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"Number of Advanced Prostate Cancer Cases Soars..."

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Posted 7/27/2016 10:09 PM (GMT 0)
Dan0-
Anyone can reasonably quibble with the autopsy numbers - they are not a random sample. What they do tell us is the magnitude of the issue - and it is enormous. In a more recent study, from 2013, the rate in autopsied 41-50 y.o. Caucasian men was 29%. In a recent survey of autopsy studies, the authors conclude: "Autopsy studies have shown that in West-European and American men, the prevalence of prostate cancer at the age of 40–50 years is about 20%–30%. Most, but not all studies show that PSA-detected prostate cancers at age under 55 years are low grade." Rates are higher among African-Americans and lower among Asian nations. Even if we take 20% as our best estimate, the public health implications of 4-5 million more men getting radical treatment (mostly surgery) are unconscionable.

Graytech-
As you can read in this study, "almost always" means a 98% 15-year prostate-cancer survival rate among men diagnosed under 50 years of age.

ShinytopPC-
You jumped to an unwarranted conclusion, and one which I never stated, based on your confusing the words "testing" and "screening." They are very different. There are many cases where we should test (but not screen) younger men - e.g., African Americans, those with strong family history that might reflect genetic abnormalities like ATM or BRCA2, and those exhibiting symptoms indicating aggressive or metastatic disease. I am saying that we should be wary of a public policy that screens all men under 50.

- Allen
Posted 7/27/2016 10:22 PM (GMT 0)
There are more than one reason for the increase in "advanced" detections. Certainly before May 2012 there was no association with the USPSTF Grade D recommendation (Which is currently under review) as at that time it was finally instated. The papers that were cited by Wilt et al, were the 2008 ERSPC screening study in Europe, and the PLCO study which was heavily flawed and contaminated. But from 2002 to sometime after the grade D was issued there was already an increase metastatic cases. Here are possible contributors:

1. Rise in obesity in the US.
2. New diagnostic tools and increased use of scans.
3. Increased use of 5ARI drugs.
4. Increased use of lymph node dissections in RP's.

The USPSTF recommendation did not take hold until May 2012. By that time the use of 5ARI drugs, without trials, was increasing heavily since the 90's. Also, lymph node dissections are being done regularly today in RP's when in fact in the early millennium they were not done more than 50% of the time. Of course a positive node would qualify as "advanced" but not necessarily "metastatic" but the article says the increase is in "advanced" cases.

To say that this increase is due solely to the USPSTF Grade D is not true at all. To state that the Grade D is a contributing factor is at best hypothesis that has never been confirmed. But to state that the increase is due to more aggressive tumors is also a speculation where we need better data. I do believe that the USPSTF will change their Grade D to a Grade I by Spring 2017. If a Grade B is going to come out it would more than likely be for men from Age 55 to 69.

But that's a stretch.

Note: I changed the references of metastatic to "advanced" keeping in line with the article.
Posted 7/28/2016 12:03 AM (GMT 0)
With more PSA tests we could find out before the cancer is not curable; but at the risk of some men possibly having side effects from over treatment. But more testing should save more lives.
Posted 7/28/2016 12:07 AM (GMT 0)
I look at myself as an example of a 40-something baseline. I don't remember exactly when I started getting annual DRE and PSA's done. It was, however, sometime around my 40th-45th bday. I've always had my annual physical within a month of my birthday...it's a good reminder. Have a birthday, call for an appointment.

My PSA was non-detectable on the standard test for a number of years, and no abnormalities on DRE. It was only after 3 successive annual increases of my PSA (from <1 to 1 to 2 to 3.3) that I sought out a Urologist. And, that, to me, is the 'right' way to go about it.
Posted 7/28/2016 2:39 PM (GMT 0)

halbert said...
It was only after 3 successive annual increases of my PSA (from <1 to 1 to 2 to 3.3) that I sought out a Urologist. And, that, to me, is the 'right' way to go about it.


Maybe, hopefully, there was more to the story than this...but this, as stated here, is not the narrative that we should be articulating to newcomers as being the "right" way to go, or encouraging them to follow this path to likely overtreatment.

