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30 Year Data on Untreated PC

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Posted 11/19/2012 4:38 PM (GMT 0)
Ralph,

It is a disservice to men to blend ("average") all cases of prostate cancer together.  Prostate cancer is two, or perhaps three, very different diseases. 

On the one hand, the "averaging" pulls-down awareness of the seriousness of the aggressive, potentially deadly versions of PC.  This is illustrated through uninformed comments along the lines of referring to PC as a "lucky" type of cancer.  Although this high risk PC only affects a small percentage of the total number diagnosed with the disease, there is nothing "lucky" about it for the roughly 25K men who will die in the US from PC or their loved ones.

 

On the other hand, the "averaging" also irrationally elevates men's "cancer" fears when they are diagnosed with a tiny case of low-risk PC which should be treated (in the words of one world-renowned PC expert) similar to how one monitors & treats a case of dandruff. 

 

The reality is that PC is among the most common and least lethal malignancies which yields a large population of survivors, but not all are survivors.  Language is important.  Should both ends of the PC spectrum be given the same disease name?  There are plenty, and a growing number, of the PC experts in the world who say this is a disservice to men like you. 

Posted 11/19/2012 4:41 PM (GMT 0)
Casey,
Don't you think that the disservice is related to telling men that most men die with prostate cancer than from prostate cancer when there has been a fairly constant number of deaths throughout the years. Once diagnosed some 12% to 15% die of the disease. Instead they tell men that only 3% die of the disease...

More so when the "overtreatment" rate number is calculated in various ways and not a real number?

The Johansson et al study used a cohort of an average 72 yo men to prove that very few men died of prostate cancer. Add to that that a significant number of men that progressed were treated with androgen deprivation to boost the low mortality figure. How is that for reliable science?

RalphV
Posted 11/19/2012 5:34 PM (GMT 0)

Casey59 said...

Both sides of this point which are notable: First, we recognize that some (not all) of the advanced cases (of which there are only a minority of the total number of PC cases diagnosed) are in fact unstoppable. It was Dr Willet Whitmore—known as the father of modern day PC oncology—who said decades ago that PC survival has less to do with treatment than with the biology of individual tumors

Casy59,

I appreciate your comments and views but I don't think your statement is supported by either cancer mortality statistics or logic:

Statistics: If you are correct, the rate of prostate cancer specific mortality should be constant over time, yet since the start of PSA testing, period mortality rate (mortality per fixed period, say 10 years, 15 years...) kept decreasing. Take 5 year rate: Pre-PSA(1975)=30.8%; Post-PSA(2004)=.1%. Take 10 year rate: Pre-PSA(1975)=46.5%; Post-PSA(1999)=1.4%. If your statement is correct, then how come those that has "bad biology of individual tumors" all of a sudden have gone away after PSA was instituted? There is nothing we can do about those "bad tumors"? You cannot explain away that the improvements are all due to improvements in treatments either since the mortality rate for those that was diagnosed after metastasized has not change much since 1975.

Logics: If we can detect cancer early before they spread, even those that has "bad biology of individual tumors" and get rid of the prostate so there is no more "bad biology of individual tumors" how can the prostate cancer specific survival be the same? There is no more prostate cells to turn into prostate cancer cells. Simple logic tells me that if I can detect it early and get rid of it all, I cannot have it again.

Of course over treatment can happen and happened but the survival benefits of PSA testing and early treatment of prostate cancer seems clear to me.

