tag:blogger.com,1999:blog-4968787219619380438.post4333990751180084484..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Employers, health insurance coverage and PSA testingSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger59125tag:blogger.com,1999:blog-4968787219619380438.post-62631310617786692942013-08-30T15:12:02.678-04:002013-08-30T15:12:02.678-04:00Larry-
I guess I betrayed my ignorance about what...Larry-<br /><br />I guess I betrayed my ignorance about what prostate biopsies can accomplish. I was assuming that there was testing that could accurately predict less-indolent tumors. For instance, a breast biopsy (which obviously is still prompted by a positive clinical finding or, more often, a screening) oncotype can be used to predict treatment (though we are still treating, just withholding more morbid treatment that might not be of significant benefit, like chemo). Currently we have no way to do that without tissue sampling (and usually a surgical specimen beyond a biopsy). I was envisioning a scenario like you described, that would enable you to biopsy many but remove fewere prostates. Of course, the issues of convincing people expectant mangement is ok remain. Cervical cancer is another example--we have almost eliminated true cervical cancers in women who are screened, but we have an identifiable premalignant lesion, and it still requires a procedure to treat. However, we have identified the high risk HPV as a marker for dysplasias we have to watch and have successfully backed off on treating though with low potential. So, it's possible sometimes to walk back the aggressiveness of treatments as more information becomes available. <br />Even an early invasive cancer concerns me, though, because it after all is invasive. <br />As Skeptical says, BRCA is a special case that should be differentiated from other types of breast CA. I can envision a day when we can perhaps screen and then sample for smaller amounts of tissue, which we can then subject to all sorts of genetic studies to determine treatment or not.<br />Finally, I'm still glad to have treated an early invasive cancer while the treatment had fewer downstream effects. Biased, I know, but thankful nonetheless<br />DrDEGnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-50632203716980473672013-08-30T13:20:12.906-04:002013-08-30T13:20:12.906-04:00The BRCA situation is quite different. The risk of...The BRCA situation is quite different. The risk of invasive breast and ovarian cancer is quite high for those women.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-4518618599894750872013-08-29T21:21:56.603-04:002013-08-29T21:21:56.603-04:00Actually, I have seen several 40 year-old women un...Actually, I have seen several 40 year-old women undergoing prophylactic mastectomies and oophoperectomies because of their BRCA status.<br /><br />My impression: how about using some common sense instead of Google searches? And that goes for the patients and their "doctors".<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-13042469612309270612013-08-29T18:32:46.368-04:002013-08-29T18:32:46.368-04:00Addendum:
Todd quotes a retrospective observatio...Addendum: <br /><br />Todd quotes a retrospective observational study:<br /><br />"A Gleason 3+3=6 cancer has a ~1.25% per annum risk of prostate cancer-caused death if left untreated" (http://jama.jamanetwork.com/data/Journals/JAMA/4974/JOC50024.pdf).<br /><br />As I read this statement, Todd appears to imply that, if NOT "left untreated," the mortality rate would be improved. But this does not necessarily follow and the cited study certainly doesn't provide any evidence to support the effectiveness of local therapy. The authors of the study Todd quotes concluded that local therapy (prostatectomy, etc.) of low grade prostate cancer was not justifiable on the basis of late recurrences, to wit: "The annual mortality rate from prostate cancer appears to remain stable <br />after 15 years from diagnosis, which does not support aggressive treatment for local- <br />ized low-grade prostate cancer." <br /><br />To illustrate the complexity of interpreting data such as this, the fact that a given man develops a non-aggressive tumor does not provide him any immunity against developing a second, aggressive tumor years down the road. Women with cancer in one breast not uncommonly develop different forms of cancer in the second breast. If someone survives one lung cancer, they are still at risk to develop a second lung cancer. So we have no way of knowing how many very late deaths from prostate cancer are owing to some mutation in previously non-aggressive disease versus second primaries, with aggressive disease. <br /><br />Presumably, one could prevent most deaths from prostate cancer by prophylactically removing everyone's prostate at age 45 or thereabouts. But we don't do this, because the morbidity to the many must be balanced against the gain to the few. This is the PSA screening controversy in a nutshell.