The Case for Progression in Untreated Prostate Cancer

Thought-provoking conversation.
I am among those that would still be undiagnosed if not for the PSA.
I did 15 months of AS due to fear of the side effects of surgery and radiation. During that time, my first two PSA's were in the mid-3's. (How could I have PSA below the threshold indicating PCa when I definitely have it!?) The size and surface of the prostate were essentially normal, but the next 2 PSA's were above 5 and the second biopsy showed a slight progression (from 2 to 3 of 12 positive with low density and still Gleason 6).
I had made the decision that brachytherapy was right for me shortly after I was diagnosed, but I had hoped to be able to wait for some of the newer treatments to mature.
So I had the procedure on 2/21 and the side effects have been minimal. I am expecting to be on the diamond when the first pitch is thrown this spring, and I expect to work a normal full schedule!
There is very little question that Americans overtreat PCa and I get the reasoning that some men may have treatment that could have been delayed or even avoided, but what about those of us that may well have had to battle a much more serious condition??
It borders on crazy to have such a simple and inexpensive test that can raise a very important flag and then set the course for a policy that it not be used.
It's like the radiation oncologist said: "Probably one-third of the guys we treat could have gone without it and not die of PCa, we just don't know which third it is!"

Tony,
From the get go the PSA test has been attacked as not specific enough. This is true because too many other prostate conditions can elevate PSA. Still, first as a marker to followup disease progression and later to test for PCa the FDA approved the test. The problem for those that detract the value of the test is that they cannot effectively explain why PCa mortality has been reduced some 40% since the commercialization of the test. In countries in which the value of the test has been mostly ignored, PCa mortality remained high. Surely the reduction in mortality cannot be solely attributed to the test, but there is no question that it has been a large contributor.

If you cannot scientifically explain the PSA test contribution in reducing mortality the next best thing is to introduce over detection and over treatment. There is no question in my mind that these are common in PCa. I question the actual rate. These rates are calculated from computer models based on definitions. See my previous post on the subject:www.healingwell.com/community/default.aspx?f=35&m=2135388

In my support group activities I have also encountered cases that seemed over treated. In some of those cases men were not knowledgeable and depended on their physicians. Still, I am a supporter of individual preferences. That remains the goal for men who are making educated decisions. One way or the other. To treat or not to treat. To use one treatment or another. Personal preferences should be the rule and no one has the right to question an individual even when that persons decision might not be what we consider scientifically correct.

The original post was about the potential for PCa to dedifferentiate in time. My caution to newly diagnosed younger men is that they should remain vigilant about disease progression while untreated even with low-risk disease. I do not believe that if given enough time most PCa remains stationary. I believe that dedifferentiation is the mechanism of PCa progression. The rate is very variable and men should be cognizant of that fact. The age of the diagnosed man is paramount. That was what the original post was about. I do not negate that over diagnosis and over treatment exists in PCa. I question the rate calculated by computer models...

RalphV

Ralph,
I agree with everything. PCa can change over time. There is no doubt. The thought that G6 will never mutate to a higher grade or become metastatic is irrational. Screening gives us a better fighting chance in most cases but not all. I do agree that screening has extended lives.

But caveats exist, too. And the argument that there is over treatment and even over diagnosis exist. In general I think screening is valuable. Please don't misunderstand my position. Finding the disease early is no guarantee that it will be treated successfully. Active surveillance is good for about 15% of all men diagnosed, but the disease will advance given enough time.

But also, early detection is not solely responsible for the reduction in prostate cancer specific mortality rates. We also have improved therapies for both local and advanced cases since the PSA test came around. I imagine that the reduction in PCa mortality of 40% since the PSA test is scientifically explained by all these things not just screening. It's good to know that if our G6 cases do regress to higher risk disease that we have better options and men can still outlive their disease.

Tony

Ed that's exactly right. I believe in the "both/and" approach when discussing these points as opposed to the "either/or" approach. That's a good way to be open to all points that can be made. As a patient, it's hard to argue against PSA screening for all men. As an active PCa advocate, it's not reasonable to test every man. It's not reasonable to say AS if for every man, it's not reasonable to treat every G6 out of fear of it mutating to more advanced disease.

Tony

Tony,

I take issue with the term "overdiagnosis". Diagnosis is not an end point but a starting point. It is a fact that is very useful in determing what, if anything, should be done.

Those who say we are finding too much cancer rationalize that if we stop looking for it there will be an improvement in the rate, with fewer people being diagnosed, and that, somehow, that is a good thing. This is of course absurd reasoning.

Cancer can be underdiagnosed....that is why we have for decades developed and utilized screening methods, and educate people to find the signs of cancer.

A diagnosis is a statement of fact that we can not alter regardless of our desire or agenda. The key is what is done, versus what should be done, with the fact.

JNF I would digress to Ralph's request to stay on topic to the question of whether G6 can progress to a more dangerous disease (even though there is more than that in the original post)

I know most will agree that "over diagnosis" sounds unreasonable but give it some thought. Should we be screening and diagnosing prostate cancer for men with COPD at age 95? I've seen it done before but I question the ethics. Do we really need to diagnose G6 prostate cancer in an asymptomatic 65yo man whom has smoked all his life, is overweight, diabetic, and has several other morbidities that have shortened his life expectancy to less than ten years?

It certainly raises a moral aspect to the equation.

Tony

I believe a Gleason 6 can progress to 7, 8, 9 or 10. Whether that be in 2 weeks or 15 years, it still progresses. After all, if it was never detected, it could kill you right?

If PCa is non-progressive, no matter what the Gleason score, why is it given a stage?

Ralph,
You are my hero--I've lived in Arizona & may move there!
My thoughts and beliefs have never been expressed better.

Bill

Tony,
I didn't laugh when I read that you had men calling you at 2am after having been diagnosed. I don't know if the opposite of fear is anger, but I recall that I was prepared to have a "discussion" with my pcp after receiving and reading my records from urology having been diagnosed with "high risk gleason 8" cancer. Fortunately, for both of us, he had been posted outside the US---just saying!
Bill