The reality of the over diagnosis rate of prostate cancer.

Ralph,
No one is saying that low grade PC never progresses and if that progression is left untreated in some cases will result in death. What your data does show is that progression is indeed slow and a G6 just doesn't turn into an agressive G8. A good AS program will identify progresssion and as Hopkins and other insitiutions have shown that delayed treatment has similar results to immediate treatment. Carrol's new data at UCSF indicates that AS patients on a diet, excercise program had significantly fewer progressions than a control group (none vs the normal 33%). The data is only 3 years old but is encouraging. Klotz also shows that the vast majority of progressions are identified in the 1st three years and he has data now out to 12 years for AS patients.
You cannot compare patients that are never treated to an AS program that is designed to identify those that need treatment and treat those.
There are always trade offs, and treatment of low grade PC has an 85% success rate, so even immediate treatment does not eliminate risks.
For selected patients, those with a psa density <1.5; a PSAD of > 3 years; low number of positive cores and low % of core involvement and low psa and G6 AS is a viable option and many of these patients will never need treatment and many will have delayed treatment for many years delaying side effects associated with treatments. Those that do get treated have the same results, (Catolona disagrees with this). At this time the only way to identify those that will progress is to monitor over time. Scans like color doppler and MRIS can also identify those that are more likely to progress and can be used to effectively monitor those on AS.
AS is not for everyone and a lot more work needs to be done to narrow the selectivity of patients. I still have a problem in reconciling that only 3.5% of men will die of PC; 17% are eventually DXed with it and according to autopies your age over 50 is the percentage of men found with PC. There are a lot of men who have PC that are never DXed and never die of it. Therefor there must be a high percentage of PC that is clinically indolant. These men never are included in any of the studies, and if they were it would definately change the data.
If our current treatments were highly effective and the side effects were minimal we would never be having these discussions.
JohnT

JohnT,
You are showing results from AS studies that have very short follow-up in a relative small number of men to demonstrate that GS6 always progresses slowly to GS8. It takes more than 15 years to really be able —in a significant size population—to demonstrate that premise. We are not there yet. In lieu of that and without comparing modern AS to untreated prostate cancer, I was pointing the studies mentioned in which progression and death from PCa is more common than we are led to believe. The intent was not to drive men away from AS. The intent is to alert them not to fall asleep with the impression that their cancer is IDLE and will never progress. That was my point. I know that eventually with many men diagnosed with low grade disease the logical choice will be AS. That is the way it should be.

The notion that “only” 3% of men die of PCa and many men have occult PCa and never die of it has been used to prove that PCa is indolent. Tell that to each man in the U.S. that dies EVERY HOUR of prostate cancer under 64 years of age. That is more than 25% of those that die of PCa every year. Those are the ones I care about!

The side effects of treatment can be bad, but the symptoms of progression that are very conveniently ignored are also very bad. I know men that postpone treatment with curative intent because they believe that they have an indolent disease and end up with cancer in their bones. At that point the disease is more difficult to treat and QOL is affected…

RalphV

Ralph said:
"Tell that to each man in the U.S. that dies EVERY HOUR of prostate cancer under 64 years of age. That is more than 25% of those that die of PCa every year. Those are the ones I care about!"

Bless you my friend. I agree with everything in this thread you posted and I am that man you refer to. Many have become complacent about how to represent "indolent" versus "aggressive" prostate cancer like it is merely defined by biopsy and Gleason sum. It isn't. We do not know a definitive way to make that determination and certainly G6 is not that definition.

There is no long term data on prostate cancer specific survival for patients that elect to go with this protocol whether they do it untreated or as a means of deferred treatment. All we have is biochemical failure rates which do not paint a complete picture.

Tony

TC-LasVegas said...
... certainly G6 is not that definition.

Tony, I think that this statement might be more complete and thoughtfully considered if you instead said,

 

"...certainly G7, G8, or higher is not that definition.  Indolent prostate cancer tumors do exist in some G6 cases, but not all G6 cases.  Active Surveillance entry protocols apply much more stringent criteria than just Gleason sums to weed out those who would benefit from more immediate treatment from those who can very safely defer treatments, which may include defering for the rest of their lives."

 

Sometimes an economy of words leads to an incomplete portrayal of concept and misses an important point...

---------------------------------------------------

Added later as an edit:  Don't feel bad about what I called an "incomplete portrayal" due to brevity.  I think at various times we are all guilty of this when we get hurried.  Sometimes the missing completness stands out more clearly to a new set of eyes.  As Horace the Roman philosopher said, "I strive to be brief, and I become obscure."  (And please don't flame me, calling me rude and condensending, for helpfully & constructively pointing this out...otherwise the moderators will have to edit you. )

Post Edited (Casey59) : 6/16/2011 7:08:15 AM (GMT-6)

Casey said, in reference to Tony's post above:  "Don't feel bad about what I called an "incomplete portrayal" due to brevity."

I do not assume to know better than Tony what Tony intended to say, so I'll take Tony at hs word.

One thing is clear to me.  This argument about the role of Active Surveillance will continue to be controversial here on HW.  Another thing that's clear to me is that there are certainly many, many cases where AS will work out OK for the men involved.  Maybe over 90 percent of the time.  Maybe even 99 percent of the time.  These men will avoid having to deal with incontinence issues and impotence (temporary or permanent) for perhaps several years, or maybe even a lifetime. 

