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Posted 3/27/2014 3:35 PM (GMT 0)
I know we have discussed the idea of testing for PC many times. Almost all of us got our dx. as a result of a rising PSA (in some cases a positive DRE did the trick).

Yet, here is an article from Urology Today. Basically, it says early detection means nothing regarding PC. In fact, mortality is increased (I assume due to the biopsy and tx.). Hard to understand the take-away from all of this. If I have a swiftly rising PSA and a high probability of PC, should I even be tested? What's the point? Here's the article:

>>>>>>>>>>>>>>

Some fundamental and inherent weaknesses of screening studies are pointed out and discussed. The meta-analysis of studies involving a total of 321,594 participants shows no reduction in prostate cancer mortality or all-cause mortality, but describes disadvantages such as unnecessary biopsies, overdiagnosis, and overtreatment. A relevant increase in overall mortality cannot be excluded. Even in future trials, the possible reduction of prostate cancer mortality or all-cause mortality by prostate cancer screening will not be detectable because of inherent methodological problems, e.g., an extremely high number of participants are needed. Furthermore, by nature, studies on the early detection of cancer last very long, such that the results are inevitably outdated at the end of the study. There is a risk that studies on the early detection of cancer suggest an advantage and at the same time overlook a relevant increase in overall mortality. Prostate cancer screening also ignores important WHO criteria for screening programs: There is evidence that early treatment of prostate cancer is not better than late treatment. There is no suitable or reliable test to identify the early stages of the disease. The benefit-risk ratio is not clearly favorable, and there is doubt whether the costs and the benefits are in an acceptable balance. There are valid reasons to advise against population-based prostate cancer screening.

>>>>>>>>>>>>>>>>>

Mel

Posted 3/27/2014 3:38 PM (GMT 0)
And... since this thread will probably be controversial anyway, regarding another hot button item another study concluded:

>>>>>>>>>>>>>>

CONCLUSIONS: This large observational study with follow-up to 15 years suggests that for most men with non-metastatic prostate cancer, surgery leads to better survival than does radiotherapy. Younger men and those with less comorbidity who have intermediate or high risk localised prostate cancer might have a greater benefit from surgery.

>>>>>>>>>>>>>

Mel

Posted 3/27/2014 4:00 PM (GMT 0)

You said...
If I have a swiftly rising PSA and a high probability of PC, should I even be tested?

You are a little wrapped around yourself there, Mel. If you know you have a swiftly rising PSA then you have already been tested and it is too late to make the decision not to test. The genie can't be put back in the bottle.

This sort of study will never make very good sense to men who have been diagnosed and treated for PCa. We inevitably think of things from the point of view of men for whom treatment is necessary, or at least sensible. It's a sort of selection bias.

The way to understand this study is to rewind your mighty brain back to just before you learned what a PSA test was. Are you back there? Ok, now you are one of millions of happy, ignorant men some few of whom have a dangerous cancer and don't know it, but many, many more of whom have some condition that raises their PSA but doesn't threaten life or the enjoyment thereof -- "indolent" Gleason 6 cancers, or asymptomatic BPH or a dab of prostatitus. That is to say that you are just one of many, many guys, most of whom don't need treatment.

Those guys with problematic PSAs who don't need treatment add to the total morbidity when you screen them. They get biopsies, for one thing. The infection rate for biopsies is increasing, actually, probably from antibiotic-resistant bacteria. It currently runs between 2 and 4 percent. Biopsies also aren't good for man with borderline ED, and can aggravate urinary problems. These aren't big problems, especially from the point of view of someone who has had a brush with a life-threatening disease, but they do count in the actuarial calculations.

Then you look at the large number of guys who have indolent cancers -- cancers that would never bother them if they lived to 100. For those guys there is no benefit to treating them early. There is no benefit for treating them at all. The later you treat them the fewer guys you have walking around with treatment side effects. They count into the totals, too.

There are, of course, a very few guys (like you and me, as it turns out) where early detection and prompt treatment do help but there are soooo many of the guys who should never be treated that we barely show up in the totals.
Posted 3/27/2014 4:18 PM (GMT 0)
Peter:

Perhaps I wasn't clear. I didn't really mean "me" per se. This is not at all about me.

