Active Surveillence ~ more study numbers!

The results shown, might be based on just that particular mixed of men in that group. Take another group of me, same number, and perhaps the outcome would be all over the place. And like you said above, do you want to be the unlucky 5%? I know I wouldn't.

Statistics can show everything, been working with them for a living all my life.

David in SC

Selmer, nice analysis.

I think the key is in the fine print, i.e. "carefully selected prostate cancer patients".  That means "real early" stage for which most of us didn't qualify.  I'll post below something I posted before re Johns Hopkins qualifications for their program:

1.  Age 60+.

2.  T1C, i.e. nothing felt on DRE.

3.  PSA density of .1 or less (this is PSA divided by size of prostate, e.g. PSA of 3 divided by prostate size of 35cc equals PSA density of .086 which is less than the .1 threshhold.

4.  Gleason 6 or less.

5.  2 or fewer cores of cancer.

6.  No core with more than 50% cancer involvment.

This is a little stricter, in some respects, than the study.  However, it still points outs that active surveillance is only for a small subset of PCa patients whose cancer is small and likely to be non-aggressive and contained.  Those who are in this subset and still choose treatment "might" meet the definition of overtreatment....this would be an interesting quandry for someone who meets the qualificaions...

Tudpock

20% incontinance or ED rate against a 5% life threatening situation? Tough call? I'd rather take the IC ED risk...That's me.

Also are we not just talking about a delay to intervention? As Mike's numbers show risk increases with time. What I would like to know is HOW long can you safely delay treatment. This is the cuswp of the argument. A guy at the median age of 64 might be fine with this approach as long as he doesn't live to 90. And a guy at 44 like me? Even with a G6 2 of 12 positive and a PSA at 4 has a tough call. I feel pretty lucky (sic)...I was G7 with a PSA of 20, 4 of 8 at 80%+ positive. Watchful waiting was a terrible idea IMHO.

Thus to Tudpocks statement ~ Most have more cancer than the study arm.

Tony

Uncle Harley,
And from looking at your long-term low psa, 1 gleason 6 core, etc, your stats look like what you are doing is a safe bet for right now, and I hope it stays that way for you long term.

David in SC

TC-LasVegas said...
20% incontinance or ED rate against a 5% life threatening situation? Tough call? I'd rather take the IC ED risk...That's me.

Also are we not just talking about a delay to intervention? As Mike's numbers show risk increases with time. What I would like to know is HOW long can you safely delay treatment. This is the cuswp of the argument. A guy at the median age of 64 might be fine with this approach as long as he doesn't live to 90. And a guy at 44 like me? Even with a G6 2 of 12 positive and a PSA at 4 has a tough call. I feel pretty lucky (sic)...I was G7 with a PSA of 20, 4 of 8 at 80%+ positive. Watchful waiting was a terrible idea IMHO.

Thus to Tudpocks statement ~ Most have more cancer than the study arm.

Tony

As I keep saying this is not about those with advanced Pca such as yourself. And I'm also long on record for recommending those in their 40s surgery. You can turn percentages all around by description such as how about a 95% non threatening life situation for those who aren't going to make it to 90 any way. Plus whose life at that age is really that wonderful? I say that with two aunts who died with very sad alzheimers whose deaths seemed more merciful than life their later years. They were 95 and 98 meanwhile their baby sister (my mother) died at age 48 so who knows?? We are talking about a delay for intervention for some not all. If you're diagnosed in your mid 60s or early 70s and you have a bad heart condition or other chronic life threatening disease it's unlikely many will then opt for radical prostate surgery. I know I wouldn't. It's debatable I agree but it should be taken into consideration before one panics or is panicked to choose a possible life changing treatment. It's the old quality of life vs possible longevity argument which is the basis for choosing or not choosing treatments. I have stated as one who is long divorced with grown children I do admit giving more weight to lifestyle over just possible added longevity. When I was born the expected life for a male then was like 69-71 years of age. My life style has not always been the healthiest for one thing I smoked like 35+ years so I don't see myself being 90 anyway. Thus I always had a hard time pulling the trigger for a radical treatment that would at least temporarily have me living like an elderly man be it only a few months a few years or for good in just a HOPE of possible longevity. If I do just live the expected at birth 10 more years or so why do I want to possibly risk the last decade and live any of it as an elderly old man who needs a diaper? Especially when my Pca seems to be more and more low risk. I think my TFT was the perfect compromise so there are more upcoming less invasive treatments to consider. for example I could've delayed my TFT using cryosurgery to HFT now. Would it have mad e a difference in waiting a year? I don't think so but I have no regrets there just showing an example time and medical science moves on. The "gold standard" is tarnishing and may soon be an antique, contrary to some beliefs here that will be a good thing in my opinion.

