Prognostic influence of 5 alpha reductase inhibitors in patients with localized prostate cancer under active surveillance

Objective: The incidence of prostate adenocarcinoma (PCa) is increased with the use of prostate-specific antigen (PSA). In the current study, we aimed to investigate the impact of 5-alpha-reductase inhibitors (5-ARI) on pathological progression in patients followed by active surveillance (AS). Material and methods: Records of 69 patients with localized prostate cancer under AS (PSA <= 15 ng/mL, PSAD <= 0.20, <= cT2c, Gleason sum <= 3+3, the number of cancer positive cores <= 3) were evaluated retrospectively. Patients were followed-up with quarterly PSA testing and semiannual digital rectal examination during the first 2 years, and semiannual PSA testing thereafter. Repeat biopsies were done annually and whenever indicated by clinical findings. Pathological progression was defined as increasing Gleason grade, number of cancer-positive cores, and/or increasing percentage of cancer in any core. Results: Patients using (29/69: 42%) and not using (40/69: 58%) 5-ARI were followed for a median of 39 (IQR: 23-45) and 23.5 (IQR: 17-37.5) months, respectively. Pathological progression was observed in 32% (22/69) of the patients at a median of 25 (IQR: 18-39) months. Pathological progression was observed in 34.5% (10/29) and 30% (12/40) of the patients using and not using 5-ARI, respectively (Log-rank p=0.4151). Definitive treatment was done in 31% (9/29) and 47.5% (19/40) of the patients using and not using 5-ARI, respectively. Patients who did not use 5-ARI received definitive treatment earlier than 5-ARI users (Log-rank p=0.0342). On multivariate analysis, more than 2 cancer-positive cores (HR: 11.62) and age (HR: 0.94) were independently associated with pathological progression (p<0.05), rather than 5-ARI use (p=0.148). Conclusion: More than 2 cancer-positive cores at the initial biopsy was the strongest covariate associated with pathological progression; these patients should not be offered AS. There was no impact of 5-ARI use on pathological progression in AS.