Regards,

Post Edited (Newporter) : 11/19/2012 10:40:10 AM (GMT-7)

Posted 11/19/2012 6:39 PM (GMT 0)
Thanks for your comments, Newporter. Dr Whitmore’s comments from several decades ago (or Dr Myers' more recently) do not mean to imply, I believe, that PC survival has ONLY to do with biology and NOTHING to do with treatment…rather it highlights that relative weighing of each.  It's not a "0" or a "1." For a fraction of the men diagnosed with PC, the disease is indeed unstoppable.   It is true, as you point out, that PC mortality has been favorably impacted in the last 2 decades by new advanced treatments (in the so-called “golden era of PC drugs”) which have prolonged life…no doubt about this.   Make no mistake, these cases are not being cured; merely outrun.   (Don’t get me wrong, outrunning cancer is a good thing…it is, in general, a better thing to die with PC than to die of PC.) But Newporter, your “simple logic” seems to promote the removal of prostates in all men who show signs of prostate cancer “before they spread” [as per your paragraph labeled:   “Logics.”]   That would be about roughly 50% of all 50-year olds in this country (based on autopsy findings of men that age who died accidentally).   Thankfully, many doctors today are realizing that—although many of their own peers have followed this agenda in the recent past—this is not conscious-based medicine.  (Nor is the gross overtreatment a healthcare model that we can sustain.)
Posted 11/19/2012 7:08 PM (GMT 0)

Casey59 said...
But Newporter, your “simple logic” seems to promote the removal of prostates in all men who show signs of prostate cancer “before they spread” That would be about roughly 50% of all 50-year olds in this country (based on autopsy findings of men that age who died accidentally). Thankfully, many doctors today are realizing that—although many of their own peers have followed this agenda in the recent past—this is not conscious-based medicine. (Nor is the gross overtreatment a healthcare model that we can sustain.)

Thanks for your reply.

I am not advocating surgery nor am I promoting removal of prostate cancer for all men who show signs of prostate cancer, I was just pointing out that Dr. Whitmore's statement was not logical.

As for the fundamental issue of prostate cancer testings and treatments, I think the jury is still out.

Have a good day.
Posted 11/19/2012 7:24 PM (GMT 0)
Casy59,

I also want to acknowledge that you are correct, that advanced treatments have prolong life, even for those with metastasized prostate cancer. The period survival rate keeps increasing; people are surviving longer and longer even though the end point mortality has not changed, just that it has been pushed back further and further into the future.

Thank you for pointing that out.
Posted 11/20/2012 4:12 PM (GMT 0)
John T
1st of all, I thank you for your service and hope that you received the VA compensation that you were entitled to. I enjoyed your "jest" regarding your toxic golf course and garden.
Exposure to AO in RVN varied of course, and in my case running convoys through central highland passes daily resulted in being sprayed frequently by both the NVA and "crop dusters"; I was being actively defoliated--LOL.
Your statement coincides with the premise that the task force utilized to help justify their recommendation of "no screening". There are "those whose cancer will result in death despite early diagnosis and treatment". I cannot subscribe to this defeatist attitude. The recommendation of "no screening" will endanger "high risk" veterans utilizing federal medical facilities. The 2008 UC Davis Cancer Center Study utilized a study group of over 13,000 vets and no-vets over a period of years. The end result was that Viet vets were 2x more likely to have prostate cancer than non vets and were 4x more likely to present with metastatic disease..My recommendation is that they be provided with the opportunity to live..They are our brothers! I assume that you and the majority of this forum were diagnosed due to screening.
Bill--Age 70--A "seasoned" vet
Posted 11/20/2012 7:03 PM (GMT 0)
gunfighter,

you said, "Your statement coincides with the premise that the task force utilized to help justify their recommendation of "no screening". There are "those whose cancer will result in death despite early diagnosis and treatment".

 

I cannot subscribe to this defeatist attitude."

I agree.

Posted 11/20/2012 7:41 PM (GMT 0)
Ralph said: "Once diagnosed some 12% to 15% die of the disease. Instead they tell men that only 3% die of the disease..."

It seems doctors cook the books the way Madoff cooked the books.

The fact is that 1.9% of men currently living with prostate cancer will die of prostate cancer PER YEAR.

This averages out to 14% over time. Thus while we cannot use the 14% number we see when we report that 230,000 will be diagnosed this year and 30,000 will die this year, the statistics used by the federal government are the 1.9% per year number...

