Invasion of the Postate Snatchers

Interesting discussion. I had never heard of this "150%" rule.

My PSA scores rose gradually over a decade from 3.0 to 4.1. The last 18 months several readings wandered up and down in a narrow range from 3.9 to 4.1. Finally a biopsy settled the matter.

With a small prostate (36 cubic centimeters), as I understand it the rule should work for me as follows:

36/10 = 3.6
3.6 x 150% = 5.4

So the rule predicts a less aggressive cancer for me, and indeed my PSA scores have been undetectable for two years after surgery. [Fingers crossed ....]

Yet my Gleason was 4 +3, and my very last PSA reading, taken six weeks after my biopsy, was a 5.7.

Comments or thoughts?

By the way, I asked my surgeon about the 5.7 reading and was told with a shrug, "PSA readings vary." Typical M. D. Anderson attitude - "Don't you worry your little layman's head about all this, we medical geniuses will make all the decisions."

Thanks in advance.

Zen9

This is a complex issue, because there really isn't adequate information for a completely rational decision. Here are some facts:

1. The rate of prostate cancer deaths was going up steadily in the 1980's, and reached 40/100,000 per year by 1990. In the early 1990's it leveled off, then it started falling, and was down to 25/100,000 by 2006. The corresponds to the time that PSA screen was introduced.
2. It isn't know what caused this very significant decrease in prostate cancer deaths. Is it the result of PSA screening? Is it because men with advanced prostate cancer are better treated and live to die of something else? Is it because of surgical or radiation treatment of earlier prostate cancer? Is there some other, unrelated environmental factor?
3. There is a controlled randomized study of prostate surgery versus watchful waiting, with 12 years of followup, with the patients mostly having intermediate prostate cancer detected by rectal exam,which shows that there is a modest decrease in death rate with surgery for these patients, but no decrease in death rate when the patients were over 65 at the time of diagnosis.
4. As mentioned before, many, many middle aged and old men have microscopic prostate cancer, which has been described at autopsy if they die for some reason other than prostate cancer. This is different from the men who get diagnosed with prostate cancer when they are still alive, because those men usually have an elevated PSA, and a lump of cancer cells big enough to hit with a biopsy needle.
5. There are lots of ways to assess how bad someone's prostate cancer at diagnosis, including PSA, PSA doubling time, Gleason score, % of biopsy positive for cancer, color doplers, etc, etc. None of these are perfect. All of these tests can help predict the chance of someone eventually dying from prostate cancer, but none of them can tell you than chance is 0. For example, even with a Gleason score of 6, the chance of dying of prostate cancer in the next 12 years is 8%.
6. Only about 12% of people who get prostate cancer will die from it: In 2010-- New cases: 217,730; Deaths: 32,050
7. No question that a lot of men receive prostate surgery or radiation where either 1. they would never die or prostate cancer anyway or 2. (in a small number of cases) they will still die from prostate cancer despite the treatment. For example, googling this topic, I found that in 2002 the number of prostatectomy procedures were 195,000 in the US. So there is a lot of surgery done to save a modest number of lives. http://answers.google.com/answers/threadview?id=367638
8. Prostate cancer treatment has significant side effects, read this forum for details.
9. Much prostate cancer is very slow growing, you may have to live 15, 20, or 25 years for there to be any chance of the surgery saving your life.

My take on all this:
1. Many prostate cancers are very early at the time of diagnosis. The treatment, surgery or radiation, has an excellent chance of getting rid of it. However, there is an excellent chance that nothing too bad would happen in the next 10 or 15 years, anyway, even if you don't treat it. If you are in this group, and you plan on living longer than 10 or 15 years, there is a low to modest chance of dying from prostate cancer if you don't treat it.
2. Prostate cancer surgery or radiation likely won't improve life expectancy if you are older, maybe older that 70 or late 60s.
3. If you have advanced prostate cancer, surgery or radiation are unlikely to improve your life expectancy.
4. If you intermediate prostate cancer, and are over 65, prostate surgery or radiation are unlikely to improve your life expectancy.
5. If you have intermediate prostate cancer, and are under 65, prostate surgery or radiation will modestly increase your chance of living longer.
6. The best data on outcomes are for prostate surgery. The studies on radiation and other treatments are less definitive.
7. There is no group where prostate treatment has a high chance of saving lives.

If you say that too many people are being treated for prostate cancer, since it will, overall, only save the lives of a small portion of the people treated, you'd be correct. If you think that we can always predict who should and who should not get treated, you'd be overstating what is known. The test results at diagnosis are a clue. The life expectancy of the person is another important clue. The third fact is the consequences of the treatment. If the treatment has a big negative effect on quality of life, the possible benefit has to be high to justify it, and this is not the case for most, prostate cancers.

Postop,
Good train of thought. The only thing I really disagree with is the 8% death rate from a gleason 6. Everything I have ever read says it is about 2% and these are varients not true G6s, and this occcurrs regardless of treatment.
Here's my take: High risk pc should always be treated. Surgary should be used only when it is confirmed that there is no extracapsular extension, low probability of mets, and the tumor is located in a place that makes a positive margin unlikely. If these are not confirmed by scans then surgery has a high risk of failure.
Intermediate risk PC should be treated if the patient's life expectancy is over 10 years.