<br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-74652626405515936942013-08-29T18:10:17.329-04:002013-08-29T18:10:17.329-04:00Hi Todd, Thank you for making the distinction betw...Hi Todd, Thank you for making the distinction between "aggressive" and "invasive." You are correct; I was sloppy. The take home messages remain unchanged, however, as do the statistics. You screen 1000 to 1500 patients, with resultant infliction of morbidity on hundreds of patients (the transrectal needle biopsies) and serious morbidity on > 50 patients (the prostatectomy), with net benefit to only a single (1) patient! <br /><br />I wasn't attacking urologists or radiotherapists. I was attacking PSA screening as a method to identify candidates for surgery or radiotherapy. And, in this case, the urologists happen to agree with me (AUA position statement previously cited). <br /><br />Finally, for the record, I don't know of any US board certified medical oncologist who has been so publicly critical of his own specialty as I have been of my specialty. To my knowledge, I was the first one to bring to the attention of Medicare the practice of choosing chemotherapy on the basis of greater financial remuneration of one regimen versus another. <br /><br />e.g. http://weisenthal.org/medicare_payment_for_cancer_chemotherapy.htm<br /><br />With regard to treating Stage I breast cancer in young patients with adjuvant chemotherapy (where the long term effects of chemotherapy, including so-called "chemo-brain," are problematic), this is an entirely different argument and dataset, and it's never a good idea to defend a bad medical practice with comparisons to other instances of allegedly bad medical practices.<br /><br />- Larry Weisenthal/Huntington Beach CA Larry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-26907025818829021452013-08-27T20:23:51.228-04:002013-08-27T20:23:51.228-04:00Larry and DrDEG:
Larry appreciate the comments. B...Larry and DrDEG:<br /><br />Larry appreciate the comments. But gosh I think attacking urologists who want to operate on prostate cancers, or neurosurgeons on brains, or medical oncologists who give chemo to Stage I young breast cancer patients (as you know the number needed to treat is high and the absolute benefit small in those cases--but I'm sure you have done it in certain scenarios), or radiation doctors who radiate... it's just unproductive. I rather choose to believe we're all good-hearted and here for the right reasons :)<br /><br />Of course the PSA is just one part of the puzzle. The only thing I disagree with Larry about is his statement that "most prostate cancer is non-invasive." That is incorrect. *All* cancers (solid tumors that is) are invasive (penetrate through the basement membrane) by definition; carcinoma-in-situ is non-invasive cancer, but no one receives therapy for prostate CIS. So maybe what Larry means is "most prostate cancers are non-aggressive" perhaps. I don't know. But a Gleason's 3+3=6 adenocarcinoma is the most commonly diagnosed prostate cancer nowadays and 100% of those are "invasive." Few are aggressive though... of course the aggressiveness is a very subjective term. A Gleason 3+3=6 cancer has a ~1.25% per annum risk of prostate cancer-caused death if left untreated (http://jama.jamanetwork.com/data/Journals/JAMA/4974/JOC50024.pdf). Other prognostic features, once a cancer is diagnosed, are the PSA, the presence of perineural invasion (even Gleason 3+3=6 cancers can show perineural invasion), the stage (even Gleason 3+3=6 cancers can invade the capsule or the seminal vesicles), and the volume of disease (the ratio of positive prostate biopsies helps determine this).<br /><br />The thing is, none of our prognostic metrics--even the hallowed Gleason--is perfect in predicting aggressiveness; thus we don't know which treatment is necessary versus unnecessary. This is why there's so much active work and research in my specialty to make the therapy as effective and non-morbid as possible.Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-59131400387353810362013-08-27T18:24:43.430-04:002013-08-27T18:24:43.430-04:00Hi DrDEG:
You ask:
"if biology of the tumor...Hi DrDEG:<br /><br />You ask:<br /><br />"if biology of the tumor is the key variable (in prostate and in breast), don't we still need to biopsy to find that out?"<br /><br />To repeat the statistics:<br /><br />Screen 1,000 to 1,500 men.<br />Find PSA elevations in 250 or so. Subject all to multiple transrectal needle biopsies. Diagnose 50 cancers. <br /><br />Now, if you removed or radiated all 50 prostates, you'd save a single life. That's the best that you can achieve, because most of those tumors destined to metastasize (the invasive tumors) have already done so at the time of local treatment. So which prostates do you remove? If we had a way of identifying the one tumor which was destined to metastasize but hadn't already done so, we would then remove that prostate and only that prostate. So then the picture would be screen 1,000 - 1,500 men. Do transrectal needle biopsies on 250 of them. Diagnose 50 cancers. Remove one prostate. Cure one patient. Maybe that would then be worth it. Maybe not. Depends on the morbidity in the 250 patients who were biopsied. <br /><br />But we can't identify the one tumor which was destined to metastasize, down the road, but still hadn't, at the time of the biopsy. If we don't do the 50 prostatectomies, we might miss out on curing the one patient who could be cured. So now we are back to the starting point.