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Questioning Surgery for Early Prostate Cancer

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Posted 7/19/2012 3:00 AM (GMT 0)
Another study questioning the efficacy of treatment for early PCa:

well.blogs.nytimes.com/2012/07/18/questioning-surgery-for-early-prostate-cancer/?hp
Posted 7/19/2012 4:04 AM (GMT 0)
Read it all, mostly the same stuff that's being debated right now here on HW.

To me, its still simple.

They need to have an accurate test, to determine the aggressiveness and/or strand of the cancer.

On the "safe" cancers, so to speak, eliminate immediate treatment until the cancer proves more agressive or dangerous, if not, i.e. entry level low risk pc - don't allow treatments, offer A.S. That would save hundreds of millions of dollars a year, and eliminate most of the alledged overtreatment. You don't cut off a finger because you have a splinter.

If you eliminate invasive treatments (surgery or radiation) out of the picture for those with an indolent cancer, that would drastically reduce overtreatment.

But we just don't have an accurate enough and practical enough diagnostic tool right now. That is the problem I see.

david

thanks for posting the link
Posted 7/19/2012 9:42 AM (GMT 0)
Well, surgery is also not effective for advanced PC. The question arises: is surgery effective at all?
Posted 7/19/2012 10:56 AM (GMT 0)
Agree, David, and sans the accurate diagnostic tool, one can only 'play the odds' as to the type of treatment he chooses....if and when he decides to be treated. The large number of 'variables' are what make this disease so very difficult.
Posted 7/19/2012 2:20 PM (GMT 0)
GOP-you are quite correct. Even with multiple opinions, seeing top doctors, in the end, for many, it's an some what educated guess, at best, when deciding one's primary treatment for PC. Also, in the end, the patient himself has to make that decision, and be willing to live with it, and with any bad results or side effects as the result of that decision.

Got to have better diagnositic tools, then the appropriate treatment would be less of a guess, and especially be geared more to the specific needs of a patient.

Then even with that, it still wouldn't eliminate all the risks or unknowns. Prior to my surgery, my surgeon did not know that I had a major anatomy issue in the narrowness and depth of my prostate bed, which led to surgical complications. He did not know that my body is prone to excesses scarring when injured, which led to the long series of strictures, stricture surgeries, and all that catheter time.

And the same can be said with Salvage Radiation decisions. Yes, I had met the basic criteria with 3 consecutive rises, so the surgery was considered failed. But after meeting with 3 radiation oncologists, SRT was pushed, yet they only gave me a 20% chance that it would stop the cancer.

Think about that point. That means there was an 8 of out 10 chance, it wasn't even going to work. Why would anyone in their right mind take on the risks, dangers, and side effects of radiation for those odds? Yet, that was what was reccomended to me, and of course, not only did the dangers of radiation directly ruin me for life, the radiation failed and didnt remotely slow down my cancer. I joke about this, but in a way, its like the radiation pissed off the cancer, because its been climbing with a vengence ever since.

I tire of all this endless debate on screening or not screening, testing or not testing, treating or not treating, if the real experts and the real doctors can't agree, not convinced our experts here have the answers either. Debating the same opinions over and over serve no purpose for those new to our disease.

The push should be for better and more accurate diagnostic tools. It's that simple to me.

David in SC
Posted 7/19/2012 3:44 PM (GMT 0)
Thanks, jazzman, for posting the link.

My crystal ball has been pretty accurate.  Over two years ago (March 2010), a couple months before the "Invasion" book was published, I wrote:  "By the way, brace yourselves for the tsunami of "overtreatment" discussions heading this way later this year when the Dr Mark Scholz book titled "Invasion of the Prostate Snatchers" gets published." 

This prediction couldn't have been more right, but two years later, even now that there is such a strong consensus among urologists and oncologists against low-risk overtreatment, I think it's sad that there are still pockets of outraged patient advocacy groups (like some folks at HW?) who think that we should resist change and continue (apparently) overtreating. The leading prostate specialists don't think it's hard to separate low-risk PC patients from others (many threads previously posted here on this)...why do the "novice/experts" here think it's voodoo?