Low risk prostate cancer should only be treated when it shows signs of progression as the treatments are far worse than the cure. Patients underestmate the side affects of surgery, these are justified in high risk cancer, but not in low risk. The best surgeon in the US will have a success rate of only 60% in achieving negative margins, continence, and potency; most surgeons will acheive much worse rates. This is much to high a price to pay for something that in all probability will never hurt you. Seeds and IMRT are better for side affects, but the possibility of permanent side affects such as urinary and bowel issues are still too high of a price to be paid for the slight benefit.
The vast majority of diagnosed PC is low risk and the majority of this will remain stable and never affect one's quality of life. This type of PC can be monitored for years very safely and treated only when it shows signs of growing with the same results as if it was treated immediately. By doing this you eliminate all side affects and quality of life issues caused by all treatments. Once you have determined that it is indeed low risk pc, you need a psa test quarterly and a color doppler test every 6 months to one year to monitor against a base line. Any changes can be seen early on and you can be treated at that point with same results as immediate treatment. The worst case senario is that you have bougnt a few years of quality of life.
The side affects of treatment have to be realistically taken into account. At the very best institutions the impotance rate for surgery is 50% and permanent incontinence rate is 8%; if defined as no pad, no leaks in 2 years it is 70%. The death rate for surgery is .5%
Every choice is personal, but for low risk PC I feel that most patients underestimate the side affects and way over estimate their chance of dying from pc. I know that a lot a people will disagree with me, and the thought of having to live with pc is something they cannot accept psycologically. If they balance this with realistic expectations of the side affects they will incurr then I have no problem.
JohnT

While many men do indeed have low risk, slow spreading cancer, a sizable percentage have Gleason 7,8,9 cancers that if left untreated can accurately be described as "terminal"..There are no small number of Gleason 6 cases who "waited too long" and are now facing metastatic disease..

Three of the docs I consulted with, a U-doc, R-doc, Surgeon ALL agreed that should I reject treatment and just let nature run its course my life expectancy was 3 or maybe 4 years if I was lucky. With treatment, I could expect to live at least 10 and probably 15 and perhaps even longer, dying of something other than PC....Thinking about it, there were FOUR doctors who agreed with this. A medical Oncologist I talked to said three years sounded about right if I did nothing..

It will be interesting to see how the Urology / PC treatment establishment react to this book..Respected researchers and authors like Patrick Walsh might have slightly different viewpoints and be able to back those viewpoints up with facts that contradict some of the positions presented here...

Every choice is personal, but for low risk PC I feel that most patients underestimate the side affects and way over estimate their chance of dying from pc. I know that a lot a people will disagree with me, and the thought of having to live with pc is something they cannot accept psychologically. If they balance this with realistic expectations of the side affects they will incur then I have no problem.

I absolutely agree with you!! You put into words exactly what I believe ! I have been greatly disturbed by some of the posts I've read on here and how quickly some guys are acting on surgery etc..... I probably won't read to much longer as its really affected me. I'm kinda waiting around checking for a post by Volunteer to see results of his color doppler [on the other site]! Even when you don't have a reason for reading here anymore, you begin to care what happens to the guys here [purgatory, and a few others especially] I hope all do well no matter what they choose, but its frustrating to read some of the fear based choices! Like I've said I truly JohnT makes the most sense he's clear, concise and knowledgeable!!! Good Luck To All

Volunteer posted here as Windquest on Aug 13.. Nothing since the biopsy..

Someone must have tabulated these figures...At initial diagnosis, the first positive biopsy, including ALL positive biopsies, no filters in place, what percentage are Gleason 6, 7, 8, 9, 10..?? Are the "vast majority" indeed Gleason 6 cancers??

Good Luck to you and yours Cooper..

Meanwhile, back to The Book...

""....Co-author Ralph Blum (an author noted for his work on Runes and UFOs) describes, early in the book, how his wife, using a gold-tipped needle, drained out negative energy from his prostate through a point on his ear. Now, who am I to say whether there is something to this? But it did make me wonder." <Amazon Book Review>

Im just trying to get my signature added here without going thru a major ordeal,

"You can quote stats all you want but having repeat PSA's and biopsies to follow a potential killer is way too nerve wracking for me even if the odds of dying from it are low. I sure couldn't do it. So a lot of us here see the da Vinci commerical where the guy has the surgery and is back running a marathon in 3 weeks. The implication is that all is back to normal within a couple of weeks. They never say you're going to be totally continent and potent after this, they just imply it, sneaky guys. ".........

I've read here many times guys are just as worried after surgery about repeated psa tests,and if you use color doppler to monitor you only need biopsy if something changes! Thank god and ourselves[for doing the research] my husband is running 3 marathons this fall ! Dr Lee did not see anything suspicious to biopsy and said see you next year! Our GP and referred urologist had him scheduling a biopsy & most likely some kind of treatment for what turned out to be prostatitis [no symptoms at all]

What most patients and doctors don't recognize is that for all cancers, including PC, it takes about 40 doublings in order to cause death. Most cancers have doubling times measured in weeks and therefore are very dangerous. The average low risk prostate cancer has a doubling time of about 7 years. If you do the math, from time of it starting at birth you would be 280 years old by the time you died from it.
JT

The skill of the doctor is extremely important, when considering color doppler! Dr Lee & Dr Bahn are the best,with years of experience between them! There are a few more that I've heard mentioned, Dr Sconti. If interested look around the sites their names will come up. I can't imagine making a decision on treatment without one.