Over treatment, not always.........

Definitely not always...as you said! Not sure if this guy is a surgery "failure" yet, but he's certainly at high risk of post-surgery PSA recurrence.

But the clinical risk category is not defined by Gleason score alone. What was his PSA? What was DRE result? how many positive cores? What percent cancer in those positive cores? Which prostate pathologist re-read his original biopsy slides? What was the result of his 2nd, confirmatory biopsy? Standard questions.

Definitely not always. Your important point is that even moving to immediate treatment does not assure one of success. Active surveillance for favorable risk men is AS GOOD, but not better, than immediate treatment, and neither are 100% perfect.

Post Edited (JackH) : 10/17/2016 3:55:34 PM (GMT-6)

Gleason 6 cancer may be "bogus" or "not-cancer". But not for me. My Gleason 6 cancer metamorphosed into an ugly recurrence 5 years after brachytherapy.

Brachy... said...
Gleason 6 cancer may be "bogus" or "not-cancer". But not for me. My Gleason 6 cancer metamorphosed into an ugly recurrence 5 years after brachytherapy.

Well that sucks. You make it that far with low grade, low volume you should be buying long-term bonds. (Well maybe not in this market) I'm likely headed for the microwave after surgery but my stats were far less favorable than yours.

Best of luck, please post what you decide to do about it.

"When you're fighting for your life over-treatment does not exist."

Amen, brother.

trailguy said...
"When you're fighting for your life over-treatment does not exist."

Amen, brother.

Amen is right.

Thankfully, only a small portion on men diagnosed with prostate cancer actually end up fighting for their life, because it is a very different disease from what most men experience.

For that small subset, undertreatment is a concern. The best studies show its best to hit those cases hard and hit it early...the complete opposite of the favorable risk cases. It's quite bewildering why we continue to give both polar opposite conditions the same name, isn't it? Need better "awareness," but HW/PC enthusiasm for September's "Awareness" month was at an all time low. Overtreatment has given PC a bad name.

I agree that "when you're fighting for your life over-treatment does not exist." But how many of us are really fighting for our lives? Isn't the PC-specific mortality rate for low-risk diagnoses that choose AS something like 2%? (Please correct me if I'm wrong...)

Again, I don't begrudge anyone their treatment choices. It's a personal decision and everyone should have the freedom to choose how they want to be treated. But if low-risk guys think they're fighting for their lives, then I do think we have an education issue.

Michael_T said...
(Please correct me if I'm wrong...)

I'll accept your invitation.

I published this info recently in another thread Oh, by the way...Happy National Prostate Cancer Awareness Month www.healingwell.com/community/default.aspx?f=35&m=3697312

I'll just copy/paste from there, to keep it simple, but note that this data does NOT separate out low-risk cases:

List of cancer mortality rates in the United States
Percentage of patients deceased within five years after diagnosis:

1. Gallbladder cancer – 97%
2. Pancreatic cancer – 93%
3. Liver cancer – 83.9%
4. Lung cancer – 83.4%
5. Esophageal cancer – 82.7%
6. Stomach cancer – 72.3%
7. Brain cancer – 66.5%
8. Ovarian cancer – 55.8%
9. Leukemia – 44.3%
10. Laryngeal cancer – 39.4%
11. Oral cancer – 37.8%
12. Colon cancer – 35.1%
13. Bone cancer – 33.6%
14. Cervical cancer – 32.1%
15. Non-Hodgkin lymphoma – 30.7%
16. Kidney cancer – 28.2%
17. Bladder cancer – 22.1%
18. Uterine cancer – 18.5%
19. Breast cancer – 10.8%
20. Skin cancer – 8.7%
21. Thyroid cancer – 2.3%
22. Prostate cancer – 0.8%


This Wikipedia page nicely summarizes the data from the CDC:
/en.wikipedia.org/wiki/List_of_cancer_mortality_rates_in_the_United_States

As alephnull says , 5-year mortality is the most common metric.

Michael_T, this type of "PC awareness/education" is excellent material for your "Movember journey"...

Post Edited (JackH) : 10/18/2016 12:27:34 PM (GMT-6)

I just have to throw in a few comments..re this subject...
This is a good conversation going on for the most part.
Regarding the issue of over-treatment, the recent media reports that I have seen indicate that the medical profession is moving in the right direction...the message has been heard..

But I think we need to be careful regarding AS. I seen a few references lately to G7's going on AS...and that is out on the edge, I think.

A G7 who takes his situation not seriously enough could very well move to a condition of "fighting for his life".

I don't think we ought to be talking about G7's routinely doing AS.

I know that I was very uninformed when I was diagnosed, and I had never heard of this FORUM. I went oround in a state of shock for a month or so.
I think many other guys are just like me..

DOUBLHH said...

