Musings about PC

The medical thought leaders in PC will tell you that today one can, with very high confidence, weed out those who do not need treatment from those who do. It does NOT come from one PSA test and one biopsy...it takes more effort than that...(which is why this PC "rule of thumb" exists: If you were aggressively treated after just one biopsy showing favorable-risk PC, your risk of having been overtreated is high).


Does that mean that nobody who goes onto AS ever dies of PC? No. There is a small percent of cases of very nasty PC which may initially looks favorable-risk but advances relatively rapidly (still measured in years).

But what many people forget to compare that to is the percent of people with initially favorable-risk cases who also seek immediate treatment who also end up dying of PC; they are a case of “failed” surgery, SRT, etc. The rates of PC death in these two groups are essentially the same. Both are very low, but they are the same.

So, apples-to-apples, there is no PC survival benefit for favorable-risk men who seek immediate treatment. Basically, if you are going to catch the nasty version, it’s not going to get stopped.

Muse on that for a while…

sheepguy said...
...who has a biopsy after one PSA test?...

The urologist I went to wanted to do so. I had misgivings, and that is how/why I found this forum.

The nurse actually acted a little haughty when I wouldn't schedule the biopsy. Then, called back a couple of days later to see if I wanted to schedule the "ultrasound." I said, " don't you mean biopsy?" She responded, yes "ultrasound biopsy." I didn't schedule.

I wanted to do more labwork prior to biopsy, several members here posted they thought it was a little early to be doing a biopsy suggested I get a PHI. Have one scheduled with a different URO next week.

The members here are well informed and on top of this subject. The general public is not. I believe overtreatment in this field is higher than it should be.

Good question. In my particular case , I had PSA rising over a period of 6 years to 6.6, having been stable for10 years or so then a biopsy revealing G6 in 3 /12 cores all less than 5%. If it continues rising I will do something. But...in the meantime I've spent a lot of time worrying about PSA levels rising for 6years...coiuld have avoided that if I had not even done the screening added stress for nothing.

I've been working on a theory that PC is actually a virus created by the federal government to reduce the population of men receiving social security and medicare payments. I nearly have all the evidence collected.

oh, no, got to go that black Cadillac just parked out front again...

halbert said... sheepguy asks a very important question about what appears to be a somewhat moving target: what is the definition of favorable risk? Here's what I think it means: G6 on no more than 25% of cores and PSA <= 10 with no other factors such as familial history. Family history of 2 or more direct line males with PC moves one up a step. PSA doubling time of 12 months or less also moves one up a step away from favorable risk. So, I was favorable on my PSA and biopsy, but moved up due to family history AND doubling time. Hahaha…oh my!   (sigh!)     There’s no need to make up a criteria from scratch to fit anyone's case, halbert.   The evidence-based work has already been done for you and published by the NCCN. If you were a newly diagnosed newbie to the site, I would direct you to look at the sticky thread titled, “Newly diagnosed with PC? – read this thread first."     There, you will find in the very first posting , the important “ Step #1 ” for all newcomers:   be able to answer the question, “ What is your risk category? ”    The criteria is provided in that posting. All men diagnosed with PC should know the answer to this question because it is so incredibly fundamental to their “patient education,” and their ability to make an evidence-based rather than emotional-based decision prior to moving to the next step.   Sadly, way too many men don’t take the time—especially those who are in the intermediate risk category or lower, which is the vast majority, because they have the gift of time on their side—to learn and educate themselves about prostate cancer, and risks, and the potential harms and benefits (or lack thereof) of treatments. Speaking directly in response to your post, above, family history is not medically significant to one’s NCCN risk category.  Prostate cancer is almost exclusively considered a sporadic type of cancer, triggered by a combination of your body’s unique biology and the accumulation of lifestyle/environmental effects…but the key is that it occurs AFTER one is born.     Hereditary cancers, on the other hand, are inherited and take place when gene mutations are passed within a family from one family to the next.   In hereditary cancers, every single cell in the body contains that mutation, although only some individuals develop the cancer. There IS, however, a recognized pattern of “aggregation” of prostate cancer in families, largely attributed to increased diagnostic activity.   If your dad or grandfather or brother has/had PC, you are more likely to get screened…and the rate of screening is directly proportional to the rate of incidence…if you look hard enough, you are likely to find PC in a man over 50. Almost a generation ago Dr Pat Walsh first made this comment in his book (“Guide to Surviving Prostate Cancer”), which was also recommended in the “Newly diagnosed…” thread for newcomers to read:   “ Prostate cancer is so common that even if there is a small hereditary factor, there will be other members of the family who will get the disease sporadically .”     As we’ve seen in another recent thread, as we are living longer, PC is so common that it is also (by far) the largest first primary cancers in cases where there are two (or more) second primary cancers. Also speaking directly in response to your post, above, PSA doubling time is also not used in risk category assessment.     How much of your PSA increase was caused by prostate infection which can often accompany/coexist with small (or larger) amounts of PC?     It’s not easily separated, and so it is not included.     The reality is that if one’s PSA shoots up or doubles in a relatively short amount of time, but has other indications for low-risk PC, then that PSA jump is most likely attributable to infection (difficult to isolate and/or treat).     This is a key reason PSADT is not useful pre-treatment.   (PSADT is, however, very important and useful post-treatment for monitoring.)   Now, perhaps, it is more clear why earlier in this thread (in response to your question about what one could/should be in favor of or against; pro/anti) I stressed the importance of “patient education.”   The education process for many men takes place after they rushed through treatment at the earliest sight of low-risk PC; I contend that it would be better to take place before irreversible treatments than after.   This has to continue to improve to drive down PC overtreatment.  I said what I’m for/against…what about you?  Others?   Post Edited (JackH) : 8/27/2015 10:27:02 AM (GMT-6)

Jack, I'm absolutely all about education..and finding medical professionals who are also all about education. The single most valuable conversation I had with a professional about my situation happened about 2 weeks after the biopsy came back. The Dr. scheduled an appointment for my wife and I to come together, at the end of his day. He literally sent all the staff home and then sat with us, gave us literature to take home, and went through all the information. He told us that IF I chose surgery, we needed to understand that he only did open surgery at the local small hospital. And then, IF I wanted referrals for either Brachytherapy or DaVinci surgery, he would have no problem with doing the referral...and handling post treatment care a long as I needed it.

