Finasteride in the prevention of prostate cancer (yet again)

A “Beyond the Abstract” article on UroToday has again raised the issue of the appropriateness of finasteride as a suitable agent for the prevention of prostate cancer in appropriately selected men known to be at significant risk for this disease.

De Nunzio and Tubaro’s “Beyond the Abstract” commentary on the UroToday web site provides insight into an original review by De Nunzio et al., giving an Italian perspective on the use of finasteride for prostatic disease (including benign prostatic hyperplasia or BPH). In this commentary, addressing the use of finasteride as an agent for the prevention of prostate cancer, they state that:

Finasteride can prevent prostate cancer in general population but as expected, it is associated with an increased risk of sexual side effects and an unexpected greater risk of developing higher-grade prostate cancer. However, the clinical benefit of chemoprevention strategy with finasteride remains dubious, even considering the higher incidence of high-grade tumors as a study-related bias. Drug price and efficacy in preventing cancer play major roles in determining the risk-benefit ratio; moreover, cost effectiveness must be adequately evaluated before mass adoption. The benefit of primary prevention develops many years after initiating treatment but the costs and the side effects must be sustained also for a large number of men who will not benefit.

The “New” Prostate Cancer InfoLink has to assume that this statement was written without any appreciation of the recent statement by the American Society of Clinical Oncology (ASCO) that “Two studies published in the last year shed light on the use of a common prostate drug to reduce the risk of prostate cancer” (see pages 9-11 of Winer et al.). This statement from ASCO is merely an introduction to a summary on the “notable developments” regarding the potential roles of finasteride in prevention of prostate cancer and in enhancing the sensitivity of the PSA test in men taking this drug.

We appreciate that there are (as yet) insufficient data to make absolute determinations about the value of finasteride in specific patient populations for the prevention of prostate cancer. The original Prostate Cancer Prevention Trial (PCPT) included only men of age 55-74; it included only a very small percentage of non-Caucasian patients; and it did not pre-classify or pre-stratify patients according to  known prostate cancer risk factors such as a family history of the disease. However (at least in America), finasteride is cheap (because it is available as a generic drug); by comparison with most other prescription drugs, it is relatively safe; and it has clearly been shown to be effective as a preventive agent in 25 percent of the very broad population enrolled in the PCPT.

De Nunzio and Tubaro do state in their commentary that, “Further analysis to identify higher risk groups of patients (familial disease, abnormal PSA, increased PSA velocity and doubling time) could be helpful to answer the debate and to decide an appropriate chemopreventive strategy using finasteride in a cost-effective way.” The “New” Prostate Cancer InfoLink would encourage studies to resolve these questions, and soon. However, we do not believe that we should be waiting 20 more years to get such a resolution before encouraging the use of finasteride in the attempt to prevent prostate cancer in those patients known to be at highest risk. We need appropriate guidelines from appropriate authorities, and we need them at an early date.

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