The effects of 5alpha-reductase inhibitors on the natural history, detection and grading of prostate cancer: current state of knowledge.
OBJECTIVE
The Prostate Cancer Prevention Trial (PCPT) showed that the 5alpha-reductase inhibitor (5ARI) finasteride significantly decreased the 7-year period prevalence of prostate cancer vs placebo. However, Gleason score 7-10 tumors were significantly more common in the finasteride vs the placebo group. We considered data on the effects of 5ARIs on prostate cancer natural history and detection.


METHODS
A detailed review was performed of the literature identified from the MEDLINE database examining the effects of 5ARIs on prostate cancer prevalence and tumor histopathology.


RESULTS
In PCPT there were fewer biopsies performed for cause in the finasteride vs the placebo group and the proportion of high grade tumors in the treatment groups did not diverge with time. Given that finasteride has an effect on prostate specific antigen and prostate volume, which are key factors in triggering prostate biopsies, they may be significant confounders of Gleason score results. Prostate shrinkage in the finasteride treated group may minimize biopsy sampling error. Furthermore, histological studies have shown that 5ARIs have a significant effect on prostate architecture, which can make the interpretation of prostate specimens in men treated with 5ARIs difficult. Further evaluation of PCPT findings will help determine the true nature of these observations.


CONCLUSIONS
5ARIs decrease the risk of prostate cancer but also alter the detection of disease through effects on prostate specific antigen, and prostate volume and histology. The weight of evidence suggests an artifactual effect of finasteride on Gleason grading in the PCPT. The role of 5ARIs for prostate cancer chemoprevention needs further examination before it can be considered for wide recommendation.
Andriole
Gerald
G
Division of Urologic Surgery, School of Medicine, Washington University-St. Louis, 4960 Children's Place, St. Louis, MO 63110, USA. andrioleg@msnotes.wustl.edu
Bostwick
David
D
Civantos
Francisco
F
Epstein
Jonathan
J
Lucia
M Scott
MS
McConnell
John
J
Roehrborn
Claus G
CG
D000970:Antineoplastic Agents / Q000627:therapeutic use; D042944:Cholestenone 5 alpha-Reductase / Q000037:antagonists & inhibitors*; D002986:Clinical Trials as Topic; D004791:Enzyme Inhibitors / Q000627:therapeutic use*; D018120:Finasteride / Q000627:therapeutic use; D006801:Humans; D008297:Male; D009367:Neoplasm Staging; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000188:drug therapy* / Q000473:pathology
D000970:Antineoplastic Agents; D004791:Enzyme Inhibitors; D018120:Finasteride; D042944:Cholestenone 5 alpha-Reductase