If one has say a fast-rising and high PSA, it seems it is time for the biopsy. The article questions all of that.

Also, I predict this thread will make you earn your money!!

Mel

Posted 3/27/2014 4:39 PM (GMT 0)
My reading of the part you quoted is that they are fairly narrowly talking about population-based PSA screening. It doesn't speak to PSA kinetics at all.

As for earning my money, you could be right. But on the other hand we all seem a bit weary of controversy just now.
Posted 3/27/2014 5:02 PM (GMT 0)
This ends up being endless argument fodder for both the "PC-experts" and we, regular every day men. It goes around and around in a circle.

With all my medical matters (let's forget about PC), my personal view, I always want to know if something is going on in my body. Good news. Bad news. Period. Not knowing, is just burying one's head in the sand, and too many men treat their personal health that way (not we, who are much more informed about men's health issues because of dealing with PC).

They take the "if it ain't broken, don't fix it" and the "what I don't know won't kill me" attitude. As a rule, women are much more prone by nature to take care of their health and bodies.

Saying that, I still say that all men need to have a baseline PSA test. Don't want to argue about what the age should be, but at least by the old standard of 50. What's it going to hurt? A simple blood test.

For the majority of me, that are found with low grade, non-aggressive PC, they probably don't need treatment, just AS. If you could take fear from the men and eliminate the greed factor of some doctors, I feel AS would be an easier sell.

But for we men, who are diagnosed with more aggressive cancers, of course you need to know what you are dealing with. You have the right to be treated, in order to save or prolong your life. Why not? Not knowing you have an aggressive cancer is only going to make one end up being a "fatal" cancer statistic one day.

I spent most of my adult life in the world of business and high finance, most things, always come down to money and the bottom line. While I don't like conspiracy theories, my hunch is most of the argument coming from up "high" on ODOT, really boils down to the bottom line. On one hand, you have doctors and facilities drumming up patients to pay for their equiptment, so PSA testing and early dx. makes for an endless stream of customers, especially when they take advantage of most men's very normal reaction that any cancer diagnosis is a bad thing. On the other hand, there's not an insurance company out there, that wouldn't like to stem the billions (or millions) of dollars being spent on PC testing, diagnostics, and treatments. Why wouldn't they want to curb it?

So there is a push not to test. Not to do biopsies. To do AS. But all of them could easily have net profit/loss implications to one side or the other.

As long as we patients, have good insurance to pay for all of this, with as little out of the pocket expenses as possible, why wouldn't we want to be tested and/or treated? Again, ding, ding. A money answer behind even that.

The number of men dying from PC seems to be staying in the same general range. With testing, without testing. "X" amount of men will have the misfortune of having aggressive prostate cancers, and they will die with or without treatment. Some will buy time with treatments, while others won't. Sad, but true.

It is still up to each man alive, to be totally responsible for their own personal health. Not their wife or spouse nagging them. Not their PCP telling that what to do. So what am I saying, more health education to men. Being ignorance is not a sin. Just means you don't know something. Stupidity is when you are told something, and then choose to ignore or deny the truth. Men need to go from being ignorant about their health issues, to becoming informed. And informed patient then can make the right decisions for their own health. And this could include regular PSA testing.

I used to be 100% against re-naming low grade, indolent G6 cancers. Totally fought against the idea. But as time goes by, perhaps it would be a good thing. If a man got diagnosed as a G6, 1 core <5% cancer, and it was confirmed with a second reading, perhaps it would be best not to call it cancer. One you say cancer, most people will freak out, think they are going to die soon, and that's what starts that entire "I got to get it out of me" attitude in the first place (or similar thoughts). If it wasn't called "cancer" under those circumstances, then there wouldn't be the fear factor, and there sure wouldn't be a need to subject such a patient to an invasive treatment such as surgery or radiation, in order to treat something that doesn't need treating, and will never harm that man in there lifetime.

Probably we still need a more precise diagnositic tool, one that could 100% tell if a cancer was aggressive or not. Don't think we are quite there yet. But if we did, and if it were accurate, you could probably curb over treatment in half or more, and doing it safely as well.

But for now, the experts and the lay, will endlessly argue these points back and forth, and no sensible conclusion will come out of it.