I could have been one of those considering "watchful waiting" just looking at my initial numbers.  Perhaps a second biopsy would have found the additional cancer not shown in the first one - perhaps not.  "Skeletal metastases developed in one patient 38 months after initiation of active surveillance."  That's one heck of a thing to happen when you don't know exactly how much cancer you have, and perhaps could have prevented the metastases with treatment.  I'm glad that I chose surgery, and then additional radiation treatment.  Had I waited, would I be be that one in 43 from the study now facing a very unknown future?  I would never take that bet with my life.

(Incidentally - last Zoladex injection today - still Zeros!)

There may be no perfect biopsy or scan but I feel the 3D mapping saturation biopsies to be far superior. With those results in hand I feel there's not too much of a risk relying on the 95%. But to each their own. I believe the old standard 10-12 core biopsy to be just chance. There's a good chance it won't detect any Pca that is actually there or detect it with questionable results. That was fine if you just needed to know enough to destroy or remove the gland. But with more hopefully upcoming lumpectomy type treatments like my TFT coming in the future the old type biopsy is quickly becoming a dinosaur. The issue here is not just that 5% risk but the outcome of better detection (PSA) resulting in over treatment. IMHO that's going on in large numbers, others think not here.

Tudpock18 said...


Dear realziggy:

I have been doing some reading up on the 3D mapping biopsy and it certainly does sound like it is a better option than the "old" kind. It was not made available to me at the time of my biopsy and I was not smart enough at the time to ask for it.

You have clearly studied this a lot and I have a couple of questions out of intellectual curiousity:

1. With more samples, doesn't that increase the probability of finding PCa? And, if so, doesn't that feed those who say there is too much overtreatment already?

2. In looking at your stats, I see that with an "old" biopsy in 2007, your docs found 3 of 12 samples. With the 3D mapping biopsy in 2008, they only found 1 of 45. I guess that's a little counterintuitive to me...I would have thought more samples would at least have found as many cancers as with 12 samples. Am I missing something?

Thanks,

Tudpock

I doubt if 3D would be offered to you. It's expensive and my insurance company initially turned it down. Reason being in the past a simple biopsy just indicating cancer anywhere in the gland was sufficient for the normal treatments to remove or destroy the prostate. The primary reason for a 3D mapping biopsy is to pinpoint the tumor for targeted focal destruction. My doctor who is the director of research won a peer to peer appeal to my insurance company I assume by illustrating it's necessity for the lumpectomy like treatment.

Because of its cost as of now it's only used on those who have had a prior normal cheaper biopsy indicating cancer already. So no at present it doesn't increase the detection any more just refines it. It is then just recommended for those with lower gleason and Psa numbers. Even after that the last I saw 43% are found to have more advanced cancer than earlier indicated and are told to persue radical treatments instead. I don't know how that compares to post radical surgical pathologies after surgery increases in further spreading and higher gleason scores, but I bet it's somewhat close.

I too asked the difference between the number of cores. I 'm trying to recall the answers for one thing the mapping biopsy is just that it's done on a grid to better locate the tumor. Compared to a normal biopsy which is kind of haphazard and not as exact at placement so a single tumor can be picked up by more than a single core. Then the university pathologist may have been better too. The fact the newsman in the video also had 3 initial cores done before his biopsy and his resulted like mine also was an explanation to me.This was over a year ago so I'm trying to exactly remember what more I was told then. I'll ask my doctor again when I see him next month before the final biopsy. Look at parts 2 & 3 video link and it will show the 3d mapping better than I can describe it.

I'm not against better detection but there's a problem I think at this time with an over reaction to it with radical treatments. Was I possibly over treated? Maybe but with TFT it has been much easier to accept and live with afterward. For one thing I still have all my valves so I'm as continent now as I've ever been. My ED problem was short lived and as my doctor stated a few viagara to kick start it and I'm back to how I was before. I will not be ordering anymore which with the current alldaychemist problems I'm fortunate. Although I took only 8 out of the 40 I ordered. I've given a few to friends and did use a couple on dates I'll admit. Hey I am turning 60 this year after all. I'm not 19 anymore. LOL Bottom line is supposedly my cancer is gone and I not only still have wet orgasms PCa for me has had the least negative effects on me compared to all others here who have had radical treatments here. Isn't that a goal for coming here? I feel so and is why I felt the need to return here to just let people know of a treatment I feel is the future. As I've said before if I had just gone with the normal treatments I'd would have left here last summer. I now still have a functioning prostate and even if Pca returns I have all treatment options still available to me. 

Each part is anywhere from 4 -7 minutes.

part 1

http://www.thedenverchannel.com/video/14776502/index.html

part 2 Options for Treatment

http://www.thedenverchannel.com/video/14776478/index.html

part 3 Deciding on Treatment

http://www.thedenverchannel.com/video/14776543/index.html

 

part 4 Getting Treatment

http://www.thedenverchannel.com/video/14776562/index.html

5/9/2008 Final update

http://www.thedenverchannel.com/reportersnotebook/16278580/detail.html