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Finasteride/Propecia post surgery

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Posted 4/11/2018 8:56 PM (GMT 0)
Folks. Had recent surgery. Recovery going well and will be taking uPSA at 3 months to see where things stand (some adverse pathology per my results below). I have been on Finasteride/Propecia for many years to halt hair loss. Wondering on pros and cons associated with stopping that now vs. staying on it in terms of how to interpret the uPSA results or any other implications (other than hair loss...:}..).
Posted 4/11/2018 10:17 PM (GMT 0)
I’m just another victim but I see no reason why propecia can’t be continued. Personally I’ve been on its cousin avodart as an adjunct to ADT ever since failed RP . I find your pathology curious in that you had “ extensive “ EPE but no positive margins. I didn’t realize it was possible but what do I know?
Good luck with your PCa and hair!!
Bob
PS latest Psa this month was .162!!🤗
Posted 4/11/2018 10:28 PM (GMT 0)
Many years ago my Dad had a Turp... i am not sure whether it was prior to his op or after it but he was put on Finasteride. He was given the choice about whether to stay on it or not.. he opted to stay on it... according to his Dr ‘it would do no harm’.

When diagnosed with pca he was initially told it was 16... when he went to see the oncologist for the first time he was told that it was in fact around the 30 mark and that the Finasteride had ‘falsely’ lowered his psa readings. I am not a Dr and am only going off what his oncologist said but I feel it is something you need to be aware of. If you continue to take it make sure your Drs are aware so that it’s taken in to account when testing psa.

Here is a link... I’m trusting it to be pretty trustworthy considering it’s Hopkins.

https://www.hopkinsmedicine.org/brady-urology-institute/specialties/conditions-and-treatments/prostate-cancer/prostate-cancer-questions/finasteride-are-the-risks-worth-it

Good luck with everything and good to hear that following your op you’re feeling good x
Posted 4/11/2018 11:30 PM (GMT 0)
Break60: thanks so much for your response! I am just learning on the pathology topic but as I understand it, this implies that although the tumor extended outside the prostate the the surgeon cut beyond that. The one area I am still a bit uncertain on is the bladder neck invasion (BNI) but I am hoping that the reference to “resection margins clear” in my path report is indeed negative margins all around. Congrats on your PSA!!

Kathy77: very grateful for your response and the link! Will indeed be transparent on taking or not so doc knows what is what. Thank you and best wishes to you and your father!

Guess one thing I am wondering is that most studies show affect on PSA when you have a prostate but not sure what happens when you don’t.
Posted 4/12/2018 12:56 AM (GMT 0)
Finasteride does lower your PSA, but I am now on it to reduce the size of my Prostate!
Posted 4/12/2018 2:51 AM (GMT 0)
Finasteride lowers PSA by reducing the output of PSA due to BPH, but not prostate cancer. You don't have a prostate to shrink, so its effect on PSA is likely to be negligible. Go for it!
Posted 4/12/2018 4:37 AM (GMT 0)
TA, I have the utmost respect your abundant knowledge on Pca and the help you give to many people at HW. But the Finasteride - Pca connection (or disconnection) really confuses me. After RP PSA is monitored and if the number increases and shows an upward trend it's my understanding that it's an indicator that the cancer has returned (or never left). So if a man has no prostate how could BPH be responsible for the rise in PSA? Doesn't it stand to reason that the Pca would be responsible for the PSA output if a man had no prostate? And if the general rule is to double the PSA number if a patient is on Finasteride wouldn't that also hold true for a man with no prostate who was on the drug? IOW's if a man with no prostate had a PSA of .05 wouldn't the actual estimated PSA (based on the 2x general rule) be .1?

As a guy who struggles with all the complex twists and turns of this disease I find this incredibly confusing. Could you dumb it down for me??? Thanks.
Posted 4/12/2018 3:33 PM (GMT 0)
You don't have a prostate. All this talk of PSA cut in half doesn't apply to you. As TA said it doesn't matter for you whether or not you take the drug regarding PCa. It won't have any meaningful effect on your PSA.

dbell, it is not logical to see this as a problem. It is logical to see this as not a problem because the effect on PSA that these drugs have is on men that have a prostate. TJ123 is not in that group.

TJ123, it is now impossible for you to have BPH, you don't have a prostate that can become enlarged. Your RP solved that one for you. I had radiation, thus I like TA and other radiation guys still have our prostates and can have BPH and/or prostitis, though the incidence of either is greatly reduced compared to men that have not been treated for PCa.
Posted 4/12/2018 6:41 PM (GMT 0)
Thanks, JNF. I guess I'm slow. I still don't understand.

