Question: What is a consequence of getting older that bothers men?
Answer: Disrupted sleep due to more frequent nighttime bathroom trips.

The increased need to pee at night is almost always due to benign prostatic hyperplasia (BPH), which is a normal aging-related noncancerous gland enlargement. To the relief of many men who would love to regain the urination patters of their younger days, a readily available FDA-approved drug, finasteride, comes to the rescue! This medication has been in use since the early 1990s. It is most often known by the brand name Proscar, but by any name, it is a cheap and effective oral medication with few side effects when used as prescribed.

Finasteride is in a class of drugs called 5 alpha-reductase inhibitors. Basically, by inhibiting certain forms of enzymes, it “mimics” a genetic mutation that would naturally alter testosterone’s biochemistry in the prostate gland in a way that discourages the development of BPH, and reverses existing enlargement. In turn, this reduces the sensation of urinary urgency. Thus, finasteride has been a tremendous success in men’s health.

Finasteride and prostate cancer

Scientists reasoned that the same biochemical alteration that decreases BPH development might also reduce the risk of developing prostate cancer — but how to find out if finasteride could really prevent prostate cancer? As early as 1992, the Board of Scientific Counsellors of the Division of Cancer Prevention (DCP) of the National Cancer Institute (NCI) recommended the exploration of the first NCI-sponsored clinical trial to determine the effect of the drug on prostate cancer risk.^[i]

Eventually, a study called the Prostate Cancer Prevention Trial (PCPT) was designed to everyone’s satisfaction. The goal was to enroll 18,000 men over a 3 years period; they would be randomized to receive either finasteride or placebo. At the end of 7 years, they would undergo a standard biopsy for prostate cancer, and the two groups compared regarding biopsy results. When the press announced PCPT in 1993, the public response was amazing. Within 3 years, 18,882 men were enrolled and randomized.

Study results

By 2001, two-thirds of participants were due for their biopsy, at which point the design committee felt that they would obtain robust data from that number, and announced the study closed so data analysis could begin. Of the men on finasteride, 803 cancers were found, compared with 1,147 among the men on placebo. This translated to a 24.8% reduced risk of prostate cancer for those taking the drug. However, there were more high-grade cancers in the finasteride group, which was concerning. As a result, controversy over finasteride use followed.

Eventually, however, further studies and more information indicated that the controversy was unwarranted. Current research updates suggest that:

• Finasteride actually improves the reliability of the PSA blood test and the detection of high-risk prostate cancer.
• It also seems to improve the performance of the DRE.
• In 2008, biostatistician Dr. Mary Redman corrected for study biases, and determined that overall risk prostate cancer was 30% lower for men on finasteride, and the risk for high-grade prostate cancer was 28% less.

We now know these results are durable, thanks to almost 20 years of follow-up using the National Death Index that lists cause of death. When the index was searched for each study participant, it revealed that out of the 9,423 men who were in the finasteride arm, 3,048 of them had died, of which 42 were due to prostate cancer; while of the 9,457 men on placebo, there were 2,979 deaths with 56 of them from prostate cancer.

In conclusion, after nearly 20 years it looks as though being on finasteride for 7 years cuts the risk of prostate cancer by 25% on average. Does this mean that men past midlife should start taking finasteride whether or not they have BPH? According to a 2019 press release, Dr. Ian Thompson, Jr. who was Principal Investigator of PCPT, commented, “Finasteride is safe, inexpensive, and effective as a preventive strategy for prostate cancer… Doctors should share these results with men who get regular prostate-specific antigen (PSA) tests that screen for the presence of prostate cancer. The drug will have its greatest effect in this group of men.”^[ii]

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] The Cancer Letter. “20-year follow-up data are in: Prostate cancer prevention works; concerns about high-grade disease dismissed.” Feb. 1, 2019. https://cancerletter.com/articles/20190201_1/
[ii] Seymour, Caroline. “Finasteride Effective in Preventing Prostate Cancer.” Targeted Oncology, Feb. 15, 2019. https://www.targetedonc.com/view/finasteride-effective-in-preventing-prostate-cancer