Survival of PCa treatment specialists

Currently, the greatest number of PCa patients being treated are low Gleason grade guys. If this number decreases significantly based on the increased use of AS how will the number of PCa treatment specialists be impacted?

Will research dollars and university research go down impacting development of new drugs and procedures for higher grade PCa?

Just an early morning thought after I read a university advertisement for a new treatment procedure for Low grade PCa guys.

JackH,

Don't you think it would be likely that the research dollars would shift to a form of cancer, such as breast cancer, that can demonstrate a greater number of patients needing treatment? Versus shifting to higher grade PCa treatment research?

Jack,

Not asking what we "need" to do, that's in the eye of the beholder.

I am asking what will happen if the number of low grade PCa treatments go down, I expect many PCa doctors (imstitutions) to be forced out of the business and research dollars to be cut.

As screening decreases we will see an increase in the number of men dx at higher risk and more advanced stages. We are already seeing this start. And as our society ages, more men will come into the high dx years from 60-75. The good urologists will continue to have their hands full even as invasive treatment of low risk men reduces. Remember AS is a form of treatment and requires an urologist to manage it and get paid for doing so. I could probably build a business model that would show a strong AS practice could rival a surgical specialist over the long run and produce very steady income.

I have discussed this with my urologist several times. He just turned 50 and has one child in college and the other in high school. While he has been neutral on their career choices, he says he would counsel that the next generation of urologists will not do as well financially as the current one, if they showed an interest in medicine. The college son is in business school and the younger working hard to get a football scholarship..

With 30,000 men dying from prostate cancer every year, there is still plenty of work to keep the urologists and surgeons and radiation oncologists busy..

Prostate cancer is multi-focal..The average cancerous prostate gland removed by surgery contains 7 separate and distinct tumors. These tumors can have different Gleason scores. In about 30% of the cases, the original Gleason 6 diagnosis is downgraded to a higher Gleason score. A.S. proponents don't talk much about this but urologist / surgeons do and men being what they are will opt to "cut it out" as they have been doing for 40 years or more...I think it's premature to start worrying about the job security of the people who treat prostate cancer..

JackH said...
Largely, no.

Prostate cancer is really 2 very different diseases which have been given the same name. We dis-respect both in different ways by giving them the same name, and cause problems and confusion like your comment.

The reality is that the "bad prostate cancer" still kills 26,000 in the US annually. This will not change, up or down, by stopping overtreatment of the "good prostate cancer."

We need to re-directed the wasted, scarce resources over to research which prolongs life and uncovers causes of the "bad PC."

This certainly seems reasonable.

If the current thread on "focal ablation" can be used as an example, it seems that the researchers/doctors are getting into advertising for new less invasive procedures ..... to treat Gleason 6.

This is very interesting.

Just the other day, my daughter's friend's dad had RP. I asked if she could find out what his gleason score was. He told her he wasn't quite sure but thought it was 6 with some 7s. Dr apparently didn't inform his patient very well,or the patient didn't listen and obviously didn't do any research on his own. He got the final Path report and the dr said there was no cancer! Yay!.....

My thought was...great but, so sad....

By the way he had just posted on facebook that he was at Walmart buying depends...

Also, I've been talking to my brother about getting checked (he's 61 ) so he went for a physical and the Dr. did give him a DRE but stated he didn't believe in PSA tests after my brother asked about getting one and telling him about me.

My best friend and I have discussed this and he told me his dr doesn't believe in DRE's but will give him a PSA test.

I had 4 different drs give me a DRE before I got a biopsy. My primary and 3 uro's. My primary and one uro felt something "unusual".

So.... who do you trust? I know from past experience with duodenal tumors, that I needed to do my own research + I was fortunate I had a GI that was humble enough to send me to Virginia Mason.

Where and how the research money goes? I don't know the answer to that... but I do know ( from my limited experience) that there aren't to many Drs that can agree on anything about PC... to me "that" is mostly where the problem lies....you can blame it on greed or laziness to stay current with new treatments or that they have too large a case load,or all of the above, but whatever it is, it's a mess......

Fairwind said...
Grade 4 prostate cancer cells are aggressive and if left untreated can lead to death...They don't disappear or go away by themselves..That's why, in many cases, it's wise to get a second opinion on those biopsy slides..If grade 4 tumor cells are verified, then you are just fooling yourself with Active Surveillance..Postponing the inevitable..This is especially true if you are under 60 years old...Just my humble opinion....

Wow! Blast from the past! about 25-years ago, when everyone was way less-informed/knowledgeable about PC, this was what everyone actually thought! Thankfully, we've come a long way since then!

Hard to know where to start with this post. The ONE thing that was correct was the recommendation to get a 2nd opinion on one's biopsy slides in order to use the best available data to make decisions.