Jumps in PSA in an otherwise favorable risk case...these were most likely indications of a prostate infection. The AUA says that the "best practice" in such instances is to work diligently to eliminate the likely benign causes of moderate PSA elevation before proceeding to biopsy...because guess what? Once a biopsy is performed on a 50+ year old man and examined under a powerful microscope, PC is likely to be found and then...welcome to the slippery slope which typically ends with one's prostate being quickly "snatched," while the doctor reassures us and deifies himself (despite the favorable post-surgery pathology that still would have qualified for AS) that it is "a good thing we got this out now."

This original description above, as worded, is not the "right" path that medical professionals today recommend to be followed...

Post Edited (JackH) : 7/28/2016 8:47:25 AM (GMT-6)

Posted 7/28/2016 3:22 PM (GMT 0)
Jack, there was also a change in the DRE finding. My observation was that after years of non-detects (at least 10 in a row), something started happening. Which IS the point of having a stable baseline first. And, with a final finding of 20% involvement, at 3+4, in all 4 quadrants suggests that I most likely would have needed treatment sooner than later.
Posted 7/28/2016 4:05 PM (GMT 0)
halbert, you shifted to defending your own case.

My point, on the other hand, was not about you in specific because your water is over the dam. My point was that you seemed to suggest that the "right" thing is for others in similar situations to follow your footsteps...while the medical profession today is not necessarily recommending that sequence, and nor would I. Following today's professional recommendations would FIRST focus on the likely benign causes of PSA elevation, but then may or may not have ultimately lead (a year later, 5-years later, 15-years later, maybe never...impossible to tell now) to a type of aggressive treatment such as you sought within weeks. AS programs lead men successfully to treatment when they need it at rates of success which equal the ultimate success rates of those who seek immediate treatment...but the point (which is for us to offer as "PC vets" to other newcomers) is that this only works when men who fit the profile give AS a chance to work. And that takes TIME for favorable-risk cases. They are given the gift of time...they should use it. Thankfully, many more are realizing this today than just a few years ago...

Post Edited (JackH) : 7/28/2016 10:08:04 AM (GMT-6)

Posted 7/28/2016 4:09 PM (GMT 0)
It's OK, by the way, to suggest to someone that it would be wise to: do as I say, not as I did.

We are all smarter today than we were yesterday.
Posted 7/28/2016 4:24 PM (GMT 0)
Sigh. The point I was (apparently very poorly) attempting to make was this: Establishing a relatively early baseline (as Jack suggests is a good thing), followed by tracking progression from that baseline, appears to be a reasonable way to go. Now, the question of when to pull the trigger as things change is a topic for another day. However, without the baseline, you'll never know whether (or if) the "change" is significant or not.

If a first reading is taken at some detectable (note I did not suggest 'non zero') value, then one simply doesn't know what is really happening. I suspect some percentage of men 'run high' as part of their normal functioning....just as some percentage of the population just runs high cholesterol. Trending it over time gives you something you just don't have from a single reading.
Posted 7/28/2016 5:10 PM (GMT 0)
This has been an interesting and informative thread for me. I never understood the magnitude of the problem. The early screening vs over treatment has strong arguments on both sides with some pretty big numbers and consequences both ways.

Most everyone here is a PC survivor, related to one or a spouse. If it exists, I wonder what the members of the "Over Treated G6 Patients" forum would be advocating?
Posted 7/28/2016 5:25 PM (GMT 0)
Graytech, pay attention to JackH's posts and you'll find out.
Posted 7/28/2016 5:31 PM (GMT 0)
With good reason the over treated G6s advocate AS.

But for you and me >G7 (3+4), it's treatment all the way.
Posted 7/28/2016 6:06 PM (GMT 0)
halbert-

I have to disagree with this "baseline" notion you advocate. The reason is because PSA kinetics are terrible at predicting anything before primary treatment. That's why PSA kinetics are not included as major factors for determining whether a biopsy is indicated. It is a factor (as are such things as age, race and family history), but not a major one. Variances in PSA are affected by too many factors: BPH, prostatitis, urinary obstruction, sex, exercise, and just normal day-to-day variations. Some virulent prostate cancers don't put out much PSA and don't have a pattern of increase, some indolent forms never increase. In fact, Klotz now advocates eliminating PSA kinetics as a reason to come off AS.

We can eliminate the sources of some of those variations: 5ARis to reduce BPH sources, sometimes (not often) antibiotics may reduce prostatitis, and no sex or bike riding 48 hrs before a test. PHI or 4Kscore can reduce (but not eliminate) the effect of other sources. Day-to-day variations remain, however - so if you test once on a "low" day and next few times on "higher days" it might seem like progression where there is none.

