1. Q: What are other prostate diseases besides cancer?
A: The two main prostate diseases besides cancer are inflammation (prostatitis) and benign enlargement (BPH). Both of these can elevate the PSA level. Benign enlargement is treated with alpha-blocker drugs, hormonal therapy, or surgery (transurethral or open surgery of the prostate). Inflammation can sometimes effectively treated with antibiotics, but sometimes patients just have to live with it.
2. Q: What is benign enlargement of the prostate (BPH)?
(Please see QUEST, Fall 2005, Enlarged Prostate: Causes, Symptoms and Treatment.)
A: BPH: Benign (non-cancerous) prostatic hypertrophy is an enlargement or growth of the area in the prostate gland that is nearest the urethra. This growth can block or constrict the urethra, causing urination problems.
3. Q: What is PIN? Is it a precursor to cancer? Do you recommend routine biopsies on men with High-Grade PIN (HGPIN)? (Please see QUEST, Fall 2003, PIN and Prostate: New Studies Show Less Risk.)
A: About 6% of prostatic biopsies show PIN (prostatic intraepithelial neoplasia) or atypia (atypical hyperplasia). Prostate cancer is caused by changes (mutations) in the DNA that affect the regulation of the growth of normal prostate cells. It is probable that several mutations (at least 5 or 6) have to occur before a full-blown cancer occurs. These mutations may accumulate over time, causing the gradual progression to prostate cancer.
It is likely that certain mutations may cause a precancerous condition, PIN. PIN is also found as a satellite lesion surrounding a prostate cancer or elsewhere in a cancerous prostate gland. Approximately 25% to 50% of men who have an elevated PSA level and high-grade PIN are subsequently found to have prostate cancer within four years.
Accordingly, repeat biopsies are routinely recommended in men with PIN. Recent studies show that the risk for finding cancer after findings of PIN is less than previously thought, especially with extended biopsies (taking 12 or more samples) being performed. However, the information is still incomplete on the long-term risk for prostate cancer in men with high-grade PIN.
4. Q: What information do you have regarding the increased risk of high-grade prostate cancer when taking Proscar or Propecia (finasteride)?
A: Proscar is in the family of drugs commonly used to treat or prevent benign enlargement of the prostate gland and to restore hair growth. It inhibits an enzyme that converts the principal male hormone, testosterone, to its more potent form, dihydrotestosterone. Thus, it is a mild form of hormonal therapy. In my opinion, Proscar might mask the presence of prostate cancer for a time, allowing more aggressive cancer cells to develop. In addition, Proscar has adverse effects on sexual function in some men.
Recent studies have reported that men taking Proscar had a 25% lower rate of prostate cancer during 7 years of follow-up but a significantly higher rate of high-grade aggressive appearing prostate cancer. Various explanations have been offered to explain this paradox.
I believe the most likely explanation is that Proscar might be able to mask low-grade cancer better than high-grade cancer and it also shrinks the prostate gland. So, when men taking Proscar undergo prostate biopsy, it is more likely that high-grade prostate cancer will be found and less likely that low-grade prostate cancer will be found.
Some doctors recommend taking Proscar to prevent prostate cancer; however, I do not.
In my opinion, more research is needed before the safety of Proscar, Propecia or another similar drug, called Avodart, in the prevention of prostate cancer can be established.
I would not recommend taking these for preventing prostate cancer or even as a first-line therapy for benign prostatic enlargement or baldness (Propecia).
Other classes of drugs, called alpha-blockers, are helpful in relieving the symptoms of an enlarged prostate in many patients, and they do not carry a risk of masking prostate cancer. Some examples of these are Flomax, Cardura, and Hytrin.
5. Q: If Flomax and other alpha blockers work to eliminate the symptoms of an enlarged prostate, why do doctors prescribe finesteride (Proscar) when Flomax doesn't hide or affect a PSA rise and Proscar does? What are the different effects on an enlarged prostate between Flomax and Proscar?
A: Flomax or similar drugs, called alpha blockers, do work well in many patients, but not in all. Studies have shown that the combination of an alpha blocker and an antiandrogen, such as Proscar or Avodart work better.
The downside of the antiandrogens is that they lower PSA levels and might mask important changes indicating the development of prostate cancer if they are not monitored and interpreted very carefully. (See other Quest articles on the finasteride controversy on this website.)
6. Q: I have heard that taking Flomax can cause complications in cataract surgery. Since taking Flomax is not uncommon for older men and neither is cataract surgery, what is your opinion about what to do?
A: What you write is true. Studies show Flomax appears to cause excessive muscle relaxation in the iris, resulting in something called small pupil or intraoperative floppy iris syndrome (IFIS) during cataract surgery.
Any man taking Flomax should inform his ophthalmologist before undergoing cataract surgery.
7. Q: Are enlarged prostates genetic? Do they run in families?
A: Yes, benign prostatic hyperplasia does run in families.