So if a man doesn't have a prostate and his PSA is rising - what is causing the rise? I always thought it was the cancer that was producing the PSA. But perhaps I'm missing something (other than my prostate). sad

Yes, I know that I can't have BPH without a prostate.

AJMan (the original poster) had a RP. He wanted to know the pros and cons of taking Finasteride post-surgery and whether it would alter or mask his true PSA measurements as he monitors for changes in his PSA numbers .

Maybe this is a better way to ask my question:

Is PSA produced by benign prostate cells different from PSA produced by cancerous prostate cells - inasmuch as Finasteride alters the measurement of the former (lowering it by one-half) while having no effect on the reported measurement of the latter?

Thanks in advance for any clarification you can provide.
Posted 4/12/2018 7:16 PM (GMT 0)
TJ, you are correct. If there is no prostate and the PSA rises, it is because of the prostate cancer that the surgery did not take out. If the prostate is cut out, or ablated through radiation, HIFU etc, and there is no cancer then the PSA will be very low, hopefully too low to detect, and stay stable. After initial curative treatment, a rise in PSA indicates cancer on the move and growing. These drugs will not markedly affect that measurement of PSA.

PSA is PSA regardless of the source. The PSA produced by the prostate is not different than PSA produced by cancer. Remember, PSA is not an indicator of cancer. All men express PSA normally until they have their prostate either removed or ablated due to cancer. If it were different PSA, then a simple blood test would indicate cancer and we would have no need for a biopsy.

In men with a prostate that take finesteride (Proscar) or dutasteride (Avodart), both being a 5-alpha-reductase inhibitor, the drug acts on the adrenal gland to reduce the production of dihydrotestosterone (DHT). This then acts to shrink the mass of the prostate gland by usually 35-50% and the PSA expressed is reduced because it is reflective of the mass. A larger prostate will express more PSA than a small prostate.

Thus when a man has been taking these drugs for a while they should expect the PSA expression to be on the low side of normal So for a 60 year old normal is up to 4.5. It might mean the man is more like 2.5-3.5. One positive attribute of the drugs is that by lowering and stablizing the PSA, minor increases due to cancer can be more easily detected.

Also the drugs can act to prevent low grade cancer from developing. There were two studies that showed this effect named Prevent and Confirm and were done about 10 years ago. My urologist was a lead investigator on each of the trials.

Once the prostate is removed, the only significantly detectable source of PSA will be PCa, unless a significant amount of benign prostatic tissue was left behind. It may then express minute amounts of PSA but will stay stable or reduce if that tissue is unable to survive. So any PSA increase would then indicate PCa that the surgery failed to remove.

So don't confuse what these drugs do to a man with a prostate versus a man without a prostate. Apples and Oranges as they say.
Posted 4/12/2018 7:21 PM (GMT 0)
nice explanation, JNF
Posted 4/12/2018 7:34 PM (GMT 0)
JNF, thanks...you have also answered my question about Finasteride use for people who still have a prostate! yeah
Posted 4/12/2018 9:23 PM (GMT 0)
Thank you, JNF, for your thorough and detailed explanation.

This is the reason for my confusion:

You wrote: "PSA is PSA regardless of the source.The PSA produced by the prostate is not different than PSA produced by cancer."

TA wrote: "Finasteride lowers PSA by reducing the output of PSA due to BPH, but not prostate cancer."

Finasteride is said to reduce the actual PSA measurement by approximately one-half on paper. So, IOW's, if a man with a prostate taking Finasteride had a PSA reading of 4 his ACTUAL PSA would be estimated to be 8 even though the lab work reported 4, since the general rule is to double the figure. Correct?

SO, if PSA is PSA (as you say), whether it comes from benign or cancerous prostate tissue, if a man who had a RP and is without a prostate and taking Finasteride for hair loss shows a PSA of let's say .05 - wouldn't that mean his ACTUAL estimated PSA level would be .1 (.05 x 2)?

Finasteride would have the same measured effect on cancerous PSA as it would on benign PSA, correct? It would mask (lessen) the true value of the actual PSA measurement by about one-half. Correct?

I'm trying so hard to ask the right question. I hope this solves it. You can probably tell that I wasn't a science major and would make a lousy doctor. tongue

Thanks again for your helpful information.
Posted 4/12/2018 9:34 PM (GMT 0)
Folks, this is a terrific exchange. JNF thanks for the clear explanation and TJ123 thank you for being as perplexed as me..:}..

