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More harsh criticism for clinicians aggressively treating low-risk PC patients…

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Posted 7/17/2012 5:31 PM (GMT 0)
More harsh criticism for clinicians aggressively treating low-risk PC patients …this one published in the most recent "ASCO Post" by Dr Gilbert Lawrence. His commentary addresses the 50% of men diagnosed with low-risk PC—so his remarks are not targeted for and are  not applicable to those in the other 50% group with intermediate- or high-risk PC diagnosis.   In the commentary, Dr Lawrence points out that “ patients with low-risk PC do just as well with no treatment ,” and criticizes his fellow clinicians (urologists and radiation oncologists; Dr Lawrence is a radiation oncologist) for having “ failed to adhere to actively and appropriately treating only intermediate-risk and high-risk prostate cancer, and selecting active surveillance for low-risk disease .” Dr. Lawrence goes on to say, “Rather, we have collectively chosen to increase our workload (as well as our academic prestige and bank balance), pad the published data, and improve our results by actively treating low-risk disease.   However, several studies have shown the outcome for low-risk prostate cancer is just as good with surveillance and delayed treatment for the 20% to 30% of patients who show biochemical or pathological progression to a higher risk category.” “It is time that leaders in our respective fields, trial designers, and journal editors show some leadership.   If it takes disincentives (for patients, doctors, and institutions) to dissuade us from undertaking unnecessary treatment , many of us will consider that a blessing in the long run.   This will be better than an ostrich-like approach of being reticent about screening and detecting early-stage intermediate- and high-risk prostate cancer. The last thing we want to do is practice medicine dictated by trial lawyers, epidemiologists, or health-care economists. Yet if that happens, we will have only ourselves to blame.” [Underlining added by me to highlight points of emphasis.]   Dr. Lawrence repeats an emerging theme previously posted at The "New" Prostate Cancer InfoLink site that seeks a new generation of PC thought-leaders to emerge from the recent commotion who will—over time—modify stale opinions and usher in change.  In Dr. Lawrence's case, he actually calls for "disincentives" as a motivator for change.     Many posters here at HW like to (naively) think of their own doctors as being saintly, having only entered the medical profession to save the wretched lives of the poor souls who would have otherwise died a miserable and unnecessary death (please cue the angel’s chorus).   But, this is yet another, balanced voice from “behind the stethoscope” that sheds new light for patients on the PC overtreatment perspective…Dr Lawrence joins a growing line of respected clinicians who have posted the same reflective, critical perspective here or in other medical journal editorials. For those in the low-risk category who think that your saintly doctor “saved my life,” that view is probably most certainly overstated, but it is likely that your perspective is still clouded from the "cancer hysteria" which accompanies a diagnosis of "cancer."   [Seperate, but related, topic...when are the emerging thought-leaders going to drive change in the "cancer" label attached to low-risk PC?]  The fact is that s/he may have done you a greater disservice by not being more clear and honest with you that your life was never at significant risk.   LINK to Dr. Lawrence’s ASCO commentary.     edit:   activated link Post Edited (Casey59) : 7/17/2012 12:16:09 PM (GMT-6)
Posted 7/17/2012 8:54 PM (GMT 0)
Casey, although I have not looked at the article aside from what you have posted, I agree with this point of view. I especially agree with the part that says:
"This will be better than an ostrich-like approach of being reticent about screening and detecting early-stage intermediate- and high-risk prostate cancer."

The point that I have had disagreement regarding screening is that some recommendations leave those of us that get intermediate- or high-risk PCa in our 40s in the "ostrich head in the sand" category. This posting is criticizing the doctors that recommend a treatment that is overly aggressive. In my opinion, this is where the education, or change in point of view, needs to be placed, not with avoiding PSA tests in your 40s.
Jeff
Posted 7/17/2012 9:01 PM (GMT 0)
But...this commentary is about overtreatment of low-risk PC patients, not at all about "avoiding PSA tests." Not at all...

Dr Lawrence's point was that disincentives to aggressively treating low-risk patients would be a blessing, and that it would offer an improvement over the hesitation others have expressed about screening (ostrich).
Posted 7/17/2012 9:26 PM (GMT 0)
It looks to me that it is ambiguous as to what he is referring to when he refers to an "ostrich-like approach".

