A second take on "PSA screening is worthless" etc.

The full text of the referenced article and accompanying editorial is now on line, and it seems that (surprise!) the popular press read in the research what it wanted to read. Summary and pointers to the original docs here: prostatecancerinfolink.net/2009/07/02/brawley-et-al-on-prostate-cancer-screening/#more-6242

I saw this post this morning. 

Again Mike puts a great reply to a study.  Clearly, the biggest confusion is using "averages" instead of individual cases.  With an average 12 year life expectency after diagnosis at the average age of 64, and a US life expectancy for males at 78, you can see how a general statement on the benefits might discount traditional therapy.  But each case is NOT the same.  Thise that are younger than the median age point, or with more aggressive cancers clealy benefit from therapy.  And the watchful waiting argument is seriously flawed as it is based on averages as well. 

In time, I remain hopeful to see a test that determines the differences between indolent and aggressive prostate cancer.  Until then, each case should be dealt with individually.

Tony

TC-LasVegas said...
I saw this post this morning. 

Again Mike puts a great reply to a study.  Clearly, the biggest confusion is using "averages" instead of individual cases.  With an average 12 year life expectency after diagnosis at the average age of 64, and a US life expectancy for males at 78, you can see how a general statement on the benefits might discount traditional therapy.  But each case is NOT the same.  Thise that are younger than the median age point, or with more aggressive cancers clealy benefit from therapy.  And the watchful waiting argument is seriously flawed as it is based on averages as well. 

In time, I remain hopeful to see a test that determines the differences between indolent and aggressive prostate cancer.  Until then, each case should be dealt with individually.

Tony

 

Every cancer is different and I think we are getting to the point where watchful waiting becomes a good alternative, taking into consideration all of the variables---age, GS, psa, biopsy results. Borderline cases should not opt for WW unless one's age is very advanced.

In general, that is very true, John,
I also know a few cases that were G6 small volume that went metastatic in two years after watchful waiting. It's back to my point that averages should not be used in case by case occurances. We do know that many cases take a sudden and uncontrollable turn as well. We have no tools to define when that might happen. But in general, we are over treating many cases of prostate cancer...

Tony

As much imaging as possible is very sound advice before moving forward with watchful waiting. It is tough enough to make that the call as a patient, I don't entirely fault the doctors. Some of us, can't weather the do nothing idea, and some of us would prefer it when it's not a good idea. I believe that when a better prognostication tool comes out, doctors will use it gladly. Until then, it's our own call.

As a 35 year old, is it best to wait with moderate grade cancer or move now to remove it? No one can answer or make a recommandation about it scientifically. Why? Because a 35 year old is never included in prostate cancer studies. And anywhere below the median age of 64 years old for prostate cancer would anyone like the average time for prostate cancer to become life threatening if they have a life expectancy beyond the average.

We do know that intervention of some kind has it's benefits.

Tony

There is a paper published by Dr Laurence Klotz, Professor of Surgery and Urology at the U or Toronto that does a good job of summarizing alot of the studies on active surviellance. It seems that PSA doubling time is the prime factor in low risk progression. As long as it stays over 3 years the chance of a progression that will kill you is virtually nihl.
In one large study 66% are still on AS after 7 years with no progresssion. 12% opted for treatment with no progression, because of the psychological stress of not treating it, so 78% showed no progression. 1% died, but their PC progressed within 6-11 months and was most likely mestastic at the diagnosis, so no treatment would have helped. The rest underwent treatment when their PSA progressed or gleason went to 7.
These results are comprable to any treatment options with a G6, low core, low PSA.
The tests are a lot cheaper than any treatment option and most insurance covers them. If PSADT is the true indicator of progression vs indolant then the tests are really cheap.
To me this is a very good low cost, low risk option for patients who meet the AS criteria. A 78% no progression rate vs a 100% chance of side affects from treatment sounds like a good risk reward tradeoff to me, especially when an excellent chance of cure still exists if the PC progresses.
I know there is always the psychological issue of living with PC, but a Swedish study showed no psychological difference in those who were treated vs those who were not. PSA anxiety and worry about reoccurrance existed in patients who underwent treatment.
David and Tony, I don't think we have any disagreements except that I believe that AS should be considered in many more cases than we are currently seeing and many patients are not given enough information to seriously consider this option.
JT

And in some people's way of dealing with cancer, is they like the confidence of working with a good, experienced doctor that they trust, and they like to have a game plan that makes sense for them, they like to have good local medical facilities to be treated in, and they like knowing that they are being pro-active at their own level to start dealing with their own personal reality of having a cancer in their body.

Not everyone we run across here is interested in every technical aspect, every possible available treatment or theories about future treatment. They have cancer, they are scared, they want to live, they want to act, and they want to feel like they have some say and control in the matter.  And some people are just simply good at making quick decisions, where others take forever to decide the simplist of matters.

Once they decide, and some decide on their primary treatment quickly by choice, they find a certain level of relief.

It's most important that we support everyone's personal decision. It is not our place to question their intelligence, their motivations, etc. In our format here, we will never know the whole person we are dealing with, we don't fully know their full medical histories, their family histories, their threshold to pain, their generalized feelings about medical care, their personal economic situations, and even the specifics of where they live and what medical facilities they have "real life" access to. There are so very many factors.

You are right to say, there are men that are more afraid of potential side affects then the means to get a cure. That is kind of the cart before the horse. Going into what was to be a non-nerve sparing open surgery, I never ever expected to have "regular" sex again, my wife and I were ok with that, and with all that said, I didn't and still don't suffer from any evidence of ED, never had to use even a pump, or not a single sex pill. I know that I am in a tiny minority, but I didn't know that ahead of time.

Judging the fear of others is hard too, what scares me won't scare you. I told my dr. on the night of my dx., that I had no fear of surgery (having had many), but I was terrified of radiation due to a bad exprience with 35 days of radiation less then 10 years ago at the time, so for me, my own fear quickly limited my choice of treatment. open vs. Robotic, easy to eliminate robotic for me, only 15 had been done in my area at the time, and I didn't want travel and logisitical problems for my loved ones, so that is how I went to open.  Our choices are often made and tempered by our current realities in our lives.

Best bet is to warmly welcome all here, to encourage all, to help abate their fears, and our own, and to support whatever choices are made by each individual man. That's my opinion.

David in SC

Engineer,

You are thinking right about this. Not knowing is never a good answer. Makes you wonder if they are blaming the PSA for being such a good inexpensive indicator of what might be going on in one's prostate gland. It is what it is, not testing won't make cancer go away, it may just make it worse by not knowing.

livin-  looks like a $30 blood test saved your life.   In my case sure I could have waited, but I really do not see the damage in taking care of something now as a bad thing.  It still has to be done.  Annual testing and monitoring with an eventual final in  5-10 years  would have cost a lot more in the long term.  Lets thank the lucky stars we have a winner in the PSA test, much better than the colonoscopy, and there are so many with no  way to get an  early tell.

I owe my future to PSA testing.

A G9 won't wait .

The "widespread screening" and "this cancer is overdiagnosed" discussion has metastasized...to breast cancer. See www.bmj.com/cgi/content/abstract/339/jul09_1/b2587 and a discussion at prostatecancerinfolink.net/2009/07/10/screening-and-cancer-the-controversies-are-spreading/.

Now the feathers will hit the fan!

This has been a great discussion topic. Different points of view presented in ways that are both thoughtful and respectful of the opinions of others. I sometimes worry that those of us on this board have a bias in favor of active treatment rather than active surveillance (myself included) but this thread illustrates an even stronger bias: Active and informed consideration of all alternatives.