<br /><br />Yes, I do agree with you that things will be clearer as the molecular genetics of prostate cancer become clearer. There's an average 7 year lag between PSA elevation and the development of symptoms, in those destined to develop symptoms. There's no disadvantage in waiting until symptoms develop to diagnose the tumor, based on the sum total of the literature. 7 years down the road, molecular diagnostics will be better. Hopefully treatment will also be better. - Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-14700652846758798212013-08-27T17:51:26.176-04:002013-08-27T17:51:26.176-04:00My understanding, as a non-oncologist, is that the...My understanding, as a non-oncologist, is that the question is not so much whether treating breast or prostate saves lives, but whether *screening* for them does so. <br /><br />By the time a tumor gets to a detectable size, whether by mammography, or PSA, the original cell has divided many thousands of times. If the prognosis is mostly dependent on the biological propensity to invade, and not on size, does it matter if the cancer is first detected at X generation or 10X generation? I think that is the biological crux behind screening strategies.<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-88751952085677831692013-08-27T17:39:51.672-04:002013-08-27T17:39:51.672-04:00Larry, even conditionally accepting all you say, h...Larry, even conditionally accepting all you say, how many men, especially younger, want to live their lives with an untreated cancer hanging over their heads? For good reason, no one in medicine will ever commit themselves to an absolute answer. Who will be reassured by "To the best of our knowledge, there's only a small risk of this cancer ever making you sick or killing you?" Who will accept a care plan of "If we find something on followup, or if you develop symptoms we'll think about doing something about it. Now go home and don't worry your balding little head about it."? Not as bad as fighting in Fallujah, but still stressful, and for longer.<br />You say "By delaying your decision, you'll have more data available. Better tests. Hopefully better treatments." Some people would rephrase that as "Let's try kicking the can down the road". <br />Prostate cancer is primarily a disease of aging, and as men get older other things intervene. Travel becomes more difficult, and you probably don't know how many men I have heard from who have to travel a hundred miles or more to find a urologist who takes their insurance, or even to find one at all. If prostate cancer existed in a vacuum, it would be one thing, but what happens when concurrent health problems developing or worsening makes a man a poor risk for treatment while he's waiting around? During that wait for worsening symptoms/better treatment, what happens if he loses his spouse or other people he has depended on for support?<br />Of course, not screening at all would eliminate the cause of that anxiety, but on the sharp end of medical practice, how many patients ignore even the worst symptoms out of fear, ignorance, other priorities, or obstacles to obtaining care, thereby losing the window for effective treatment? No matter the numbers you provide educating the public, all too many will develop symptoms and say "Nope, never happen to me." Others will take the other kind of PSA to heart and come in at the drop of a drop in flow. Would you fail to do a PSA on someone who thought they had symptoms after reading an article? Many PSAs will still be done until something better comes along (not holding my breath) and will still pose dilemmas. People will still be treated on the basis of them with the imperfect methods we have (not holding my breath for that either).