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Is the overtreatment rate of PCa overstated?

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Posted 10/28/2011 6:24 PM (GMT 0)
JohnT,
What I really meant by under treatment across the world and even here in the US is that because of low use of PSA testing many men are diagnosed with more advanced disease than necessary and many of these men die of the disease that is more difficult to treat and control.

This situation is similar to the situation that existed before the commercialization of the PSA test. Then men were diagnosed with more advanced disease. How can this be possible if PCa is not a disease that can progress silently before a diagnosis is caused by a symptom?

This assumption is supported by a number of studies that were cited about the high mortality of untreated prostate cancer in the Scandinavian countries. Why is this data being ignored simply by saying that now more men are diagnosed with low levels of the disease? The difference is that now PSA testing signals that something is happening in the prostate environment. Not necessarily cancer but other condition such as inflammation, enlargement and yes also prostate cancer. That red flag is an indication to further eliminate cause. The consequence is that now they diagnose earlier stages of the disease.

If those men in Scandinavia progressed and became metastatic and died of the disease in very high numbers is not proof enough that given enough time PCa can be a deadly disease when they don’t die of other causes, I would like to have an explanation of what caused those men to die of PCa other than their disease progressed undetected until it caused some symptom. Granted that PCa cell proliferation is variable and it is generally slow (which is a good thing to be able to avoid dying of this cancer), but this proliferation variability is driven by genetic changes and what is a benign slow process can become aggressive and metastatic in time.

The current USPSTF recommendation is a step backward as it ignores the heterogeneous and multi-focal character of PCa. A disease that when symptomatic is more difficult to treat or control. There is a need for us patients to address this issue rather than accept this with a passive attitude.

RalphV
Posted 10/28/2011 7:04 PM (GMT 0)
Ralph,
I don't disagree with what you say, except that you seem to be implying that ALL pc will eventually go metastatic. My only point is that pc is really three or four completely different diseases that act differently. The problem we have is lumping all PC together. We need to watch carefully the low risk types and only treat when it is apparant that it will be harmful. The other types should be treated according to thier agressiveness with the most agressive getting combination treatments. It not about screening but getting enough information about one's PC to make an intelligent choice about treatment as one size doesn't fit all. It is obvious from all the data that most pc does not cause death. We now have enough technology to identify the really harmful from the not harmful. It not 100% but treatment is far from 100% either. Treat those that need treatment and watch those that do not.
Posted 10/28/2011 7:24 PM (GMT 0)
John T,

Are  you saying that some prostate cancer will NEVER go metastatic?  If so, why do we even do AS on so-called "indolent" low-volume G6 cancers?  If it's not capable of going metastatic, why watch it at all?

My understanding is that it MAY not go metastatic, but that all prostate cancer has that capability.  And that leads me right back to feeling that if I were 40-something, with hopefully 40 years of life ahead of me, a  young wife and kids, a big mortgage, I would want to be treated.  I would not want to run the risk of metastatic cancer, and until every uro and onco is willing to give me his BMW if I do become metastatic, I'll tend to believe the risk is higher than I'm being led to believe.  (exaggeration added for effect)

Posted 10/28/2011 8:47 PM (GMT 0)
Absolutely some pc will never go metastastic. In fact the vast majority of pc will never go matastastic. In fact the majority of prosate cancers are never even diagonosed. Only 16 out of 100 men are ever Dxed with pc and we know that 60 out of 100 men who are 60 years old have some pc as confirmed by autopsies. So what do you think happened to the 44 men out of 100 that have pc and never know it. Nothing at all; they lived perfectaly normal lives until they died of something else.
Yes, there is such as thing as indolant cancer. It's your choice to get treated or not. It's a simple risk reward situation. Klotz indicates the risk of death for a low risk patient choosing AS vs getting treated immediately is 2 out of 1000 or exactly the same risk as immediate death due to surgery complications. This risk is offset by a 60% chance of living 20 or more years with ED or incontinance or other complications plus a 15% risk that treatment will not result in a cure. I'll take those kind of odds any day.
JT
Posted 10/29/2011 1:20 AM (GMT 0)
Thanks for this more detailed analysis. I tend to agree with the overtreating at the less aggressive end of the scale and undertreating and lack of a strong PSA screeing for men at the more serious end.

My first ever blood test at age 53 when I had gone to my GP for an unrelated matter revealed a PSa of 7.7. This rose to 10.9 within 6 weeks and biopsy showed 3+4 G7 and I was on the Da Vinci slab 3 weeks later. Would watchful waiting have been a good option for me? I tend to think not. The patholgy on the removed prostate revised the score to 4+3 and my surgeon expressed the opinion that 6 months of waiting and I would probably be looking at other treatment methods.

A friend of mine who died earlier this year of PCa was operated by open surgery about 12 years earlier. There had been almost 12 months of procrastinating since his first positive biopsy (watchful waiting?) and his 3 month post op PSA revealed, I think from memory, 0.3 which continued to climb. He was resigned to dying early from this disease. 3 months before he died he had to give up golf and was 67 when he left his grieving family behind.