But the story about Gleason Grade 4 cells is not quite the one-size-fits-all story that it used to be. Active surveillance is recommended for many cases with 3+4 biopsy results. The notion of "postponing the inevitable" is a myth from the past because today's reality is that many men may never need treatment; but moreover it fails to recognize the powerful benefits of postponed treatments due to the rapid improvements made over time.

I think rather than spend a lot of time refuting item-by-item, it may be most expeditious simply to provide the reader with a myth-busting authoritative article, this one from Johns Hopkins and The James Buchanan Brady Urological Institute. The article is published in the Prostate Cancer Discovery newsletter, which is a publication of the Patrick Walsh Prostate Cancer Research Fund. The article titled "Good News for Men Diagnosed with Gleason 7 Cancer" was published 10-years ago. (In case you are unfamiliar, Johns Hopkins is one of the worlds' leading PC care centers.)

Here's the link, but this is the big take-away: "Not all Gleason 7 cancers are alike, and today we can tell them apart. Fortunately, most men have the less aggressive type."

urology.jhu.edu/newsletter/prostate_cancer_discovery_96.php


For some of you better-informed folks, I apologize for sharing such an old article (old news), but sometimes it's valuable to get back-to-basics.

Post Edited (JackH) : 9/23/2016 9:32:29 AM (GMT-6)

alephnull said...
What doesn't seem to make sense to me is the discounting of 3+4 PCa.

I'm not sure where you get the notion of "discounting."

That's what active surveillance is all about. That's why we watch it, not ignore it. Some cases may need action (treatment) some time in the future. (And just to be clear, some 3+4 cases have other case characteristics which may make it be unfavorable-risk, which makes this part of the discussion moot; the risk category is based on more than just Gleason score which is a common misunderstanding for newbies.) But we know today is that most of the secondary Gleason 4 advances at a slow rate (read the link from 10-years ago)--so slow for some men that it makes no difference and may have for all intents stopped growing. For the subset of initially favorable men who do have cases which advance to the stage of needing treatment, the studies show that their outcomes are statistically the same as those who went to immediate treatment...no better, but no worse. Bottom line, there was no penalty for attempting AS for those men and only the gain of further technological advancement, and for those who never need treatment, the benefits are astounding. Beyond that, I'm not grasping which part is confusing to you.

Post Edited (JackH) : 9/23/2016 11:55:00 AM (GMT-6)

I can respect that you have an opinion on this, and can articulate it thoughtfully and without ad hominem attack...and I will continue to do likewise.

In the very early days of Active Surveillance (which was only in the early 2000's), doctors took a very conservative approach, understanding that to have prematurely started with a looser criteria for AS would create a media frenzy and which would probably have been unrecoverable, and initially most ONLY allowed 3+3 cases. This was true with most the programs early on, but not all.

Dr Laurence Klotz at Sunnybrook was a good example of an AS program--and his program was/is one of the largest and most sophisticated--which took carefully selected Gleason 7 cases, mostly 3+4. Many of the current guidelines are now re-written based on his findings...although many are still have the conservative approach and are in a state of transition. Klotz wrote: "Active surveillance may also be considered for patients with Gleason score 7 (3+4), grade group 2, who have low-volume and percentage Gleason 4 pattern pathology (<10 to 20 percent pattern 4)."

I hope this helps to clarify that nobody is calling the 3+4 cases "just like" the 3+3 cases. They are similar, but different.

So, as I tried to clarify before, the risk category is NOT based on Gleason score ALONE; rather it considers other case characteristics...I would encourage you to try not making that mistake in your characterizations when talking about AS.

Active Surveillance is, and always was, for carefully selected men. It's just that about half of all new diagnoses are candidates for selection.


If you are interested in learning more, I would encourage you to look up Klotz's work.

Post Edited (JackH) : 9/23/2016 3:15:39 PM (GMT-6)

All I can say is "Wow, blast from the past." You pretty much nailed it...the thought processes from 25-years ago, that is, before there was data about AS and there was only anecdotes.

Today, we know that most men who undergo aggressive treatments are successfully...most but not all. But we know there still is a number of them that "fail" that treatment. When we peel back the onion and examine today's data more closely, this still happens with a very small number of men who were initially diagnosed with favorable risk PC. There is a wolf in sheep's clothes (which initially looks low risk) that aggressive treatment does not stop.

Let's look then at a cohort of similar men, also today, also initially diagnosed with favorable risk PC. A small percentage of them will also have, unbeknownst to them or their doctor, that same wolf-in-sheep PC. It doesn't happen more frequently, or less frequently than their cohort peers who sought immediate treatment; it happens at the same rate. They are the case "failures" of PC. The rate of failures between the two groups is the same. The SAME.

But there are two other groups of men who went the AS route who are case "successes." First, those who stayed on AS the rest of their lives. Second, those who moved successfully to treatment, once treatment was needed.

So today we realize that AS is not a "cure" for PC. There are some "failures." But the data tells us that the rates of failure are the SAME for low risk cases treated immediately or treated after AS.

Pretty much blows that old-school, pre-data thought process out of the water.