<br />If it's a problem, throwing statistics at it is only a part of any solution.Old Rockin' Davenoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-73502636103344224912013-08-27T16:29:26.423-04:002013-08-27T16:29:26.423-04:00This has been a fascinating discussion, and I'...This has been a fascinating discussion, and I've appreciated that you've kept the level of dialogue civil and respectful, even though there are many hard-felt feelings about this issue. <br />As a gunecologist and someone who had an early INvasive breast cancer, albeit with a relatively benign oncotype, I struggle with these sorts of screening questions. Even one positive node would significantly affect long-term survival (I'm only in my early 50s) and morbidity (e.g., chemo), so it seems to me that surgery at this point was curative. But, I may be making the same fallacious assumptions, just since I'm glad to be here. <br />Two other points: one, if biology of the tumor is the key variable (in prostate and in breast), don't we still need to biopsy to find that out? will the PSA score tell enough in prostate? I know that imaging won't in breast) CLearly, that still leaves the problem of avoiding over-intervention in noninvasive more indolent cancers, and we need better ways to follow these. Also, we have to think, what is the baseline "5 year survival" (or 10 or 20 year) for a 56 year old man? I haven't been able to find the answer, but it clearly bears on these questions. If my 20YS with treated breast ca is 90% at 52 and my actuarial survival before that is 92%, maybe it doesn't matter. But if it's 98%, maybe it does. <br />Admittedly, it is impossible to be dispassionate about it when it's one's own survival, but we are scientists and we should heed our evidence. I suspect this will get easier as the molecular genetics of cancer become clearer.<br />DrDEG Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8617079804245377262013-08-27T14:51:35.278-04:002013-08-27T14:51:35.278-04:00Part 2 of 2
No need to make it complicated, when ...Part 2 of 2<br /><br />No need to make it complicated, when considering the decision to go with PSA screening or not. Listen to the American Urological Association, which is the trade organization representing the surgeons who earn a portion of their livings operating on prostate cancer:<br /><br />http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm<br /><br />"The greatest benefit of screening appears to be in men ages 55 to 69 years."<br /><br />"For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences."<br /><br />To put it in human (i.e. my own) terms:<br /><br />If I get PSA testing, there's a 1 in 5 chance that I'll get transrectal needle biopsies. If I get transrectal needle biopsies, there's a 1 in 5 chance that cancer will be diagnosed. If cancer is diagnosed, and if I'm treated with surgery or radiation, there's a 1 in 50 chance that the treatment will actually prevent my death. In other words, there's a 49 out of 50 chance that I would either have non-invasive cancer that would never need treating or else that I have invasive cancer which has already invaded and metastasized at the time of surgery.<br /><br />So why on earth would I, as a functional male, ever want to get a screening PSA test? <br /><br />Note that the AUA's estimate of a 1 in 1,000 benefit is generous. It's probably closer to 1 in 1,500.<br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-64464512449436731872013-08-27T14:50:52.331-04:002013-08-27T14:50:52.331-04:00Part 1 of 2
Hi Todd, You have the luxury of posin...Part 1 of 2<br /><br />Hi Todd, You have the luxury of posing a number of short questions; I have the burden of providing long answers. I do have a day job; so it will take some time.<br /><br />I will address the question most germane to the prior discussions on this thread:<br /><br />"Based on the totality of the randomized evidence, do you think that 1) screening has the potential of improving survival, and that 2) therapeutic nihilism for prostate cancer is unjustified?"<br /><br />As I tried to make clear, most prostate cancer is non-invasive (precisely analogous to in situ breast cancer) and doesn't need to be treated. It is not "therapeutic nihilism" to spare men the non-trivial side effects of unnecessary local treatment. The fact that certain local treatment modalities may be less morbid than others is no excuse for offering unnecessary treatment. <br /><br />You would not propose to perform breast radiation for in situ breast cancer and you should be just as careful to avoid offering prostatic radiation for non-invasive prostate cancer (i.e. the majority of prostate cancers).<br /><br />Now, what about the invasive cancers, which can and do kill people? That's where screening comes in. Yes, were there a sensitive and specific screening test which could be performed to identify invasive prostate cancer before it actually invaded and metastasized, then that would be very valuable. Unfortunately, we don't have such a test. What we have is the PSA -- and PSA suffers from the problem that, by the time it is elevated, invasive prostate cancers have already invaded and metastasized. So if you go performing surgery or radiation on prostate cancers diagnosed on the basis of PSA screening, most of which will be non-invasive tumors, you will be unnecessarily subjecting hundreds of men to transrectal needle biopsies, and you will be unnecessarily subjecting 50 men to mutilating surgery or radiation for every 1 lucky lottery winner (out of the 1000 - 1500 who are screened with PSA) who actually benefits.<br /><br />Once again, to make it simple: most prostate cancers diagnosed through PSA testing are non-invasive tumors which won't ever threaten the patient's survival. Of the remainder, most are diagnosed too late, because PSA is not sufficiently sensitive and specific, and local treatment won't help.<br /><br />(concluded in next message)<br /><br />- Larry Weisenthal/Huntington Beach CA<br /><br /> Larry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-24405458158956923802013-08-27T10:56:50.906-04:002013-08-27T10:56:50.906-04:00meant to add this also
