prostatectomies from the PCPT and found that the relative increase in high-grade tumors in the finasteride group was less than originally believed. The findings presented by this group also suggest that enhanced detection may have contributed to the increase in high-grade disease in the finasteride group.

The “New” Prostate Cancer InfoLink is in no position to tell patients that they should or should not consider the use of finasteride as a therapy to prevent prostate cancer. However, we do believe that there are good reasons to discuss this possibility with your doctor if you fall into any of the following categories:

  • You are an African American of 45 years or older with a low PSA and no specific signs or symptoms suggestive of prostate cancer
  • You are a man of any race of 45 years or older with a family history of prostate cancer — particularly if that family history involves a direct relation such as a grandfather, father, or brother
  • You are a man of any race of 50 or older who has no specific signs or symptoms of prostate cancer but who already needs treatment for BPH
  • You are a man of any race of 50 years or older whose fear and anxiety about the possibility of definitive therapy for prostate cancer at some time later in life is such that you are liable to avoid regular testing to ensure early diagnosis of this disease.

Others (e.g., Fleshner and Kulkarni ) have expressed a similar perspective on this topic.

Unless and until some other form of treatment is clearly shown to have the same impact on risk for prostate cancer as finasteride, but without the possibility of induction of higher grade disease, it has to be said that finasteride is the only form of therapy that has ever been shown to reduce risk for prostate cancer in a large, randomized, double-blind, placebo-controlled clinical trial.

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