From the Guidelines
The next step for this 58-year-old asymptomatic man with a dramatic PSA increase from 2.4 to 28 ng/mL while on finasteride should be to stop finasteride and repeat PSA in four months, as the finasteride can affect PSA levels, and this significant increase warrants further evaluation after discontinuing the medication. This recommendation is based on the understanding that finasteride, a 5-alpha reductase inhibitor, can lower PSA levels by approximately 50% 1. Given the significant increase in PSA despite the use of finasteride, it is crucial to assess whether this elevation is due to the medication or an underlying prostate issue. Stopping finasteride and rechecking PSA levels after a period allows for a more accurate assessment of the patient's prostate health without the confounding effect of the medication.
Key considerations in this case include:
- The patient's age and the fact that he is asymptomatic, which still necessitates careful evaluation given the PSA increase.
- The role of finasteride in potentially masking or altering PSA levels, making it essential to discontinue the medication before further testing 1.
- The importance of a thorough evaluation, which may include a digital rectal examination (DRE), additional PSA testing after discontinuing finasteride, and potentially imaging studies like multiparametric MRI of the prostate before considering a biopsy.
- The need for an informed decision-making process regarding further diagnostic steps, such as biopsy, considering the patient's overall health, preferences, and values, as emphasized in guidelines for prostate cancer screening 1.
Given the information provided and the current guidelines for prostate cancer screening, the most appropriate next step is to discontinue finasteride and reassess PSA levels after an appropriate interval to determine the best course of action for this patient's care.
From the FDA Drug Label
In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. This decrease is predictable over the entire range of PSA values in patients with symptomatic BPH, although it may vary in individuals For interpretation of serial PSAs in men taking finasteride tablets, a new PSA baseline should be established at least six months after starting treatment and PSA monitored periodically thereafter Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor. To interpret an isolated PSA value in patients treated with finasteride tablets for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men.
The next step is to stop finasteride and repeat PSA in four months or to interpret the PSA value by doubling it, but since the patient's PSA level increased from 2.4 ng/mL to 28 ng/mL, which is a significant increase, the most appropriate step would be to stop finasteride and repeat PSA in four months to determine if the increase in PSA is due to the finasteride or if it's a sign of prostate cancer, as the increase in PSA may signal the presence of prostate cancer and should be evaluated.
- Key consideration: Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer.
- Action item: Stop finasteride and repeat PSA in four months 2.
From the Research
Next Steps for Prostate Cancer Screening
The patient in question is a 58-year-old asymptomatic man with a Prostate-Specific Antigen (PSA) level increase from 2.4 ng/mL to 28 ng/mL while taking finasteride 1 mg daily for hair loss prevention. Given this scenario, the next steps should be considered carefully, taking into account the effects of finasteride on PSA levels and the implications for prostate cancer screening.
Consideration of Finasteride's Effect on PSA
- Finasteride is known to decrease PSA levels by approximately half 3, 4. Therefore, the significant increase in PSA from 2.4 ng/mL to 28 ng/mL in this patient is particularly noteworthy and warrants further investigation.
- The increase in PSA levels, despite the use of finasteride, suggests a potential issue that needs to be addressed, such as the possibility of prostate cancer.
Diagnostic Approaches
- Digital Rectal Examination (DRE): While DRE is a recommended screening tool for prostate cancer, its sensitivity and specificity can be limited 5, 6. The use of finasteride may improve the sensitivity of DRE for detecting prostate cancer, but it is essential to consider this in the context of other diagnostic tools.
- PSA Velocity: The rapid increase in PSA levels in this patient is a significant concern. PSA velocity, or the rate of change in PSA levels over time, can be an important factor in assessing the risk of prostate cancer 3.
Recommended Next Steps
- Stop Finasteride and Repeat PSA: Given the significant increase in PSA levels, it is reasonable to consider stopping finasteride and repeating the PSA test after a suitable period, such as four months, to assess the impact of finasteride on PSA levels and to re-evaluate the patient's risk for prostate cancer 7.
- Further Diagnostic Evaluation: Depending on the results of the repeated PSA test and other clinical factors, further diagnostic evaluation, such as a prostate biopsy, may be necessary to determine the cause of the elevated PSA levels and to assess for prostate cancer.
Key Considerations
- The patient's age, family history, and other risk factors for prostate cancer should be taken into account when determining the next steps in management.
- The potential benefits and risks of finasteride in the context of prostate cancer prevention and detection should be carefully considered, including the possibility of high-grade prostate cancer 4.