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Posted 8/21/2013 9:58 PM (GMT 0)
We constantly hear how “only” 3.0% on men die of prostate cancer and most men die with PCa rather than from PCa. We also hear that “most” men diagnosed here these days have low risk disease that does not require treatment. If there is a cancer to have, we are frequently told, it is prostate cancer because of its indolent nature.

If such is the case, in the US they have been treating thousands of men unnecessarily for at least 15 years and if that is true most of these men are not likely to die of prostate cancer. The implication is that none of these overtreated men (who were never destined to die of the disease anyway) have impacted the mortality rate. Note that interestingly the US PCa mortality rate has been reduced some 40.0% plus during the same time period.
Some other patients destined to die of PCa have to be involved for that reduction to happen.

This reduction is not an insignificant number. Not when compared to other areas of the World where PSA testing is not actively used and many men die of the disease after a higher number of more advanced disease diagnosis.

Why are so many more men dying of PCa in some parts of the World? If it is such an indolent disease, wouldn’t that be true across the World? The numbers tell a different story. Almost 30.0% of men across the World die of PCa once diagnosed. In the absence or by restricting PSA testing here in the US more men will die of the disease. That is a high price to pay by this convoluted way to avoid overtreatment...

Interesting data from: globocan.iarc.fr/factsheets/cancers/prostate.asp

Note that the number of deaths here is almost half of that of the World figure. Could PSA testing and effective treatment applied at an earlier stage have something to do about it?

Cases* Deaths*
World 899 258 (28.7%)
More developed regions 644 136 (21.1%)
Less developed regions 255 121 (47.5%)
WHO Europe region 379 94 (24.8%)
WHO Western Pacific 109 33 (30.3%)
United States of America 186 28 (15.0%)
China 33 14 (42.4%)
India 14 10 (71.4%)

* Figures are in thousands
Not all World regions reported here

RalphV
Posted 8/21/2013 10:05 PM (GMT 0)
Ralph, the term "stunning silence" was used in a different thread in a completely different context earlier today.  I notice that your convincing posts are often met with that very phenomenon, even though everyone seems to agree that you are one of the most knowledgeable guys here on the site. 

As I said in that thread, thinking that doesn't fit the current paradigm seems to be met with the "ignore" button.

That's unfortunate.  Thanks for posting.

Posted 8/21/2013 10:11 PM (GMT 0)
No doubt, as always thanks for keeping it sane.
Posted 8/21/2013 10:23 PM (GMT 0)
Ralph,
If you search for PCa as earlier as possible you have higher incidence rates. But if you dilute the patient pool with a ton of low risk cases then you will have lower death rates per incidence.

I acknowledge that screening saves lives and as much as 40%, but 21% to 31% is more likely due to screening versus better treatments.

My support of AUA guidelines comes with the understanding that we are still testing the high risk groups so that number won't be skewed 40% but following them.

But your point here is well taken. When you are not looking for low risk cases the patient pool is smaller and filled with a higher percentage of higher risk cases. But I caution all to not look at those hard numbers without considering the fact that there are a ton of low risk cases in our numbers and few in the statistics of other countries.

In the US the lifetime risk number is 1 in 6. In the UK it's 1 in 8, and in China it's 1 in 40.

So it is relative to how hard you search for the disease.

Tony

Post Edited (TC-LasVegas) : 8/21/2013 4:46:07 PM (GMT-6)

Posted 8/21/2013 11:00 PM (GMT 0)
Tony,
Somehow we are talking apples and oranges. Incidence is very much related to the use of PSA in testing for disease. The mortality rate is calculated for a certain period in a population by using the deaths claimed by the disease. Usually given as a number per 100,000 population the calculation has nothing to do with incidence. Where is this dilution coming from?

I do agree that treatments applied at an opportune moment when the disease is localized is a factor in the reduction of the PCa mortality rate here in the US. These treatments by necessity have to change the natural course of the disease. The same treatments that exist here are available in Europe but their mortality rates have not been reduced by the same order of magnitude. One reason is that even when diagnosed earlier they tend to be more conservative in treatments. By a long measure AS cohorts in Europe are considerably larger than here.

The point of this thread is to signal that when PCa is diagnosed late in spite of the notion proposed here most PCa is indolent, PCa has a high mortality.
More so when it goes untreated.

