Assessed as up to date: 2008/02/14
Five-alpha-reductase inhibitors (5ARI) are frequently used to treat bothersome lower urinary tract symptoms associated with benign prostatic hyperplasia and male androgenic alopecia. They have potential as chemopreventive agents.
We sought to estimate the effectiveness and harms of 5ARI in preventing prostate cancer.
MEDLINE, PreMEDLINE, and the Cochrane Collaboration Library were searched through April 2007 to identify randomized trials.
For prostate cancer outcomes we included randomized controlled trials of at least 1 year in duration published after 1984. For non-prostate cancer outcomes, randomized trials were included if: they were at least 6 months in duration published after 1999.
Data collection and analysis
The primary outcome was prostate cancer period-prevalence "for-cause." "For-cause" was defined as prostate cancer clinically detected based on symptoms, an abnormal digital rectal exam, or detected as a result of an abnormal prostate specific antigen value. Trials were categorized as long (> 2 year), mid (1 to 2 years) and short (< 1 year) term.
Nine trials reported prostate cancer period-prevalence. Three trials using finasteride lasted four years or longer but only one (the Prostate Cancer Prevention Trial) was specifically designed to assess the impact of 5ARI on prostate cancer period-prevalence. The mean age of enrollees was 64.6 years, 91% were white, mean PSA was 2.1 ng/mL. For-cause prostate cancers comprised 54% of all cancers detected. Finasteride was associated with a 26% relative risk reduction in prostate cancers detected for-cause among all randomized subjects (relative risk 0.74 (95% CI 0.67 to 0.83); absolute risk reduction = 1.4% (3.5% versus 4.9%). Six trials assessed prostate cancers detected overall with a pooled 26% relative reduction favoring 5ARI (relative risk 0.74 (95% CI 0.55 to1.00); 2.9% absolute reduction (6.3% versus 9.2%). Reductions were observed regardless of age, race or family history of prostate cancer but not among men with baseline PSA > 4.0 ng/mL. A greater number of high Gleason score tumors (7 to 10 or 8 to 10) occurred in men on finasteride in the PCPT. Impaired sexual or erectile function or endocrine effects were more common with finasteride than placebo.
Five-alpha-reductase inhibitors reduce prostate cancer risk but may increase the risk of high-grade disease in men who are undergoing regular screening for prostate cancer using prostate specific antigen and digital rectal examination. Effects are consistent across race, family history and age and possibly 5ARI but were limited to men with baseline PSA values < 4.0 ng/mL. The impact of 5ARI on absolute or relative rates of prostate cancer in men who are not being regularly screened is not clear. Information is inadequate to assess the impact of 5ARI on mortality.
Wilt Timothy J, MacDonald Roderick, Hagerty Karen, Schellhammer Paul, Kramer Barnett S
Five-alpha-reductase inhibitor drugs, such as finasteride or dutasteride, reduce the risk prostate cancer in men who have routine prostate cancer screening
Five-alpha-reductase inhibitor drugs have potential as chemopreventive agents. Reduction of prostate cancer was similar between racial groups, age groups (aged 65 years or older compared to younger age groups) and those with or without a family history of prostate cancer. Reduction of prostate cancer was limited to men who had a baseline prostate specific antigen (PSA) values less than 4.0 ng/mL. However, use of five-alpha-reductase inhibitors may also increase the risk of high-grade prostate cancer in men undergoing prostate cancer screening. Future research is needed to determine if the use of five-alpha-reductase inhibitors can reduce prostate cancer in men who are not being regularly screened for prostate cancer. Future studies should also determine whether five-alpha-reductase inhibitors can reduce death and prostate cancer death and further evaluate the risk of developing high-grade prostate cancer.
Implications for practice
Five-alpha-reductase inhibitors reduce prostate cancer risk but may increase the risk of high grade disease in men who are undergoing regular screening for prostate cancer using PSA and digital rectal examination. The impact of 5ARI on absolute or relative rates of prostate cancer in men who are not being regularly screened is not clear. Effects are consistent across race, family history and age and possibly 5ARI but were limited to men with baseline PSA values < 4.0 ng/mL. Information is inadequate to assess the impact on mortality. Long term compliance in randomized trials is high. Decisions to initiate chemoprevention with 5ARI should incorporate this information.
Implications for research
Future research is needed to determine whether 5ARI reduce overall and disease-specific morbidity and mortality; whether any beneficial effect is drug or class-specific; whether the increase in high-grade tumors is real or artifactual. Future trials should also determine appropriate "PSA adjustments"/indications for prostate biopsy in men on 5ARI.
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