5-alpha reductase inhibitors on active surveillance were linked to less grade progression

Design

Retrospective cohort, single institution

Population

1938 men with Grade Group 1 prostate cancer on active surveillance

Primary outcome

Grade progression, outlet procedures and definitive treatment

Effect

5-ARI per year: grade progression HR 0.80 (0.72–0.89); definitive treatment HR 0.53 (0.41–0.67)

A US cohort of 1938 men on active surveillance for Grade Group 1 prostate cancer examined how prostate size and 5-alpha reductase inhibitor (5-ARI) use related to outcomes.

Larger prostates were associated with lower rates of grade progression and of moving to definitive treatment, about 9–11% lower per 10 mL. Each year of 5-ARI use was associated with a 20% lower rate of progression to Grade Group 2 or above and a substantially lower rate of definitive treatment. Men with glands over 80 mL more often needed a bladder outlet procedure.

The practical point is that men on surveillance with troublesome prostatic enlargement can be treated for it, including with a 5-ARI. These drugs halve PSA, so PSA must be interpreted accordingly. This is retrospective, and lower detection of progression in large glands may partly reflect biopsy sampling rather than biology. The study was published in June.

• Treat bothersome BPH symptoms in men on active surveillance; 5-ARIs were not associated with harm.
• Double the PSA value, as a rule of thumb, when interpreting it after six months or more of 5-ARI use.
• Remember that large glands can hide cancer from biopsy; MRI targeting helps.
• Discuss bladder outlet procedures for very large glands when medical therapy fails.

Why it matters

Many men on surveillance also have obstructive symptoms, and clinicians have been unsure whether treating them interferes.

Don't overread it

This is a retrospective association; it does not show that 5-ARIs prevent progression, and they are not licensed for that use.

The statistics, in plain English

A hazard ratio of 0.53 for definitive treatment per year of 5-ARI use means about half the rate, but PSA suppression by these drugs may also have changed when doctors chose to treat.

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