2. surgery: http://www.nejm...meant to add this also<br />2. surgery: http://www.nejm.org/doi/full/10.1056/NEJMoa1011967Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-39654337815692368592013-08-26T21:18:05.337-04:002013-08-26T21:18:05.337-04:00sorry messed up a few links, and you guys only tx ...sorry messed up a few links, and you guys only tx prostate CA in the METASTATIC setting ;)<br /><br />1. screening: http://1.usa.gov/1diDkmF<br />3. adjuvant ADT: http://1.usa.gov/1diDM4s<br />Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-11831680477579024642013-08-26T21:06:44.566-04:002013-08-26T21:06:44.566-04:00Hey Larry. You're a med onc. I really don'...Hey Larry. You're a med onc. I really don't talk much w/ med oncs about prostate CA; you guys only tx prostate cancer in the non-metastatic state, and so the med onc's experience treating curable prostate cancer is limited. Anyhoo, a few questions. Honestly just curious. You can infer from my questions what my answers would be.<br /><br />1. Do you think that the randomized screening trials have overall shown a benefit from screening in terms of increased survivals (http://1.usa.gov/1diDafg, http://bit.ly/1diDjiC, http://bit.ly/1diDjiC)<br /><br />2. Do you agree with certain literature that operating on prostate cancer patients improves survival versus watchful waiting (http://1.usa.gov/1diCS8c)<br /><br />3. Do you think that for men with localized prostate cancer, the addition of androgen deprivation to local therapy improves survival (http://1.usa.gov/1diDFGc, http://1.usa.gov/1diDFGc)<br /><br />4. Do you think that for men whose cancer has invaded the seminal vesicles or capsule after surgery, the addition of adjuvant radiation improves survival (http://1.usa.gov/1diE3EH)<br /><br />5. For men with metastatic prostate cancer, do you think therapy (hormones, chemo, Ra-223) improves survival?<br /><br />Based on the totality of the randomized evidence, do you think that 1) screening has the potential of improving survival, and that 2) therapeutic nihilism for prostate cancer is unjustified? Todd J. Scarbrough, M.D.https://www.blogger.com/profile/09254631173069503684noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-48814760611204249012013-08-26T19:19:35.889-04:002013-08-26T19:19:35.889-04:00Further comments in reply:
A small point, but my s...Further comments in reply:<br />A small point, but my surgery was not at MSKCC; I worked under Dr. Norton at another major institution and had my surgery at a third. My mention of him may have led you to a wrong, albeit not very relevant, conclusion.<br />I did not know about the upgrading of my Gleason score until a few hours before my post. Coincidentally, I had a followup visit with my urologist that afternoon. I may have given the impression that I knew about it before and this was not correct, but definitely influenced the operating urologist's decision to go ahead. My doc also knew about it but didn't tell me then. We had good reason to defer to the judgment of these two men and to accept their assessment now, too much to go into here. <br />You also know that cancers can spread by direct extension and by direct contact with suitable tissues. If I have seen such cases when my experience and knowledge are definitely less than yours, you must have seen them too.<br />Also, from the number of ovarian cases I have seen, I agree that aggressive surgery should certainly be done for it. I have seen patients whose longterm survival with other cancers was due to surgeons willing to operate over and over at each sign of recurrence; if the patient can tolerate it, it sounds like a worthwhile approach.Old Rockin' Davenoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-89545821076547336252013-08-26T17:27:57.228-04:002013-08-26T17:27:57.228-04:00Very interesting discussion on all sides. Thank y...Very interesting discussion on all sides. Thank you all, I've learned a good bit with this, or at least gained some new perspective. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56199370762339339422013-08-26T16:05:47.397-04:002013-08-26T16:05:47.397-04:00Hi Dr. SS,
