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How nice that you even enjoy the morose Google translation! I did it myself and indeed you get some idea of what I am writing about, however sometimes it's unreadable and the subtle dutch semantics are completey missed. But I agree you can follow the argument a bit.
Henk has given me excellent advice over the years and has been a great comfort to me – walking the Active Surveillance path is never too easy, given the general views of the medical profession. I believe he has been thrown off more Lists and Forums than I have because he gives his views plainly – and they are not always what people want to hear. If you click on his name in this thread you’ll see some of his other posts which make very interesting reading.
Primary androgen deprivation therapy is not associated with improved survival among the majority of elderly men with localized prostate cancer when compared with conservative management.
Those with poorly differentiated Pca fared somewhat better on ADT
(from abstract)
However, in a prespecified subset analysis, PADT use in men with poorly differentiated cancer was associated with improved prostate cancer–specific survival (59.8% vs 54.3%; HR, 0.84; 95% CI, 0.70-1.00; P = .049) but not overall survival (17.3% vs 15.3%; HR, 0.92; 95% CI, 0.84-1.01).
I hope to catch those men with derivates especially doubling time en serial PSa density.
Besides in my experience (not so much but I saw a few and by reading digests ) men with poorly differentiated tumors more often have symptoms ie strange feelings down under, blood in urine and ejaculate, voiding problems.
The reason that those men are more often symptomatic at presentation is that the surrounding tissue has not the time to accomodate around a fast growing tumor. On the other hand surrounding tissue has ample time to accomodate around a sluggish one.
One other remark. I have the feeling that ADT is often done without much enthousiasm. When people really concentrate on it, changing antiadrogens, using estrogens etc when PSA risings occur, the results might be much better.
I agree with your comments regarding the shortcomings of conventional biopsy. 3-D mapping biopsy seemed to me to be a better way. Please see:
http://alprostate.com/mapping.aspx
http://www.hopeforprostatecancer.com/3d.asp
As long as about 25% of men aged 50 to 60 years with below average PSA for their age continue to have prostate cancer, PSA would seem to fall short as well.
3d mapping biopsies take on average 45 cores, I repeat: 45 cores. Undoubtedly they will yield more cancers, but not all. Remember at autopsy some 40% of men in their fiftees harbour Pca up to almost 100% of men in their eightees. The reservoir (read business opportunity for urologists) is immense. Understandingly the procedure has more side effects. In one study 8% of men needed a catheter after the biopsies.
Indeed, in absolute terms more PCa is found in under the 4 ng/ml range than above. But PCa per se is not what matters, it's the speed of growth of Pca we are interested in. The best we have at this moment is serial doubling times and densities. You can start with it at a PSa of 0 ng/ml, although I would not advice this.
Having had 13 negative biopsies over the last 10 years I agree with a lot that you have to say. A color doppler targeted biopsy finally found a large 2.5cm tumor in anterior transition zone that even an MRIS had missed. A color doppler biopsy done by a skilled radiologist like Fred Lee or Duke Bahn is an effective alternative to regular biopsies or 3 D mapping.
JohnT
My mapping biopsy took 51 needles. I had some minor flow problems going in, so I was glad that I was catheterized. Things improved quickly after the first day.
Your approach is certainly non-invasive and would definitely be for someone who doesn't want needles, surgery or radiation. Doesn't it pose the risk of missing some very aggressive prostate cancer - Gleason 8 or above or the atypical varieties - where the patient would be better advised to go for more drastic treatment measures?
I suspect that those who have Gleason 8 or more will have short doubling times, ie less than 3 years. In my book the workup in the first year is a PSA every 2 months. So delay would not be substantial. Doubling time less than 3 years would mean start of IHT.
Besides information from PSA derivates and DRE's, Gleason 8 patients might present with symptoms more often than those with lower scores.
Question to those on the list who presented with Gleason 8: did you have symptoms?
There was this article (there have been others) that seem to make PSA alone quite suspect:
1: Urology. 2009 Feb 19.
Prebiopsy PSA Velocity Not Reliable Predictor of Prostate Cancer Diagnosis, Gleason Score, Tumor Location, or Cancer Volume After TTMB.
Bittner N, Merrick GS, Andreini H, Taubenslag W, Allen ZA, Butler WM, Anderson RL, Adamovich E, Wallner KE.
Department of Radiation Oncology, University of Washington, Seattle, Washington.
OBJECTIVES: To evaluate the effect of prostate-specific antigen (PSA) velocity (PSAV) on prostate cancer diagnosis, Gleason score, tumor location, and cancer volume in men undergoing transperineal template-guided mapping biopsy (TTMB). PSAV has been associated with greater Gleason scores and greater prostate cancer-specific mortality. METHODS: From January 2005 through September 2007, 217 patients underwent TTMB. The inclusion criteria included a persistently elevated PSA level and/or diagnosis of atypical small acinar proliferation or high-grade prostatic intraepithelial neoplasia on previous biopsy. The prostate gland was arbitrarily divided into 24 regions, and a median of 58 cores were obtained per patient. The patients were divided into 3 velocity cohorts according to the following changes in PSA level in the year before biopsy: =0.0, 0.1-1.9, and >/=2.0 ng/mL. The PSAV was evaluated as a predictor for prostate cancer diagnosis, Gleason score, tumor volume, and cancer location. RESULTS: The mean patient age was 64.2 years, with a mean prebiopsy PSA level of 8.5 ng/mL. Prostate cancer was diagnosed in 97 patients (44.7%). The study population had undergone an average of 1.8 +/- 1.0 biopsies before TTMB. PSAV did not predict for prostate cancer diagnosis (P = .84), Gleason score (P = .78), the percentage of positive cores (P = .37), or tumor location. CONCLUSIONS: Among patients with persistently elevated PSA levels despite previously negative biopsy findings, PSAV did not reliably predict for a diagnosis of prostate cancer nor did it correlate with prostate cancer grade, volume, or location using TTMB.
Maybe you miss the point. This TTMB 50+ core thing remains a biopsy and a biopsy is....
Undoubtedly it finds more tumours, but this is quantity not quality. Even so, it still may very well miss small false kittens whose only sign is a fast PSA doubling time.