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The over treatment problem

I am going to continue to try to get some feedback on this issue. Estimates vary but somewhere between 50% and 70% of new prostate cancer diagnoses are treated unnecessarily. Of course we don't yet know exactly which ones. We have a pretty good idea that all the low risk T1c Gleason 6 type tumors really should not be treated at least right away. Yet probably only 10% of patients who should enroll in active surveillance protocols do so.

Why is this? Right now, doctors seem to be blaming their patients and the prostate cancer survivor groups blame the doctors. I am writing a series of essays trying to think it through. It is now generally recognized that there is a big problem, but what to do about it isn't clear. e.g. . PSA Rising: http://thescienceofprostatecancer.com/category/psaovertreatment/
I would appreciate comments here or there.

Re: The over treatment problem

Whoops - dont know how I got the PSA rising site in there. My html is not so great. should be >: http://thescienceofprostatecancer.com/category/psaovertreatment/ :

(I hope)

Re: The over treatment problem

Had I not had a PSA screening test in 2006, in all probability I would be now dead. Gleason 7 (4+3), PSA 6, otherwise asymptomatic.
John

Re: The over treatment problem

John - statistically you'd probably still be alive and asymptomatic but you are someone who may well have benefitted from PSA screening.

Re: The over treatment problem

Peter if you wish to argue that PSA screening leads to over treatment without any demonstrated tangible increase in overall survival, then one surely must ask at what stage would you like to see men with PCa presenting? Take my own circumstance for example. In 2006 my PSA was 6, Gleason 7 (4+3), T2B, eight positive cores >60%, and one palpable nodule. At the time I was 56 years of age.

So assuming I would still be asmptomatic today, which I do not dispute btw, I can but wonder that should I have been presenting today, I would almost certaintly have either locally advanced or distant metastatic PCa? As a former health professional let me be quite unequivocal in declaring that treating my localised disease 2006 as it was back then, was decidedly preferable to treating an advanced one now. I say that, even given the plethora of new therapeutics that are coming online now.

Peter those of us that have dabbled in academia know that research statistics can be massaged to produce certain pre determined outcomes, particularly when $$$ and political processes are in play. What are the real costs in PSA screening? At what point are we prepared to ethically condemn a minority for the greater good, whatever that is? Perhaps you may care to enlighten us?

john

Re: The over treatment problem

John,

The advice in the UK remains - test PSA annually from age 50. I'm sure that's good advice worldwide. The testing of itself does not lead to over-treatment. It is the medical advice thereafter which may cause that. I hope it is now becoming obvious that in Gleason 6 cases, watchful waiting is advisable but that in Gleason 7 cases treatment may be required. I wonder if your PCa would have been picked up earlier and therefore been easier to deal with had you had PSA testing at ages 54 and 55, for example. In my own case, my GP had abandoned annual testing because of a mistaken concern about false negatives or positives (I can't remember which). I had testing from about age 50 to 57 or so, but never thereafter, to my cost. When the next testing took place (at my insistence) after the usual symptoms, when I was 64, it was too late, I was Gleason 9 with a PSA of 62. If only....

OC in England

Re: The over treatment problem

OC, PSA screening in Australia for men 50+ is pretty much the norm now among practising GP's. Believe me it took a lot of manoeuvring and education for that to become the accepted standard of good clinical practice. And now we have Peter, an American Radiation Oncologist suggesting we throw PSA screening out the window to save what, a few measly dollars for a pathology test? But we have to remember that in the United States they have a user pays health system, whilst you have the NHS and us Medicare. Their concept of health care is, if you cannot afford it, you don't get it.

In relation to my own circumstance, I am ashamed to admit my laxity in not having regular PSA tests from 50 years of age onwards, as I have a background in oncology. Still my GP ordered the test without my knowledge and had he of not done so, my PCa would almost certainly be in an advanced state by now. As I said to Peter, I had no symptoms. What a shock it was to find that I had PCa. Without PCa screening neither of us would have been any the wiser of the cancer that was progressing within our bodies albeit at different stages. Is ignorance bliss, as Peter would have us believe? Methinks not.

Well OC it will be interesting to see if Peter answers our critique? Perhaps our logic flawed. Over to you Peter.

Re: The over treatment problem

I am a physician who was diagnosed with a G 9 in 2009. I did a lot of library research on the problem. This is what I came up with:

A single spot PSA is a lousy way to diagnose prostate cancer. There is no lower limit beneath which you can be confident that there is no cancer, nor an upper limit above which you can be confident that there is a (still curable) cancer.

