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Prostate Cancer OVER-TREATMENT: improved, but not yet defeated

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Posted 5/30/2018 8:04 PM (GMT 0)
Health & Science article last week in Washington Post: LINK

Article passage regarding low-risk PC:
"A study published in JAMA last week found that 72 percent of men younger than 65 with prostate cancer chose surveillance over surgery or radiation; a decade prior, the numbers were reversed: Only 27 percent chose monitoring."

That's tremendous progress...hoorah for men!

But let's do simply math on how many new low-risk cases are still being overtreated: 27% * 250,000 diagnosed in US per year = 67,500 overtreated per year.

We should stop, take a breath, and celebrate the successes we've seen. The 10-year turnaround has come about only as a result of many parallel efforts—one man at a time! But after we're done patting ourselves on the back, then it's time to recognize that more work needs to be done here at HW/PC and elsewhere...67,500 low-risk cases overtreated is 67,500 too many.

The article goes on to say:
"As the study numbers suggest, many physicians are counseling men with low-risk prostate cancer to choose active surveillance over surgery and radiation; not only is this approach less invasive, it can help men avoid the incontinence and impotence often associated with more aggressive treatment — and do so without impacting survival rates." The "many physicians" needs to be "all physicians." Root out the laggards.

Today there are still men with low-risk PC making emotional-driven decisions for treatment over fact-based decisions, often under heavy influence of family members who know nothing about the disease but think of all "cancers" as a death-sentence. And these emotional decisions are often gently stimulated by bass-ackwards doctors who subtly feed the patient's bewildered fears. So while patients must be vigilant to be their own health advocates, today coming out of our major institutions more doctors are being equipped with "tools" to help. The article goes further to describe how doctors "...used techniques from behavioral psychology to help the doctors better explain active surveillance to prostate cancer patients."

Bravo to the doctors who have helped lead the way. Article: "And at Memorial Sloan Kettering, over 80 percent of such patients [low-risk] choose that option [monitoring]." See...! It's doable!

Post Edited (NKinney) : 5/30/2018 3:00:29 PM (GMT-6)

Posted 5/30/2018 8:24 PM (GMT 0)
Umm... not everyone diagnosed with prostate cancer is low risk. Did I miss something?
Posted 5/30/2018 8:24 PM (GMT 0)
I get that there is overtreatment. But are you saying that all those diagnosed younger than 65 should be under surveillance and not treated?

I actually started a topic awhile back asking for info from guys who were diagnosed at younger than the age of 50. A fair number of the responses came from guys who were diagnosed young from screening, without any symptoms, but with GL numbers/PSA's that would indicate the need for aggressive treatment even at their young age.
Posted 5/30/2018 9:01 PM (GMT 0)
I'm editing my original response. I think I now understand the OP's point to be that the 27 percent refers to the number of "low risk" cases, not the number of all other cases - e.g., not intermediate and high risk cases like mine.

Jim
Posted 5/30/2018 9:08 PM (GMT 0)

Bohemond said...
I'm editing my original response. I think I now understand the OP's point to be that the 27 percent refers to the number of "low risk" cases, not the number of all other cases - e.g., not intermediate and high risk cases like mine.

Jim


I didn't see your original response...but yes, only about 1/2 of the 3+4 cases would fall into the "well-selected" candidates pool for AS...but 50% of all 3+4 diagnosed cases is a darned big number!!

Post Edited (NKinney) : 5/30/2018 3:12:13 PM (GMT-6)

Posted 5/30/2018 9:16 PM (GMT 0)

Works Out said...
A fair number of the responses came from guys who were diagnosed young from screening, without any symptoms, but with GL numbers/PSA's that would indicate the need for aggressive treatment even at their young age.


Age is not part of the fact-based AS/treatment decision equation for favorable-risk men...although for those who need treatment, it may play a role in the type of aggressive treatment one chooses. Virtually all 3+3 are going to be "well-selected" candidates, and about half of 3+4 driven mostly by PC volume.

Post Edited (NKinney) : 5/30/2018 4:04:56 PM (GMT-6)

Posted 5/30/2018 9:19 PM (GMT 0)

RobLee said...
Umm... not everyone diagnosed with prostate cancer is low risk. Did I miss something?


Yes. The article (and discussion) is about favorable-risk PC cases, which is roughly half of all new diagnosed cases.
Posted 5/30/2018 9:22 PM (GMT 0)
It's so easty to take the word "treated" and turn it into "over-treated" without knowing the first thing about any of the individuals affected. the term "over-treated" is a broad generalization. The trick seems to be to refine the definition of "over-treated" until virtually everyone can be said to over-treated. I was not over-treated, yet I'm sure some would say I was. As a man, I assert my "right to choose" my response to a cancer diagnosis, though some would deny men that right by making them look foolish, impulsive, or ill-informed. I think women sometimes run into that same attitude when others criticize them for choosing mastectomy when surely a lumpectomy would have been sufficient.

