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The more things change, the more they stay the same
I was rummaging in the messy lump of electronic files which passes for a system looking for a study and came across an exchange from 2006 on one of the now defunct lists where the poster took me to task, yet again for posting my lunatic idea that there were some diagnoses where immediate invasive treatment was not essential.
This is an edited version of the exchange:
Poster: You've always been a gadfly, challenging what you believe to be the status quo in CaP research and therapy. I do not understand your years-long polemics, attempting to convince newbies (and not so newbies) that watchful waiting was , and remains, the approved solution. In my opinion, you may have done more harm than good in presenting the newly-diagnosed with the Niverna of doing nothing for some period of time. In the computer world, we have individuals we call "trolls," viz., those who love to stir up controversy just for the sake of eliciting controversy. I have to believe that you are, indeed, a CaP troll.
Terry Herbert: A troll, eh? Well I suppose it is somewhat better than some of the others I was called back in those bad days when there was no legitimate support at all for the concept of not having immediate conventional treatment. Back then it was inferred that I had sexual congress with my mother and that I was a geriatricide amongst other insults from those who declined to consider any view other than their own. Fortunately for those men whose diagnosis is one that can be considered an insignificant tumour there is a growing tide amongst even the staid prostate cancer centres like MD Anderson and Johns Hopkins to counsel those men against rushing into unnecessary treatment.
I thought we had got over these issues by now with the wealth of evidence that Active Surveillance is an appropriate choice for some, but not all men. As I found out, when posting on another Forum recently, that ain’t necessarily so. There are still many people around who will not accept the fact that some variations of prostate cancer are indolent diseases that are unlikely to pose a threat for many years, if ever.
Re: The more things change, the more they stay the same
Terry,
That's pretty funny...it's definitely not a radical message anymore.
One thing that bothers me about the latest recommendations against PSA screening is that they seem to equate testing with aggressive treatment - "don't test because if we discover you have cancer you'll get treatment you may not need". Why isn't there more pressure on the medical community to support active surveillance in cases with lower PSA and Gleason scores?
Anyway, I'm glad you weren't deterred by being called a troll!
Re: The more things change, the more they stay the same
Dave the problem of how to stop ggresive action being taken aganst indolent disease is simple, I think. Stop giving the indolent disease a frightening name. It is the word CANCER that drives people into decisions. As Dr Lu-Yao says "The deep-rooted fear about cancer may drive the decision-making process, rather than scientific evidence."
I posted a piece on my other site many years ago that I called WHEN A CANCER DIAGNOSIS IS WRONG . It quoted an excerpt from a speech given by Dr Christopher Logothetis in 1993. He saw the problem clearly as did Dr Jonathon Oppenheimer in his BLOGwhen he suggested:
It is time to reconcile the discrepancy of the term that pathologists assign to a microscopic finding to the historical and practical significance of that term. The most common significant finding made by contemporary pathologists on prostate biopsies cannot be adequately described by “tumor” (Greek: swelling), “cancer” (from the crab-like extension), or “malignant” (threatening to life or tending to metastasize). I propose the terms “prostatic tubular neogenesis” (creation of new epithelial tubes or acini) and “potentially malignant” to better describe the microscopic findings that we have in the past labeled “adenocarcinoma” “cancer” “tumor” and “malignant.”
Dr Scholz says much the same thing in his book. We do it with other diseases, including other forms of cancer, so why not do it with PCa?
Re: The more things change, the more they stay the same
A Big Change
Earlier this week I invited one the countrie's leading PCa oncologist to talk at a support group meeting. When asked about AS she said this is definitly a treatment, but she insists on the following
1. PSA test every 4 months together with a DRE
2. Any changes in the PSA or DRE then a saturated biopsy
3. Every 2 years a biopsy.
Anybody to do AS as her patient must sign that they agree to the above conditions
Anothe interesting comment she made was by all means look at alternative ways, but do it under a medical doctor who has changed sides.
Re: The more things change, the more they stay the same
(Hi ya Lenny)
Some USA docs are using color doppler sonography to help a baseline and followup sonographies to try and capture the suspecious areas, they show up in red (I hear) and can show changes for suspecious blood flow areas for possible PCa advancing (is the theory or such). But needs to be done by docs whom are very good at analyzing this, and so is also used in A.S. concepts for management.
You can get these doppler guided biopsies to just the suspecious areas, if a doc wishes to go that route.
Dr. Lee and Dr. Bahn are amongest the best, there are some others perhaps in that league or close to it.
With Ralph Blum's/ Dr. Scholz book out- The Prostate Snatchers....A.S./W.W. will be a hotter topic than in the past, as can be seen on some forums right now. Just know the book is Ralph's doing and his biography or a 20 yr. journey and also entertainment with humor additions..doesn't mean alot of men can do A.S. for 20 yrs. safely and the cost of doing as he did would be prohibitive for many average men ( lots of travel, multiple docs, multiple opinions, various testings). He even admits some his journey is luck, prayer and such things. Has useful information in the book and I personally like Dr. Scholz and his tailoring treatments to the patient, I know of a few of his patients getting better findings or results. I support A.S. as my brother is in year 6 as doing such, without psa change and found with defined 'indolent PCa', alot to be considered in PCa issues.
You're absolutely right that there ARE changes in attitude among many of the enlightened doctors, but interestingly, there was a report recently that implied that the number of men choosing AS was dropping, not increasing, despite the evidence accumulating regarding the prevlence of Low Risk or indolent disease.
One thing that DOES bother me a little is that where a Gleason 6 was clearly likely to be a Low Risk disease, the 'migration' of Gleason Scores, which started in 2005 is ikely to continue, so there will, over time be more an more men with graded higher Gleason Scores than they would have in the past, thus making them ineligible for AS.
In passing I wondered what change in a PSA level would trigger a saturation biopsy in your expert's protocol? Given the variances possible in PSA scores, I'd hope it was a very clear and continous increase that triggered this dratsic move.
