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

Design

Single-centre retrospective cohort

Population

1,938 men with grade group 1 prostate cancer on active surveillance

Primary outcome

Grade progression, outlet procedure and definitive treatment

Effect

5-ARI per year: grade progression HR 0.80 (95% CI 0.72–0.89); treatment HR 0.53 (0.41–0.67)

This retrospective cohort reviewed 1,938 men with grade group 1 prostate cancer on active surveillance at a single US centre, examining prostate volume and 5-alpha reductase inhibitor use against biopsy grade progression, bladder outlet surgery and definitive treatment.

Larger prostates were associated with less grade progression (HR 0.89 per 10 cc) and less progression to treatment. Each year of 5-alpha reductase inhibitor use was associated with less grade progression (HR 0.80), less progression to grade group 3 or above (HR 0.84) and less definitive treatment (HR 0.53). Men with prostates over 80 cc more often needed outlet procedures.

For a man on surveillance with troublesome lower urinary tract symptoms, this supports using a 5-alpha reductase inhibitor without concern that it worsens cancer outcomes. These drugs lower PSA by about half, so PSA kinetics must be interpreted accordingly. Because this is observational, it does not show the drugs prevent progression.

• Consider a 5-alpha reductase inhibitor for lower urinary tract symptoms in men on active surveillance.
• Re-baseline PSA after starting the drug, as it roughly halves PSA.
• Treat a rising PSA on a 5-alpha reductase inhibitor as significant and investigate.
• Continue scheduled MRI and biopsy surveillance regardless of the drug.

Why it matters

It removes a hesitation about treating urinary symptoms in men on surveillance.

Don't overread it

This was retrospective and single-centre; it does not show 5-alpha reductase inhibitors prevent cancer progression.

The statistics, in plain English

A hazard ratio of 0.53 for definitive treatment means a lower rate of moving to treatment per year of drug use. This is an association; men on the drugs may differ in ways the model could not adjust for, and lower PSA may reduce prompts to biopsy.

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