<p><strong>Clinicians should counsel patients with LUTS/BPH on active surveillance for prostate cancer that 5-ARI treatment is unlikely to increase the risk of prostate cancer progression. (<em>Expert Opinion</em>)</strong></p>
Discussion
Discussion
<p>The FDA has issued a warning about the higher risk of high-grade prostate cancer in men treated with 5-ARIs.<sup>183</sup> This is based on studies which tried to establish a chemopreventive effect of 5-ARIs on prostate cancer.<sup>175, 182</sup> These trials showed a lower rate of prostate cancer, but this effect was entirely confined to low-grade cancer and in fact showed a higher rate of high-grade prostate cancer in patients treated with 5-ARIs. This effect may be due to detection bias (i.e., same number of samples in a smaller prostate because of the decrease in prostate volume by a 5-ARI that may lead to higher detection of cancer which may not decrease in volume) and has not been replicated in active surveillance cohorts.</p>
<p>Patients on active surveillance for prostate cancer with LUTS are generally treated the same as those with LUTS/BPH. A study which did not specifically evaluate the effect of 5-ARIs on LUTS, but did follow progression of prostate cancer, reported no increase in the rate of high-risk prostate cancer in the group of patients treated with finasteride on active surveillance for prostate cancer.<sup>481</sup> While this is not direct evidence, it did provide enough information for the Panel to discuss and come to a consensus that 5-ARIs are unlikely to increase the rate of high-risk prostate cancer in patients on active surveillance. It should be noted that 5-ARIs change PSA kinetics and this should be taken into consideration while monitoring these patients.</p>