Treatment Complications and Progression

BPH is considered a progressive condition. Longitudinal data from a large-scale trial known as the Proscar Long-Term Efficacy and Safety Study (PLESS) in which 3040 men were randomized to treatment with finasteride (Proscar) or placebo for 4 years, with an additional 2-year follow-up period showed that finasteride prevented progression.59 However, baseline PSA and prostate volume could predict those patients at greater risk of symptom and quality of life deterioration, and those at risk for the development of AUR or BPH-related surgery. Those patients with a prostate size greater than 40 cm3 and PSA of 1.4 ng mL or above were at the greatest risk for developing AUR, and serum PSA was a strong predictor of prostate growth; the annual growth ranged from 0.7 mL year_ 1 for patients with a PSA 0.2-1.3 ngmL _ 1 to 3.3 mLyear _ 1 for PSA range of 3.3 to 9.9 ngmL _ 1.60 In the MTOPS study, which also assessed the impact of medical treatment of BPH progression, baseline PSA, Qmax, PVR, and prostate volume were all significantly associated with clinical progression.60 Figure 16 shows the effect of prostate volume on several progression endpoints, including AUR and BPH-related treatment.

Given that a number of baseline variables can predict outcomes in BPH, they are often used to chart management progress in these patients. In a recent survey of 1859 BPH patients, PSA was found to reflect prostatic enlargement with sufficient accuracy to be of clinical benefit. From the data, these researchers produced a nomogram that could predict prostate volume at 5-year intervals based on serum PSA values.61 PSA has also been shown to be a predictor of BOO In a study of 302 men with LUTS and a PSA less than 10 mgnL_ 1, where patients had a PSA greater than 4ngmL_ 1, mild or definite BOO was likely in 89% of cases whereas if the PSA was less than 2 ng mL _ 1 then the chance of having BOO was much lower (approximately 33%).62 In another study, the appropriateness of choosing a particular treatment in relation to the patient risk profile was considered against a reference profile; these findings are shown in Table 5.63

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