Prostate cancer detection and dutasteride: utility and limitations of prostate-specific antigen in men with previous negative biopsies.
BACKGROUND
We addressed the question whether the change of serum prostate-specific antigen (PSA) in men who use 5α-reductase inhibitor (5-ARI) dutasteride is sensitive for the detection of aggressive prostate cancer (PCa).


OBJECTIVE
The case of a man using dutasteride diagnosed with Gleason 7 transition zone cancer at biopsy indicated by a rising PSA is described. The following issues are discussed: (1) Is a rise of PSA in patients using dutasteride predictive of aggressive PCa in men with prior negative biopsies? (2) Is it safe not to biopsy men using dutasteride who do not show a rising PSA? (3) How can we avoid potentially unnecessary biopsies in men using dutasteride without a rising PSA?


METHODS
We reviewed the recent literature addressing our objective that relates to two studies: the Prostate Cancer Prevention Trial and the Reduction by Dutasteride of Prostate Cancer Events trial.


RESULTS
In men using dutasteride, the positive predictive value/detection rate of Gleason 7-10 PCa is 13.2% and 4.0% for men with and without a rising PSA, respectively. However, a substantial proportion of Gleason 7-10 cases (42.9%) would be missed if a rising PSA was used as the only biopsy indication. Currently available data do not provide selective mechanisms to diagnose these cancers.


CONCLUSIONS
A rising PSA for a patient using dutasteride should be an indication for prostate biopsies. Currently, in the case of stable PSA a biopsy may still be considered. Options for a selective approach are therefore suggested in this review to avoid unnecessary biopsies and to achieve a more selective PCa detection in men on 5-ARI treatment.
Department of Urology, Erasmus University Medical Centre, Rotterdam, The Netherlands. p.vanleeuwen@erasmusmc.nl
Pim J
PJ
van Leeuwen
Konrad
K
Kölble
Hartwig
H
Huland
Thomas
T
Hambrock
Jelle
J
Barentsz
Fritz H
FH
Schröder
D058891:5-alpha Reductase Inhibitors / Q000627:therapeutic use*; D001378:Azasteroids / Q000627:therapeutic use*; D001706:Biopsy; D000068538:Dutasteride; D006801:Humans; D008297:Male; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology; D012307:Risk Factors
D058891:5-alpha Reductase Inhibitors; D001378:Azasteroids; D017430:Prostate-Specific Antigen; D000068538:Dutasteride