Overtreatment? Catalona says that's exaggerating.

Excellent report, Tony. He's quite a guy. That line of thinking is how I feel about the matter. Sounded real balanced to me.

P.S.

It's almost like the other side wants you to believe that PC is because of testing, not the other way around. PSA testing doesn't make more PC appear, the cancers are there and growing whether a man knows about it or not. If a PSA test cost $1,000 a pop, perhaps there could even be a economic argument, but its a realatively low cost blood tests, and we know, it has saved thousand of lives over the years.

Don't know why people have to put a negative bias on a good thing. Guess they never dealt with PC first hand in their own bodies

Excellent presentation; thanks for posting it. The problem is not with PSA screening; everyone should be screened; it's what you do with the information you get from the PSA. Even Cantalona's extremely low estimation that up to 20% of PC detected may result in overtreatment that's a lot considering the side affects and complications of the treatment. (most think it's a lot higher). If there were no side affects then treatment for everyone would be a no brainer. I think AS is still a valid option for a lot of patients whose biopsy reflects a low grade pc. I for one would never go on AS without a color doppler ultrasound and even an MRIS to confirm the biopsy results. I also think that the older you are the more sense AS makes. I think that treating every case of PC discovered is just as radical as saying that screening should not be done. Both arguments are at the extreme and there is a very large middle ground.
JohnT

The issue is not really whether men should get a PSA test - they should if they wish.

The heart of the matter is why, a generation after the introduction of the PSA test, we still don't have any good way to distinguish which detected cancers are going to metastasize and cause suffering and perhaps death and which detected cancers will stay in the prostate for the remainder of the patient's life (and hence treatment will only lead to unnecessary incontinence, impotence, etc.).

The reason is that urologists, radiologists, and cancer centers have no financial incentive to find an answer to that issue.  Since the advent of the PSA test, for example, the average income of a urologist has jumped immensely. 

Thus, it is not a surprise to learn that the money, time, and energy is going into finding better ways to operate and radiate - not whether most of the surgeries or radiation sessions are justified in the big picture.

Catalona's last slide is too ridiculous to merit comment.

Otis Brawley has written some very intelligent and thought-provoking articles and editorials recently.  For example, read online his editorial "Prostate Cancer Screening: Is This a Teachable Moment?" from the August 31st edition of the Journal of the National Cancer Institute.  Then get the two long-term studies and read them yourself.  The American study suffers from many methodological problems - one of them fatal, in my opinion.  The European study, while far from perfect, is much better and raises some very troubling questions.

To be clear: I strongly suspect that most of the men on this board correctly chose to have their PC treated.  I am still comfortable with my choice.  But one should not extrapolate from the unrepresentative sample of PC patients on this board that the "overdiagnosis - overtreatment" issue isn't a very real and troubling one. 

Now I'll stand back and wait to get flamed.

Zen9

    

I think AS should be presented as a very respectable choice when dealing with PC. If we are talking about men with no PSA velocity issues, lower PSA readings in general, biopsies with real low numbers of positive cores, and low percentage of cancer present, and assume they have no serious family history of PC, I think they should be encouraged to try AS.

If their cancer is more prone to become agressive quicker, its ugly head will rear soon enough to make a sensible non-AS treatment choice.

In the meanwhile, this group of men can enjoy a good season of no side effects and quality of life issues longer, and perhaps in some cases, forever.

David in SC

Tony, I agree with the sentiments of your very last post above. Well said.

Ohio, I know you often speak of the 12 known types of PC, and I know that is true ,but the vast majority of men with PC have
the most common variety. Ultra rare cancers are a special concern by their nature. That is how it was when I battle d porocarcinoma three different times in my past, was one of only 38 known cases in the US at that time. My oncologist at that time had one other patient with it, a female, and for extensive purposes, he was the expert with 2 cases.

TC-LasVegas writes, "Dr. Brawley recommends against PSA screening which I believe is flat wrong. This would put this idea ahead of providing options to the patient and that is unethical in my opinion."

Actually, Dr. Brawley belives that "[t]he patient and physician should make a shared decision about screening."  CA Cancer J Clin 2009, 59:220-224.

Calling someone unethical is an extremely serious matter.

Zen9

Tony, I read every link you just posted. Horrifies me. What is the real motivation for such an anti-PSA testing scheme? I must be dumb, because I can't comprehend the other side of this issue. They even admit that the death rate has gone done, and it may be because of testing, though they won't come out and give credit.