BTW, the PCa incidence in the UK is lower than here while the mortality rate is 30.0% higher

RalphV
Posted 8/21/2013 11:11 PM (GMT 0)
Ralph I understood your point but don't think it's apples and oranges in my reply. China does nithave the same issues with PCa and that is one of the reasons they don't screen for it. Does that mean higher death rates? Yes it does. But because it's not the same issue there it does not make sense to start a "baseline at 40" program, for example. Same in other countries.

Heck if we want to impact PCa death rates in America it would not start with screening and early detection ~ it should start with lifestyle changes. Now you can really impact cancer in America and not be so focussed on prostate cancer. 30% of cancer in America is said to be avoidable. We can save hundreds of thousands of lives each year in that way.

Your point about the UK is exactly my point I was making. If you screen less the incidence is lower but the mortality higher. Same apples.

You and I are in agreement. Perhaps from differing angles.

Tony
Posted 8/21/2013 11:15 PM (GMT 0)
We aspire to be China now? Should we practice female infanticide then?

Lifestyle changes? You can make that argument for a magnitude of conditions. What are we going to do, start policing lifestyle choices as if we were in China?
Posted 8/21/2013 11:25 PM (GMT 0)
Davidg,
Not sure what you are saying. Are you mad because China has lower cancer rates than America? Or are you saying that eating healthier and better exercise is a bad way to save lives? LOL.

It's really not the government of China that is directly involved. They eat less red meats, more vegetables, very few processed foods, high in soy consumption, and other ways they have higher life expectancy. We don't have to govern like China to have better health. But we can learn from nations that have less cancers.

Yes you are right, our lifestyles in America do in fact cause more issues outside of cancer. But that makes my point. We're fussing over screening when in fact it's a molehill next to a mountain of life saving measures...

Tony
Posted 8/21/2013 11:25 PM (GMT 0)
The apples and oranges was in reference of you talking about incidence diluting mortality. It does not.

I am not willing to accept higher mortality rates by not testing at an opportune moment.

Lifestyle changes? They would be one of the most difficult things to institute. Why not create a medical team to rule about the way a patient should be treated or not. This with the understanding that there are no law suits if the panel makes an error and the proviso that the ultimate decider is the patient if he wants treatment against the panel's advice.

RalphV
Posted 8/21/2013 11:28 PM (GMT 0)
Right Tony, I'm LOLing myself straight to a Chinese restaurant now.

Tony, in case you forgot, it's our molehill and the very focus of this forum.

I don't need a lecture on learning from other nations. I've lived in multiple countries and continents and can write you a thesis on all that we can learn and all that we can export in return.
Posted 8/21/2013 11:41 PM (GMT 0)
Ralph,
"The apples and oranges was in reference of you talking about incidence diluting mortality. It does not."

We'll have to agree to disagree. My reference was in your 3% mortality RATE. Screening creates higher incidence which dilutes mortality RATES.

Your second point about litigation in America is a very good point. As long as huge awards are in place for malpractice in America you can probably forget about doctor restraint and utilization of more AS protocols. And so it is that litigation will lead to more over-treatment.

But that makes my point as well. You can't sue a doctor for not recommending a screening protocol such as failure to provide a PSA screening. Though I imagine some lawyer would like to try that case.

Why can't we do both, screening higher risk men, and promote healthy lifestyles?

Tony
Posted 8/21/2013 11:49 PM (GMT 0)
  • But at the end of the day there are still too many men and women dying from Prostate and Breast cancers.
  • I live in Australia and here are our statistics :-
  • Each year in Australia, close to 3,300 men die of prostate cancer, which exceeds the number of women who die from breast cancer annually. Around 20,000 new cases of PC are diagnosed in Australia every year.
  • Each day about 32 men learn news that they have prostate cancer - tragically one man every three hours will lose his battle against this insidious disease
  • One in 9 men in Australia will develop prostate cancer in their lifetime.
  • Prostate cancer is the most common cancer in Australian men and is the second most common cause of cancer deaths in men.
  • Each year more Australian men die from prostate cancer than women die from breast cancer. This could be attributed to women being better informed about medical things and men's relucance to go to the Doctor.
    • Posted 8/21/2013 11:49 PM (GMT 0)
    Tony said:
    "We'll have to agree to disagree. My reference was in your 3% mortality RATE. Screening creates higher incidence which dilutes mortality RATES"
    How? Can you explain?

