Editorial Comment

Abstract

The challenge of trying to reduce additional biopsies in men with an elevated prostate-specific antigen (PSA) level and an initial negative biopsy result is nothing new to the clinical urologist. Plausible approaches currently include the use of additional markers (such as free PSA, urinary PCA3, OPKO 4Kscore, or Prostate Health Index testing) and/or magnetic resonance imaging of the prostate. PSA velocity (PSAV) has been shown to be unreliable in untreated men, whereas in men receiving 5α-reductase inhibitor (5ARI), PSAV has been shown to be beneficial. 1 Marberger M. Freedland S.J. Andriole G.L. et al. Usefulness of prostate-specific antigen (PSA) rise as a marker of prostate cancer in men treated with dutasteride: lessons from the REDUCE study. BJUI. 2011; 109: 1162-1169 Crossref PubMed Scopus (39) Google Scholar In this study, the authors reanalyzed data from the REDUCE trial to further define the benefit of PSA and PSAV in this group of men. 2 Andriole G.L. Bostwick D.G. Brawley O.W. et al. Effect of dutasteride on the risk of prostate cancer. NEJM. 2010; 362: 1192-1202 Crossref PubMed Scopus (879) Google Scholar Unfortunately, their analysis is not ideal as their assumption that serum PSA level will nadir within 6 months of initiating dutasteride therapy is inaccurate. In fact, only 13% of dutasteride-treated men in REDUCE achieved nadir by 6 months. 1 Marberger M. Freedland S.J. Andriole G.L. et al. Usefulness of prostate-specific antigen (PSA) rise as a marker of prostate cancer in men treated with dutasteride: lessons from the REDUCE study. BJUI. 2011; 109: 1162-1169 Crossref PubMed Scopus (39) Google Scholar It is for this reason that our prior analysis of the utility of PSA in dutasteride-treated men considered rise from nadir rather than as rise from a specific time point after initiating therapy. In our analysis, a PSA rise from nadir in a dutasteride-treated man was superior to the then (2011) relevant National Comprehensive Cancer Network PSAV guideline for untreated men. Decision Analysis of Dutasteride Use for Patients With Negative Prostate BiopsyUrologyVol. 85Issue 2PreviewTo determine whether the additional benefits of improved prostate cancer detection associated with 5α-reductase inhibitors are sufficient to warrant chemoprevention in the case where the degree of prostate cancer risk reduction is deemed inadequate. Full-Text PDF ReplyUrologyVol. 85Issue 2PreviewIt may well be true that our analysis “is not ideal” (after all, is any?). The key question is whether taking an alternative approach would change our conclusions. We repeated all analyses measuring change in prostate-specific antigen (PSA) level from nadir instead of change from 6 months. As the authors of the letter point out, this led to different estimates for many individual patients. However, this did not affect our conclusions at the group level. In no case did measuring from nadir instead of from 6 months lead to consistent changes in either inference or estimation. Full-Text PDF