Posted 7/19/2012 4:07 PM (GMT 0)
There is a misconception that there is no way to identify low risk PC from aggressive PC. Nothing could be futher from the truth. The AS guidelines published by Hopkins and Klotz alone do a pretty good job. If you add color doppler, MRIS and muliparametric MRI scans you improve the odds. Bostwick has a new test that can reliably distinguish aggressive from indolant pc and psa kenetics has always been a good indicator over time. If you combine all of these together you will get a probability that is well into the mid to high 90% range. Given that there are no 100% solutions in the pc world this is about as good as it gets. There are reliable ways to separate low risk from aggressive, it's just that most doctors don't use them or are uneducated about them.
Posted 7/19/2012 4:21 PM (GMT 0)
SpecialLady,

Surgery makes sense for younger men with intermediate PSA and biopsy results who don't like their luck. My urinary oncologist and I both had our prostates removed with test results for which the new conventional wisdom would encourage surveillance. His post-op pathology suggested that he could have waited, possibly for the rest of his life, and been OK. He probably has regrets. My post-op pathology report showed that my pre-operative tests had grotesquely underestimated the extent and the stage of my cancer, which is how I came to meet my urinary oncologist.

While I am depressed and grouchy that my surgery, which I had hoped would be curative, was instead the first step in a more-extensive treatment regiment (yet to come: chemical castration and radiation), I think of the surgery as a full-organ biopsy. It is dismaying that the only way to get any reliable information about the size and the stage of organ-contained prostate cancer is to cut the thing out, slice it up like prosciutto, and look at it under a microscope, but that's the state of the art just now. If I had not opted for surgery neither I nor my doctors would know that I have an aggressive cancer. I will be better off with my surgery, and the adjutant radiation and hormone therapy, than I would have been if I had waited for the cancer to progress so far that even the current crappy diagnostic tools couldn't miss it.
Posted 7/19/2012 4:31 PM (GMT 0)

SpecialLady said...
Well, surgery is also not effective for advanced PC. The question arises: is surgery effective at all?

SpecialLady,

There are situations in multi-modal treatment of advanced cancer cases where surgery can be beneficial (not curative)...although these are unique situations and every case is different (no one-size-fits-all solutions should be applied).

As PeterDisAbelard points out, surgery makes sense for most intermediate-risk cases.  (And for clearer differentiation, please note that much of the discussion in the last 2-years or so has been about overtreatment of low-risk cases...not intermediate-risk cases.)

PeterDisAbelard was not a low-risk case based on the subset of information he provided, and so active surveillance would never have been a viable option for him.  (He was not 3+3 or less)

To help answer your question, I've previously posted that PC is really two (or three) different diseases, and the treatment strategies are very different.  We should probably call low-risk PC by another name so that this type of confusion could be reduced/eliminated.

hope this helps...

Posted 7/19/2012 6:51 PM (GMT 0)

Casey59 said...


This prediction couldn't have been more right, but two years later, even now that there is such a strong consensus among urologists and oncologists against low-risk overtreatment, I think it's sad that there are still pockets of outraged patient advocacy groups (like some folks at HW?) who think that we should resist change and continue (apparently) overtreating. The leading prostate specialists don't think it's hard to separate low-risk PC patients from others (many threads previously posted here on this)...why do the "novice/experts" here think it's voodoo?

Where are these "Pockets," Casey? I've never seen anyone on this board advocate for overtreatment. That's a canard, and you know it.
Posted 7/19/2012 6:57 PM (GMT 0)
And also, which of us fall into the "novice/experts" category? Are all of us here on HW in that group, or do some of us fall into a higher category?

Post Edited (clocknut) : 7/19/2012 1:05:45 PM (GMT-6)

Posted 7/19/2012 7:33 PM (GMT 0)
Casey, precisely, because of what John T wrote at the end, that most urologists do not use the combination of all available tools that can accurately assess how aggressive PC is, if I had an early PC, I would be very, very suspicious about the diagnosis of "indolent disease". So many times, biopsy shows small disease and surgery pathology reveals an extensive cancer, we have seen this on HW a lot, just like Peter reports above, as well.

