Over Diagnosis is an oxymoron - ANYONE, please refute this. . . . . .

Clocknut-

The harms of treating an overdiagnosed PCa certainly outweigh the benefits - that is certainly everyone can agree upon. We can quibble over the exact number, but the stats show that a lot of this is going on. This is a statistical fact -- statistics are applicable to the group, but are not predictive for any individual. So what can we do to minimize the risk to the individual? That's where the AUA recommendation comes in.

The AUA is not saying to not diagnose -- they are saying to do it as part of a knowledgeable choice with eyes wide open to potential downstream harms. They are saying to consider screening for those most at risk of PCa and those that stand to benefit most from it.

- Allen

clocknut said... But her question was about "knowing," not guessing, or thinking, or wishing, hypothesizing, or relying on statistics or someone's model of how things should happen. Unless someone has a crystal ball, or a direct connection to the Almighty, isn't it true that there is now way of KNOWING that it will not cause harm in their lifetime? clocknut, it seems to me that your question has been addressed numerous times before. I know you asked Tall Allen to respond, but I’ll add my response.   I’ll try to take a somewhat different approach than has been taken on previous attempts; another attempt to try to resonate... “Certainty” (or, 100% proof, as some here have previously requested) is perfect knowledge that has total security from error.   Certainty, in real life, is impossible in practice.   To understand sciences, one has to identify the degrees of certainty, or uncertainty.   Ask a scientist for 100% proof, and he may look at you funny because he realizes you don’t understand that what you are asking for is an impossibility.   Instead, we gather data and use descript ive statistics to identify whether a preponderance of evidence exists, or not.   In many fields, we often call this “risk management.” For purposes of the discussion at hand, the preponderance of data says that men with low-risk PC do not need to rush to immediate treatment.   The preponderance of another set of data says that men initially diagnosed with low-risk PC who defer treatment have the same outcomes as those who sought immediate treatment.   The preponderance of data helps us make evidence-based decisions rather than emotion-based decisions.   Clearly, no "guessing" or "wishing" is involved; I assume that was included by you just for dramatic affect.  I don’t know how to answer your otherwise “impossible” question other than that explanation…   “ Doubt is not a pleasant condition, but certainty is absurd. ”   — Voltaire “ In this world nothing can be said to be certain, except death and taxes. ”   — Benjamin Franklin “ There is no such thing as absolute certainty, but there is assurance sufficient for the purposes of human life. ”   — John Stuart Mill “ If you tried to doubt everything you would not get as far as doubting anything. The game of doubting itself presupposes certainty. ”   — Ludwig Wittgenstein #115 from On Certainty           Post Edited (Casey59) : 8/22/2013 1:20:02 PM (GMT-6)

Tall Allen said...


The harms of treating an overdiagnosed PCa certainly outweigh the benefits - that is certainly everyone can agree upon. ...

- Allen

TallAllen - you are certainly more knowledgeable on PCa than I currently am or probably ever will be.

However, I still do not agree with this statement nor your reply to Mrs Worry Wart.

On the former, the harms are financial and potentially physical if there are bad SE's, a known risk. I just think you are ignoring the benefits from the perspective of the patient (customer always right and all that jazz).

I do agree that due to insurance, Medicare etc, people make the diagnosis choice more readily than if it were 100% out of their own pocket. However depending on their financial situation they might still opt for the diagnoisis, at least, if not the treatment and trying to keep the two topics distinct.

That argument BTW applies to all of helath insurance, amd Medicare not just to prostate cancer screening. Too much utilization due to semingly "no cost' or minimal cost. So solve the systemic problem without penalizing only the prostate patient.

Tall Allen said...

MsWorryWort said...
I just don't understand how they could know that it would not cause harm in their lifetime, if they are not screened.

Because the PSA-screening detection of the prostate cancer would be irrelevant in those men -- something other than prostate cancer would have caused their death before they ever experienced any of the clinical symptoms (e.g., skeletal events, kidney failure) of prostate cancer. Such high rates of overdiagnosis occur because prostate cancer typically progresses very slowly. Then, on top of that, PSA screening further increases the lead time before clinical symptoms would ever surface. So those men would have lived their full lifespan unconcerned by a diagnosis of prostate cancer (and untreated for it!) had it not been for PSA screening.

