Re: Erectile difficulties from dutesteride and finesteride

Dear All,

I agree that one has to read internet postings and all medical
information on the internet with care, it is full of inaccuracies and
interpreting this information is also difficult. Many times information
is simplified for the sake of better understanding, or written by
medical writers that are not specialists... that was good advice by
Pete.

The posting that started this thread is incorrect in many of it's
points. C. Palmer already dissected the text.

We say in Spain, "he can hear the bells, but he does not know where the
sound comes from" to express that there is some truth in what he says,
but he is not accurate nor correct in many of the points he defended in
his posting.

Prostate cancer is a very difficult to study disease. Average survival
without treatment is relatively long in comparison with other tumors
that kill in a period of months despite oncological treatments
(survival without treatment seems to be longer the lower the Gleason
grade is). So, in order to study this disease, studies must recruit
many patients, and these studies must follow up patients for a very
long time (more than 10-15 years). Even then, it is difficult to
compare the results of different studies, or to arrive to conclusions
that can be extrapolated to the general population. I will tell you a
little story so you can understand this.

"A study was carried out to determine if a drug was useful for erectile
dysfunction (ED). The study had two groups of 10 patients. A placebo
was fiven to Group A, whereas group B received the drug which promised
to be effective for ED. After several trials of the drug during a week,
all patients of Group A were not satisfied, they were not able to
sustain intercourse, and their counterparts were not satisfied either.
On the contrary, all patients in Group B were fully satisfied with the
drug, they were able to sustain intercourse, and counterparts were very
happy and surprised of the effect of this drug. In conclusion: Placebo
0% efficacy, Wonder drug 100% efficacy. This seemingly impressive
results are less impressive when you read the small letter in the
materials and methods section of the article. In group A, of patients
receiving placebo, all male subjects were older than 80 years, and
female counterparts were younger than 25. In group B, of patients
receiving the wonder drug, all male subjects were 25 years old, and
female counterparts were older than 70......

This relatively funny story reveals a fact in medicine. Often one can
arrive to conclusions that are not correct. And specially in prostate
cancer, with such a long survival, it is very difficult to arrive to
evidence enough to arrive to conclusions that are considered certain or
the truth.

So, doctors have to interpret the medical literature the best they can
and try to offer their patients the advice they believe works in their
best interest.

Regarding finasteride, I think the erectile dysfunction rate is much
lower than what he mentions, and it is usually a reversible effect when
you stop taking it.

Regarding PSA testing, this is an ongoing discussion. Many patients
with a high PSA suffer several sets of biopsies without a diagnosis of
cancer, some of them experience complications after the biopsies. They
become anxious about it and sometimes wished they never had had a PSA
test. Only about 2 out of 10 biopsies is positive nowadays. This means
that 8 out of 10 patients receive an "unnecessary biopsy". An this
happens because PSA level can rise due to BPH (the higher the volume of
the prostate, the higher the PSA level), or to chronic or acute
inflammation (acute prostatitis can rise PSA up to 40 ng/mL, and when
the inflammation subsides, it drops down to normal levels). So it is
not such a perfect tumor marker. e.g. a rise in PSA does not always
equal prostate cancer. (I recommend my patients to have a biopsy if PSA
is higher than 4 ng/mL, and sometimes with a lower PSA if there have
been consecutive rises or if there is family history of prostate
cancer)

On the other side, those patients with a positive biopsy can harbour a
lethal cancer, and this cancers can be cured. A recently published
study carried out in scandinavia has demonstrated that radical
prostatectomy offers a survival advantage, freedom from metastasis and
other benefits to patients after a follow up of 8 years. This study was
carefully designed and compared Radical Prostatectomy versus Watchful
Waiting.

The old autopsy data (the incidence of cancer in autopsies was higher
than the incidence of clinical cancers, apart from other difficult to
explain facts, as a 5% incidence of Gleason 7 cancer in 30 year old men
in autopsy - if I remember correctly this figure) made urologists think
that there are cancers that would probably never progress and end up
killing a patient ("the cats"), and other cancers that are aggressive
and potentially lethal ("the tigers"). Unfortunately, Pathologists
cannot differenciate cats from tigers yet. (There have been very
interesting recent autopsy studies that show that the incidence of
cancer in autopsies is much lower nowadays, due to the widespread use
of PSA, most cancers have been already detected and treated- so the
data our "physician" presents is no longer accurate).

So it is likely that some men with a high PSA, with a cancer in their
biopsy, will receive an operation that would not have been necessary.
For some others, radical prostatectomy or other treatments with
curative intent will be their only chance of long term survival.

So we keep discussing if PSA testing should be offered to every man
after a certain age, because if we do this, we will detect more "cat
type" cancers, and these men will receive "unnecessary treatments". The
urological community is divided, some urologists believe we treat too
many cancers, and some others think that cancer should be screened in
every men... and we do not know for sure what is the right thing to do
yet. We know both attitudes (to screen or not to screen) would cause
damage to patients - too many "unnecesary biopsies" - or too many
cancer deaths that could have been prevented, but we cannot say for
sure what option is the best.

It is usually difficult to tell a patient with a cancer that he does
not need treatment, or that his cancer might not kill him and that you
recommend not to treat... so diagnosis has usually been followed by
treatment in most of the cases. Now a new option is being proposed,
specially in the UK, "active surveillance with an intention to cure".
Once the cancer has been diagnosed, specially in older patients, PSA is
followed up, and biopsies repeated yearly, and treatment is offered
only if PSA rises progressively or repeat biopsies show a bigger or
higher grade cancer....

So, this is a field where we do not have certainty on how to proceed in
many cases, and there are conflicting points of view, and data from
studies supporting opposite attitudes.

When you see a patient dying from prostate cancer, with bone mets and
needing pain treatments, you hope that cancer had been detected and
cured before it was too late. Morbidity of surgery, radiotherapy,
brachytherapy and cryosurgery is an issue, but it is not as bad as our
"physician" was mentioning.

I am sure he believes what he wrote in his post, but I am not so sure
there is evidence to support his firm beliefs.

Another interesting fact. I heard at the last AUA meeting that a
patient with a higher than 4 ng/mL PSA went to see a urologist. He said
he would not recommend a biopsy, but to repeat it in 6 months to see
what happened. The patient was not satisfied with this and he went to
see another urologist who recommended a biopsy. The biopsy detected a
tumor, and the patient went to court and the original doctor was
sued...

So I guess prostate cancer is a difficult issue, and there are no easy
answers.... I know of a number of urologists with prostate cancer that
go for a radical prostatectomy, or radiotherapy.... I also know of
urologists that choose not to have a PSA.....

All the best to all of you, did I wish you a very happy new year?

Fernando Gómez Sancha
http://drgomezsancha.blogspot.com

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