Given some adverse pathology in my recent surgery my uro advised on possible radiation down the road and that we should observe the PSA going forward. Will be taking uPSA at 3 months to see where we are at. I have read TA's website concerning the value of adjuvant action once certain uPSA thresholds are surpassed and wasn't sure if adjustments would be required to my eventual reading given finasteride use.

From the above it sounds like, if there is some residual benign prostate tissue remaining that there could be some affect on the baseline but that any increase over time would be attributed to pCA. That means we would want at least a couple measures to show the change. I guess this same logic would apply regardless of the finasteride use. Assuming that no benign prostatic tissue remains post surgery, the first measure should be indicative in the same way it would be without finasteride use.

I checked with my uro and he is suggesting I stop taking it for a year to see where we land. I am looking to arm myself to plead my case...:}..let me know if I have screwed anything up
Posted 4/12/2018 9:37 PM (GMT 0)
TJ123...I posted before seeing your question and am looking forward to hearing the groups response to the question as you posed it as well!!
Posted 4/12/2018 11:21 PM (GMT 0)
TJ, no. You are confusing the man with a prostate with a man that no longer has a prostate. And, no, a man with a prostate on these drugs does not double his actual PSA. You watch the actual PSA being expressed to see a trend. If it stays level it indicates there is probably not any cancer. If it starts going up it might indicate cancer, but more investigation like a biopsy would be needed.

These drugs do not mask or reduce the PSA expressed from cancer. They only reduce the PSA expressed by the prostate.

They are also used as part of ADT3, which I used. This includes a drug that suppresses the testosterone produced by the gonads (lupron, eligard, trelstar, firmagon), reduces the DHT (avodart and proscar) and blocks the testosterone from the cancer (casodex). This strategy is used in high risk and metastatic situations. Hopefully it knocks down the cancer so the man goes into remission. You know this by the reduction in PSA which means the cancer is less active and or dying.
Posted 4/12/2018 11:27 PM (GMT 0)
This is a question I had been researching and seeking advice on from doctors. There isn't anything definitive on what to do after surgery and even the doctors can only give opinions. Ultimately, given the fact that I had adverse pathology and persistent PSA, I've elected to stop finasteride use. If I would have had good pathology and no PSA I probably would have continued with finasteride.
Posted 4/12/2018 11:28 PM (GMT 0)
AJ, your actual PSA of 5.25 was abnormally high, indicating further investigation. No need to double it since you were on proscar. Now you have no prostate, so it really doesn’t matter. That your urologist wants you off for a while makes sense but may not make a difference. Is it helping your hair enough to continue to use it? If so, as TA said, go for it. if not, then go with your urologist for a while and see what happens.
Posted 4/13/2018 12:35 AM (GMT 0)
AZ, that is actually backwards. These drugs suppress DHT, which is a food/fuel for PCa. That is why ADT3 uses it to achieve the lowest Testosterone level possible. How much they work on their own is debated. The reknowed PCa oncologist Snuffy Myers used these drugs when he put advanced cases on ADT vacation. So if you are fighting cancer you would want to use the drug. Just don’t know how effective it might be. I was kept on for three years as part of ADT. I used Jalyn, which combines avodart and flomax.
Posted 4/13/2018 5:16 AM (GMT 0)
Thanks, JNF. But that's not the way it was explained to me by my urologist. I was actually on 5mg Finasteride during AS due to BPH. While on Finasteride the PSA lab report came back @ 5. My doc told me that to get an accurate reading of my actual estimated PSA when on Finasteride to double the number shown on the report. So instead of having PSA 5 (as shown on the lab report) I had an actual estimated PSA value of 10 since the rule is to double the number while on Finasteride. I realize that the doubling rule is a rough estimate. But that was one factor that persuaded me to get a RRP. I felt PSA 10 was getting a bit too high for my comfort zone. That's my personal experience.

My question was whether Finasteride has the same PSA effect on a man without a prostate who is taking Finasteride when his PSA is rising. Like in the example I gave: If the post-RP ultra-sensitive lab shows a PSA of .05 does the doubling rule still apply? Would make the actual estimated PSA be .10 instead of .05? Doubling does make a big difference when the numbers start to increase.

No need to respond or to answer the question for me. I'll just move on. My hope is that AJMan has a firm understanding of how it works since he asked the question originally.

Thanks again for your all your time and effort.
Posted 4/13/2018 2:36 PM (GMT 0)
So I think I am getting clearer but "firm understanding" is always elusive in this business.