Sure, any smart person will be cautious and deliberate in deciding an appropriate method of responding to a prostate cancer diagnosis. Yes, some, perhaps many, should consider Active Surveillance. But if a man considers his options, gathers opinions, prays for guidance, and chooses to go with surgery or radiation treatment, I will support him to the hilt, even if I myself would have chosen a different way

I'm not sure we're doing everyone the favor we think we're doing when we keep telling them that hey, you're low risk. Do AS. Stop thinking you should have surgery or some other treatment. I say, yes, consider Active Surveillance in many instances, but in the end make the decision that's right for you...not what I say you should do. Since I've never laid eyes on you, haven't seen your health history, don't know what other health issues you may have, don't know your family history or your wife's thinking on this...I'm really in no position to do more than offer support and general advice. I'm certainly not in a position to make someone feel guilty or ignorant for choosing surgical intervention rather than Active Surveillance.
Posted 5/30/2018 9:28 PM (GMT 0)
Re AS, I agree with Clocknut that we should not guilt people into picking AS. And I've always felt like some guys just aren't cut out for AS. But I also think we need to tell low-risk guys that it's a possibility since: 1) it's rarely anyone's first instinct upon a cancer diagnosis and 2) not all uros seem to bring it up. (Although I think the latter is changing.)
Posted 5/30/2018 9:34 PM (GMT 0)

clocknut said...
I was not over-treated...


You make yourself the center of all your posts.

This post is not about you.* This post is about others. This post is about those who have NOT yet made a decision…or not yet been eased into a decision by their “caring” physician who may lagging behind the changing best-practices of his profession.



*But the nature of your comment has been thoroughly discussed elsewhere. For that and in order to be appropriately sensitive to the topic, I’ll just share the words of others—not my words—to consider how this topic should be addressed. Dr Bradley Hennenfent wrote, in his book Surviving PC Without Surgery:
    It is difficult to engage in conversations with low-risk men who have already had an RP because I don't want to hurt anyone's feelings. A RP can't be undone. The men that are post-RP, that geared up for their major surgery, and are gung ho—you can't tell them that they might have done the wrong thing, not after what it has cost them financially, emotionally, and physically. While men are unwittingly rushed into a drastic operation without a full understanding of the consequences, they defend their surgeon (the one who did the rushing) with the notion that he "saved their lives," when in fact for low-risk patients the surgery probably had no impact on their longevity.

Post Edited (NKinney) : 5/30/2018 4:00:01 PM (GMT-6)

Posted 5/30/2018 9:37 PM (GMT 0)

Michael_T said...
...we should not guilt people into picking AS.

I've reviewed this thread. We are not guilty of that. Don't believe I've seen that elsewhere, either.




Michael_T said...
And I've always felt like some guys just aren't cut out for AS.

Read the article. This problem you describe is better understood today, and doctors are now being better equipped with behavioral psychology techniques to help guys overcome irrational fears or misgivings...and it's helping.

Post Edited (NKinney) : 5/30/2018 3:55:45 PM (GMT-6)

Posted 5/30/2018 11:17 PM (GMT 0)
Hey, thanks. I always look forward to your rude replies.

Actually NKinney, I think I made others the center of my post above, not myself. Still, if guilty, I apologize, although I think this forum has always involved sharing our personal experiences and insights. My point was that men are, in general, not as stupid as some seem to think they are, and the majority of doctors are"caring" individuals concerned with helping their patients. I think we do a great dis-service to newcomers if we consistently mis-characterize physicians and give the impression that any choice other than AS is probably wrong.

The men I personally know who have had to confront this disease have done so with caution, diligence, intelligence, and research. Their doctors have not tricked them into surgery. Quite the opposite. I suppose that happens, but unlike you, I don't think it's all that common.

I would point out, though, that if my posts are all about me, yours are certainly all about you. Your posts make it abundantly clear that you believe you possess the truth; you know what men should do. You're often willing to insult anyone who doesn't share your opinions.

Obviously, many men should opt for AS as long as they can, but ultimately they have the right to make their own decisions, even if someone else thinks they should pursue a different way forward.. It's their body, their life, and their future. You know more about this disease than I do. Some of your posts have been amazing. But rarely do I sense that you respect anyone's opinion other than your own. That's a shame.

Post Edited (clocknut) : 5/30/2018 5:38:13 PM (GMT-6)

Posted 5/31/2018 12:07 AM (GMT 0)
I agree with many of the words in this thread. It dismays me that a few of the the most knowledgeable posters on this site are at times the most condescending, and even rude. I have frequently seen some “important” contributor’s poor behavior go unchecked. It’s not hard to be diplomatic even when we strongly disagree.

