overtreatment post primary treatment. Has it run rampant and how would we even know?

It's a tough question...because it's being based off of observations and personal preferences. To say it's "run rampant", I can't agree with that statement. It's too vague first off...

The other big issue is what is the definition of "over treatment"... another key factor.

Are some people choosing treatment paths that they dont' need to at that time? yes.... but at the same time, I've seen many G6's at biopsy, choose surgery, and post surgery pathology is upgraded to G7 or G8...

Until the staging is more concrete, there will always be an issue. So we need better diagnostic measures, along with education of men.

Bozolegos,

As I recall you seem to feel that the trend toward pulling the trigger on salvage radiation after surgery at lower and lower PSA levels is unjustified. Your question is broader -- encompassing all modes of primary treatment -- but I don't remember a lot of controversy (or even discussion) of follow-on treatments after radiation/brachytherapy so I will assume that radiation after surgery is your primary concern.

From my point of view as a high-risk case -- and as a result of my review of the research into such cases -- I am of the opinion that it is hard to overtreat high risk men and I am quite OK with using a confirmed reading on the ultra-sensitive PSA test of > 0.03 as a trigger for salvage radiation for high-risk patients. There is fairly compelling research showing that men whose PSA rises to 0.03 after surgery will see their PSA continue to rise to whatever PSA level is more conservatively considered a "recurrence" (generally either 0.1 or 0.2). Since recurrence is generally a bad thing for such men it is appropriate to take early action to prevent it (as some recent research has shown).

So, my answer to the first part of your question is that it depends on the degree of risk -- higher risk men are unlikely to be overtreated and lower risk men are usually encouraged to wait a bit longer. But ya never know.

Which leads me to the second part of the question: how would we know? The clear answer is that we never can know on an individual level because of the definition of overtreatment which is a treatment that produces a result that is worse than the untreated disease would have produced. Since an individual man can never be both treated and not treated we never, ever get to know. But we can compare similar populations of men who choose treatment and men who are not treated and can draw some statistical inferences.

PeterDisAbelard. said...
GeetarMan,

I agree that your uro seems a bit trigger-happy but it's best to bear in mind that that isn't a "get out of jail free" card for you. You seem like a good candidate for Active Surveillance.

All,

The question that BozoLegos asked is a more interesting one than the question you seem to be answering. We've beat the question of overall overtreatment to death here on the forum. What he was asking us to discuss was whether there is a similar over-use of salvage treatments after primary treatment.

Totally helps if you actually read....that is my bad, was in mode of other thread.

My apologies Bozo for comletley going off from intended topic...

I can only speak from my own experience. I had SRT after my PSA doubled twice (from .1 to .4 over a period of 10 months. After that I remained completely undetectable 0.00 for nearly 5 years. I think it is reasonable to assume that had I not opted for SRT when I did my PSA would have continued doubling every 6 months or less and I'd have been on ADT several years ago. So, whether or not the SRT has extended my lifetime, it has definitely given me a few extra years without ADT.
Jim

PeterDisAbelard. said...
The question that BozoLegos asked is a more interesting one than the question you seem to be answering.

Solly Cholly. I misunderstood.

Geetarman
You are indeed blessed! Amazing how your PSA declined and stayed low after you opted for AS. The trend before that was worrisome and I'm not surprised that your uro was concerned.
Bob

If you are saying over treatment as treatment vs Active surveillance, I would greatly disagree. I see way too many guys with G 6 go on AS and eventually end up with G7 or greater that should have even treated early on! Just my unprofessional observation.

I'm another who is dubious about labelling anything over PSA 0.03 as biochemical recurrence. I suppose because my URO has an instrument that gives it's lowest possible reading of 0.04! By that definition, because I'm <0.04....I could be a 0.03 and not know it. I'm just not convinced that the QA/QC is good enough at that low level.

The question at hand appears to be....are we treating BCR too early and unnecessarily? I'd suggest that this is a different question that asking whether the 'throw the kitchen sink at it' attitude towards treating heavy G8-G9 disease is appropriate.

Who knows? Who is going to sign up to be the control group that doesn't get their potentially early BCR treated? I don't forsee a rush of volunteers for that study.

Thanks guys...been out and about all day...am pleased with the response, including those who misunderstood the question...no worries... I misunderstand a lot myself and that has never stopped me commenting. PeterD, as usual,{preceding 2 words not meant as diminishing or patronizing} understood my intent. I just hate to see guys go into srt at such low levels of psa, based on studies that are obviously skewed{not intentionally...naturally} because the folks who may never have recurrence and are cured are willy nilly part of the studies that lead such men into the the very treatment they didn't need. The preceding sentence is not paradoxical but straight forward if followed logically. I guess I just wish more men had faith,not in a religious sense, but a real quantifiable sense, like the sun will come up tomorrow. having said that, who am I, or who is anyone to really question anyone else on what is right or wrong for anyone else, especially when I cannot for myself. Its a wonderful life, with valleys and peaks, much like a heart monitor. None of us want to flatline...so there is my existential response, I guess, to a question not even formed...
Thanks for the input.. One thing I do believe...Too Much... to believe in...is that it all ends well...I must...and If I am wrong...that in itself would be wrong. That is the power of the human spirit...in my view...............

Post Edited (Bozolidat) : 12/21/2015 8:03:21 PM (GMT-7)