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

From a personal, high-risk, patient perspective, I like it when a doctor is known for NOT overtreating. Then, if I get an aggressive treatment recommendation, there is more credibility with the recommendation .. i.e. "I guess I really need to do this because this is not their standard response .."

That was my situation with Dr. Lam: I went there with the idea of possibility cutting short HT. The come back was: no way, and we recommmend chemo as well. They wanted more, not less, aggressive treatment, in my case. I think it meant more coming from doctors that are well-known for discriminating and careful treatment recommendations based on risk profiles. And, as a bonus, it helped validate my radiation oncologist's recommendations as well. 

Thanks for you comment, Southern Comfort.  Your point helps to highlight that PC is really two (or perhaps three) distinctly different diseases that need distinctly different stratagies.  [Probably another good reason to change the name currently given to low-risk PC.]

While this thread has been focused on low-risk overtreatment which needs a higher degree of restraint before action, on the other end of the spectrum aggressive PCs like yours benefit most significantly through an aggressive course of treatments. 

Good point, Phenom. PSA testing, prostate screening, biopsies, etc, are not bad things and should never be discouraged. What is done with that information may or may not be a problem, but that is entirely seperate to the testing up to the point of a positive diagnosis.

One minute, I hear people here pushing for "knowledge" and "learning all you can", and now this new mixed message is even trying to tear that down, and for what real reason? You can't have it both ways, knowing is always better than not knowing.

david in sc

I don't see how more information, if used judiciously, can do anything but help everyone, no matter what their situation. If you want to go to the extreme and say "what about the terminally ill?," then OK, you've got me there. Other than that, I say take the information this cheap and easy test gives you and use it to your best advantage, whatever course that might take.

When someone can tell me exactly what low-risk prostate cancer is, I'll start to listen to this foolishness. Even G6 that escapes the prostate is not necessarily low-risk. I'm alarmed by some who seem to think that there is a magic time at which to begin "proper" treatment. How is this determined? The problem is, none of these articles are good at projecting exactly what "low-risk" is and when "proper" treatment should begin.

dude1969 said...
When someone can tell me exactly what low-risk prostate cancer is, I'll start to listen to this foolishness. Even G6 that escapes the prostate is not necessarily low-risk. I'm alarmed by some who seem to think that there is a magic time at which to begin "proper" treatment. How is this determined? The problem is, none of these articles are good at projecting exactly what "low-risk" is and when "proper" treatment should begin.

dude1969, I have to keep reminding myself that there are lots of newbies and not everyone knows what "low-risk" means, and that some people mistakenly think that Gleason 3+3 equates to low-risk.  I've posted this definition previously (and curiously, I see that in a thread last December when I posted this definition, you posted just afterwards...but perhaps you've forgotten).

I wrote this:

Gleason score alone is inadequate to describe risk.

The NCCN, the National Comprehensive Cancer Network (they are the organization that develops treatment protocols which doctors follow) updated it's Prostate Cancer Guidelines to more clearly define both "low risk" and a new category called "very low risk" PC.  Im going to just copy/paste from an article:

Patients in the low-risk category are those with a stage T1-T2a tumor, a Gleason score of 2-6, and a PSA level less than 10 ng/mL, whereas very-low-risk patients are those with a stage T1a tumor, a Gleason score of 6 or less, a PSA level less than 10 ng/mL, fewer than three positive biopsy cores with no more than 50% cancer in each, and a PSA density below 0.15 ng/mL per gram.

 

These case characteristics help to more fully define those who should consider AS.

 

Shades of gray, Casey.

I'll use myself as an example. 42. G6. 75% chance of being organ confined. Nodule felt on DRE. PSA of 3.6. 6 of 12 cores on the left side were positive. No idea the % of each core.

Dr.'s advice (Hopkins): "Take some time to think about what you'd like to do, surgery or some radiological method, but don't take a year. You have time, but you should take care of it in a timely, reasonable way." Dx'd in August... Surgery 11/4/11

I presume from your definition, of which I was already aware, that I was over treated and should have gone on AS until I actually "needed" treatment. I consulted the top people in their field and took their advice along with information. So while I might still be considered a "newbie" here, I'm certainly not a newbie to guiding personal health care. Surgery it was.

Luckily, my pathology came back the same identical to what I went in with. G6, organ confined, T2A. But so many others here have come back G7 after the biopsy of G6, that the idea that a Dr. can really differentiate, truly differentiate, "low-risk" or not from initial screening methods is a game of Russian Roulette that I think, truly informed people, probably wouldn't like to play.

dude1969, if you are talking about "Russian Roulette" for low-risk cases then your cloud of "cancer hysteria" hasn't worn off...that's quite natural, and exactly why other threads are talking about the importance of informing/educating men about PC early. 