I think the best case can be made for PSA kinetics if someone is taking a 5ARi. Then, if the PSA (or better yet, PHI) remains elevated or goes down but then rises, a biopsy seems warranted. I would love to see a randomized clinical trial of this.

- Allen
Posted 7/28/2016 6:23 PM (GMT 0)
TA, I hear you. I suppose I fall in the category that says that something is better than nothing, and until things like PHI and these other newer tests become commonly accepted and understood, then we're back at square 1 again.

I'm still of the party, however, that lays the overtreatment blame squarely on the physicians who, for whatever reason, don't take the time to do true assessments and give patients real information. It just drives me nuts the way our system has moved: that it is the patients who are held responsible for their treatment decisions, and the doctors are given a free pass when they fail in their responsibility to their patients.
Posted 7/28/2016 6:49 PM (GMT 0)

Graytech said...
T...I wonder what the members of the "Over Treated G6 Patients" forum would be advocating?


Clarification for Graytech, and others...

Gleason score is ONE OF, but NOT the ONLY important case characteristic. Most with 3+3 are great candidates for AS, but so are many 3+4 cases...depending on other case characteristics. These are what we call the "favorable-risk cases." Generally, 4+3 and higher are "unfavorable-risk cases" for which immediate treatment (or WW) is the appropriate choice.

My own case is a great example of what I am talking about. I was diagnosed with 3+4, but the other case characteristics combined with my Gleason score to indicate I was clearly "favorable-risk." I had a moderate (gray zone) PSA between 4 and 10ng/mL, I had only several cores positive, and none were above 50%. I was absolutely a solid candidate for AS. What I should have done was to have a confirmatory biopsy 12-18 months later...but I had ants-in-my-pants.

No, I'm kidding about ants-in-my-pants; what actually happened was that nobody suggested to me that a second, confirmatory biopsy later would be the right thing (to re-use halbert's earlier phrase)—I was pushed into a quick surgery—and I wasn't on HW/PC where someone could have/should have suggested I educate myself first, before getting overtreated. I had TIME, but I didn't take advantage of it.

Post Edited (JackH) : 7/28/2016 12:52:19 PM (GMT-6)

Posted 7/28/2016 7:09 PM (GMT 0)
JackH, did the post-surgery pathology confirm the results of the biopsy? My biopsy indicated Gleason 7 cancer in six cores, but low percentages, all on the left side. The eventual pathology, however, showed more Gleason 7 cancer on the right side as well.
Posted 7/28/2016 7:11 PM (GMT 0)

Tall Allen said...
In the article that Andrew cited, Mike posed the hypothesis that improvements in the technology (i.e., the use of PET scans) may have contributed to the recent rise in metastatic diagnoses. I decided to look into Mike's hypothesis. I reasoned that, if true, many cases that would formerly have been diagnosed as high risk would now be diagnosed as metastatic. So I simply added together the number of high risk and metastatic cases over the years.

High risk diagnoses rose rapidly until 2008, and then fell sharply to a nadir in 2012 and about the same in 2013. Metastatic diagnoses reached a nadir in 2007, and then increased steadily through 2013. Adding them together, the overall pattern is flat. There were a few years 2007-8 & 2010-11) where the combined total was over 18,000 cases per year, but the other years averaged around 17,000 cases. This seems to support the Mike's hypothesis.

While the total number of high risk plus metastatic cases is pretty steady, their percent of all diagnosed cases has risen from 22% in 2011 (range was 21% to 23% in 2004 to 2011) to 24% in 2012 to 26% in 2013. This is exactly the pattern we hope to see if we have a more rational screening policy: the number of diagnosed higher risk cases stays flat while the number of diagnosed favorable risk cases declines.

The data in their analysis seem to support the hypothesis of improved screening technology and policy over the last few years.

- Allen

I think this may be the most valuable comment in this thread. The perspective that the raw numbers of high risk cases PLUS metastatic cases are essentially flat, combined with the perspective that their percentages in relation to total diagnoses are increasing does suggest a positive thing:

Total numbers of diagnoses are going down, while the nasty cases are being found at about the same rate as a percentage of population as before. Which does suggest that the fear engendered by the headline may be misguided.