My point is, where's the overtreatment evidence in many of the anecdotal cases we suddenly start hearing about once we have joined the club? I am a huge sceptic of statistics but I thank John T for his careful and methodical presentation of these with valid explanations. I believe I was a timebomb with a doubling time of less than a year, maybe less than 6 months. A PSA of around 180 in 2010 would have surely proved to be a life-shortening condition so I am personally convinced that the ED and strictures I suffer are a worthwhile price I have paid for ridding myself of a dangerous tumour.

Muz
Posted 10/29/2011 6:31 AM (GMT 0)
I have a question (for John T & ralfinaz):

If we follow the recommendation of USRSTF and eliminate PSA testing, how do we know who has high risk and who has low risk prostate cancer? The only people seeking treatment will be those who has symptoms and would that then bring us back to the exact situations back in the 60s, 70s and early 80s?
Posted 10/29/2011 6:52 AM (GMT 0)

Newporter said...
I have a question (for John T & ralfinaz):

If we follow the recommendation of USRSTF and eliminate PSA testing, how do we know who has high risk and who has low risk prostate cancer? The only people seeking treatment will be those who has symptoms and would that then bring us back to the exact situations back in the 60s, 70s and early 80s?

Newporter,
That is correct, the recommendation is not to offer PSAs to asymptomatic men. This recommendation is for physicians so that PSA tests should not be prescribed to asymptomatic men. Understand that any man who asks to be tested even when asymptomatic is not to be denied. The problem is that many men are uninformed and also in time there is the possibility that the cost of testing might not be covered by insurance.

This recommendation is a step backward and uninformed men will again be diagnosed with more advanced prostate cancer. Sad situation...

RalphV
Posted 10/29/2011 4:35 PM (GMT 0)
Undoubtably there will be more cases of advanced pc that are discovered and more deaths due to pc. As I understand the recommendations they do not recommend mass screenings, but leave it to the patient and doctor to decide if screening is appropriate. All at risk men, African Americans, those with a family history of breast or prostate cancer should be screened. Before screening a patient should be told of the risks and benefits of screening before the psa box on the lab order is checked off.

I have no problem with this as it is the patient's decision along with a doctor's recommendation. My only issue is that this may be a way that Medicare and insurance companies will stop paying for screening and that would be unacceptable.

I see this as no different than screening for colon concer or getting an Xray for lung cancer. These are optional and a patient must decide if he wants them.

JohnT

Posted 10/29/2011 5:27 PM (GMT 0)

John T said...
Undoubtably there will be more cases of advanced pc that are discovered and more deaths due to pc. As I understand the recommendations they do not recommend mass screenings, but leave it to the patient and doctor to decide if screening is appropriate. All at risk men, African Americans, those with a family history of breast or prostate cancer should be screened. Before screening a patient should be told of the risks and benefits of screening before the psa box on the lab order is checked off.
I have no problem with this as it is the patient's decision along with a doctor's recommendation. My only issue is that this may be a way that Medicare and insurance companies will stop paying for screening and that would be unacceptable.

I see this as no different than screening for colon concer or getting an Xray for lung cancer. These are optional and a patient must decide if he wants them.

JohnT

JohnT,
What you say is not correct. The recommendation does not exclude all at risk men, African-Americans and those with a family history of PCa. Consultation of those uninformed men with their physicians leave them at the mercy of their opinions. Hardly unbiased when the Task Force recommends that those physicians do not offer PSA testing to asymptomatic men. This is the wording of the proposed recommendation:

"This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history."

"This recommendation applies to men in the general U.S. population. Older age is the strongest risk factor for development of prostate cancer. However, a more favorable balance of benefits and harms for PSA-based screening does not accompany this increase in risk. Across age ranges, African American men and men with a family history of prostate cancer have an increased risk for developing and dying from prostate cancer compared with other men. However, the observed risk differences for race/ethnicity or family history are each relatively small when compared with the risk differences seen with increasing age (1), and there are no data that suggest that the net benefit of PSA-based screening is altered by race or family history."

This is an indication of how far off this recommendation is. African-Americans die at more than double the rate of Caucasians but in their wisdom the Task Force considers it to be small potatoes...As a matter of fact it considers death from PCa as small potatoes.

RalphV
Posted 10/29/2011 5:32 PM (GMT 0)
The aspect of all this that worries me most is that the message being communicated to the average American male is that the PSA test is so flawed that it's not worthwhile, and even worse, that prostate cancer is a disease that will very likely never cause them harm.

It's my experience that most men don't pay much attention to prostate cancer.  We here on HW certainly do, but the guys I know really don't, and these USPSTF recommendations, even if it turns out they're never implemented, have had a negative effect on men's health and prostate cancer awareness that will be difficult to undo.

I accept that many cases of prostate cancer will never metastasize, that they're indolent cancer, and that they will never cause death.