Seems kookie but that's how they report it...

Tony
Posted 11/20/2012 10:25 PM (GMT 0)
When I was diagnosed with PCa, I was told it was low risk and I could watch it. I also knew that they took a very small sample of my prostate and that I could have had (a) a greater volume of cancer than suspected, (b) more aggressive cancer than the biopsy samples revealed and (3) a chance that the tumor would grow and spread before detected by active surveillance. I also knew that the older I got, the harder recovery would be.

Whatever the biology of actual cancer I had, it wasn't going to improve on its own or go away on its own, but it could have grown and spread on its own. So while I don't love all of the changes I've gone through as a result of the surgery, I would still opt for treatment rather than watching.

Each of us is a universe of one, and in a universe of one, statistics are meaningless.
Posted 11/20/2012 10:33 PM (GMT 0)
Here is a link to Johns Hopkins data for RRP over 30 years.

The article in this thread was on low risk PCa not treated and the mortalitiy rate. The Johns Hopkins low risk group who were treated experience only 2 deaths over 30 years and both had SVI. All of the OCG6 survived without even developing systemtic spread. Some suffered BCR but did not progress. I think this says alot about treating low risk PCa with surgery. Seems to almost wipe mortality out if you treat it.

http://urology.jhu.edu/SupplementaryResources/Kaplan-Meier.php
Posted 11/20/2012 11:20 PM (GMT 0)
In spite of the advanced age(mean 72 years of age) of the study participants, 40% progressed after diagnosis. This tells a different story about the fact that low risk cancers never or hardly never progress when untreated.

There are lessons to learn about this study. The assumption that progression is without consequence is negated by the study; The authors reported:”Postponement of death is not the only treatment objective because local progression may create substantial suffering. Indeed, many of our patients experienced symptomatic local growth without generalized disease (Table 1), requiring treatment with estrogens or orchidectomy.” To this day, this lesson continues to be widely ignored…

RalphV
Posted 11/21/2012 1:12 AM (GMT 0)

ralfinaz said...
In spite of the advanced age(mean 72 years of age) of the study participants, 40% progressed after diagnosis. This tells a different story about the fact that low risk cancers never or hardly never progress when untreated.

One of the key lessons from this data supports that Active Surveillance is such an important option for men today with low risk PC, and the importance of not rushing into treatment.  40% progress; but a significant proportion of men with low risk PC do not progress, which makes aggressive treatments unnecessary.  This is a potential huge success for thousands of men who are overtreated today and suffer unnecessary QOL consequences. 

With today’s AS protocols (which were a generation away when this study was started), men who show signs of progression are successfully treated before treatment becomes a jeopardy…the rates of cancer control success are essentially the same for those initially on AS as those who seek immediate treatment.

To FrankMe’s earlier question/comment about not grasping how statistics can be useful to the individual, men and women who understand statistics successfully use statistics every day; it has become an indispensible tool for the leaders in medicine, business, manufacturing, farming, and just about every way of life.   While our industry leaders use stats as a tool, Scientific American magazine recently published an article about how many people in other walks of life fail to understand even basic statistics, and how more basic statistics education is needed for our general population. 

One of the mistakes many people make is believing that statistics will predict exactly what will happen in their case.  This is not a problem with statistics; it is a problem with people not understanding statistics.

Statistics are estimates that describe trends in large numbers of people.  What statistics can tell you is whether you are in a great big fight, a medium-sized fight, or a little fight.  People win and lose all three, so it just tells you what your fighting mind-set is.  It tells you what level of risk you might be wise to take in treatment.

The meaningful statistics show that low risk men have an extremely low risk of ever dying of prostate cancer, whether they are treated aggressively or not...and not a lot of difference in outcomes whether they were treated or not.