    RalphV
    Posted 8/22/2013 12:06 AM (GMT 0)
    Ralph,
    Thanks for this thread. You have always provided excellent information that is timely and accurate. A month or so ago Yoop posted an article from the UK that grabbed my attention. Your graphs are excellent but this is what I recall: Only 1 in 8 is diagnosed in the UK versus our 1 in 6..but wait, 40,000 were diagnosed with 70% of them advanced cases with 10,000 projected to die within 5 years!
    In my opinion, that's rough love.
    Bill smhair
    Posted 8/22/2013 12:08 AM (GMT 0)
    China? Asian? The same?
    Interesting that China was referenced to try and prove points. o.O

    It's known that the Asian population develop and fair better, than the rest of us in regards to PCa.

    health.usnews.com/usnews/health/articles/070817/17prostate.b.htm
    Posted 8/22/2013 12:18 AM (GMT 0)
    We have more men in America with a PCa diagnosis than any other single country. We also have a higher number of G6 men diagnosed. If the PCPT trial data is correct that we could see as high as 30% less diagnosis, mostly in the low risk cases, we could see 230,000 per year diagnosed reduced to 161,000. And if that PCPT data is correct then we also would not have any impact on the number of men dying of PCa. The new mortality rate would be about 5%.

    The mortality rate climbed but the reduction of G6 cases impacted that rate. The quantity of men would still die. So by reducing incidence we increased the mortality rates among those diagnosed and have no evidence that would lead to more PCa deaths.

    Second, the more we screen younger men the more low risk cases we will get and at a higher incidence that high risk cases. The rates will be skewed.

    Tony
    Posted 8/22/2013 12:38 AM (GMT 0)
    Tony,
    I am sorry but I do not understand how incidence dilutes the mortality rate. The mortality rate is purely the number of PCa deaths during a period per 100,000 population. The number can only be affected by the number of PCa deaths or by the size of the population. How people diagnosed with PCa in a certain period (new diagnosis) affects mortality remains unexplained.

    RalphV
    Posted 8/22/2013 12:49 AM (GMT 0)

    iSpark said...
    China? Asian? The same?
    Interesting that China was referenced to try and prove points. o.O

    It's known that the Asian population develop and fair better, than the rest of us in regards to PCa.

    health.usnews.com/usnews/health/articles/070817/17prostate.b.htm

    Here is another interesting one on China and cancer.

    www.earth-policy.org/plan_b_updates/2011/update96

    If people want to eat liek thedo in China, by all means, knock yourselves out. But let's not use China as an example of healthy lifestyles because their environmental policies are poisoning their people.

    " Lung cancer is the most common cancer in China. Deaths from this typically fatal disease have shot up nearly fivefold since the 1970s. In China’s rapidly growing cities, like Shanghai and Beijing, where particulates in the air are often four times higher than in New York City, nearly 30 percent of cancer deaths are from lung cancer. (See data.)

    Dirty air is associated with not only a number of cancers, but also heart disease, stroke, and respiratory disease, which together account for over 80 percent of deaths countrywide. According to the Chinese Centre for Disease Control and Prevention, the burning of coal is responsible for 70 percent of the emissions of soot that clouds out the sun in so much of China; 85 percent of sulfur dioxide, which causes acid rain and smog; and 67 percent of nitrogen oxide, a precursor to harmful ground level ozone. Coal burning is also a major emitter of carcinogens and mercury, a potent neurotoxin. Coal ash, which contains radioactive material and heavy metals, including chromium, arsenic, lead, cadmium, and mercury, is China’s number one source of solid industrial waste. The toxic ash that is not otherwise used in infrastructure or manufacturing is stored in impoundments, where it can be caught by air currents or leach contaminants into the groundwater. "
    Posted 8/22/2013 12:49 AM (GMT 0)
    Ralph,
    Sorry, but I posted in error. 30% of the UK cases diagnosed were advanced and not the 70% that I listed..
    Bill smilewinkgrin
    Posted 8/22/2013 5:26 AM (GMT 0)
    Ralph, I think where I missed is your use of the 3% number and later compared prevalence versus mortality. I apologize. I was using per 100,000 men diagnosed and that dat was wrong. But...

