For all the talk of overtreatment, what are your suggestions to curb it? Part 1

TC-LasVegas said...
David it took me more than a couple years to step out of my own case and see a bigger picture. When I'm speaking before a group of potential patients that haven't been treated as yet I always mention that they will get one shot to make a decision about what to do about their own case. As I run a patient education and support group it is imperative that the message that an educated decision is by far better than an uneducated decision gets delivered. That's a first step to curbing ODOT. What a patient does from there is their decision and how it affects them for the rest of their life is now in their hands.

How they interact with other patients can be positive or destructive. With everybody on board about ODOT except the patient pool, we will lose our voice as decisions get made into the future.

That's destructive behavior.

Tony

Tony, I'm not arguing here and apologize in the tone of my written word comes across that way.

I'm not sure exactly what to make of your response. Here is what I am honestly seeing.

1 - Once again you are not answering my direct questions with straight answers.
2 - You seem to imply that you have a holitic broad view of this and we (I) don't and that therefore we (I) are perhaps part of this destruction.
3 - An assumption that guys aren't making informed decisions in the majority of cases. think they are.
4 - A newly found "drive" to change people/minds while not taking their genuine beliefs (including expert analysis by many experts) into consideration. A campaign of sorts.

I just wonder if you might be better served to go down that road without the mod handle in effect but with your personal handle because it can appear to be a conflict of interest and perhaps even intimidating to some. I'm not suggesting you give up the mod role, just saying you might want to consider a clear distinction between the two because I see a potential conflict.

I have not only seen a radical change in position form you in what seems to be a matter of weeks, but also a very different way of approaching interaction and in moderating conflict/debate. If I had to guess, I would guess that it is a result of your genuine passion and belief in what you believe.

Guys,

If you look at Tony's profile you will notice that it no longer identifies him as a moderator. Please bear that in mind and try to respond to his positions on merit, and not out of resentment that a moderator has the ability to have the last word.

I think that this thread has wandered off in to weeds. There is too much ad hominem argument, too many people alternating between deliberate provocation and peevishness. I think we can do better.

142 has repeatedly asked you to stop.

I'm going to lock this one down for 24 hours. Feel free to start other threads to continue any side discussions here that you feel are worth exploring but please leave the personality arguments to cool off for a while. You can resume this thread at noon tomorrow.

Until then... PeterDisAbelard.

Click.

Unlocked your thread.

This will not be Nobel prize worthy. Just expressing the obvious.
I wish everyone had access/money to seek out a great physician. We often create work-a-rounds to compensate for the ones less than great.

Tony...I said it before...you are a great asset to this site. You have been blessed to communicate with the "movers and shakers" in the treatment of prostate cancer. Your knowledge of the subject carries a lot of weight with me.
paul

As predicted, my Nobel winning comments were lost to me forever so I will just have to scratch along with what remnants I can remember.

First of all, I do feel this is an appropriate subject and is worthwhile discussing.  If only we could get the AUA to focus on ODOT instead of just screening I think patients would be better served.  In any case, if I was King of the Prostate World I would dictate a three pronged approach to ODOT:

1.  The AUA and ASTRO out with specific guidelines for biopsy and treatment.  For example, how many cores in a biopsy should be standard?  Should PCA3 and free PSA tests be performed pre-biopsy?  What about MRI and Color Doppler prior to treatment?  How about Polaris and/or Prostyvision?  And, most importantly, when should AS be recommended as the primary treatment instead of a more radical first step, e.g. what G score, how many cores, what % in the cores and what PSA?  The point is that patients and their doctors are pretty much left to their own devices on these matters today and I think it would be quite helpful if there was more prescriptive documentation from the experienced associations of physicians.

2.  Along the lines of what PeterDA suggested in another thread, the name of G6 cancer should have some differentiation rather than just another prostate cancer.  Something like Extremely Early Prostate Cancer or Pre-Treatment Prostate Cancer.  Anyway, some descriptor that asknowledges the likely situation.  I just can't quite get to totally changing the name away from cancer.

3.  Having Medicare and, subsequently, other insurance carriers refuse to approve payment for radical treatments for men who are recommended for AS per the guidelines in #1 above.  This has been suggested on this site for years by David (Purg).

Anyway, thus endeth my miscellaneous thoughts for the day.

Jim

Since they're on a roll, I hope the next AUA report (and an ASTRO report too) will be about overtreatment. The 90% radical treatment rate is ridiculous, especially considering the hugely increased population of diagnosed cases.

I hope they will take a similar approach as they did with screening and find:

• that there is no "one size fits all" formula for treatment -- it must be examined on a case-by-case basis rather than a routine basis
  
• that the doctor's diagnostic task includes comprehending the patient's values and preferences
  
• that the doctor helps the patient fully understand all the risks, including SEs and cure rates -- patients should have to sign off that they received this information
  
• that there be a shared decision-making process using neutral patient-decision aids
  
• that there be discussions with doctors expert in surgery, radiation, hormone therapy and active surveillance, as well as meetings with a psychotherapist and sexual medicine therapist.
  
• that all low risk men be given the option of active surveillance, and shown the data on it
  
• that there be more and longer randomized clinical trials comparing various treatments and active surveillance

And while I'm pipe-dreaming...

How about changing the way urologists are paid by insurance companies/Medicare. What if the Uro was paid a fee per patient diagnosed with PC, say $1000/quality-of-life-year, regardless of what treatments he prescribes for him for PC over the patient's lifetime? Treatments, diagnostics and medications would be reimbursed at cost with no profit margin built in. So the Uro makes the same money no matter what treatment or active surveillance the patient gets. It encourages the Uro to give whatever treatment affords the best quality of life over the longest time span.

The downside is that it encourages him to diagnose more patients :-(

- Allen

Allen,
That list of yours looks familiar. And it looks reasonable.

Tony

Tony.

If improved treatment has contributed to the 40% drop in mortality alongside testing, it would seem to me that testing that brought us to treatment is to thank.

That's not good news to a 40 year old like me Tony. I want it found, caught early, treated and hopefully cured. I appreciate having that hope and option

Tony - you may need to scratch the above post in my name. When I was re-reading what you wrote, it appears that you may have written it to davidg and not me.

There are too many david's here at hw, and in a busy thread it gets confusing, even for us with the name david, lol.

davidg should be identified as davidg, and if its to me, I usually identify as david in sc or just purg will do. hoping to curb some confusion, makes a big difference in these busy conversations

So Tony: if what I was asking above wasn't directed to me, then no need to answer my question, just a question of being a david at the wrong time and place, lol

David (Purg),
No problems I was responding to Davidg and it was my mistake to not be clear.

Tony