Post Edited (Casey59) : 11/20/2012 6:18:29 PM (GMT-7)

Posted 11/21/2012 3:34 AM (GMT 0)
Casey,
The 40% progression happened in a study in which the participants were diagnosed at an advanced age. Would the same hold true if the average age is 55 to 60? This study does not answer that question. Most of the AS current studies are not mature enough to answer that question either. What is worse is that there is little support for AS by urologists at this point in time. Sad but true.

This is to say that AS needs to be considered as a proper strategy by those that by their age, disease aggressiveness and proper medical monitoring qualify for the treatment.

I totally disagree with your concluding paragraph. How then is it possible to explain the 40% PCa mortality reduction during the last 17 years?

Statistics might not tell what happens in an individual case, but it tells you what happens when large populations are properly sampled and followed. The study in question here intended to define the untreated natural history of prostate cancer.

The population chosen was rather small and biased as related to age. Those that progressed were treated with physical castration or estrogen. In other words, results were contaminated to an extreme in which the definition of the natural history of untreated disease cannot be explained for a younger populations of men.

I know that over treatment for PCa exists. I have had first hand experience of that in the 20 years I have survived the disease. The real question is: what is the true rate of over treatment? Many figures are reported based on definitions and using computer models. In real life and based on surgical histology results the Tyrol study yielded 8.7% of over treatment. The number here might be somewhat higher but never the 80% to 90% reported.

RalphV
Posted 11/22/2012 2:54 AM (GMT 0)
Crasey59,

I did not say I don't grasp how statistics are useful to an individual, I said they are meaningless to a population of one. If there is a 95% chance of survival in a population, that means 95 of 100 will survive and 5 of 100 won't. In a population of 1, you either live or die from the disease, you don't live 95% or die 5%. The 5% of the sample die and it doesn't matter to them that 95% survive. Each of the 5% have a 100% mortality rate.

Go into a casino. The casino has a 1-5% edge, but you will likely lose 100% of what you risk. Does the 1-5% edge have any meaning to you?
Posted 11/22/2012 3:46 AM (GMT 0)
it seems like some have intent on saying it does not matter what one does for their cancers ~ they either don't need treatment and treatment for local low risk disease gives no benefit...

I do not agree with that. And I do not agree that this study of 223 men in Switzerland draws ANY conclusions in that direction. Like I stated earlier, until we have a test that can tell us what disease is aggressive or indolent, we will have to accept that at least some men will be treated when they didn't need it, and some men will die of apparent low risk PCa identified at biopsy.

I stand with Ralph. Until someone can explain the 40% reduction in the rate of death by prostate cancer since the initiation of screening and early treatment began, I will attribute it to screening and improved therapy.

When you take retrospective study and try to apply the future to it, it is truly of very little use...

Tony
Posted 11/22/2012 3:52 AM (GMT 0)
were young men in their 40s in this study?

Seems like a fetish to disprove the dangers of PCa among some. No idea why...
Posted 11/22/2012 4:44 AM (GMT 0)
David,
It is not likely that there were enough men in this study to give us many young guys if any at all. Without PSA screening it is very unlikely that more than just a very few men in their 40's were a part of the study. And if they were in the study, they were more likely advanced cases...The average age of diagnosis in the 80's was about 73 years old...

Tony
Posted 11/22/2012 5:03 AM (GMT 0)
Didn't anyone actually READ the link before commenting or grasp what it means...?

ALL of the men in this study were symptomatic...ALL of them.
Posted 11/22/2012 2:21 PM (GMT 0)
Here is Johns Hopkins view on surgery and PSA testing put out on their 30th anniversary.

The cumulative impact of these discoveries has

been an improvement in prostate CSS in the PSA

era. In fact, estimates of prostate cancer death rates

in the United States have decreased more than 40%

since 1991, and in recent years, there has been a

continued annual decline of 3.0% to 3.5%.

Surgery in improving cancer specific

mortality was demonstrated in a randomized trial,

in which at 15 years, surgery improved MFS, CSS,

and overall survival by 50% compared to watchful

waiting, especially in men younger than 65 years.

 

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