From the Editorial Board

E. David Crawford, MD

In this issue of Grand Rounds in Urology J. Curtis Nickel presents a discussion of phytotherapy for benign prostatic hyperplasia (BPH) with an invited commentary from Paul D. Maroni. Though natural and herbal remedies have been around for centuries, it is only within the last 20 years that patients have embraced herbal remedies. It is time to stop viewing them as viable treatment options without definitive research studies. These treatments not only empower patients by allowing them to do their own research (via the Internet, by watching infomercials, through ready magazine and newspaper articles, etc.), but also allow patients to circumvent the traditional health care treatment process. Today’s patients are more interested in the concept of “prostate health” than those in the past, but unfortunately few if any clinical trials have been published that assess the long-term effects with respect to disease progression.

Since natural remedies have been de ined as dietary supplements, manufacturers do not have to demonstrate effectiveness to the US Food and Drug Administration (FDA) before marketing, nor are the products subject to the pre-market safety evaluations that new food ingredients or pharmaceuticals have to undergo. The manufacturers are not even required before marketing to demonstrate that the product contents match the labeling. This quality issue might be one of the reasons that urologists are reluctant to advise patients to consider these agents. Other concerns include the lack of proof of ef icacy for many of these dietary supplements. Even evidence supporting the many commonly used herbal agents (saw palmetto, African plum tree, rye pollen, pumpkin-seed, etc.) that have been subjected to clinical ef icacy and safety trials are usually based on small, short, non-randomized, and/or non–placebo-controlled studies.

However uncertain we are about the use of natural remedies, a recent report from Naslund et al highlights the enormous socio-economic importance of treating prostate diseases, both benign and malignant, to our society and within the health care delivery system. At the annual meeting of the American Urological Association in 2006, Naslund and colleagues presented data that represented more than 1 million male patients over the age of 50 with a total of more than 960,000 years of follow-up. They found that BPH is the fourth most common treated disease following coronary artery disease and hyperlipidemia, hypertension, and type 2 diabetes mellitus. The authors also analyzed the costs associated with the treatment for the 10 most common conditions and found that prostate cancer and BPH were among the 10 most costly diseases to treat, according to this database, with prostate cancer being irst and BPH eighth on the list.

While BPH is the fourth most common treated disease, the available research on phytotherapy, or complementary alternative medicine (CAM) therapy, shows that some of the compounds being used by patients present opportunities for managing BPH that may even compare with those afforded by today’s pharmaceuticals. Nickel points out that perhaps some of the prostate cancer prevention trials of “nutraceuticals” will be helpful. In the interim, he suggests that urologists should become as knowledgeable as possible about the treatment options their patients might be taking and/or requesting information about. In addition, Maroni offers the opinion that urologists should embrace herbal therapies and certainly consider including them as part of their evidence-based armamentarium for treating interested patients with moderately bothersome BPH who do not have absolute indications for more aggressive therapy.

Sincerely,

E. David Crawford,

 

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