You are using circular logic. As a Monday morning quarterback you know that the PCa ended up being Gleason 6 and therefore techncially not necessary from either a diagnosis or a treatment perspective. Whether one now or in future defines G6 as Cancer or not is moot.

But until you did the biopsy, you had no clue whether this particular man was G6, or G9, just that on average few have advanced PCa. That was Mrs WW's point.

Of course this ignores the psychological aspects of knowing one did eveything possible to rid their body of what they consider potentially lethal even it the stats or people such as you more knowledgeable than they say odds are something else will have killed them first.

It's just a matter of whether one views the discussion from point of view of the patient or from point of view of medical board trying to minimize costs with what they consider acceptable collateral damage.

Patients such as me who turn out G9 with bone mets at initial diagnosis, part of the 1% club, would not consider our life collaterally acceptable risk.

As I implied Tall Allen (and Tony) I and all the posters on HW appreciate the extent of your knowledge and your willingness to share it. I find that those who caution "not a Medical Professional" tend to be some of the most knowledgeable, but there I go using stats and averages.

LupronJim

LupronJim,

Interesting:

Patients such as me who turn out G9 with bone mets at initial diagnosis, part of the 1% club, would not consider our life collaterally acceptable risk.

I have always considered myself a flag-bearer of the 2% club. Now to meet the really hard-core inner circle!

davidg,

Even if I were to agree, and I certainly do not, that "a majority are not subjected to those" side effects, subjecting a man to unnecessary surgery or radiation is unconscionable. Overdiagnosis means that any treatment for that disease are unnecessary.

There are surgeons who categorically state that 80-85% of their patients do not suffer form ED within a year and 90+% do not suffer from Incontinence.

I believe those numbers because I and other people I know who went to these surgeons are living proof.

Other numbers out there are still higher than 50%. This means that at worse it's a calculated risk and then when various nuances are taken into consideration a man has a very good chance of not being maimed (as you put it)

To determine that a man with cancer in his body does not need treatment is a personal opinion. The man with cancer may choose treatment for many reasons. Many men here, including quite a few with a G6 have given those reasons but have been ignored. I could give you my reasons for having treatment, and I know these reflect the same thoughts many of my brothers here shared before me and after me, but I suspect you don't care and/or would dismiss them. If I am unfairly characterizing your position on this please correct me and I will tell you why I thought treatment was a wise choice in my own opinion (and that of every expert and oncologist I talked to)

Your definition of over diagnosis relies on a premise that you cannot prove, and it completely ignores all other factors such as psychological issues, physical issues, family history etc that might result in a man benefiting from treating cancer.

Casey59, I am not so obtuse that I fail to understand the points being made by you, Tall Allen, et al.  I do.

However, when you say things such as, " Certainty, in real life, is impossible in practice.  To understand sciences, one has to identify the degrees of certainty, or uncertainty,"  my reaction is that I'm taking the positions I take not out of some useless search for "certainty," but out of a sense of uncertainty.  I'm not looking for certainty.  No one can tell a man just biopsied with a Gleason 6 PCa  with certainty that his cancer will not progress and that he will die of something else...only what is "likely" or what "may" happen.  And, therefore, I say that a man has every right to make the personal decision to err on the side of caution, and I will not judge him for that.  We should give men that choice, that option, even while we look to science for answers that it can never completely provide.

 

When you talk about the "preponderance" of evidence, I understand what you're saying.  Maybe it's a left brain/right brain thing, but when making life-altering decisions, I respect the preponderance of evidence, but I'm always aware of the exceptions, and we have quite a few of them right here on HW. 

 

Someone actually accused me the other day of not caring that tens of thousands (or a million?) men are overtreated.  That's a terrible thing to say to someone, and though I don't remember right now who said it, they should be ashamed of themselves.  I could as easily say that certain arguments display a distinct lack of empathy with those who don't fall into that "preponderance," but I prefer to believe that all of us have men's best interests in mind, though our approaches differ. 

 

There are no easy answers to a lot of these PCa questions.  I'm not so stupid as to look for "certainty" when approaching these important decisions.  Frankly, it's treating every new medical study as if it's dogma that is disconcerting to me.  I have faith in science, but I'm also aware of its limitations.