I am in agreement that we need to not over-treat low-risk PC patients. However, I am in favor of using the PSA tests to aid in the process of determining who is a "low-risk PC patient". Did I just end up agreeing with the study or disagreeing?
Posted 7/17/2012 9:37 PM (GMT 0)
Read the link. It's not lengthy, and not complicated. It's a commentary (as I said) and not a study. And it's about low-risk over treatment (as I said) and not screening. You are mixing topics.
Posted 7/17/2012 10:03 PM (GMT 0)
Casey, the topic of screening is brought up in the study (I read it per your suggestion), and continued in the sentence that I referred to. My interpretation of being "reticent about screening" is implying that the better approach over avoiding screening is to make it a disincentive to over-treat diagnosed indolent cancer. I don't think he is implying that this takes away the controversy about screening, and he may not be an advocate for screening. I think his point in reference to "reticence to screen" is that if one is diagnosed with PC (usually starting with a PSA test and biopsy), we should not over-treat.

I am in agreement with this point. Perhaps the controversy regarding PSA screening would become moot if doctors took this to heart.
Jeff

Post Edited (Im_Patient) : 7/17/2012 5:58:43 PM (GMT-6)

Posted 7/17/2012 10:15 PM (GMT 0)
I couldn't agree more with Dr. Lawrence's basic premise. The problem lies not in too much testing but rather on too much treatment. I'm certainly not an expert at determining what should be considered "low risk" or indolent - aside from perhaps newly diagnosed patients in later years.

I was 50 at diagnosis and I'm not sure whether or not my cancer was high risk. I assume because of my age that treatment made sense. As the age of diagnosis moves into the later years (with moderate Gleason scores, etc.), the decision to treat or not becomes more nebulous.

I think the entire discussion/argument should be based on whether or not to treat, not whether or not to test.
Posted 7/17/2012 10:42 PM (GMT 0)

I admit I am biased since I have recently started consulting with Dr. Scholz/Lam's practice. But, I think they have a rational approach to prostate cancer that seems to address Dr. Lawrence's criticism, the overtreatment concerns in general, and in a way, seems ahead of their time. Here are a couple of very recent (one is from today) blog posts by Dr. Scholz that seem relevant to the discussion.

http://www.prostatesnatchers.blogspot.com/2012/07/good-prostate-cancer-bad-prostate.html

http://www.prostatesnatchers.blogspot.com/2012/07/what-is-mindless-biopsy.html

Posted 7/17/2012 11:25 PM (GMT 0)
Thank you for the article.

I think that one thing that we all may be able to agree on is that given it's prevalence and potential seriousness, prostate cancer is very under-researched. People with other cancers will not likely go to two top specialists in the field and get such vastly different treatment advice that I've received.

In particular, the urological community has to come to a consensus on whether active surveillance has any meaningful impact on life-expectancy for smaller amounts of Gleason 6 cancer and whether age is indeed a meaningful criteria. I've heard strong arguments both ways from top experts in the field.
Posted 7/18/2012 2:08 PM (GMT 0)
windycitytiger, haven’t heard much from you recently…sounds like you are doing well.   Hope your are surviving the heat.  I went to a bluegrass concert last night at the Chicago Botanic Garden which was scheduled to be outdoors in the esplanade but was moved indoors in the Regenstein Center because of the heat.  You were, by the way, classified as an “intermediate-risk” mainly because of the high number of positive cores.   Risk is completely independent of age. Your question is exactly the right one to ask… whether to treat or not .   PC is “omnipresent,” and the focus of biopsies needs to continue to shift from looking for the presence of PC to looking for intermediate- or high-risk PC.   We need to see a good-sense blend of curative treatments (intermediate- and high-risk) and active surveillance (low-risk), and NOT an actively-treat-everyone-no-matter-what approach.   Southern Comfort , thanks for the blog links you provided.   Scholz and Lam are among the most highly respected PC experts.   The notion of “Good Prostate Cancer, Bad Prostate Cancer” was originally coined by Dr Willett Whitmore, known as the “father of urologic oncology” who also pointed out that survival from PC has less to do with treatment than with the biology of individual tumors.   Dreamerboy , agreed that there are many research opportunities.   Today we are able to successfully separate patients with indolent vs. aggressive prostate cancers, but it requires time .   A simple one-time test to separate them would be nice (especially in light of the Whitmore quote I mentioned, above, regarding tumor biology), but don’t hold your breath.     Post Edited (Casey59) : 7/18/2012 8:19:10 AM (GMT-6)
Posted 7/18/2012 3:04 PM (GMT 0)
I assume that studies have proven that there has been significant overtreatment of low-risk PC. If so, this should be a major focus of doctor and patient education. Once this has been accomplished, we will no longer have to be concerned about PSA screening. That cheap and easy test will then be regarded as just another piece of information and not the catalyst for panicked reactions among uros and patients possibly leading to damaging overtreatment.
Posted 7/18/2012 3:19 PM (GMT 0)
Phenom, it has been estimated that today there are about a million men living in the US who have been overtreated for low-risk PC. Prostate cancer is among the more common and less lethal malignancies, yielding a large population of survivors (many with life-altering side effects and a long string of related follow-up treatments which might have been unnecessary)