    In that light, screening affects the mortality rates among those diagnosed. As you data clearly points out. The US has a 15% mortality by including tons of low risk cases. We diagnose more prostate cancer than any other country. Most of these cases are not high risk cases. Most are low and very low risk cases. My understanding is that 899,000 cases per year are diagnosed world wide and the US accounts for 21% of the diagnosis.

    The complete chart:
    globocan.iarc.fr/factsheets/cancers/prostate.asp

    The US accounts for just 4.5% of the world population. and 21% of the diagnosis of Pca. Either the US is predestined genetically to have more PCa, or our habits are terrible, or we are finding a lot of unnecessary cases. Pick your poison. I doubt we are genetically different in the human race. But socioeconomics (diet, exercise, exposure to carcinogens) are likely contributors and so is screening. But I'll agree to all three components.

    In any case. Most in this thread would be ok if we screened and found half of the world population's detected annual prostate cancers. I'm that if we screened every man starting at age 40 that's likely what would happen.

    Another point not directed at Ralph.

    So China and India are to be ignored? Why is it that they have 3 billion people and only 28,000 deaths per year to prostate cancer? Same number as the US with one tenth of that population...They don't even partake in screening.

    Tony
    Posted 8/22/2013 10:48 AM (GMT 0)
    Two quick observations regarding this discussion.

    1. Men that do not have prostate cancer rarely read or participate in this forum.

    2. Men that have prostate cancer come here nervously seeking information and advice on cure and management.

    Perhaps this disease has wrung too much of the altruism out of my soul but my allegiance is devoted to the latter group and any advice or sympathy that I can afford them I offer unconditionally.
    I don't mean to sound so cynical but I just can't see the merits of debating the politics of screening in this particular house. I don't believe it was built for that reason. Fireproofing is a totally different arena. We're here to treat the burned.

    Jim
    Posted 8/22/2013 12:36 PM (GMT 0)
    Oncas, I agree and appreciate the wisdom and efficacy of your brief but effective post.

    I hope this doesn't re-open the issue of broad tent versus support debate. I feel that was always framed incorrectly. You can have both without falling in the trap you outline above.
    Posted 8/22/2013 12:42 PM (GMT 0)
    Debate/discussion on this or any other subject related to PCa is unlikely to be restricted or eliminated even if it unpopular with some. As long as discussion is held respectfully and within the rules it is ok.

    Jim
    Posted 8/22/2013 3:14 PM (GMT 0)
    Hi Tony,
    If those low risk men that they overdiagnose here in the US and are claimed to be overtreated at an incredible rate are never destined to die of prostate cancer even when not treated, how can those men impact mortality?

    The PCa mortality rate in the US is lower here because testing with PSA finds cases that were going to die of PCa and by intervention that death is either postponed or avoided. It is as simple as that. The fact that we screen more than most helps save lives. The test is not to be blamed. The uncertainty of our diagnostic results; fear of law suits and a vastly uninformed and misinformed population results in an undefined amount of men who are treated when they could postpone or totally avoid treatment.

    The whole point of this thread is to show, with some data, that when PCa is diagnosed late; underdiagnosed and the population is uninformed, PCa can be a more deadly disease than is generally portrayed here.

    RalphV
    Posted 8/22/2013 3:21 PM (GMT 0)

    ralfinaz said...
    Tony,
    I am sorry but I do not understand how incidence dilutes the mortality rate. The mortality rate is purely the number of PCa deaths during a period per 100,000 population. The number can only be affected by the number of PCa deaths or by the size of the population. How people diagnosed with PCa in a certain period (new diagnosis) affects mortality remains unexplained.

    RalphV


    I have been trying to follow the ebbs and flows of this discussion, and agree with RalphV on this.

    I would think that the proportion of G6's screened versus G7 & G8-G10 and versus non cancerous would be in the same proportion as those not screened, since before screening their Gleason score is unknown.

    That's not totally true since symptoms would cause some PCa men to be screened, but not enough to throw the percentages out of kilter.

    That would roughly be offset by those diagnosed getting treatment they would not otherwise have been given had they not been diagnosed.

    LupronJim
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