A few concerns about prostate treatment
DEAR DR. ROACH: I have an enlarged prostate but no diagnosed prostate cancer, having had a prostate MRI.
My most recent exam showed an enlarged prostate. My PSA is still below 4, and I have been taking two tamsulosin pills daily, but from time to time I get up more than several times during the night. My doctor is recommending adding finasteride to my regimen to help shrink my prostate and reduce getting up in the night. That is a big plus. He said I might grow more hair, but nothing else negative or positive. In spite of some negatives I have read, I am inclined to go ahead and give it a try. What do you think?
ANSWER: Finasteride blocks a form of testosterone that is responsible for both prostate enlargement and hair loss. It is commonly used in combination with medicines like tamsulosin (Flomax), as the two medicines work very differently and thus have additive beneficial effects.
There are two concerns about finasteride. The first is that some studies showed an increase in aggressive prostate cancers in men taking finasteride. Subsequent analyses have suggested this is due to a methodologic weakness in the study, and I think the risk of prostate cancer is lower in men taking finasteride, compared with those not taking it.
The second is that you should expect your PSA to go down by 50 per cent when on finasteride. If it doesn’t, that’s evidence that your PSA may have actually gone up at the same time, and it should be evaluated by your doctor.
DEAR DR. ROACH: I am a healthy 80-yearold female. I had surgery to remove my uterus, ovaries, fallopian tubes and cervix when I was 65. No cancer was found anywhere. I have continued to go for a yearly Pap smear, but it seems pointless to continue to do this. What is your opinion?
ANSWER: I agree with the guidelines from the U.S. Preventive Services Task Force that screening for cervical cancer in women who have had normal regular screening (which I assume is the case with you) is no longer appropriate after age 65, except in women with a history of cervical cancer. I know that some of my colleagues continue to recommend performing the test even in older women, and I am sure they are doing so out of a desire to help.
However, the likelihood of developing cervical cancer after age 65 is very small, and there is the potential for harm if a false-positive test leads to an unnecessary procedure. Because the potential for harm appears to be greater than the potential for benefit, I recommend against Pap smears in women over 65 who have always had normal Pap smears.
I know that some physicians use a Pap smear to get women to comply with their annual exam. I think a periodic visit with a provider on an annual basis is a good idea: It allows for other appropriate screening, including for blood pressure and depression, both common problems among the elderly. A gynecological exam is appropriate for women; however, the Pap smear itself is unlikely to lead to significant benefit in this age group.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.