But common sense tells me there will be some who will be misdiagnosed in spite of having excellent physicians and frequent testing who will develop more advanced cancers, and whose lives will be ruined in ways that make ED issues and incontinence issues look somewhat insignificant.  Some of these men will turn out to have unusual strains of cancer that act with unexpected aggressiveness.  We have men like that here on the HW site, I believe.  Others will get involved with AS and then become a bit careless...skipping doctor visits, procrastinating about PSA tests and DRE's. 

How many men will this be?  Is this just a "cost of doing business" that's justified in order to avoid the SE's that we all dread? 

So, while I can agree that AS can be an option for many, many men, I'll never buy the argument that we can know with certainty that it will work for any particular man or that his cancer won't progress beyond the point where it can be effectively treated before this is noticed by his medical watchdogs.  I don't know how many men that might happen to, but when we're talking about tens or hundreds of thousands of diagnoses each year, it could be a lot more than anyone would care to admit.  It seems to me that this sub-group gets swept under the rug when we have these discussions about AS and overtreatment.

 

That's not at all what I'm suggesting, and you're misreading my comment. I'm suggesting that both scenarios produce a "cost of doing business, not just the second. I would also add, though, that a program that fails to take human nature and its tendency to let even the most important things in life "slide," is neglecting a very basic fact. No, that's not the AS program's "fault," but it's a reality that needs to be considered. How do we predict if this particular individual is the kind of guy who will follow the program faithfully? I'm glad you trust the program to weed out the first class I mentioned I hope so. But if it ignores the second human characteristic, then it has a huge blind spot.

I've seen new guys posting on here who would literally sell their souls to avoid surgery. They're emotionally distraught, and in that state of mind would likely jump at the chance to do AS and avoid surgery. But, months later, when they're feeling good and asympomatic, will their fervor and commitment remain? And will the doctor be sufficiently mindful of his patient to say, "Oh, Jack hasn't been in for a few months. I think I had better call him and get him in here."

We routinely tell new people here that their typical small town uro/surgeon isn't all that great at treating prostate cancer....that they need to go to a center of excellence and so forth. But most will do as they do now. So, if we don't have all that high opinion of their uro/surgeons generally, why would we think that those same docs can faithfully adminster a first-rate AS program?

I know the AS program makes excellent logical sense. Unfortunately, human beings (and prostate cancer) don't always act in a logical manner.

What a wonderful series of post, very much appreciate ALL the info.  A reasonable person with little knowledge on this subject could go away with a real good understanding.

Thanks

Hero

A ten year old quote that you're not even sure he still agrees with???

As someone whose successful treatment wasn't likely even thought of back then, just let me say I'm glad I'm not so orthodox in my Pca thinking and research. For I sure wouldn't be enjoying the PC status I have now. A best case scenario I couldn't even dream of back in 2007.

If I was just dx I'd likely would be doing AS now. For those of the get it out of me crowd I never could understand how those 3-6 month AS psa checkups are so much worse than those they take post radical surgery? I think the latter would be worse for a poor result triggers SRT and a 70% failure rate while those who need to go to a radical treatment after being on AS are just begining initial treatments and have had a number of months/years of normal life without SEs, post dx. IMHO that's worth a slight increase in risk.

Tudpock and Ziggy.  Thanks.

I guess this might be considered a really good example of how dramatically the science of fighting prostate cancer has evolved in the last decade. 

It was just striking to see Dr. Epstein making those comments. 

 

Thanks, Tony. Once again, we have largely converged on many points of agreement.

I'll just summarize, then move on...feel free to tweak what I say, or not...

First, we both agree that G6 is not enough by itself to move to AS. On the one hand, it doesn't really matter what we agree...no doctor would every look only at Gleason score, but men here need to recognize this when giving feedback to newcomers. If someone simply posts in their first thread that they are G6 without furter info, we should not respond that they would be a candidate for AS; rather, that they might be a candidate for AS depending on other case characteristics. The way I've worded it in some other recent threads that the criteria for AS is "stringent", and if I remember correctly, you (Tony) were the one about a month ago who first posted about the publication of stricter NCCN guidelines for AS. I think we are saying the same thing here.

Second, you are correct about Dr Horan's viewpoint, but I'm not sure that precludes the facts he presented on thee early RPs mostly given to older guys (we know this is true, compared to the much younger guys today), and the higher mortality issues they had. Two sepeate things completely...although I have no further comment on this.

Third, I think you voiced concern about the AS pendulum swinging too far in the opposite direction...resulting in men who going on AS that are poor choices. If that happens I agree that would be bad, but that would be the completely opposite direction that it is now. We have far too few of the appropriate/eligible men going that route. I think we would agree at we should help move to the right level and not overshoot.

thanks

Casey said:
"...I think you voiced concern about the AS pendulum swinging too far in the opposite direction...resulting in men who going on AS that are poor choices. If that happens I agree that would be bad, but that would be the completely opposite direction that it is now."

I think until we have data on prostate cancer specific mortality for folks on AS we are playing craps with putting some folks on it. Some winners and some losers. The fact is we lack factual long term data. The pendulum has swung as far in the AS direction as ever before. And it has become quite common and yet we don't have the overall results still.

I think every AS patient should hear a balanced story about it...

Tony

Tikvah said:
"At the very least I WILL be getting frequent
tPSA & fPSA checks."

That is the smart thing to do for now. The day will come when urologists will recognize the value of separating those that need treatment from those that do not. AS is the first step in that direction. HOPE should never be ignored!

RalphV