He gave us information about AS as well, and indicated his office would manage AS if that was the choice I made.

Like I said, that one hour or so was more helpful than anything I encountered with a professional. And, he was very careful to NOT push in any particular direction. He did, when I asked about AS, indicate that his OPINION was that I could do AS, but I would probably not be on it for more than a year or two, based on his experience with cases like mine.

I also think that the FIRST educational bit we have to do is to convince men (and their PCPs) that they SHOULD get that baseline PSA sometime in their 40's. Regardless of how many headlines they read that say that PSA is a worthless test and that screening is not encouraged.

For example, under NCCN guidelines what risk level is PSA 10, G6, T1c ...according to NCCN guidelines that puts you at intermediate risk by virtue of a PSA of 10.

Boy howdy....as I've said before, as a farmer,I'm in no position to travel from NY to chicago, seattle, down to LA, over to Houston the Florida, Baltimore , Boston etc. Unless, of course, I want to give up farming and live under a bridge..better than being dead? Marginally.

halbert said...

I also think that the FIRST educational bit we have to do is to convince men (and their PCPs) that they SHOULD get that baseline PSA sometime in their 40's. Regardless of how many headlines they read that say that PSA is a worthless test and that screening is not encouraged.

I'm going to respectfully, yet strongly, disagree. (And the medical community also STRONGLY disagrees with you; see below.) The changes must be made together.

If you just push the testing down to a younger age without informing/educating men about the extreme limitations of the PSA test, the potentially severe consequences of over-reacting to PSA test results, and about prostate cancer/prostate health, then you fail to address the root cause of overtreatment and will simply DRIVE UP THE RATE OF OVERTREATMENT.

Thankfully, we ARE seeing increased educational materials going out...and are seeing an increase in the update of Active Surveillance as a direct result. But sadly we still anecdotal stories here at HW/PC of men who rush with low-risk PC in only a matter of a few months into an aggressive, irreversible treatment that they may never have needed. More work in the education area is needed.


I guess one should never assume too much, but you do know, don't you, that there is not a professional medical organization in the world that said the PSA is a worthless test, right? Even the USPSTF's very thoughtful document included the appropriateness of a PSA test discussion between a man and his physician. I think that the description in the AUA's guideline is very well stated not just as a recommendation, but as a STRONG recommendation: "...the Panel strongly recommends shared decision-making for men that are considering PSA screening, and proceeding based on men's values and preferences."

There has been an unfortunate hyperbole and hysteria about the PSA test that we SHOULD NOT PERPETUATE at sites like this which confuses men. The message we should be spreading is: irrespective of patient age, a screening PSA test should not occur without a thorough discussion of the risks and benefits of screening between patient and physician.

Your questions were low-hanging fruit...I believe I answered them several days ago.


Now, if you want your own blog with just your own comments, you should start that...somewhere else. This forum is open to civil dialogue, including civil disagreement.


I will civilly encourage you to consider the potential harm to others caused by being one of the ones to perpetuate the hyperbole:

halbert said...
...the way to break the chain is not to stop screening...

Nobody said stop screening. What they (the AUA, for example) did say was:

The Panel concluded that PSA-based screening should not be performed in the absence of shared-decision making. Thus, we recommend against organized screening in settings where shared-decision making is not part of routine practice (e.g., health fairs, health system promotions, community organizations).


http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm

Post Edited (JackH) : 8/28/2015 12:26:25 PM (GMT-6)

halbert said...
I had annual PSA's for over 10 years, and it doubled 12 months apart for 2 years before I had a biopsy. The question the scientist in me is asking is....whether my understanding is correct: that a "true" G6 NEVER goes anywhere or does anything. Which suggests that the common model is wrong. That Prostate cells do not progressively go from "normal" to G3, then to G4, then to G5. That, instead, somehow prostate cells go from normal to nasty in one step.

Is it possible to be "pro-screening" and "anti-overtreatment" at the same time?

Maybe one more?

But do they go anywhere(as far as a G progression)? Or is a 9 born a 9? Believe it or not, I asked this question to one of the residents( I felt he was likely pretty new at all this) at Vanderbilt the morning after my surgery. He got all embarrassed because he had no clue to the answer. I felt kind of bad for hi, but then again he did ask if I had any questions!

Jack,
Just from Halberts first post, seems like you were trying to shoot down a rather simple, and hopeful thought.You obviously have done your homework and are all up on treatments, etc, etc. Appreciate your info and advice and what you think. I obviously do not know all the info about which you speak, and may have the wrong take on this ,so forgive me ahead of time. To give you a little civil disagreement ,Halbert is not blogging, Mods should look this debate.Mods can delete my post if they want as negative on my part, but I thought the whole idea of this forum is to help each other, not bring them down. A healthy dose of realty is good, but anyone expressing hope or limited knowledge like myself, should not be chastised! And no one will ever convince me that early PSA screening is wrong. Some here have a right ti disagree. This is from one of those of us who think different!! Just seems like you were trying to be dismissive of Halberts post.
Dan

Post Edited (Wings of Eagles) : 8/28/2015 3:17:00 PM (GMT-6)