Prev: psa update
Next: Screening for PCa
From: safire on 5 Aug 2008 03:31
In a move that could lead to significant changes in medical care for
older men, a national task force on Monday recommended that doctors stop
screening men ages 75 and older for prostate cancer because the search
for the disease in this group was causing more harm than good.


....various studies suggest the disease is �overdiagnosed� � that is,
detected at a point when the disease most likely would not affect life
expectancy � in 29 percent to 44 percent of cases. Prostate cancer often
progresses very slowly, and a large number of these cancers discovered
through screening will probably never cause symptoms during the
patient�s lifetime, particularly for men in their 70s and 80s. At the
same time, aggressive treatment of prostate cancer can greatly reduce a
patient�s quality of life, resulting in complications like impotency and
incontinence.
....
The Journal of the American Medical Association reported in 2006 that in
a group of nearly 600,000 older men treated by the Veterans
Administration, 56 percent of those ages 75 to 79 had been screened for
prostate cancer. Given the large numbers of men over 75 who are being
screened, even a small decline in testing may greatly reduce the number
of prostate cancer cases detected.
....
[For Steve Jordan:] Dr. Calonge said it was important that the
guidelines not be viewed as �giving up� on older men. While the new
rules should discourage routine testing of older patients, the
recommendations will not prevent a man from seeking screening if he
desires it, Dr. Calonge said. [Hey Steve, read it again if you didn't
understand this.]
....
Recently, Swedish researchers collected 10 years of data on men whose
cancer was diagnosed after the age of 65 and found no difference in
survival among those who were treated for the disease and those whose
cancers were monitored but treated only if the cancer progressed. The
finding suggests that for most men, stopping screening at 75 is a safe
option.





http://www.nytimes.com/2008/08/05/health/research/05prostate.html
From: len on 5 Aug 2008 20:15
On Aug 5, 2:31 am, safire <saf...(a)telenet.com> wrote:
> In a move that could lead to significant changes in medical care for
> older men, a national task force on Monday recommended that doctors stop
> screening men ages 75 and older for prostate cancer because the search
> for the disease in this group was causing more harm than good.
>
> ...various studies suggest the disease is “overdiagnosed” — that is,
> detected at a point when the disease most likely would not affect life
> expectancy — in 29 percent to 44 percent of cases. Prostate cancer often
> progresses very slowly, and a large number of these cancers discovered
> through screening will probably never cause symptoms during the
> patient’s lifetime, particularly for men in their 70s and 80s. At the
> same time, aggressive treatment of prostate cancer can greatly reduce a
> patient’s quality of life, resulting in complications like impotency and
> incontinence.
> ...
> The Journal of the American Medical Association reported in 2006 that in
> a group of nearly 600,000 older men treated by the Veterans
> Administration, 56 percent of those ages 75 to 79 had been screened for
> prostate cancer. Given the large numbers of men over 75 who are being
> screened, even a small decline in testing may greatly reduce the number
> of prostate cancer cases detected.
> ...
> [For Steve Jordan:] Dr. Calonge said it was important that the
> guidelines not be viewed as “giving up” on older men. While the new
> rules should discourage routine testing of older patients, the
> recommendations will not prevent a man from seeking screening if he
> desires it, Dr. Calonge said. [Hey Steve, read it again if you didn't
> understand this.]
> ...
> Recently, Swedish researchers collected 10 years of data on men whose
> cancer was diagnosed after the age of 65 and found no difference in
> survival among those who were treated for the disease and those whose
> cancers were monitored but treated only if the cancer progressed. The
> finding suggests that for most men, stopping screening at 75 is a safe
> option.
>
> http://www.nytimes.com/2008/08/05/health/research/05prostate.html

As a new recommendation, there may be less there than meets the eye.
Thus, even a strong proponent of testing like Patrick Walsh has
questioned whether routine PSA testing is merited in men past a
certain age, although I don't know if he would put it precisely at 75.

I read the story today in my copy of the NY Times, and there were
several things that bothered me about this recommendation. First,
it should really be expected life expectancy rather than age. Some
men can be expected to live 15 years or more at age 75, and I don't
see why such men should necessarily stop PSA testing.

The second thing that bothered me in the article, and confirmed by an
interview from a proponent of this standard on PBS, was the way this
is all treated as a black box.

Testing -> ? benefit or harm

as though this were an either or question. Unfortunately, it is not
that simple. Some men, even men over 75 with a relatively short
lifespan may in fact benefit from PSA testing. For example, men with
aggressive prostate cancer, it seems to me, are better off if the
cancer is detected earlier rather than waiting until it has
metastasized to the spine, which is the way prostate cancer was often
detected prior to the PSA testing era. Of course, there are also
some men who will suffer needlessly from treatment which they didn't
really need because their cancers would never have bothered them.
So you can totla up a cost by assigning some value to each different
outcome and seeing if you, for the group as a whole, are doing more
benefit than harm. But it seems somewhat heartless to sacrifice
those who might benefit in order to protect those who might suffer
harm.

