Gee, I could've had a V8!
Alvin B. Lin, MD, FAAFP
Dr. Lin is an associate professor of family and community medicine at University of Nevada School of Medicine and an adjunct professor of family medicine and geriatrics at Touro University Nevada College of Medicine. He also serves as an advisory medical director for Infinity Hospice Care and as medical director of Lions HealthFirst Foundation. Dr. Lin maintains a small private practice in Las Vegas, NV. The posts represent the views of Dr. Lin, and in no way are to be construed as representative of the above listed organizations. Dr. Lin blogs about current medical literature and news at http://alvinblin.blogspot.com/.
Continuing along the lines of last Wednesday's theme of 20:20 hindsight, I thought I'd also mention a study published towards the end of last month in the Lancet in which the authors concluded that dutasteride might slow down the progression of localized low grade prostate cancer in men interested in active surveillance. It's important to note that this was another analysis of a randomized, double-blind, placebo-controlled trial, Reduction by Dutasteride of Clinical Progrression Events in Expectant Management (REDEEM), in which 289 men, average age 65 years, with biopsy-proven localized Gleason 5-6 prostate cancer, and who had elected active surveillance were randomized to dutasteride 0.5 mg daily versus placebo and followed for 3 years. We should note that their prostate-specific antigen (PSA) was less than 11 ng/mL with life expectancy of at least 5 years.
In the past, we used the phrase watchful waiting. In other words, we just checked and repeated their PSA at regular intervals looking for an increase beyond some prespecified level. Nowadays, we think of active surveillance in which the patient undergoes repeat biopsy at regular intervals to demonstrate stability of the neoplasm or progression to high grade disease. Again, I can only imagine the look on the faces of those randomized to placebo now slapping their forehead and exclaiming, "I could have had a V8," or at least daily dutasteride to slow down the progression of disease.
I thought about this study a bit more and finally realized that the study had been published early online back in January when I had first written about it. Upon looking back, I'm glad to say that I'm at least consistent. Whether that's good or bad is open to debate. Sure, REDEEM was a randomized controlled trial good for demonstrating cause and effect. However, in this situation, reality isn't so much black and white as it is various shades of gray. It turns out that dutasteride, just like finasteride, can decrease the incidence of prostate cancer but only while increasing the risk of high grade cancer. You'll need to decide for yourself whether less hair loss or improvement in prostate symptoms is worth the potential risk and side effects.