But by emphasizing the overtreatment aspect, by calling for an end to prostate cancer screening according to the fairly reasonable standards previously outlined by the ACS, we run the risk of reinforcing in the popular mind the idea that this is, in fact, the "good cancer," that it's not very dangerous, and that a man is better off not getting caught up in screening and all that follows.  And I think that's where we are finding ourself right now.

Posted 10/29/2011 6:00 PM (GMT 0)
JohnT

You have posted a lot of numbers and percentages during this discussion, and I am curious as to their source.  I'm not going to argue yea or nay about them, but if they can be verified by a specific reliable source, I will add them to my PC info library for future reference.  If not, then, its time for me to move on to another subject of interest.

I would be interested in sources in addition to:

From Dr Klotz, Journal of Clinical Urology, march 2004

Posted 10/30/2011 1:55 AM (GMT 0)
Putt,
"Invasion of the Prostate Snatchers" has most of the numbers that I have quoted and they are documented to the original source studies so one can look at the original studies. Klotz has a new published paper that Tony sent me and I can email it to you if you wish along with some of Klotz's other papers. Send me an email if you want them.
JT
Posted 10/30/2011 3:30 AM (GMT 0)
John T
I sent you an e-mail....
Thanks
Posted 10/30/2011 9:08 AM (GMT 0)
I have since diagnosis been rather angry about the official line on "Prostate Cancer Screening" but because I don't live in USA have sat on the sidelines on this. Now it appears the official line is the same in NZ to USA I make this observation.

I was an "asymptomatic" patient whom my GP recommended take the PSA test for no other reason than I was over 50 (no family history of PCa). 7.7 PSA reading led to the dreaded digital and a second PSA of 11 followed by biopsy and confirmation. Surgery resulted and the path lab reported 4+3 grade and at a very healthy 53 years my life expectancy went up. OK it could be surmised that PCa would have taken 10+ years, let's say 12, and it could be said that there are plenty of other things that could kill be by the time I reached 65. This is what authorities seem to be leaning on with their whitewashing of the value of precautionary PSA tests, along with the fact that the test can be unreliable on both sides of the scale (like mammograms and many other early indicator tests).

I think it's time, given the nature and death rate of this disease to take it more seriously. Further, it's a disease which is anecdotally at least, is becoming more and more, a younger man's disease, and as such, more common. The death rate in NZ, and I would assume in USA, is heading upwards, so why are the authorities being so hands-off in their attitude to data collection and methodical diagnosis? I think they are hiding behind PSA reliability, which is a pretty weak argument, and the "old man's disease" which is both low on the priority list of modern feminist focussed society, and easy to fudge over with suppositions of other diseases, "dying with it not of it" and so on.

There is coming a time when men are going to have to stand up and fight for a better deal and better education on this. It is one of the biggest killers of men if the stats I have seen are to be believed and it is getting worse. Things like "watchful waiting" may have their place but not as a generalised approach. In NZ "Movember" has been a damp squib, barely achieving the smallest of recognition factors, unlike breast cancer awareness where many men march alongside women. I will watch this debate, if it happens, with interest.

Muz
Posted 10/30/2011 4:00 PM (GMT 0)
Muz

I agree with you. As an active member in a PC support group, I have found that most men refuse to acknowledge problems or discuss any subject that might be going on below their belt buckle.  Therefore it is most difficult to organize any kind of support for our cause.  Unfortunately, we will never see the "blue" becoming as popular as the "pink", because PC is just considered an old man's disease.  We will never be able make the noise required to keep from being stepped on.  Posting information on these forums is an excellent way of notifying men (and women) how to respond to groups that are hurting our cause.  We need to keep the pressure on those groups.  No one is going to do it for us..................

Posted 10/30/2011 6:59 PM (GMT 0)
Putt,
I never received the email and the one I sent to your sktc.net got kicked back. I have three papers supported by reference to original studies, two from Klotz and one from Hopkins. In rereading them I found an interesting point:
"Autopsy studies have demonstrated that prostate cancer typically begins in the third or fourth decade of life.1 This means that, in most patients, there is a period of slow subclinical tumor progression that lasts approximately 30 years, followed by a period of clinical progression (potentially to metastatic disease and death) lasting about 15 years. The implication is that most patients have a long window of curability. This is particularly true for patients with favorable risk, low volume disease."
JT
Posted 10/30/2011 7:57 PM (GMT 0)
"The current USPSTF recommendation is a step backward as it ignores the heterogeneous and multi-focal character of PCa. A disease that when symptomatic is more difficult to treat or control. There is a need for us patients to address this issue rather than accept this with a passive attitude.

RalphV"

Fact: 32,000 men will die from PC this year....

How many men would have died if prostate cancer was NEVER diagnosed or treated but just left to run its course?
Answer: Unknown. But I suspect far more than 32,000.......
Posted 10/30/2011 10:12 PM (GMT 0)
John T
I tested the e-mail address that I use on this forum and it worked fine. Don't have any idea why yours failed. Disregard trying again.
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