The ability to detect lower-and-lower levels of PC has resulted in more-and-more clinically insignificant cases being diagnosed. In our society today, the "C word" (cancer) sparks hysteria and an overriding desire for treatment, even if there's little benefit. These conditions have stimulated debated, at a national level, about changing the language of low-risk prostate cancer; many doctors have expressed that even the use of the term "cancer" is misleading for low-risk PC cases.
Posted 7/18/2012 3:23 PM (GMT 0)
I'm for more screening, less overtreatment.
Posted 7/18/2012 3:36 PM (GMT 0)

Phenom said...
I'm for more screening, less overtreatment.

You are entitled to your view--and that was indeed the view of many in the 1990's--but since those two points have been shown to be incongruous (read my last post, above), the knowledgeable experts today (the ASCO being only the most recent) are moving in the direction of smarter screening, and less overtreatment.

Posted 7/18/2012 3:56 PM (GMT 0)
A very sobering article. Frankly, I don't find it surprising. It probably takes courage for a doctor to, basically, call out some of his colleagues.

Thanks for posting it.

Juliet
Posted 7/18/2012 4:27 PM (GMT 0)

You are welcome, and I agree, Juliet. It's sorta akin to pointing out that "the emperor has no clothes."



For those interested, here is the link to yet another doctor's similar comments. Dr Anthony Zietman published this editorial in the Journal of Clinical Oncology titled:

"Evidenced-based Medicine, Conscious-based Medicine, and Management of Low-Risk Prostate Cancer"


If you are interested/concerned about this topic, read the editorial; but here is a passage:

"Indeed, it is the top-ranking oncologic priority. A perfect storm of clinical evidence and economic reality has arisen in which urologists and radiation oncologists need to examine the evidence, examine their souls, and start to carefully look at every new patient asking, before anything else—is treatment really needed at all? If it is not, and that will frequently be the answer, then they must be prepared to lead the patient along the less financially rewarding and decidedly unglamorous path of active surveillance."

[underlining added by me for emphasis]

Posted 7/18/2012 4:45 PM (GMT 0)
It is encouraging to hear the responses to Casey's post. If this post was posted three years ago the responses would have been entirely different, and Casey would have been run off the forum.

Mindsets about low risk PC are changing, and I have seen a remarkable shift over the past few years in both doctors and patients. As long as data and not emotion drives the way we view and treat PC we will continue to make progress and improve the lives of milions of men.

JohnT

Posted 7/18/2012 4:56 PM (GMT 0)
Casey, in your reply to Phenom, you labeled his thinking to be of the 1990's variety and said that "more screening and less overtreatment" are inconguous.

To that, I say, "only if we allow that to be the case."

How is it more difficult to encourage wise decisions regarding cancer found during screening than it is to move physicians into the mindset of less intervention and wider use of active surveillance?  It seems quite logical to want to be aware of a cancer in the body, whether in the prostate or elsewhere, and then determine what, if any, medical intervention is warranted.

It seems quite illogical to me to avoid the test which might show that cancer, with the goal being to avoid "overtreatment." 

As several have pointed out in this thread, most of us rely on our physicians to tell us, during our annual physical exam, what tests we should have at this particular stage in our lives:  occult blood, blood profile, colonoscopy, glucose tolerance, and yes, PSA.  Truly, what percentage of men, without prompting from their doctor, will ask that these tests be ordered?  And yet all of these tests can have life-altering consequences and side effects.  It drives me a bit crazy that we keep trying to act as if the PSA test belongs in a different category from the rest.  It's just a test, and it can be informative.  It's painless. 

I need to quit posting in these threads.  Everyone has pretty well stated their personal beliefs, and that's good.  What I don't like is being told by medical authorities that I'm not smart enough to make wise decisions regarding prostate cancer, so they have elected to protect me from all that by simply doing less testing. If I'm still around ten years from now, I wonder if I'll be reading about an epidemic of advanced cases of prostate cancer presenting at doctor's offices, all cropping up in men who, thank the Lord, were not "overtreated."

Posted 7/18/2012 5:22 PM (GMT 0)
Re: As several have pointed out in this thread, most of us rely on our physicians to tell us, during our annual physical exam, what tests we should have at this particular stage in our lives....