On the other hand, and this is just my theory, who can guarantee that "the moment" of indolent PC turning into an intermediate risk will be caught in time? What if there is a major life change, a man´s immune system that has kept PC in check is somehow compromised, which systemically allows PC to grow, and the next MRI and biopsy identify this, but by then some cells have migrated outside? It seems to me (and this is simply my observation from individual histories posted) that the surgery is very effective at a very early stage of PC, when PSA goes from 1.2 to 2.0, for example, and that the percentage drops significantly when it comes to intermediate disease. I realize this study claims otherwise, but statistics and a personal decision are worlds apart, perhaps even for the authors of those studies.
Posted 7/19/2012 7:49 PM (GMT 0)
SpecialLady, I hope you aren't implying that people on AS use only their initial case information and that an AS decision is forever...because your comment seems to overlook how a well-run AS program works. Someone needs to have consistent, repeated favorable results of ongoing surveillance to stay on AS. A low-risk case that migrates to intermediate-risk has moved into a treatment-appropriate stage, which is why those in AS programs who progress (about 30%) and have deferred treatments have the same outcome results as those who pursued immediate treatments...but 70% will have avoided the life-altering side effect consequences. Both are considered AS "successes": those 70% for the obvious reasons, but also the 30% because they were no worse off for having given it their best shot (and hopefully, they did give it their best shot by modifying their lifestyle choices to stack the odds in their favor).
Posted 7/19/2012 8:05 PM (GMT 0)
clocknut, your question is off-topic; but as JohnT indicated earlier in this thread not all doctors have educated themselves about PC to the same level, nor have patients (naturally).

Phenom, your question has already been answered (copied/pasted below); I think it was you who supported PSA testing (and biopsy? and next steps?) of asymptomatic men with <10 yrs LE (or were you just playing devil's advocate?):

Phenom, PC is generally slow growing. If a man is asymptomatic with <10 years life expectancy, then he likely has already demonstrated (deductively) that he doesn't have a rare fast-growing variety. Slow-growing PC takes longer, generally much longer, than 10 years to significantly affect quality of life. Treating someone asymptomatic with <10 years of life is the purest definition of OVERTREATMENT.

Posted 7/19/2012 8:24 PM (GMT 0)
Yeah, wondering who the condenscending remark of novice/experts applied to in particular? Didn't know we different classes here of people? This thread is full of snide remarks, apperently, to whomever doesn't exactly agree with a certain poster. I find that very displeasing on a support site.

david in sc
Posted 7/19/2012 8:38 PM (GMT 0)
Well, I freely admit I'm a "novice" and not an "expert" on PCa. I'll leave it to others to tag themselves as "experts," even if they don't have a medical degree.
Posted 7/19/2012 8:48 PM (GMT 0)
Agreed, clocknut.   And I hope that you see the point isn’t about you…and it isn’t about me.   When we read declarations made here that it’s purely voodoo on separating low-risk from high-risk, that’s a comment not based on knowledge which unnecessarily frightens people.   That’s bad for the site.   (Please note that the “voodoo” term is one I made-up for illustrative purposes; but I’d be surprised to hear you say you haven’t seen such comments posted.   Don’t ask me to go back and research the actual examples…)
Posted 7/19/2012 9:24 PM (GMT 0)
I came down on the aggressive side with my cancer. I don't regret although I'm still recovering. The great thing about Medicine now and PCA is we have many choices of treatment. I think that's unusual in Medicine and we're lucky to have these options. I hope that lasts and I hope it expects to other diseases. We're fortunate to have the option to err on over treatment.
Posted 7/19/2012 9:28 PM (GMT 0)

BillinChicago said...
The great thing about Medicine now and PCA is we have many choices of treatment. I think that's unusual in Medicine and we're lucky to have these options.

 

It's a blessing, and a curse.

 

What it indicates is that there is not one outstanding treatment choice...

Posted 7/19/2012 10:27 PM (GMT 0)

Casey59 said...


Phenom, your question has already been answered (copied/pasted below); I think it was you who supported PSA testing (and biopsy? and next steps?) of asymptomatic men with <10 yrs LE (or were you just playing devil's advocate?):

Phenom, PC is generally slow growing. If a man is asymptomatic with <10 years life expectancy, then he likely has already demonstrated (deductively) that he doesn't have a rare fast-growing variety. Slow-growing PC takes longer, generally much longer, than 10 years to significantly affect quality of life. Treating someone asymptomatic with <10 years of life is the purest definition of OVERTREATMENT.