Let’s support each other, not stress each other out. We already have plenty of stress.
Posted 5/31/2018 12:16 AM (GMT 0)

Bohemond said...
I think I now understand the OP's point to be that the 27 percent refers to the number of "low risk" cases, not the number of all other cases - e.g., not intermediate and high risk cases like mine.

And apparently I made the same mistake. Perhaps we all see every post in the light of our own experiences.

We seem to forget that we come here for support. We have all been thru enough already without what we say we say being picked apart.
Posted 5/31/2018 12:47 AM (GMT 0)
If the definition of overtreatment is that everyone who is diagnosed as low or low-intermediate risk and who chooses aggressive treatment is "overtreated", then all of this data makes sense.

Do we REALLY have to here again?

The whole point of all the screening recommendations is that doctors and patients should actually discuss options and seriously look at the big picture for each patient. If THAT is done, can we still call decisions that lead to aggressive treatment of low or low-intermediate risk overtreatment?
Posted 5/31/2018 1:43 AM (GMT 0)
I think many of you are missing the point of AS. Prostate cancer is either aggressive or harmless. If a man is DXed with low risk cancer, AS is the most effective method of determining whether he should be treated or not. Monitoring over time is the only way to determine if a low risk cancer is becoming aggressive.
Outcomes are similar for immediate treatment and delayed treatment so there is no advantage to treat immediately and lots of downside. AS identifies effectively those that need treatment from those who don't.
Posted 5/31/2018 2:00 AM (GMT 0)
mmmmmmm... Balance Point probably the hardest thing to do in life, balance diet, balance family and job, and yes balance PCA treatment and our views on it. Anything good thing overdone is not good and sometimes Pca treatment is probably overdone, on the other hand wasn't there just a report saying that deaths from aggressive Pca was going up? What's right for one guy might not be right for the next guy so I think we need to be understanding and let each person learn about the disease then be their own advocate. JMHO

Larry
Posted 5/31/2018 2:18 AM (GMT 0)
This thread has finally convinced me that life is too short and the ignore button is a Valuable tool to make it more enjoyable. But I can’t remember how to put someone on my ignore list. Can someone refresh my memory?

Serious question.
Posted 5/31/2018 2:44 AM (GMT 0)
Press the thumbs down button on a post with that person's name. You can see who is on your ignore list in your profile.

oh darn, I wasn't going to post on this thread...
Posted 5/31/2018 3:06 AM (GMT 0)
Thanks Andrew. I will do it now
Posted 5/31/2018 4:11 AM (GMT 0)

clocknut said...
It's so easty to take the word "treated" and turn it into "over-treated" without knowing the first thing about any of the individuals affected. the term "over-treated" is a broad generalization. The trick seems to be to refine the definition of "over-treated" until virtually everyone can be said to over-treated. I was not over-treated, yet I'm sure some would say I was. As a man, I assert my "right to choose" my response to a cancer diagnosis, though some would deny men that right by making them look foolish, impulsive, or ill-informed. I think women sometimes run into that same attitude when others criticize them for choosing mastectomy when surely a lumpectomy would have been sufficient.

Sure, any smart person will be cautious and deliberate in deciding an appropriate method of responding to a prostate cancer diagnosis. Yes, some, perhaps many, should consider Active Surveillance. But if a man considers his options, gathers opinions, prays for guidance, and chooses to go with surgery or radiation treatment, I will support him to the hilt, even if I myself would have chosen a different way

I'm not sure we're doing everyone the favor we think we're doing when we keep telling them that hey, you're low risk. Do AS. Stop thinking you should have surgery or some other treatment. I say, yes, consider Active Surveillance in many instances, but in the end make the decision that's right for you...not what I say you should do. Since I've never laid eyes on you, haven't seen your health history, don't know what other health issues you may have, don't know your family history or your wife's thinking on this...I'm really in no position to do more than offer support and general advice. I'm certainly not in a position to make someone feel guilty or ignorant for choosing surgical intervention rather than Active Surveillance.

Clocknut, Reading your signature, I agree that you chose the right course to have treatment. I would have done the same thing, although most likely with SBRT. No need to defend your opinion, it sounds like common sense to me.
Posted 5/31/2018 5:06 AM (GMT 0)
As a Sample Size of 1, my anecdotal history is that I had a normal DRE and PSA test at age 52, when I was with a large HMO. Thereafter, the topic of screening or testing for prostate cancer never came up again, from that HMO, or another health care system, or any doctors, family, or my unsuspecting self.

I was very "distracted" around age 58 by some melanoma treatment, and all my doctors were thereafter far more interested in my colon health than anything else.