However a rise of PSA above an established baseline is significant. That assumes that a baseline has been established.

In my case, my PSA never went above 2.8. Would that warrant a biopsy? However my PSA had risen rapidly from a baseline of 2.1 up to 2.8. That change was significant, regardless of the absolute value, and did call for a biopsy. Which found a small G 9, which called for prompt treatment. Observing a relatively small but rapid change from baseline caught a very malignant tumor while it was still intracapsular. A baseline very likely saved my life. It is worth getting a baseline.

Re: The over treatment problem

Because it is called cancer.

Re: The over treatment problem

I feel that the current diagnostic regiment is pretty good. Men can make a decision to ( 1 ) try to get rid of the cancer one way or another - and perhaps be saddled with some ongoing side effects ( 2 ) delay treatment - active surveillance - so as to delay the possibility of negative side effects or ( 3 ) gamble and hope by doing nothing. Each man can make his own decision based on his priorities at the time of diagnosis. I don't think that there is an over treatment problem per say....just a need for the urologists to "calmly" give us our options upon diagnosis along with a recommendation based upon how they perceive our unique circumstances.

Re: The over treatment problem

Bobbyboy - The Europeans just published their 13 year update comparing PSA screening vs not screening and found an almost 30% decrease in prostate cancer mortality among those getting regular PSA tests. Never the less they conclude "Despite our findings, further quantification of harms and their reduction are still considered a prerequisite for the introduction of populated-based screening." To reduce 1 prostate cancer death they had to find a27 men with prostate cancer and treat all of them. That means that 95% of the men who were treated didn't need to be treated. Its a tough decision and hard for the doctors to make that decision for their patients. Its hard for the patients to decide.

Re: The over treatment problem

Yes, we tend to get kind of panicky upon diagnosis. It's not a nice feeling knowing that cancer is present in your body. I went to two urologists and neither made a recommendation. After I made the decision to have the prostate removed by a very high calibre urological surgeon he remarked that because of my age ( only 57 ) and good condition and with low grade cancer " it was a no brainer " to have it removed and move on with my life. I wish that he had given me more guidance beforehand to help with my decision - rather than allowing me to stumble into the " no brainer "treatment he felt best for me.
I think that screening is a very good thing, but those of us with low grade cancer could be advised to simply get another test done in 6 months. Perhaps liability concerns prevent this from happening. I don't really know what to make of the European studies....and I'm personally not a fan of active surveillance/delay. My Gleason was only 6, but they found that I had Gleason 7 after examining my prostate once it was removed. Gleason 7 is nothing to fiddle with so I feel I made the correct decision and should live longer for doing so - thanks to the PSA test.

Re: The over treatment problem

If the PSA test were good a picking up early high risk prostate cancer e.g. Gleason 4+3 it would be a no-brainer. But it is a test for irritated prostate tissue which occasionally is associated with cancer. The biopsy when positive is usually Gleason 3+3, T1c. That diagnosis is a real problem. There is probably a 10% chance the disease is significantly worse. So what do you do? You have to factor in your age and health and your odds on living another 20 years into the calculation.

The point is that doctors cant make that choice for their patients. Reasonable men might make very different decisions than their doctors would make for them. The huge problem is that most men have no reason to know all they need to know to make that decision until their diagnosis. Then they have to make a big decision on too little information.

Re: The over treatment problem

Peter whilst I agree with your PSA analogy, it is the only screening test we have to indicate possible prostate pathology. Whilst I understand your concern re unwarranted surgery being undertaken on persons with low grade tumours, we all know that physicians advise what is best for their patients. But of course that expert advice given by the physician is consistent with their training. Good luck in presenting your case to urologists.

Somehow I suspect your wish to halt unwarranted surgery may come to pass but not through the abolition of PSA screening. If advanced metastatic PCa can eventually be managed as a chronic long term disease as say diabetes, then the need for early surgical intervention decreases substantially. That day may perhaps be upon us in the not to distant future.

john




Re: The over treatment problem

To put it another way, the Gleason 3 type (3+3) cells are only marginally more likely to turn deadly than normal prostate epithelial cells. Most men wouldn't have their normal prostates taken out, but they would have them taken out if there are Gleason 3 type cells.

Re: The over treatment problem

Agree 100% . But who need's the education re long term implications? The patient or the urologist?

Re: The over treatment problem

Both

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