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Published in Advanced Prostate Cancer

Expert Opinion / Cases · May 21, 2018

Using PHI or PHID to Defer Repeat bx in pt on Dutasteride

Joseph Egert

 

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  • Thomas McBride

    May 25, 2018

    Another reason PSA density should be combined with MRI decision making, and a great case for 5-ARI in AS.  Is the plan for repeat MRIs (vs. PSA while on dutasteride) in order to determine need for future repeat cognitive biopsy?   Perineal biopsy?

  • Gregory Lewis

    May 26, 2018

    There are a number of potential benefits to treating this pt with the 5-ARI dutasteride. Given this pt’s very large BPH-related prostate volume, dutasteride will reduce this pt’s risk of both urinary retention and the need for BPH-related surgery in the future. There has been at least a 24% reduction in his prostate volume in the 18 months or so that he has been on dutasteride. With regard to his previously diagnosed low-grade, low volume Gleason 6, there is evidence to support that dutasteride has the potential to both delay progression in growth of his existing Gleason 6 PCa as well as development of more clinically significant Gleason 7–10 PCa though there is lack of consensus on this issue. Also, any rise of Total PSA and presumably its counterparts p2PSA, PHI, and PHI density has been shown to be associated with both progression of PCa and the development of higher grade (>Gleason 6) disease. This pt has an excellent chance of doing well on current Rx from a PCa perspective with continued active surveillance. As to which biomarkers to use to follow this pt and frequency of obtaining these as well as follow-up imaging (MRI) and/or repeat prostate bx, as long as his total PSA kept declining and/or remained stable, I would argue for less testing, taking into account pt’s age, co-morbidities, LUTS, and costs.

  • Jeffrey Tosoian

    Aug 08, 2018

    This is an interesting and complex case. If I am reading correctly, he has not been biopsied since December 2015, which is worth keeping in mind. 

There is certainly reason to believe the patient’s symptoms will benefit from use of the 5-ARI. I do not think we know how 5-ARI use impacts potential progression/reclassification in men on AS, as there remains a lack of consensus on the impact of these medications on PCa development in the overall population. Certainly, as Gregory stated above, any rise in PSA in such a patient would be concerning and merit additional workup. Some other points to keep in mind:

-In a small cohort at Johns Hopkins we found that a PHI density < 0.43 was 97.9% sensitive for detecting clinically significant PCa - GS 7 or GS6 in >2 cores or >50% of a positive core (http://doi.wiley.com/10.1111/bju.13762). Unfortunately there are no data on PHI density in men on 5-ARIs. 

-The Hopkins data and a large proportion of the overall AS data which demonstrate the safety of AS were obtained in the setting of frequent scheduled prostate biopsies (annually at Hopkins for many years). While a patient such as this one currently does not exhibit concerning features, it is worth noting that much of the data on AS was obtained in this setting of frequent biopsy. 

Unfortunately, we just don’t know the answer to many of the questions surrounding a patient such as this. In light of that, our recommendations will be largely dependent on the conversations had with each specific patient and where their values and preferences lie.

  • Jeffrey Tosoian

    Aug 10, 2018

    It is also worth noting that there have been two studies in the past year that assessed 5-ARI use in patients on AS. The first study from the Cleveland Clinic (https://doi.org/10.1016/j.juro.2017.08.006) looked at 371 men on AS, of which 70 (19%) were on 5-ARI. The most recent was from the multi-institutional Canary PASS cohort (https://doi.org/10.1016/j.juro.2018.07.065), considering 107 5-ARI users and 902 non-users. Although men in PASS treated with 5-ARIs were less likely to undergo definitive treatment (19% vs. 24%, p=0.04), both studies found no significant impact of 5-ARI use on the risk of reclassification during follow-up.

  • May 08, 2024

    Pending Moderator approval.
    Delete

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