But I think we need to be careful regarding AS. I seen a few references lately to G7's going on AS...and that is out on the edge, I think.

A G7 who takes his situation not seriously enough could very well move to a condition of "fighting for his life".

I don't think we ought to be talking about G7's routinely doing AS.

Do you want to know what I think? I think that on issues like this we should be following the lead of the world's leading medical/prostate cancer care-givers rather than exaggerating or going "out on the edge."

* Are the medical leaders saying that men on AS should "take his situation not serious enough?" No. Personally, I've never heard of such foolishness. Have you?

* Are the medical leaders saying that "G7's" should routinely go on AS? No. I've never seen anything, anywhere with any credibility ever suggest that; rather they use the term "carefully selected" to indicate who should go on AS. That's quite different from "routinely."

These seem like hyperbolic (exaggerated) statements. Let's strip unsupported opinions and exaggeration out of the conversation.


What I think is that men poorly educated on PC probably shouldn't be talking about it at all. But for those that are educated on PC, or striving to improve their education, some important points to know are:

• Use of the term "G7" is largely a thing of the past because of the wide gulf of differences between the cases formerly included in "G7"; instead, use either 3+4 or 4+3.
  
  
• 4+3 cases are largely labeled "unfavorable intermediate risk" cases. Generally men with 4+3 have prostate cancer-specific mortality and all-cause mortality rates similar to the rates in patients with high-risk prostate cancer, and are not candidates--at all--for AS.
  
  
• 3+4 cases are largely labeled "favorable intermediate-risk" cases and have prostate cancer-specific mortality and all-cause mortality rates similar to the rates in patients with low-risk prostate cancer and thus may be candidates for active surveillance as an alternative to aggressive treatment, dependent on other case characteristics. Some of the men carefully selected for AS will move, later, to a deferred treatment...when treatment is needed.
  
  
• Gleason score alone does not determine whether 3+4 men are good candidates for AS. Other case criteria also figure into the equation (see below).
  
  
• Read this article from the PC InfoLink site about the NCCN's physician's guidelines update on PC treatment which now states that active surveillance can be considered as a first-line management option for "men with favorable intermediate-risk prostate cancer that has predominant Gleason grade 3 pathology (i.e., Gleason score 3 + 4 = 7), a percentage of positive biopsy cores < 50 percent, and no more than one NCCN intermediate risk factor (i.e., a clinical stage of T2b or T2c or a PSA value of 10 to 20 ng/ml)" /prostatecancerinfolink.net/2016/01/14/nccn-expands-role-for-active-surveillance-in-initial-management-of-localized-prostate-cancer/

I do see that the medical community is moving away from treating all cases in a one-size-fits-all approach...they are slowly getting the message. But clearly there is more patient education needed.

Post Edited (JackH) : 10/18/2016 2:35:37 PM (GMT-6)

Whenever this rolls around, I always want to remind myself that the only way to judge a past event is by looking at the state of generally understood knowledge at the time we're discussing. We should never judge historical events or persons based on what we know (or think we know) today. A classic example is arguing that Abraham Lincoln was a racist because he used the "N" word. Well, look at what was common and understood in 1860.

Same thing applies here. Looking back, yes, we can say that many were overtreated in (say) the year 2000. But, ask the question: what was truly known in 2000, compared to what is known today. (NOT what the cutting edge researchers were figuring out) There has been a tremendous increase in understanding in the last 16 years. And who knows where the state of understanding will be in 10 years from now?

And never forget the lesson from Isaac Asimov's great short story, "The Dead Past". The past truly begins one instant ago. Once I hit send, this posting is in the past.

David, I'm with you on this. And, as many of us can attest, biopsy results are not definitively diagnostic. The trick, the issue, is simply stated: Our diagnostic tools are not good enough (yet) to differentiate between the indolent "true" G6, and the other variants. Which is why I keep saying that I'm one who may have treated "early" but not without necessity, given my post surgical pathology. It was only a matter of (short) time before a follow up biopsy would have revealed what my pathology showed.

Michael_T said...
Thanks for the info. I do realize that 5-year mortality is a very common metric. But my specific comment was about the PC-specific mortality rate for low-risk guys that chose AS as I think that's a pretty good indicator of how many guys are "fighting for their lives."

Hi Michael_T, sorry I missed your question earlier, which was focused only on a cohort of low-risk PC.

You asked "...about the PC-specific mortality rate for low-risk guys that chose AS... The PC-specific and overall survival is the same as those low-risk guys that chose immediate aggressive treatment.

In other words, treatment does nothing for these men to improve longevity. I guess this is pretty much a "working definition" of PC overtreatment.

I think you also answered your own question later. Mortality is a small percent for both groups of low-risk men even at 20-years...AS or immediate treatment.

Post Edited (JackH) : 10/19/2016 8:57:44 AM (GMT-6)