"Number of Advanced Prostate Cancer Cases Soars..."

halbert said...
And Jack, you missed my point. What IS the solution? If not PSA, then what gets us "there"?

I also want to know "what then" is the solution? The thread title says a lot: PSA testing down, those 1st being diagnosed with advanced disease soars". Wasn't the opposite the case earlier in the PSA era? As PSA testing rose, diagnosis with advanced disease plummeted? The latter to me seems a good thing, is it not? The thread title seems a bad thing, at least for all the extra men diagnosed with advanced disease.

So, what is the solution to that? Preferably other than just saying "that is a shame" for all the extra men who will now be diagnosed with advanced disease? Massive education of the patient seems to be one way to help, but is that happening? Plus, even if educated, how many men will be able to stand against the recommendation of their doctor to have aggressive treatment for low risk cases? The average Joe is going to be wondering who to believe, his doc or the educators? Many will go with the doc.

How to educate the public that does not come to this web site? How to help men who no matter what he reads at a place like HW, is bound to say "all I know is it is a cancer and I want it out of there"? One way might be if the medical experts decide to stop calling low risk cases cancer.

But whatever the solution, surely there must be something better than denying high risk guys the chance to find out they are high risk early in the game? Like my case, probably not all that uncommon. Even though I failed to listen, I had the chance to have my high risk case identified several years earlier than I did. Wouldn't that probably have been helpful in my case, and thousands like me, to have treated my G9 several years before I did? Before it got out into my SV? Even with my refusal to seek my UROs input when I finally broke 4.0, or even a bit before, when my PCP recommended(over my concerns) another check of my PSA and it doubled sending me finally to the URO, am I not probably better off now than waiting for the physical symptoms to get me diagnosed? It is a long game, and the outcome is unknown for now, no guarantees. But wouldn't I likely be in a much worse circumstance right now- about 2.5 years later, either having finally been forced to a Bx because of symptoms or still waiting for the symptoms to show up?

I think I would be worse off, and far more advanced at Dx, if that PSA had not scared me into agreeing to a Bx. And I think I am significantly better off regarding my odds of surviving X years than if I had waited another year or 3 years for symptoms and Dx. And I think I would be even better off if I had listened to those rising PSA messages over a period of years, taking action 2 or maybe even 4 years earlier. Am I wrong about that?

And how was I going to be diagnosed at my stage, or preferably even earlier as I most certainly could have been if I had listened, without a PSA test that was done as part of a routine checkup? ( one was for a life insurance physical, the one that was 4.1 and flagged as needing follow up, which I ignored).

What is the main argument against me getting those PSAs done and listening to what they were telling me even earlier than I did? That there will be way more guys than me who will be diagnosed with low risk and needlessly hurt by the treatments? Well seems to me we should just find a way to cure that problem without dooming the other group. I don't know what the answer is, but in the past many medical abuses have been ended by law suits. As a man who paid big bucks for malpractice insurance for many years and who could not practice without it, I can assure you that if there were even a few big payouts to men who were needlessly severely hurt for treatment for low risk cases, recommendations from the docs for such would plummet. But we will still have patients insisting on radical treatment, and then there are the guys in between and their decision about what to do, or not do. I don't know what the answer is for those groups, other than dooming the guys with aggressive PC who might actually benefit from treatment before it breaks out.

My PSA when I was diagnosed with PC was 3.87 and 2.5 the year before. If my GP didn't send me to a Urologist I could have been one of those with advanced metastatic PC or dead already. PSA testing and my doctor's awareness of the PSA velocity saved my life.

It is quite possible that I don't even quite understand what is being, and always ends up being, debated.

If I am a 50 year old man and go for a physical with no urological symptoms, is it recommended that I NOT get a PSA? Or maybe use age 60, same question. If so, then I would not have tested for PSA which led to my Dx of G9. But wait, I see several different groups have different answers for the above questions.

If the USPSTF recommends against PSA-based screening, regardless of age, then at what point would a G9/SV+ but asymptomatic man like me have been diagnosed?

John 16

My feeling is that screening won't do it alone, as even urology doctors who adequately screened themselves succumb to the disease. If you want to eradicate the disease, lets get a cure just like HEP C or HIV cocktail, because it is a killer.

John 16 tell me about how the chemo went and how you feel,and what it was like for you to go thru it.

In the article that Andrew cited, Mike posed the hypothesis that improvements in the technology (i.e., the use of PET scans) may have contributed to the recent rise in metastatic diagnoses. I decided to look into Mike's hypothesis. I reasoned that, if true, many cases that would formerly have been diagnosed as high risk would now be diagnosed as metastatic. So I simply added together the number of high risk and metastatic cases over the years.

High risk diagnoses rose rapidly until 2008, and then fell sharply to a nadir in 2012 and about the same in 2013. Metastatic diagnoses reached a nadir in 2007, and then increased steadily through 2013. Adding them together, the overall pattern is flat. There were a few years 2007-8 & 2010-11) where the combined total was over 18,000 cases per year, but the other years averaged around 17,000 cases. This seems to support the Mike's hypothesis.

While the total number of high risk plus metastatic cases is pretty steady, their percent of all diagnosed cases has risen from 22% in 2011 (range was 21% to 23% in 2004 to 2011) to 24% in 2012 to 26% in 2013. This is exactly the pattern we hope to see if we have a more rational screening policy: the number of diagnosed higher risk cases stays flat while the number of diagnosed favorable risk cases declines.