The challenge, of course, is that PCa is generally asymptomatic until it's well advanced...and incurable. It is a reasonable question to ask then, how can we find these cases while they are still curable?
Posted 7/28/2016 7:24 PM (GMT 0)

clocknut said...
JackH, did the post-surgery pathology confirm the results of the biopsy? My biopsy indicated Gleason 7 cancer in six cores, but low percentages, all on the left side. The eventual pathology, however, showed more Gleason 7 cancer on the right side as well.


Mine, like yours, was roughly the same...in the ballpark and about what you would expect (or better than one might expect) from a 1% sample.

A really interesting data point about biopsies...for initially 3+3 men who had a second, confirmatory biopsy about a year later, about half resulted in pretty much the same reading (the same Gleason score); but the other half was split about 50/50 where half (25% overall) went up (by far mostly to 3+4), and half (25% overall) found no cancer whatsoever. Great overtreatment example. Think about how many of those guys were thinking about how close they came to immediate treatment...!

And we've had those cases here at HW/PC...favorable-risk guys who went through with surgery, and then their post-surgical pathology FOUND NO CANCER! Sucks to be them!

Post Edited (JackH) : 7/28/2016 1:31:22 PM (GMT-6)

Posted 7/28/2016 8:26 PM (GMT 0)
So what are the generally accepted AS guidelines?

At biopsy I was a G7(3+4) 2 of 12 positive with 10% and 20% involvement in the cores. Low volume, certainly less than 50%. My PSA was high though at 9.75.

We discussed AS but the uro said I was not a good candidate and discounted that as an option. He may have said why but I don't recall it. I don't feel he pushed me towards surgery and actually suggested and setup the RO referrals so the insurance part of it would be taken care of.

Now in hind-sight the surgical pathology upgrade G7(4+3) confirms I needed treatment now, I only hope it was in time. Next PSA is in a week or so and I will find out more.

So I wasn't over treated, doesn't matter in my case but should I have qualified for AS by the generally accepted standards? Honestly I'm glad I didn't because if I had it may have changed what I hope is a good outcome at this point.
Posted 7/28/2016 8:37 PM (GMT 0)

Graytech said...
So what are the generally accepted AS guidelines?

At biopsy I was a G7(3+4) 2 of 12 positive with 10% and 20% involvement in the cores. Low volume, certainly less than 50%. My PSA was high though at 9.75.

We discussed AS but the uro said I was not a good candidate and discounted that as an option. He may have said why but I don't recall it. I don't feel he pushed me towards surgery and actually suggested and setup the RO referrals so the insurance part of it would be taken care of.

Now in hind-sight the surgical pathology upgrade G7(4+3) confirms I needed treatment now, I only hope it was in time. Next PSA is in a week or so and I will find out more.

So I wasn't over treated, doesn't matter in my case but should I have qualified for AS by the generally accepted standards? Honestly I'm glad I didn't because if I had it may have changed what I hope is a good outcome at this point.

Graytech: link to JHU AS criteria:

www.urology.jhu.edu/prostate/active_surveillance_selection.php

Note that this is considered one of the more stringent programs out there. They generally don't take anyone who presents at G7 unless they are old enough that their life expectancy is less than 10 years. Other programs might have taken you in provisionally pending a follow up biopsy/MRI/ etc.
Posted 7/28/2016 8:42 PM (GMT 0)
Graytech-

It was only this year that NCCN included AS as an acceptable option for "favorable intermediate risk" cases. That doesn't mean it's preferred or that every hospital would accept that on their program. It's just based on the observation that favorable intermediate risk cases seem to have no increased risk by starting on AS. How long they will be able to go before a GS 4+3 biopsy core is discovered (as it might eventually have been for you) is unknown.

- Allen
Posted 7/28/2016 8:51 PM (GMT 0)
I'll just add, Graytech, that you would be a candidate for AS with your favorable intermediate risk characteristics. In general, you don't change from being a candidate to being on AS until after your confirmatory biopsy (or maybe mpMRI) is completed and confirms the initial assessment. The purpose is to weed out men who need treatment...and AS programs are very successful at doing this and moving them into treatments which are successful at the same rates as those who pursue immediate treatment.

Post Edited (JackH) : 7/28/2016 2:54:03 PM (GMT-6)

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