For me, I have a cancer that's more aggressive than the numbers show. If it were not for regular PSA testing at age 50, it wouldn't have been spotted. If it's this bad now, I can only imagine how bad it would be, if I hadn't been diagnosed in 2008. As fast as my PSA was multiplying and climbing from 2007 to 2008, I could have stage IV cancer, mega-mets, and a PSA in the thousands. So for me, and for most here, the whole subject is mute. It's easy to look at this with hind sight, and with the luxury of having already been diagnosed and treated.

That's my take. I am not a doctor, I have no special knowledge on the subject.

David
Posted 3/27/2014 5:30 PM (GMT 0)
Mel,
What we are talking about is mass screening where everyone gets screened regularly regardless of risk characteristics. We are all naturally biased because all of us had our cancers detected by psa, but we are also a small select group that does not represent the universe of men in the large picture. In the large picture 16% of men will be Dxed with PC in their lifetime. 70% will have low grade or low intermediate cancer, which they will never die from. Some portion of the remaining 30% will have aggressive cancer, even when treated will eventually cause death, and the remaining portion is the sweet spot in which those who are treated will be cured. PC deaths are about 28,000 per year and if we estimate 50% of these would have died regardless of treatment we end up with 14,000 deaths that could have been saved by screening and treatment. The off set is that 1 in 1000 will die from a biopsy multiplied by 1 million biopsies or 1,000 deaths. Another 1500 will die from treatment itself so that leaves 11,500 of the total population that would be actually saved by screening and treatment. This does not include those that die from stress due to a cancer DX. The incidence of heart attacks rise significantly 30 days after a cancer DX. So mortality could exceed the 2500 from treatment. Since we don't currently screen everyone the 2500 who die from screening and treatment would increase, but so would the number of men that could potentially be saved, so the actually number is somewhere between 11,500 and 20,000 who could potentially be saved through mass screening. so the question is it worth it to screen everyone to save 11,500 to 20,000 given the fact that the 250,000 Dxed each year would also increase to above 500,000 and 250,000 of them will have side effects from treatments and medical costs would increase significantly. Your values will determine your answer to that question.
Posted 3/27/2014 6:00 PM (GMT 0)
John: Given your views, would YOU personally have been tested? If not, where would you be now?

Purg:

You said:

>>>>>>>>>

Saying that, I still say that all men need to have a baseline PSA test. Don't want to argue about what the age should be, but at least by the old standard of 50. What's it going to hurt? A simple blood test.

>>>>>>>>>>>>>>>>>>>

I totally agree with this and most of what you said. But the article is answering the "what's it going to hurt" part. It's going to lead to more testing and biopsies and deaths from the stress/testing/tx. That's what THEY SAY. That is what's going to hurt. I guarantee you that if your age-50 baseline is say 3.1, assuming you are knowledgeable about this issue, you would not rest with that figure.

Regarding the classification of G6 as being kind of an indolent, non-cancer type thing. I agree that this is indeed the case. What is oft-putting to me is the fact that so many (30%) get upgraded upon surgical pathology. So, suddenly, a G6 becomes a G7 or even worse in a few cases. Knowing what I know now just by reading HW, I would not be satisfied in doing nothing with a G6 biopsy result because of the not-real-small probability that it could be worse. Yes, we do have improved imaging, etc. But I don't think we can get enough information gleaned from these tests to say that you have a 95% or 99% probability of having a TRUE G6. That's the probability I would require and in fact that is usually the requirement for statistical significance.

Mel

Posted 3/27/2014 7:28 PM (GMT 0)
do as I say not as I do.

ed
Posted 3/27/2014 7:37 PM (GMT 0)

compiler said...
And... since this thread will probably be controversial anyway, regarding another hot button item another study concluded...

I don't think that is at all controversial. 15 years ago it was true that surgery was more curative than any of the forms of radiation available at the time, and surgery was a better choice for younger men. There have been a lot of excellent advances in the last 15 years.

The problem with all long-term studies is that they tell you what you wanted to know 10 or more years ago, but not what you want to know now.
Posted 3/27/2014 8:00 PM (GMT 0)
Allen:

I quoted you the conclusion. It was published today.

Yes, the study I think covered 1996-2010.

Your comments are appropriate, but with such a conclusion on a just-published work, I guess that would be controversial. Your comments explain why it is controversial!

