Sarah Bland
Author: Sarah Bland | Date July 11, 2019

Drugs for BPH May Delay Diagnosis of Prostate Cancer

Benign prostatic hypertrophy (BPH) is a very common condition in older men, affecting about 50% of men between the ages of 51 and 60. In men older than age 80, the prevalence may increase to as high as 90 percent. Because this condition can cause uncomfortable urinary symptoms, medications such as α-blockers and 5-α-reductase inhibitors (5-ARIs) are often prescribed to relieve discomfort.  

Common 5-ARIs are finasteride and dutasteride. They work by inhibiting the enzyme that converts testosterone into its more potent relative, dihydrotestosterone, in selected tissues. Treatment with 5-ARIs also causes prostate-specific antigen (PSA) levels to be reduced.  The degree of PSA suppression varies, but a median of 50% has generally been accepted, and studies including patients on 5-ARIs typically use an adjusted PSA level of twice the measured level to account for this effect.

A recent study published in the Journal of the American Medical Association (JAMA) - Internal Medicine investigated whether the prediagnostic use of 5-ARIs was associated with a delayed diagnosis or more advanced disease at diagnosis in over 80,000 men who had prostate cancer. The researchers looked for deaths specifically related to prostate cancer as the primary outcome. They also looked at the time from the first elevation of PSA to prostate biopsy, tumor grading and staging at diagnosis, as well as deaths from all causes.

The study found that patients taking 5-ARIs had unadjusted PSA levels at the time of prostate biopsy that were approximately the same as patients taking only α-blockers or taking neither class of medication. Hence, adjustment for the PSA-suppressing effect of 5-ARIs would suggest that PSA levels would have been twice as high in these patients at the time of biopsy. Patients taking 5-ARIs had delayed biopsies and more advanced disease when diagnosed with prostate cancer with more positive lymph nodes and metastasized disease. Patients on 5-ARIs also had a higher incidence of death, either due to prostate cancer or other causes.

Over 23,300 prescription renewal requests for 5-ARIs have been processed at healthfinch customers since the beginning of 2019. The study findings strongly suggest that PSA suppression due to 5-ARIs is not widely recognized or taken into account in everyday clinical practice. As with any drug that can impact the accuracy of laboratory results, providers and members of the prescription renewal team should remain aware of the risks associated with unadjusted PSA levels and consider alternative laboratory processes and education to close this potential knowledge gap. If PSA screening is included as a criterion in 5-ARI prescription renewal protocols, awareness of the importance of using adjusted PSA results is critical to ensure the safety and accurate diagnosis of prostate cancer in this patient population.

 

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Reference:  Sarkar RR, Parsons JK, Bryant AK, Ryan ST, Kader AK et al. Association of Treatment with 5α-Reductase Inhibitors with Time to Diagnosis and Mortality in Prostate Cancer. JAMA Intern Med. doi:10.1001/jamainternmed.2019.0280

Sarah Bland

Written By: Sarah Bland on July 11, 2019

Sarah Bland is a freelance consultant pharmacist with several years of experience in a variety of pharmacy roles, including administration, antibiotic stewardship, drug shortage management, Pharmacy & Therapeutics Committee support, and policy/guideline development. Sarah works with healthfinch as a pharmacy adviser, providing clinical experience and expertise to support protocol development and maintenance.