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Posts Tagged ‘active surveillance’

PROSTABLOG NZ: The debate within medical circles about the benefits – or not – of mass screening for prostate cancer just got a little more foggy in NZ.

Parliament’s Health Select Committee inquiry into prostate cancer was due today to hear from Lannes Johnson, medical director for the Harbour Health PHO, who – if a report in last week’s NZ Doctor magazine/website is to be believed – would enthuse about the results of a “new” study just released from Sweden.

Prostablog reported (also somewhat breathlessly) on the Göteborg study back in July after it appeared in Lancet Oncology, pointing to commentary by Mike Scott at the New Prostate Cancer Infolink.

Despite the positive tone of the NZ Doctor article – the majority of whose sources depicted the study as proof that population-based screening is fully justified – Scott’s analysis does not support that.

And neither does an editorial (represented by one paragraph in the NZ Doctor article) by Cambridge University’s Prof David Neal, which appeared at the time of the Lancet Oncology report.

After rehearsing the contents of the Goteborg study, Scott had this to say:

  • This study appears to show clearly that, in a screening-naïve population of men aged between 50 and 70 years of age, biannual PSA testing can lower the risk for prostate cancer-specific mortality by at least 40 percent.
  • In addition, the study shows that the proportion of patients diagnosed with prostate cancer and requiring hormone therapy in the screening group (103/1,138 or 9.1 percent) was much less than half that of the patients in the control group (182/718 or 25.3 percent), implying that early detection also reduced the risk for metastatic disease.
  • However … the study also shows clearly that (at 14 years of follow-up) biannual PSA screening has no impact whatsoever on the overall mortality rate in the same population.

We are therefore potentially faced with the difficult question of whether mass, population-based screening that does affect disease-specific mortality but does not affect overall mortality is justifiable based on the costs, the effort, and the potential harms to the men who are over-treated.

The single most important fact about this study, as far as The “New” Prostate Cancer InfoLink is concerned, is that it finally has provided us with a highly structured, ongoing assessment of the potential value of mass, population-based screening for prostate cancer in a previously screening-naïve population.

The study also includes full treatment information on all men diagnosed with prostate cancer over the course of the study.

This means that at last we have a real baseline against which to assess the data from all other screening studies, and we can use this baseline to recognize the inherent problems of the PLCO and ERSPC studies, which include short follow-up (to date) in both studies, variation in protocols (within the ERSPC cohorts), and data adulteration resulting from PSA testing among the “unscreened” patient cohort (in the PLCO study).

The data from the Göteborg study may still not provide a convincing rationale for mass, population-based screening based on use of the PSA test, but it certainly does set the standard for what must be expected from any new test that may come along and show promise as a true screening test for prostate cancer in the future.

The one regrettable fact about this study is that if it had included just one additional age cohort (of men born between 1945 and 1950), we might have been able to gain real insight over time into the benefits of even earlier detection for a period of up to 30 years.

A much more cautious note here, then, than these comments in NZ Doctor:

“The Government can hardly say they won’t screen for prostate cancer if the science supports it,” Dr Johnson says, referring to an ongoing Parliamentary inquiry into the early detection and treatment of prostate cancer.

Auckland urologist Robin Smart says the bottom line for him is that the study shows prostate cancer screening could prevent 300 of the 600 deaths from prostate cancer that occur every year in New Zealand. “All of the results strongly suggest that PSA screening is a really good idea,” Dr Smart says.

NZ Doctor concluded:

The results of the Göteborg trial are due to be presented to the Health Select Committee next week (today, September 15) as part of its inquiry into prostate cancer. Dr Johnson will talk about the results during a presentation by Harbour Health on PHO capability for reducing the burden of cardiovascular disease, smoking and diabetes.

Let’s hope the committee takes the time to read more widely about the study.

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URO TODAY: Men who choose watchful waiting after diagnosis of prostate cancer face higher risk of death from the disease than those who choose treatment, a Swedish study of nearly 7000 men has shown. READ MORE>

After adjustment for risk category, co-morbidity, and socio-economic status, there was a lower risk of prostate cancer-specific death in the radical prostatectomy and radiotherapy groups compared to active surveillance.

Overall and regardless of treatment strategy, the risk of prostate cancer-specific death at 8.2 years after diagnosis for all 6849 patients was 17%.