My comments on this thread should by n...Hi Dr. SS,<br /><br />My comments on this thread should by no means be taken to be a denigration of the role of surgery in cancer management in general. Surgery is, far and away, obviously the most important discipline for cancer cure, in those many forms of cancer and clinical situations in which it is appropriately utilized. <br /><br />My personal opinion is that surgery is actually underutilized in ovarian cancer, which tends not to invade and tends not to metastasize until very late, but kills by direct extension within the abdomen. So a two surgeon team of a gynecologic oncologist and a surgical oncologist could do long, meticulous operations with each recurrence, to grossly remove all of the disease, which tends to kill by bowel obstruction, ureteral obstruction, etc., and keep the patient going for many years, at which time, hopefully, better and better systemic treatments would be available. The problem is that these are very long, difficult operations, and the surgeons are frankly underpaid for the time they spend; so ovarian cancer tends not to get managed in this way.<br /><br />Anyway, each type of cancer is unique, as is each patient's situation. Gradually, we are getting better at matching treatment to patient.<br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-65485876497344556142013-08-26T11:52:31.980-04:002013-08-26T11:52:31.980-04:00Larry, thanks again for your most thorough review ...Larry, thanks again for your most thorough review and thoughts.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-82775532781408388092013-08-26T00:55:52.043-04:002013-08-26T00:55:52.043-04:00Hi Anon:
You say/ask:
>>But, if local trea...Hi Anon:<br /><br />You say/ask:<br /><br />>>But, if local treatment is mostly ineffective, then does it matter whether if the Gleason is 6 or 10 at first diagnosis absent mets?<br /><br />>>In other words, what if we move questions about PSA screening one step further. Does treating Gleason 6 vs Gleason 10 save lives?<<<br /><br />The following is my personal opinion, based on the literature -- not based on personal experience, which is as worthless for me as it is for any urologic oncologist -- even those at MSKCC, Johns Hopkins, MD Anderson, the NIH, the Mayo Clinic, or any other such famous institution you would care to name. <br /><br />The issue is this: with rare exceptions (e.g. glioblastoma, basal cell carcinoma), cancer kills people by invading lymphatics and blood vessels and then metastasizing. Some cancers never invade and metastasize, and, therefore, don't generally kill people. Examples: in situ breast cancer (very, very common). True bronchioloalveolar cell lung cancer (not adenocarcinoma, but true, "pure" bronchioloalveolar cell carcinoma). And a great many (e.g. the majority of) prostate adenocarcinomas. <br /><br />If the tumor doesn't invade, it doesn't metastasize and it doesn't kill. <br /><br />So the whole ballgame is invasiveness. If you don't have an invasive tumor, you don't need radical surgery. If you have an invasive tumor, you are only helped by radical surgery if it is done before the invasion occurs.<br /><br />With PSA screening, the problem is that PSA is generally only elevated at a point where invasion has already occurred, in those patients who have invasive tumors. So, if you go whacking out prostates in patients who are diagnosed by virtue of having elevated PSAs, you are generally on a fool's errand. You are mutilating scores of men who don't have invasive tumors, at no benefit. And you aren't curing most of the men who do have invasive tumors, because they have already had invasion and metastasis at the time the PSA is elevated.<br /><br />Prostate cancer generally comes in two flavors: live with it and die of it.<br /><br />Now, of course there are anecdotes...individual cases where patients, for example, don't have invasive disease at a certain point but who's tumors undergo a mutation which causes them to become invasive at a later point. So if you whack out those prostates before they become invasive, you can cure them. But, according to the statistics in the literature, this is lottery odds. You have to screen 1000 to 1500 patients with PSA testing to get a single lottery winner, while you subject hundreds of men to unnecessary transrectal needle biopsies and you mutilate more than 50 men unnecessarily (or, at least, unnecessarily early).<br /><br />Look, if you want to be conservative, at least wait until you have symptoms. Then, if you are diagnosed with prostate cancer, you can decide whether or not surgery makes sense for you or whether you are better served by radiation or cryotherapy or microwave therapy. The overwhelming conclusions of the medical literature is that it won't make a difference if you are diagnosed by PSA or by symptoms. By delaying your decision, you'll have more data available. Better tests. Hopefully better treatments. <br /><br />But you won't hear this from the surgeons. They aren't dishonest, but they are human. They believe in their craft. So do the radiologists. So do us chemotherapists. Let the buyer beware. But to beware requires knowledge. Forewarned is for armed. <br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-90415454196858149152013-08-25T23:33:47.557-04:002013-08-25T23:33:47.557-04:00Part 2 of 2:
Expert, world class urologists at Me...Part 2 of 2:<br /><br />Expert, world class urologists at Memorial Sloan Kettering Cancer Center and similar institutions don't have the personal experience to trump the world literature, and the world literature is just as available to private practice medical oncologists like me as it is to surgical oncologists like them. <br /><br />Surgeons have the mentality that, if there's a tumor, you should cut it out -- just based on logic. Surgeons swore for decades that the only way you could cure breast cancer was with the horribly mutilating radical mastectomy. But they were wrong -- proved wrong by the same sorts of clinical trials which are now defining more appropriate (and humane) management of prostate cancer. Colon surgeons used to have this elaborate "no touch technique" which was likewise consigned to the dustbin of history. Both the radical mastectomy and no touch technique were the product of "experience" and "common sense."<br /><br />How on earth do they (the MSKCC urologists) have the personal experience to say that your tumor was about to invade your capsule? Do they have examples of patients who had tumors like yours whom they just followed over years to determine the natural history of the disease? This is a rhetorical question. Of course, they don't have data like that. But the world literature does have data like that. <br /><br />With respect to your age, the VA study of PSA-screened patients who were diagnosed with prostate cancer and randomized between surgery and observation did not show an advantage of surgery in older men and it didn't find an advantage in younger men. If you waited until there were symptoms, you might have had many years of asymptomatic life and then, when the disease was finally diagnosed because of symptoms, you might have then been over the age of 65; you'd have had a better idea of what type of treatment you wanted to receive; and the ability to predict invasiveness (through emerging molecular technologies) would doubtless have been at a more advanced state, allowing the best choice as to most appropriate local and/or systemic therapy.<br /><br />Look, I'm not trying to beat you up. You did what you did, based on the best knowledge and advice available to you at the time. But you are wrong in being a cheerleader for PSA screening, with your incorrect assertions that PSA screening saved your life, and thereby encouraging other men to subject themselves to serious morbidity for a lottery chance that they'll actually benefit from such screening, with the very high possibility that they'll suffer the morbidities.<br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-3511092386632663052013-08-25T23:32:46.632-04:002013-08-25T23:32:46.632-04:00Part 1 of 2:
Dave, Two comments.
First, I was ...Part 1 of 2:<br /><br />Dave, Two comments. <br /><br />First, I was simply going by the data about your personal case that you provided. You said that initially you had multiple needle biopsies (6 or 7 or whatever) which were positive. You said that the original Gleason score was 6 (which would be 3 + 3, in all the biopsies). You said that this was upstaged to 7 at the time of your radical prostatectomy. Based on this, it was apparent that your major pattern was three and your minor pattern was 4 (3 + 4). Now you are providing entirely different data. Why don't you fax me your pathology report (redacting your name) and give me a decent chance to analyze your case? Fax to 714-596-2110. Larry Weisenthal (you can Google me).<br /><br />With regard to your tumor being in imminent danger of capsular rupture, this is poppycock, based on a Gleason 3 + 4, which is what I still believe you most likely had. What I wrote earlier is true. Danger of capsular invasion is determined by tumor biology, not by geographic proximity to capsule. Either the tumor is invasive, or it's not. If it's not invasive, it doesn't matter how big it is or how many sectors of the prostate it involves. It's a benign tumor, not a malignant tumor, and benign tumors don't need to be treated, except for symptomatic management.<br /><br />With respect to the 1 in 13 possibility of cancer specific mortality after 13 years, you are again making the mistake of believing that the determining factor would be surgical (or radiotherapeutic) treatment. <br /><br />No, the determining factor is biology. Did you have an invasive tumor or didn't you? By the time invasive tumors get large enough to raise the PSA level, they have quite often already metastasized. This is the "die of it" disease. Local surgery doesn't help those patients.<br /><br />The clinical trials data (as I described earlier) are clear. If you've got non-invasive disease, then you don't need local treatment (precisely analogous to ductal carcinoma in situ in breast cancer). If you've got invasive disease, then local surgery (or radiation therapy) doesn't help, because what kills you is not the local tumor but the metastases.