It seems to me that there is a way out of this dilemma. The issue is
not testing per se. The doctor being interviewed on PBS discussed
side effects of biopsy as if that were a significant problem, which,
or course, is misleading, but even he admitted the serious question is
treatment. It seems to me that patients are adults, and given all
the facts, they can decide, when diagnosed, what to do next. Since
each man's circumstances are different, there won't be one single
response. It may be an interesting scientific question to determine
if on the basis of some overall cost/benefit analysis, testing
provides a positive benefit for a groups as a whole, but it seems to
me it doesn't really help determine just what physicians should be
doing with real patients.

The remaining thing that worried me was the unattributed Swedish
study. I wonder if this is the same study that previously showed a
benefit for RP over WW. It could be that when they looked in their
sample just to men over 65, it showed no signficant overall benefit to
RP over WW. If that is the basis, this would be a case of picking
out a subset after the study was done, rather than prospectively.
That is supposed to be a statistical no-no for a randomized study.
And of course, this was a study abou t treatment, not about testing.

If anyojne has a reference for which Swedish study the reporter had in
mind, I would like to see it.
From: Alan Meyer on 5 Aug 2008 20:23
"Ken T" <bogusloop(a)cox.net> wrote in message
news:Br0mk.5792$Zv3.789(a)newsfe01.iad...
> ... Most of the men in my 6-gen ancestry died between the ages
> of 80 and 105. True, they lived in an era with fewer toxins
> about and they had unsurpassed work ethics - they were farmers
> and lumberjacks, in Canada and northern Maine, mostly. But none
> had PC and only one had cancer, stomach cancer. He died fairly
> young at 60.

Makes you wonder if an outdoor life is superior to our sit behind
a computer, sit on a sofa lives, doesn't it?

> ... But my surgeon is insecure and wants me to have radiation
> also. I'm at odds with this. I have my post-op physical coming
> up in a few weeks where I will try and see why he feels this
> way. Assuming his 95% success rate with me is accurate, is this
> radiation really necessary? Is it going to set me back in my
> efforts to get back to normal? Back in diapers again?
>
> Is there a point where we are over-treated? How do we know when
> we need the extra treatment or not? Am I safe in waiting a
> while and monitoring my PSA before jumping right into rad?

I'm not a doctor and not qualified to give medical advice, and
even if I were, I haven't examined you or seen your test results.
So my opinion is hardly authoritative. However, having said
that, I'll say further that I agree with the previous responses
you have received.

I have heard of radiation being given after a prostatectomy with
no preceeding rise in PSA, but I've only heard of it in cases
where there were clear signs of aggressive disease. Such signs
might include: higher than expected Gleason score after a
pathologist examines the prostate, positive margins, and perhaps
worst of all, positive lymph nodes.

I think you should ask your doctor what signs he saw that
indicate that further treatment is necessary. If he gives a
vague, "let's just be sure", I wouldn't do it. If he gives clear
indications of why it might be necessary, then I would take all
of his test results to another specialist, preferably to one who
doesn't know him, and get a second opinion.

Can radiation set you back? Absolutely! It is usually well
tolerated but it can definitely have side effects. Urinary
incontinence is rare but not unheard of. Bowel inconentinence is
rare, but also not unheard of. Impotence is common. Long
lasting proctitis is not uncommon. Even secondary cancers
brought about years later by the radiation damage, although rare,
are not unheard of.

I believe that radiation is an invasive treatment that people
should not get unless there is a clear medical reason for it.

There are two reasons why you might get a recurrence of the
cancer. You could have cancer cells in your body that have
already left the prostate and travelled to distant regions. If
so, radiation will do no good.

The other possible reason is that you could have a "local"
recurrence of cancer in the prostate bed, either from prostate
tissue that the surgeon didn't get, or from extra-prostatic
extensions ("positive margins") that extended outside the
prostate but are still very near by. Radiation could cure that.

In either case, if the cancer recurs, there should be some rise
in PSA. If there is such a rise, you probably need to act
quickly because the success of "salvage" radiation is generally
greater when the PSA is still below 1.0, and maybe greatest when
it's significantly lower than that. So frequent PSA testing for
a while after surgery might be warranted.

But in the absence of a rise in PSA, unless the doctor actually
knows there is cancer left because he's seen it, e.g., in the
lymph nodes or with positive margins, I personally would not even
consider radiation.

One thing I can't help wondering about your posting is why the
doctor is recommending radiation. Is he ultra-radical in his
treatment philosophy, i.e., hit cancer with everything possible?
Is he trying to help a friend who is a radiation oncologist? Is
he concerned that maybe he didn't do a great job in the surgery
and wants backup from radiation?

If either of the last two reasons are the right ones, he'll
probably never admit it. Alas, doctors are only too human.

Alan


 | 
Pages: 1
Prev: psa update
Next: Screening for PCa