You didn't provide complete staging information, but even with what you provided (6 of 12 positive cores) you were not among the 50% of men diagnosed with PC that appears indolent.  (I thought I had gone through this, too, with you previously...?)

Read it again. It's a question. What would you do next...?

Phoenom, I have simply asked you the basic, obvious "next" question that those who are knowledgeable in PC asked themselves regarding PSA testing of an asymptomatic man with less than 10 years LE. In the 1990’s it was not uncommon to test everyone despite < 10 yrs LE, and biopsy everyone with high PSA despite <10 yrs LE.   As more was learned about the natural history of PC (discussed above), the “light came on” and the realization was made that performing a biopsy on those men was inappropriate.   If we aren’t going to biopsy them, why test them when the purpose of PSA screening is to see who might be a candidate for a biopsy.  The answer became clear.   I applaud the ASCO screening recommendations.

dude1969, thank you for your contribution. If nothing else, your comments probably helped remind folks how prostate cancer is really two (or three) different diseases. A "cancer hyseria" often grips the newly diagnosed, and then the facts start running together and appear clouded. Half of all new diagnoses are low-risk (which was the original topic of this thread), but people hear the word "cancer" and they demand treatment while the facts about their risk gets blurred. Ninty percent (90%) of all diagnoses get aggressive treatment.  That's a lot of what the doctors are telling us is unnecessary aggressive treatments with life-altering side effects. We can do better...for our son's sakes.

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A quote from Dr Tim Wilt in today's NYTimes illustrates the "cancer hysteria"...

“Many men, when they hear about a diagnosis of prostate cancer, become fearful,” Dr. Wilt said. “They think if they aren’t treated they will die from it. Our results clearly demonstrate that’s not true. The overwhelming majority will not die of their disease if it’s left untreated.”

If I remember correctly, using the rates from the recent past, 48 are treated to save one life...which sparked THIS cover to the book "Let sleeping dogs lie."

edit:  added Dr Wilt quote later

Post Edited (Casey59) : 7/19/2012 2:21:48 PM (GMT-6)

I encourage others to follow this straight-forward approach: follow the EVIDENCE, rather than the EMOTION. In hindsight, that does seem sage...but it's just common sense. In the midst of an emotional "cancer hysteria," sometimes common sense can be difficult to see...

Dude,
I'll attempt to answer your questions to Casey. First you were not even close to be considered for AS. Your tumor volume was too high, any felt nodule would disqualify you from AS. At your age, 42, AS would have not been recommended as the cancer would have had too much time to progress. So by all the AS criteria you were not eligable, and your cancer was not indolant. AS only deals with those cancers that have a very high probability of being indolant.

For those that are eligable using the criteria published and listed by Casey there are various established protocols for monitoring. These include quartely psa tests and a follow up biopsy within a year. More strict protocols include imaging that is compared to a base scan to see progression. If psa doubling time decreased to below 3 years or a follow up biopsy indicates any progression in gleason grade then treatment is recommended as these are indications that the cancer is a progressing type of cancer and not an indolant cancer. In the vast majority of instances those patients that meet the intitial criteria of AS have indolant cancer as most men over 60 do. These are cancers or cancer cell clusters that just don't grow at all or grow so slowly that they would never escape the prostate during one's lifespan. This is usually determined by psa doubling time which reflect's the cancer's growth. Most indolant versions have doubling times in the 5 to 10 year range so by doing the math you can see that it would take a long time for a tumor to grow to the size that would hurt you. This is why most men with indolant PC never know they have it. The psa doubling time for a tumor is genetically imprinted in the cell's DNA and does not change over time. Over a man's lifetime entirely new tumors may form and these could be a higher grade. The vast majority of progressions for those on AS are due to the first biopsy not picking up a higher grade tumor that exists elsewhere, as PC is multifocal which means that there are more than one tumor in the prostate. Many men have both indolant tumors and higher grade tumors. This is why a follow up biopsy is required and most progressions are picked up on this follow up biopsy.
If progression is identified, which is most likely within the first 2 to 3 years then treatment is given and the results are statistically the same as if the patient was treated immediately. This occurrs in about 30% of all patients on AS; the remaining 70% usually live out their lives without treatment, but must undergo constant monitoring as they have been proven to have a predisposition to PC.
There are various AS programs that have been running for a long time, at Hopkins and UCSF and the longest running program at Sunnybrooke is in it's 12 year. The remarkable thing is the data from all of these programs is very consistant. The 12 year data indicates AS is very safe if monitored. We don't know yet if 20 or more years would drastically affect the numbers. We do know that watchful waiting, that does not include monitoring or treatment on progression, has a 5% worse outcome in 20 years than treatment, so we can assume that an active AS monitoring program with treatment for progression should do much better.