<br /><br />(concluded in next installment)<br /><br />- Larry Weisenthal/Huntington Beach CALarry Weisenthalhttps://www.blogger.com/profile/04892331375579791198noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-22744806411072587622013-08-25T20:36:51.285-04:002013-08-25T20:36:51.285-04:00Interesting discussion. My dad is a dentist and to...Interesting discussion. My dad is a dentist and took his time to be as informed as possible before deciding on surgery. He did not rush into it and certainly did not make a decision based on emotions. He can be maddeningly detached about medical decisions. I don't know all the details, but I do know that, like Dave, one of the factors motivating his decision for surgery was his age. Personally, I don't know that I would have made the same choice in his place. Hennahttps://www.blogger.com/profile/06909051603602725365noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-55611920372186192202013-08-25T18:03:31.641-04:002013-08-25T18:03:31.641-04:00Dave,
it is great that you are doing well. But, y...Dave, <br />it is great that you are doing well. But, your example of 100% after a dice throw is wrong. Some guy just won $400 million in a lottery. So?<br /><br />Cancer "survivors" will always support their decisions and providers. For prostate CA, a very common reaction is " I was 45, got screened, got treatment, now I wear diapers and need a penile implant, but I am alive. Therefore I made the right decision and the doctors saved my life." To believe otherwise would be to recognize that they and doctors made a sketchy decision and spend 20 years unnecessarily impotent and incontinent.<br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-72243437510477869602013-08-25T17:01:55.362-04:002013-08-25T17:01:55.362-04:00Larry, I need to add a few comments in response.
F...Larry, I need to add a few comments in response.<br />First, you are assuming my Gleason score was 3+4 and not 4+3, or even 5+2 (not likely, I know). As you know, pathologists can disagree. The biopsy was read as a 6 originally, but a second opinion gave it an 8, and the surgical path scored it as a 7. I have been going by 7 as my Gleason score, but it may have been higher. By the way, I had 7 positive cores, not 6, from all four quadrants. This is suggestive of multiple foci of disease, which has it's own implications.<br />As you and I both know, aggressiveness correlates with age at diagnosis. Having worked under Larry Norton, I have some basic, minor grounding in growth modeling, and I think it's safe to say that while a Gleason score of 6-8 is not the worst, at 56 it is different from the same score at 75 or 80.<br />You also mention "the proximity of one area of his tumors to the capsule". I said nothing that allows you to draw the inference that it was one area. The surgeon said there was a very large amount of tumor in my prostate (suggesting to me a doubling time toward the shorter end) and not only wasn't he sure he could spare the nerves, bi- and not unilateral, he wasn't even sure that he had gotten clean margins until the path report. It was not "close" to the capsule; it was distending it. The GU that did the diagnosis and the one that operated are not connected professionally or personally; both are of the opinion that I was at imminent risk of capsular rupture - weeks to months, with significant, certainly non-zero, risk of intrapelvic dissemination, and possible distant mets not very long after. These gentlemen have a great many years of experience inside and out of the OR; they are familiar with my case and I defer to their judgment. The diagnosing GU has a long history with my family, both as physician and as parent of a patient. Since he didn't operate, has no need to make the other urologist look good (I dislike the other guy greatly, and with reason, and his entire department as well), and knows we value him for his candor, I am as certain as I need to be that he is not shading the truth in any way. <br />Surgery was my choice; I could then preserve radiation as a future option, meaning less potential morbidity than the other way around. I was not thrilled with other forms of ablation, and in retrospect I believe I was right about them for me.<br />Looking at your stats for 10-year survival, the way you read my score means one chance in 13 of recurrence within ten years. The other way around means a 1-in-4 risk, a large jump. If it was "actually" an 8, that rises to nearly 1 in 3. I wouldn't play Russian roulette with those odds. Or even casino roulette. Even if the risk of my death from recurrence is only 1%, and average survival after recurrence is 13 years, surgery was a gamble I was willing to take. Statistical averages are just that. To make an average at the craps table means someone throws a seven and someone else throws snake eyes, and others everything in between. But when you're the one in a hundred or a thousand that craps out, it's one hundred percent of you.Old Rockin' Davenoreply@blogger.com