You would think that PSA testing was some hokey, expensive, invasive test to hear them talk. I must be missing something here.

David in SC

David hits the point I am trying to make. The last link I included is clearly showing the confusion coming out of the ACS with regards to prostate cancer. It clearly says that the best way to deal with prostate cancer is with the early detection, and yet it also states that the ACS does not support screening in men.

1> Exactly how do you find asymptomatic early stage prostate cancer without PSA screening? A DRE? It would be just as easy to say that DRE's would cause the same concerns and don't help either. However, in the NEJM, the European study clearly supports screening is helping by as much as 20% in reduction in mortality, even the US study supports this though to lesser degree. And to far too many, Brawley is saying PSA screening does NOT save lives by saying it is misleading to say it does. To me that is a 100% false statement. One he admits to later in the same paper that PSA screening in fact does save 1 in 43. More on those NEJM things later.

2> Brawley states that testing should only be done when doctor and patient have had a thorough conversation about the test. My point is ~ Exactly what can be discussed to improve what he says is the problem with PSA screening? He also states that folks are saying that PSA testing absolutely saves lives and that he does not agree with that. PSA is a screening test, in itself it saves no lives. It is not a treatment. What it gives a patient is valuable information. The patient can make better informed decisions if AFTER the PSA test when the doctor does a great job explaining the ramifications. The fact is that many patients will require an intervention (remember the ACS says early detection is key). And without PSA screening how will they know that they have treatable prostate cancer?

One more tidbit on the NEJM screening controversy. Those studies clearly are flawed. They have one very huge common flaw. They both skip a younger generation of men. Neither study, nor the ACS, has screening information on men in their 30's and 40's. The question of if PSA screening can help younger men is widely accepted as plausible and likely.

Until such time, I will gladly take the world re-knowned word of Dr. Catalona ahead of Dr. Brawley when it comes to prostate cancer. He has quite a few more prostate cancer patients as I don't believe that Emory College has a world re-knowned prostate cancer program...ACS spends 80% of it's money on Breast, Lung, and Cervical cancers, and the rest on all of the others combined. But it's stature in the press is taken for way more than it's worth in prostate cancer. If anyone wants to donate to prostate cancer research because they have prostate cancer or know someone who does, perhaps they should be aware of this fact before they choose the ACS...

Please note: I respect Dr. Brawley for all the good work he does. But I personally find him to be too obtuse when it comes to prostate cancer and the only tool we have for early detection. As flawed as it is.

Tony

Tony

David, I
think the motivation is two fold: one being cost of treatment and the other being quality of life issues, If it really takes 48 men being treated to save one life then both of these are significant. I don't know if it is truely the case, but Brawley and others believe it. If it is indeed fact then, at $40k per treatment it would cost nearly $2,000,000 to save one life in addition to the 47 men having side affects, some rather severe complications. I may not agree with it, but it is a valid argument.
Today everyone is looking at how to reduce the total cost of medicine to society; in this framework it makes sense that someone is looking at PC.
JY

David,
These are tough questions and I don't have a clue about the answers; What's a life worth, $2mm, $10mm, $20mm? It's pretty obvious that most European countries have already made this determination and some day we will also have to. Is it worth saving one life if it means that 10 men will be incontinent, 20 will have ED, 1 or two have severe rectal proti***. I'm glad someone is asking the questions and thinking about it, even though I may not like the answers.
You are absolutely right; until we can distinguish agressive from indolant and as long as most doctors recommend treating every single case of PC uncovered we will continue to have these debates in the medical community.
JT

Not screening because of the SE's and cost? That is precisely the ethics question I raise. The patient deserves the right to make his own decisions. I do not believe that it should be a joint decision between a patient and a doctor. The doctor should tell the patients what is available. He can tell them the upside and the downsides, and then get out of the decision process. If a doctor refuses, or refuses to give the patient the options, then he is having his own opinion or emotions getting in the way. I believe that a position against screening is a position against a patient being able to make his own decisions.

John, we are not at the points for I/C or ED yet. We are only at the point of a patients right to information in this discussion. Namely ~ whether he may have cancer or not. If a good job is done with providing him the options after his screening indicates an issue, then more patients will make better choices.

Tony