At age 65 I presented in excruciating pain to my lower back and abdomen, and was diagnosed with Stage IV prostate cancer metastatic to about 15 sites each in bone and lymph nodes, and a PSA of 5,006, ultimately incurable, despite probable very large personal and societal costs and side effects prior to my very probable earlier death.

I did not have the chance nor the option to try for a curative initial treatment.
With time, I have come to realize that my situation was/is pretty rare, in the larger scheme of things.
Yes, if I were in a population screening program, I might have had a different set of early options. And to the possible detriment of others (perhaps even myself) who might have been "over treated". On the other hand, I might still have developed advanced or earlier recurring prostate cancer, anyway, despite having earlier detection. There is no way for me to know with certainty ..... in my individual case.

I do know that I had some pretty high quality of life between age 52 and 65, before I became symptomatic. Physically, sexually, etc. Perhaps it would have balanced out in the end, regardless? That's probably unknowable.

Just some thoughts,
Charles
Posted 5/31/2018 12:43 PM (GMT 0)
Charles, Sorry to hear and feel for you.

I'm an evangelist for screening and I push guys I know who are past a certain age to get this done. I get that it's controversial and that it is not done everywhere and there will be worries for guys with high PSA's who don't actually have cancer, and over treatment of low risk cases that are discovered. And that the guys with low risk cases need to better advised that treatment is not necessarily needed.

But there are enough guys who are not screened and would have been better served if they had started regular screening in their 50's.

My father was diagnosed with advanced prostate cancer when he was 57, so there was never any doubt for me that I was going to be regularly screened. But I have a brother living in the UK and screenings are not normally done there. And general checkups are done less often than here. The link is to a UK document from the NHS with their rationale for not screening. The document indicates that you have a higher risk for cancer if there is a family history - but STILL does not suggest you should personally screen if you have a family history. I made sure my brother has started regular testing.

https://www.nhs.uk/conditions/prostate-cancer/should-i-have-psa-test/





CuriousCharles said...
As a Sample Size of 1, my anecdotal history is that I had a normal DRE and PSA test at age 52, when I was with a large HMO. Thereafter, the topic of screening or testing for prostate cancer never came up again, from that HMO, or another health care system, or any doctors, family, or my unsuspecting self.

I was very "distracted" around age 58 by some melanoma treatment, and all my doctors were thereafter far more interested in my colon health than anything else.

At age 65 I presented in excruciating pain to my lower back and abdomen, and was diagnosed with Stage IV prostate cancer metastatic to about 15 sites each in bone and lymph nodes, and a PSA of 5,006, ultimately incurable, despite probable very large personal and societal costs and side effects prior to my very probable earlier death.

I did not have the chance nor the option to try for a curative initial treatment.
With time, I have come to realize that my situation was/is pretty rare, in the larger scheme of things.
Yes, if I were in a population screening program, I might have had a different set of early options. And to the possible detriment of others (perhaps even myself) who might have been "over treated". On the other hand, I might still have developed advanced or earlier recurring prostate cancer, anyway, despite having earlier detection. There is no way for me to know with certainty ..... in my individual case.

I do know that I had some pretty high quality of life between age 52 and 65, before I became symptomatic. Physically, sexually, etc. Perhaps it would have balanced out in the end, regardless? That's probably unknowable.

Just some thoughts,
Charles

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Posted 6/1/2018 8:52 PM (GMT 0)

Skypilot56 said...
mmmmmmm... Balance Point probably the hardest thing to do in life, balance diet, balance family and job, and yes balance PCA treatment and our views on it. Anything good thing overdone is not good and sometimes Pca treatment is probably overdone, on the other hand wasn't there just a report saying that deaths from aggressive Pca was going up? What's right for one guy might not be right for the next guy so I think we need to be understanding and let each person learn about the disease then be their own advocate. JMHO

Larry


Not quite sure if I got your main point, Larry, but there is also PC under-treatment…completely different from over-treatment. I think that the high-risk/aggressive cases need “the kitchen sink” thrown at them, and in my view (although I’m not as strong in understanding all the treatments of aggressive cases) many cases are under-treated.

Post Edited (NKinney) : 6/1/2018 4:20:55 PM (GMT-6)

Posted 6/1/2018 8:53 PM (GMT 0)

halbert said...
...can we still call decisions that lead to aggressive treatment of low or low-intermediate risk overtreatment?

You don’t get to make up your own definition of overtreatment. It’s a medical term. From an epidemiological standpoint, overtreatment signifies the potential lack of benefit as well as unnecessary cost and harm from treatment of an overdiagnosed case.

Overtreatment may be synonymously referred to as an “elective” treatment…which frankly should not be paid-for by our (at least not my) taxes via Medicare or through elevated private insurance rates. Other “elective,” unnecessary surgeries are not covered.
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