Mel

Posted 3/27/2014 8:21 PM (GMT 0)

John T said...
Mel,
...................This does not include those that die from stress due to a cancer DX. The incidence of heart attacks rise significantly 30 days after a cancer DX. So mortality could exceed the 2500 from treatment. Since we don't currently screen everyone the 2500 who die from screening and treatment would increase, but so would the number of men that could potentially be saved, so the actually number is somewhere between 11,500 and 20,000 who could potentially be saved through mass screening. so the question is it worth it to screen everyone to save 11,500 to 20,000 given the fact that the 250,000 Dxed each year would also increase to above 500,000 and 250,000 of them will have side effects from treatments and medical costs would increase significantly. Your values will determine your answer to that question.

It seems to come down to: is it worth putting huge numbers of men, the majority of whom would never die from PC, through the expense, anxiety and even possible death from treatment or other diseases arising from the stress? In order to save the relatively small number of us who most likely would die from PC, and whom the treatment actually saved or prolonged our lives?

What a rock and a hard place! So I just posted a study on here where 42% the men with G8-10s and chose conservative treatment died of PC out 10 or 15 years, compared to 13% of those who had RP That is quite a difference in survival. ( caveat: even in the conservative group, 40% had HT, presumably the other 60% had nothing?) Also, I recently quoted Mulhall ( the ED doctor) who claimed that 80% of G8-10s would die of PC in 10 years. Now we couldn't figure out what study he referenced, and I assumed he must mean with no treatment, as yet another study here showed that only 31% of G8-10s who had RP had died PC even 25 years out! Only 27% had died of PC 20 years out, 73% had not, and 89% post RP G8-10s HAD NOT died of PC at 10 years.

So all of that seems to me ( maybe I am just hoping and grasping at straws) that for people like me, diagnosis and treatment has a big benefit statistically compared to doing nothing.

But for me to benefit(hopefully), how many men are going to be tested, and Bx, and treated, and maybe even harmed by their treatment for a disease that would have never hurt them? And is all that a worthwhile sacrifice of the entire group so that I can benefit? Some harm will come to some men even just from the Bx.

Now in my case, a G9 with some SV involvement, don't the stats say that I would have most likely been dead of PC within 10 years if I had not found this and had it treated? So it seems to me the PSA and hopefully the treatment is a no brainer. But for the fellow that is only G6 and who may have been harmed- and certainly stressed- from the Bx or treatment, it's much harder to say if it is all worthwhile. Then again, without the testing and even maybe an RP, how do you ever really know if you are just a G5 or 6?

So I am leaning towards worthwhile. But someone who disagrees with me mentions this study(sorry, I don't have the link): in Russia and 1 other nearby country, where PSA testing is rarely done, some 1000 or so men who died of heart attacks/stroke etc, age 60 on up, were autopsied. 60-75% or so were found to have PC which had not yet caused them trouble, or not enough to yet get diagnosis and treatment. Some of the PCs were aggressive and advancing, some were neither. The argument made was that 100% of these men would have been harmed by a PSA, considering that 100% of those with PC died of something else and with undiagnosed PC, didn't even know they had it. There is a selection bias in that study, since you know going in that all died from other than PC. Still, it is hard to argue that, at least for that 1000 men, the PSA diagnosing PC could only have proved harmful. How could any of those men have benefited from Bx or RP or RT or HT and all the side effects thereof? Including some possible death from treatment complications?

Now if you had another study of 1000 men who died of PC, then PSA leading to treatment might seem more worth while, at least for that group.

Still, I think I did the right thing getting that last PSA and really do wish I had had more done sooner sooner. I did myself harm by making excuses for my 1st PSA of 4.0 up from 2.6 four years previously. I just knew it was my BPH and 30 years of prostatitis, heck, why wouldn't my PSA be up? And I knew of all the controversy about PSAs and treatment. So I put it off. Big mistake, says Mr. G9 with SV+!
Posted 3/27/2014 8:53 PM (GMT 0)
Mel,
Personally I'm against mass screening, where an entire population base is screened on a regular basis using psa. I'm all for an intelligent screening process and I think we are getting close to getting one, but there are still a lot of different opinions on what it would look like. At risk men should be screened, family history, chemical exposure, African American ect. A psa test when one is in his early 40s should determine the frequency of future screenings depending on data, which we yet do not have. anyone with a life expectancy of less than 15 years should not be screened. I do not believe in annual psa tests for everyone, only those that show an elevated psa.
I had a psa test in my early 40s that was normal, as part of an executive physical at scripts. My next psa test was 10 years later at 4.4 and I was treated 10 years after that. A five year screening interval would have found my cancer well before it was dangerous.
Posted 3/27/2014 8:54 PM (GMT 0)
Billybob:

I enjoy reading your erudite posts.