I never supported any such thing. Show me where I did. I support more information rather than less, that's all. As for your asymptomatic man with <10 years life expectancy: when they tell you that you have less than ten years to live, are you going to just accept that as inevitable and give up fighting for more? I think not. I also think that if you had a PSA test under those circumstances and it showed an aggressive cancer that could well kill you within two, three, or five years without treatment, you would at least want that information to help make a decision about whether to do battle with it to try for another five years or so of life. I would.
Posted 7/19/2012 11:23 PM (GMT 0)
In my case having surgery with a 3+3 Gleason and a t1c going in was a big winner because I had urinary problems due to the size of my prostate. No More!!......Most people become very aware of stats and options after they find out they have PC. It might take them a couple of months to decide what to do but when they finally decide it is important for them to be very positive about their decision and for members of the support group they hopefully have established to feel the same.

The best URO in the world could be dead wrong about an aspect of cancer treatment. Improvement of diagnosis and treatment like Purgatory has mentioned is much more important than arguing about PSA or treatment of low-risk PC.
Posted 7/19/2012 11:34 PM (GMT 0)

Casey59 said...
SpecialLady, I hope you aren't implying that people on AS use only their initial case information and that an AS decision is forever...because your comment seems to overlook how a well-run AS program works. Someone needs to have consistent, repeated favorable results of ongoing surveillance to stay on AS. A low-risk case that migrates to intermediate-risk has moved into a treatment-appropriate stage, which is why those in AS programs who progress (about 30%) and have deferred treatments have the same outcome results as those who pursued immediate treatments...but 70% will have avoided the life-altering side effect consequences. Both are considered AS "successes": those 70% for the obvious reasons, but also the 30% because they were no worse off for having given it their best shot (and hopefully, they did give it their best shot by modifying their lifestyle choices to stack the odds in their favor).

Right! I'm on an AS program with Dr. Scholz and he's continually on my back about diet, exercise, and reducing my stress in addition to making sure that I have my yearly check-ups at my regular doctor for heart, lungs, bones, etc.

I had been putting off my second biopsy after my initial biopsy which had found my cancer. I put it off longer than I should because I feel fine and I watch my diet and exercise. Dr. Scholz insisted on a second biopsy or he would no longer keep me as a patient in the AS program. Begrudgingly I had it done and was happy to find that my cancer had not progressed.

AS is not a do-nothing option. You have to be committed to it to make it work. Given the option of doing AS or having my prostate removed or radiated (and the possible side effects), I consider myself lucky that AS is an option I can choose.
Posted 7/20/2012 12:30 AM (GMT 0)
Franchot,
Good for you. As indicated, I did AS (we called it WW then) for 18 months. I knew of a man who did it for 11 years before he actually needed treatment. Even though I never met him, he was my hero. I wanted to 'be that guy'. My 'numbers' got a little worse, and it became evident that I had to do something well before the 11 year mark. I'm glad that I did what I did, but I'm also glad that I put off any treatment until it was necessary. Good luck to you, Brother.
Posted 7/20/2012 12:59 AM (GMT 0)
Another questioning of a "no brainer". If I had taken the new gospel I'd be dead or doing hopeless hormone therapy by now. Mine was early and a GL 3+4.........so I should have let that stay in my body an hope for the best? I dont think so.......
Cancer is cancer...roll the dice or deal with the cards dealt you.
.
Posted 7/20/2012 1:07 AM (GMT 0)

gift of breath said...
... it is important for them to be very positive about their decision and for members of the support group they hopefully have established to feel the same.


gift of breath, you are right about that, and you will never see me be critical of a treatment choice that someone has already made. But I'm sure (I hope) that you can also see the fine line one walks in cases where we are strongly encouraging "the next guy through the door" that some of the conventional wisdom of the 1990's to aggressively treat everybody is starting to border on unethical today in light of the many studies that have emerged in the last years showing that low risk patients do not have better outcomes treated or untreated. The "next guy through the door" may be my son! I want him treated only if he needs it!

For those who have made their choices, better to celebrate their successes...


Great to hear an update from you Franchot!! And thanks for communicating to all of us about how Dr Scholz (one of the world's top experts in PC) stresses diet, exercise and stress reduction on a daily basis to patients wanting to stop or slow PC progression. Keep up the "active" good job!
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