When I was the proud owner of a prostate I read a numerous articles re-inforced by my uro that you should double (approx) the PSA to get a better sense of where you would be if you were not taking the Finasteride. After reviewing with my generalist doc I saw (that while she did annual digital rectal exams) she had only taken my PSA once a number of years ago. The result of that was apparently 2+ and she did not flag anything or even mention it given she assumed it was normal (even though she had prescribed the finasteride). While it wasn't necessary to double my PSA at the 5.25 level (since the absolute number was already a flag) it sure would have been nice to know about the adjusted level over 4 a number of years ago. I think it is very important to make sure this point is clear for other folks who are taking finasteride who may be assuming their absolute reading keeps them in safe territory. Who knows but I may have lost out on an opportunity to deal with this earlier.

Also I used the adjusted PSA to help stratify my risk level. My diagnosis in October (MSK) was low volume, low risk G6 and strongly recommended for AS with followup in 6 months for a PSA test. My research suggested that the one constant explanatory variable for higher grade Gleason is PSA density. I accumulated data across articles on how the finasteride affected both PSA levels and prostate volume (not the same impact) and determined that by any calculation my density was very high. Armed with this I sought a number of other opinions which set the path for my signature below.

As noted by AZ Guy there is not much out there that academically discussed this topic post surgery with the exception of the references to treatment options including finasteride referenced by JNF, So at a minimum this suggests finasteride will not harm anything and may do some good. The only exception in possibly interpretation of the first absolute level of uPSA reading where I admit to still be a bit wobbly. Having said this I am equally wobbly on possible implications of stopping finasteride consumption as its original effects work themselves out of the system. In view of all of this I will just plead my case to my uro and see if he has any reasons he can articulate for what benefit he expects to get from stopping. You guys have been very generous with your time and thoughts on all of this. Very grateful.
Posted 4/13/2018 3:25 PM (GMT 0)
JNF, that was my assumption too. That suppressing DHT/testosterone is exactly what I would want to do. So taking finasteride would be a good thing. Most literature suggests that finasteride can reduce the chance of low-risk cancer but can increase the chance of more serious cancer. I looked hard into the notion that it could be simply because of the suppression of PSA readings, but it appears that isn't always the case. Given that I did have a more serious case of cancer at my young age I've come to believe that finasteride did impact me negatively during my 20 year use. It could be that men with fathers who had PCa should not take finasteride. Again, these are opinions as the research just isn't there. I've asked all my doctors their opinion on this subject. The responses seem to be that the research isn't there so we can't know definitely....but when asked "so what would you do if you were me?" the answer from two docs was "I wouldn't take it."
Posted 4/13/2018 4:32 PM (GMT 0)
AZ Guy, the articles a few years back suggesting finasteride promotes higher grade cancer have been disproven.
Posted 4/13/2018 4:41 PM (GMT 0)
That's right. When the Prevent trial was published a noted PCa specialist jumped to a conclusion that it promoted high risk PCa development. Thus, the Confirm trial was done. It does not promote the development of high risk PCa, rather it identifies it earlier then if one was not on the drug. So actually a good thing.
Posted 4/13/2018 5:11 PM (GMT 0)
Maybe I missed it in all the post...forgive me if so...to hone it done a bit...Does the psa that is produced after the prostate is removed...not talking psa from leftover prostate tissue..(.benign or not we all agree that is halved....not the psa itself but its reading as exhibited on a psa test}.... the question is...is the psa that is produced from PCA ya know cancer elsewhere...wherever...whereever is...is that psa's reading value halved...not the psa itself... the reading... posted on the psa test...the one...gets from the lab...
The question has nothing to do with whether or not it matters or not for treatment...{it may or May not}the answer has nothing to do with who is the smartest or the dumbist...it is a simple question...tho difficult to explain...due to whatevahs. and please...please...stay on point...ego's aside no faces need saving...just hone in on the question and answer it as simply as possible....If my analysis is wrong ...try to explain where and why or that it has already benn covered and I just missed it...in good...faith logo Damm Im sure I missed something...but to try is to do...regards to nutshell...if I am too late for the party please...tell me don't leave me hanging....would thatbe ok? confused or am I wrong in that the psa itself is halved and the test just reflects that...no that can not be... the psa stays the same amount in reality ..aand the psa tes reading is halved but confused remember it is the response-ability for those that do understand to explain it to those who do not...as their claim of ability arguably rules...no eyerolling please...dig fricken deep I am trying to...
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