I guess we can talk in general about large groups. But then you have to make an individualized decision.

I have been pushing my son to get a PSA, large group be darned (he now has a history of PC in the family on both sides)..

It's not a simple situation when you try and make a decision based on large group results.

If we use the large group arguments, think of how many HW members would now be in dire straits?

Yoiu know, if we only had better diagnostic tools that can dx PC and tell us the TRUE G-score and TRUE aggressiveness, then this conversation would be moot

Mel

Posted 3/27/2014 9:10 PM (GMT 0)
BillyBob,

You are still making the mistake of dividing the population into groups and then looking at their decisions separately. Then you get into the idea of how much obligation members of one group owe to the other and it your notions of altruism muddy the water. You have to look at the decision to screen or not given only the information available at the time -- which is a vague sense of the odds.

A loose parallel would be whether to go out on the beach to swim during a thunder storm. As you stand there at the shelter and look at the ocean you can think: Ooooh, those are some righteous waves. It'd be fun to get out there with my boogey board and at the same time you also might think: every year on this beach out of thousands who swim here one or two is struck by lightning. The decision process isn't any different for the guy who is going to get struck by lightning that it is for the guy who frolics in the surf. At the point the decision is made they are both the same guy figuring his chances.

Since your surgeon cut wide to get it all you may pretty soon be joining me in the club of the Trimix needle. It's a happy place compared to the alternative but its not something that any natural man really wants to need to do. To some extent it is the price that you and I pay for a shot at a cure for our aggressive Gleason 9 cancers. But guys who are treated for cancers that would never have bothered them wind up in the club, too. And that sucks. Big time.

So going back to that moment of decision, before all the alternate-universe yous had split off along other probability tracks, you were faced with a one in a thousand chance of avoiding getting struck by lightning by staying out of the surf, but only at the price of a very substantial risk of hanging up you boogey board for good. So, as it turns out: yes, you made a good decision. But did you make the right decision given only what you knew? That's not so clear.
Posted 3/27/2014 9:13 PM (GMT 0)
Mel,

Quite true. Or if we were convinced that AS was as safe and as certain as we wish it were, then we would not need to fear the PSA test either.
Posted 3/30/2014 9:51 PM (GMT 0)

PeterDisAbelard. said...
BillyBob,
................................................
Since your surgeon cut wide to get it all you may pretty soon be joining me in the club of the Trimix needle. It's a happy place compared to the alternative but its not something that any natural man really wants to need to do. To some extent it is the price that you and I pay for a shot at a cure for our aggressive Gleason 9 cancers. But guys who are treated for cancers that would never have bothered them wind up in the club, too. And that sucks. Big time.


It sure does. And yes I will be joining you in the trimix club, he told me that up front on my pre-op visit. He said he had a guy with similar stats as mine, there that same day for his post op visit same day I was, who was functional with the pills, but that was not usual, but not to worry too much because I could use injections. I'll find out on my Apr 7 visit if he left me any nerves at all. The way he put it on my pre-op visit with him is that he could not do actual nerve sparing, and would need to cut close (to the nerves) on the left and kind of close on the right. What he actually ended up doing I do not know. Pretty dead so far after almost a month of Cialis 5 mg/day. Plus still quite wet when standing/walking.

PeterDisAbelard. said...
So going back to that moment of decision, before all the alternate-universe yous had split off along other probability tracks, you were faced with a one in a thousand chance of avoiding getting struck by lightning by staying out of the surf, but only at the price of a very substantial risk of hanging up you boogey board for good. So, as it turns out: yes, you made a good decision. But did you make the right decision given only what you knew? That's not so clear.

Exactly, not so clear. In fact, it never was clear to me. It is not all that much clearer now. Especially now that I am living with the complications of the surgery.
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