Not sure that's a very good idea anymore. And less so as we move towards a universal system with universal protocols. You want to be an educated consumer of healthcare are relying solely on your doc a bad move. I had a PSA of 4.0 followed by 3.9 30 days later, followed by a 4.6 five more months out. A biopsy then revealed a gleason 6 cancer.

I told my buddies to start getting and trending their PSA results. My friend age 59 saw his doc had omitted the test at his last annual physical, and he went back for it.

You have to wonder if the doc omitted the PSA test on my friend because he was getting screening and "over treatment" confused.
Posted 7/18/2012 5:25 PM (GMT 0)
clocknut said... If I'm still around ten years from now, I wonder if I'll be reading about an epidemic of advanced cases of prostate cancer presenting at doctor's offices, all cropping up in men who, thank the Lord, were not "overtreated."   Clocknut, although it’s been posted here many times previously, several AS studies have over 10-years of follow-up already.   The sky didn’t fall.
Posted 7/18/2012 5:40 PM (GMT 0)
Casey, I'm well aware of the benefits of AS.  That wasn't my point at all.

My point was that it is completely illogical to restrict the use of a test that might show the presence of a cancer in the body.  Yes, any cancer found may be indolent or aggressive, high risk or low risk, but wanting men and their physicians to know that it's there is more logical than decreeing some kind of selective screening which is bound to leave millions of men ignorant of their situation.

I fail to understand how screening fewer men in order to avoid overtreating some makes more sense than screening more but treating smarter.  Am I to believe that with emerging knowledge the medical community is unable to adopt protocols that will preclude hasty surgeries or radiation treatments, or that men are so stupid and irrational that they are incapable of choosing appropriate methods of treatment?

I'm all for AS.  I'm all for the least medical intervention necessary.  But I absolutely don't see why more screening and less overtreatment are incongruous.  As I said in the earlier post....only if we continue to allow that to be the case.

BTW, that epidemic of men I mentioned in the earlier post would be those who were never tested because they had no family history, showed no symptoms, never asked, or were never encouraged to take the test....not those who were on AS.

 

Post Edited (clocknut) : 7/18/2012 11:50:56 AM (GMT-6)

Posted 7/18/2012 5:40 PM (GMT 0)

John T said...Mindsets about low risk PC are changing, and I have seen a remarkable shift over the past few years in both doctors and patients. As long as data and not emotion drives the way we view and treat PC we will continue to make progress and improve the lives of milions of men.

Change is difficult, and change occurs slowly.  My crystal ball, however, shows that for the next few years people will continue to be unscientific and continue to practice "faith-based medicine" instead of one rooted in the best evidence.  That trend will decline, however, as more "disincentives" are put in place for the overtreatment of low-risk PC.

Posted 7/18/2012 5:53 PM (GMT 0)

clocknut, your comments about screening might be well-suited HERE in a current, but separate, thread about screening rather than this thread about low-risk PC overtreatment.

But, heads-up, you won't find that anyone in that discussion, including the ASCO who recently published screening guidelines, recommends the "never tested" approach you discuss...or was this comment just extreme hyperbole for dramatic effect...?   (You aren't re-hashing USPSTF, are you?  ugh!)

clocknut said...

BTW, that epidemic of men I mentioned in the earlier posts would be those who were never tested because they had no family history, showed no symptoms, never asked, or were never encouraged to take the test.... 

 

Posted 7/18/2012 6:04 PM (GMT 0)
OK, one last try, Casey, I was responding to your comment to Phenom.  He had said, "I'm for more screening, less overtreatment."  You called that 1990's thinking, said the two were incongruous, and said that we're moving toward "smarter screening and less overtreatment."  So, no, I think my comments belong in THIS thread. All of my comments were in reaction to your comment in THIS thread about more screening and overtreatment being incongruous.
Posted 7/18/2012 6:58 PM (GMT 0)
Dr Mark Scholz is another well-respected PC expert to speak-out against PC overtreatment (note in particular the criticism at the end directed to his fellow-urologists in the spirit of "the emperor has no clothes"). Last month, he wrote: "Prostate cancer treatment is out of control …Because there is so much confusion about the different types of prostate cancer our book [Invasion of the Prostate Snatchers] pays special attention to the modern methods for distinguishing between the good and bad types.   Suffice to say in this brief blog, as long as there is a modicum of attention to detail, telling the difference between the good and the bad types is usually pretty simple.   Far more difficult is getting the uninitiated to slow down and study the situation before taking irreversible action. In the rushed process leading up to treatment, many fail in their struggle to believe that something termed CANCER really represents no threat at all.   Others, even more sadly, never hear their over-enthusiastic doctors marshal a single argument against immediate treatment ."
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