STUDY: Successful "wallet biopsy" leads to highest probability of PC overtreatment

Married, caucasions with high socioeconomic status are at the highest risk of PC overtreatment.

PubMed link:  Who Bears the Greatest Burden of Aggressive Treatment of Indolent Prostate Cancer?

Surprised?

Tony Soprano learns what a "wallet biopsy" is:  https://www.youtube.com/watch?v=O7CVXO2pBLc

 

OK, I'm going to be really dense here. The word "overtreatment" gets thrown around in here a great deal, and nobody bothers to define what it means. I am well aware that from the mid-80's (when PSA came in to common use), and about 2000 or so, there were a lot of men given surgery based mostly on PSA, who probably didn't need it.

Since the ACS guidelines came out a few years ago, and with all the publicity around it, there appears to be a lot more sanity around treatment options today compared to 15 years ago. There is also what sounds like hair-splitting, but it really isn't: AS IS a treatment. Non treatment would be: "go home and come back in a year".

So, my question is, what is the definition of over-treatment, in today?

I also note, relative to the OP, that married white males in upper socioeconomic status are more likely to have quality health care and medical insurance. Therefore, we are more likely to be getting screened.

Last, I suggest that in some ways, an individual will only know if they were 'overtreated', if the treatment is proven to have been unneeded. It's a bacwards look, not a forward look.

Overtreatment is a guy who is worse off from the side effects of his treatment than he would have been if he'd chosen no treatment or a less aggressive one.

IMO, as the more sophisticated imaging tools become more common and widespread (and paid for by insurance), then overtreatment will go down. The hope, that I see, is that it will become truly possible to identify the low PSA but aggressive cancers, and treat them without also treating the truly indolent cancers.

I just don't think we're there, yet.

I suppose it's personal for me. By some definitions, I did not require treatment based on test results. I probably fall in that gray area.

What a strange study and what an odd conclusion. I don't question the numbers, but I do question the underlying assumptions.

Since married Caucasian men in high socioeconomic groups generally receive "the highest quality health care," one must assume that the authors consider all the other medical procedures men who meet those descriptors undergo to be medically necessary and free from overtreatment.

In other words, men who meet the authors' description often have procedures such as knee replacements, hip replacements, hernia repairs, and who knows what else, and all these are apparently automatically deemed "good medicine" and "appropriate" Isn't it fair to consider that the wealthy white married guy could have limped around for the rest of his life on a painful pair of legs, just like the poor man who couldn't afford that surgery? Was he "overtreated"? Lately, I've been reading that many knee surgeries, for example, provide no better relief than the passage of time and less invasive procedures might have offered. But, we don't sweat "overtreatment" when we think about knee surgery. For whatever reason, we only seem to worry about "overtreatment" when it involves the ability to get an erection.

Are there men who could have postponed prostate surgery, or who could have chosen a less aggressive treatment? I'm sure there are.

Are there women who could have avoided a mastectomy, or a double mastectomy and chosen a lumpectomy instead? I'm sure there are.

Are we to assume that all the cardiac by-pass surgeries that men in these categories undergo are entirely necessary? That all cardiac catheterizations are necessary? That these procedures couldn't have been deferred in favor of lifestyle changes or less aggressive therapies? I guess so.

Most of us choose some sort of cause or issue as the center of our focus. For some, it's global warming or environmental issues, for example, and they see everything through the filter of that way of thinking.

I can't escape the feeling that some have chosen "overtreatment" as the windmill against which they must wage combat, and when they think of prostate cancer, that's their center of focus.

I'm still inclined to give men the benefit of the doubt. If they're in the group described, they're probably not ignorant of the issues involved, and if they make the decision to sign on the dotted line for their treatment, I just don't consider it to be "overtreatment." It's what they chose. It's their choice. And isn't "a man's right to choose" something to be respected? His body, his choice.

I may disagree with that choice, but I'm reluctant to call it "overtreatment."

Post Edited (clocknut) : 3/4/2015 8:45:02 AM (GMT-7)

clocknut, exactly the kinds of thoughts I've been having. This is really a fundamental question of medical ethics. I have a hard time accepting the idea that most, if not all, medical professionals are urging unnecessary treatment so they can buy their next yacht or whatever.

The bigger issue, to me, is undertreatment of people at high risk because of their inability to pay. It kind of falls in a similar vein to the classic legal construct that goes something like this: I'd rather see 100 guilty men walk free than see one innocent one imprisoned.

I'd rather see any number of men be overtreated (whatever that really means) than see one die of this horrible disease because he couldn't pay for treatment.

BTW, the "Overtreatment" article by the American Family Physicians lists a number of other proceedures as examples of overtreatment, in addition to treatment of low-grade prostate cancer.  I believe clocknut took a cut at a list, but the AFP list includes:

Anticoagulation for a small, subsegmental pulmonary emboli

Arthroscopic surgery for knee osteoarthritis

A1C targets below 7.0%, especially for middle-aged and older patients

Medical therapy for moderately elevated triglyceride levels

Treatment of prehypertension and mild hypertension

Using the same low-density lipoprotein targets for low-risk patients as for high-and very high-risk patients

Vertebroplasty for painful vertebral compression fracture

 

halbert, while I agree that PC overtreatment is difficult to accurately size — current estimates are that there are somewhere be 1 and 1.5 million men living today in the US who have been overtreated for PC — that doesn't imply it's "not fact based."

And you are also correct that the understanding of who does or does not need treatment is evolving with time as the body of scientific knowledge grows with time. It was only a generation ago when detection capabilities were inferior to what we have today that (essentially) everyone was treated immediately. The biggest change, and the change that has sparked overtreatment, is that we are now detecting smaller and smaller traces of "natural aging" which we brand with the term "cancer."

Current new imaging techniques have highly refined the abilities of knowledgeable specialists to separate who does and does not need immediate treatment.