The data in their analysis seem to support the hypothesis of improved screening technology and policy over the last few years.

- Allen

I've written this before, but I think that the best balance is struck with a PSA baseline test at age 40, followed by "smart" testing (which is NOT mass, routine screening). Intervals for retesting can be individualized by the baseline PSA result. (If Spamadi had made himself more clear by talking about "smart" testing following the baseline, I would agree with him...but being familiar as I am with his work, he probably just wants to initiate mass, routine screenings earlier.)

Men with a baseline PSA level in their 40s above the age-specific median of 0.7 ng/mL had a significantly higher risk of future prostate cancer diagnosis and aggressive disease. A young man's baseline PSA value was a stronger predictor of PC than family history, race, or suspicious digital rectal examination findings. Conversely, among men with a baseline PSA level below the age-specific median in their 40s, only 0.3% reached the PSA threshold for biopsy of 2.5 ng/mL within the next 5 years. As I mentioned earlier, this will not catch every single case...the PSA test is simply too poor, too inefficient of a test.

john16, not sure if you are still reading this thread...you said you had PSA tests since age 45...what was your first PSA result? It sounds mostly like you were a victim of "length-time bias" which is unique to some strains of PC (and a few other cancers).

Allen,
I tend to agree with you. (those words are Dr. Samadi's not mine)

I do not subscribe to routine, population based psa screening.

I do think a baseline psa is warranted after age 40, and I think men with urinary function issues should be tested more frequently. Often the first physical symptom of PC is urinary difficulty or frequency (just like SPH)

Thank you ShinytopPC !!

Ed C, watch out you might make JackH repeat himself. ;) ;)

So now we are where we always are.

In general the less serious cases G6s call for active surveillance while the G7-G10s call for screening.

alephnull said...

In general the less serious cases G6s call for active surveillance while the G7-G10s call for screening.

That's apples and oranges.

The "kitty cat" cases call for active surveillance and the "tigers" call for active treatment.

JamesE said...
I quickly get upset when I see comments like Jack implying that G6s are 'kitty cat' cases.

You are correct, JamesE, I didn't "imply" what you wrote above. To be more clear: most initial 3+3 cases plus a substantial number of the 3+4 cases are "kitty cats." Cases are not characterized by Gleason score alone.

That is the whole purpose of Active Surveillance...to successfully separate out the "kitty cats" from the "tigers." I'm amazed at how many people miss the whole point/big picture.

JamesE-

We have to deal with the world as it is, not as how you (or I!) would like it to be. Information can be power, as you say, but it can also be misleading. While you say "we should not keep them from that information" just because we know most doctors will abuse that information, I, in dealing with the world as it is, argue that that's exactly why we should not be screening at 40. The abuse has been proven -- it's not a matter of conjecture. Universal PSA screening, for example, has been a public health nightmare. You can argue all you want that PSA screening was "just" information, but we have seen and suffered the results of that- a generation of men maimed by unnecessary surgery in the real world, not some idealistic imaginary one.

The difference between an ad for a medical center and a universal PSA screen at 40 is this: there is no potential harm in informing people that there is a medical center they might want to choose. There is potential harm in telling a 40-year old that he has prostate cancer. Autopsy studies show that about 40% of 40-49 yos have some prostate cancer. (See this chart) There are 20-25 million men in the US in that age cohort. Can you imagine what would happen if they all were screened? Most of those would have unnecessary biopsies with all the dangers that entails. And 8-10 million men would be diagnosed with PC. These men will be told, because they are being told, that it is better to have it out now -- the disaster I predict. And why stop at 40? As you can see from the autopsy chart, about 30% of 30-somethings would have some PC if we look hard enough. Men with PC in their 30s and 40s almost always have indolent and insignificant PC that will never progress. Should the entire population be maimed to find the handful of cases that have rare dangerous forms?

I am thrilled that AS use is on the increase. I wish that were as true for younger men as for older men. AS is still viewed by most urologists as appropriate only for older men. Active surveillance takes time. It is not instant and complete information (the kind of information that might be power, as you suggest) at the time of screening or biopsy; it is information that is slowly accumulated, hopefully over many years. We do not currently have the tools now to predict at the first decision point in time whether it will be indolent or aggressive eventually. PSA, stage, grade, and genetic tests are clues, not certainty. Until we have better tools and until urologists change their ageist recommendations, it would be a disaster to screen men in their 40s.

- Allen

So we shouldn't test because we will find too many cases that doctors will advise to treat too early? The lives of the few who can be saved by early diagnosis should just be sacrificed?

The marching anthem we should be stepping to is not "Don't test so the doctors won't overtreat", we should be demanding accountability of and by doctors of those who overtreat, of those who do not present all the options to patients.

In other words we should not be scared of the numbers of 40-50's diagnosed with cancer, we should be very afraid of the doctors who rush to treatment without further testing, without giving the patient all the choices.

We should be concerned about accepting the overtreatment as a reason to not test. We should never oppose giving patients and doctors all the information we can.

Post Edited (ShinytopPC) : 7/27/2016 2:35:31 PM (GMT-6)