Death from competing causes was 17.6% for the active surveillance group, 6.8% for the radical prostatectomy group and 10.9% for the radio therapy group.

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What I now know – or think I know – about prostate cancer

MY PC Adventure – Chapter 25

See the full story HERE>

I was alarmed recently to get a call from a mate who has just been diagnosed with prostate cancer.

Alarmed on two counts:

  1. Here was another friend diagnosed with the disease.
  2. His doctor told him to get in touch with me – because I’m an expert!

I hope very much the doctor prefaced the “expert”: with the word “lay”, meaning I’m a non-medical authority.

But I’m not keen on that label, either. I would never give medical advice, and I’m wary about giving any other kind, other than to point people in the direction of information sources I have found to be useful.

What people are after, I think, are:

  • Some comforting words from someone who’s been through treatment, a word of hope that their first thoughts about imminent death are likely to be misplaced (even though they will probably have heard truly expert advice to that effect from their medics).
  • Some translation of the medical jargon they have just been subjected to. Some doctors seem better than others at speaking in plain English, and all of them are justifiably wary about making predictions. Some may even unconsciously favour the kind of treatment they offer, to the neglect of other options.
  • Some insight into what they face. Men are suddenly very keen to know what treatment to choose, what happens with each kind, and what it will do to them, especially in terms of potential incontinence and impotence. And (if they’ve never had one) what it’s like to have a catheter.

So, am I in a position to help? What do I actually know about prostate cancer? Is my “little knowledge” a dangerous thing?

To the first question, yes, I can help a little, even if it’s to calm someone down and provide solid evidence that people do indeed live through the experience of prostate cancer.

But then we run into the big problem: every man’s case seems different. No two patients will tell you the same story, which is hardly surprising given the mathematical possibilities.

Consider the variables:

Do the maths: there’s any number of possible scenarios and outcomes.

Add to that the constant development and refinement of new drugs and treatments, and the option of taking part in drug and treatment trials, and nobody can say with any certainty just how any one newly diagnosed patient will fare.

All I can claim to offer in the way of help is to urge people to find out more for themselves so they can ask their medical practitioner the right questions.

As has been told on this blog (see John and Mary’s story), nobody has to take the bad news and the first opinion(s) and accept their fate without question.

Mary is an average Kiwi woman with no medical training who refused to accept everything the doctors said about her partner’s options. She researched so thoroughly she was able to query what she was being told in the same technical language as the doctors.

Most people could do that, but it’s not easy. When first diagnosed, I attempted to find out more on the internet (not that I didn’t feel comfortable with the urologist’s views) and it seemed overwhelming.

It wasn’t until after my surgery – when I had a couple of months with nothing do but get better – that I researched the ‘net properly, and identified the very few websites worth looking at.

Most of the prostate cancer stuff on the ‘net is either

  • incomprehensibly technical;
  • incomprehensibly sensationalist (read: most news media);
  • written by public relations hacks paid by drug companies,
  • the ranting of idealogues and polemicists.
  • or porn-related (prostate milking, whatever that is, seems a big fetish with some).

The aim of this blog has been to mine technical sites (like Uro Today) which report the latest news and research and then try to translate the incomprehensible into the digestible.

It’s noticeable that whatever else doctors and researchers learn about their trade, little of it encompasses the ability to communicate.

I’m often helped in this task by the writing of Mike Scott, the non-doctor webmaster of The New Prostate Cancer Infolink, whose prose is fluent and clear. He runs the best site on prostate cancer in the world.

So, what do I know (or think I know)?

  1. All men above 50 should get themselves tested for prostate cancer. After the age of 60, it should be an annual event.
  2. It must involve both the PSA blood test and the digital exam. Some people (like me) don’t register PSA change in the event of cancer.
  3. A worrying number of men pretend prostate cancer (or any other kind of disease) doesn’t exist and never go to the doctor for a checkup.
  4. If you have been, and the news is bad, get more than one medical opinion of your diagnosis, preferably including one from a cancer specialist (oncologist). Urologists tend to favour surgery, radiologists radiotherapy, etc.
  5. There’s rarely any reason to panic, except perhaps if the diagnosis is late in the piece and the cancer has spread. But even then, it depends…
  6. As many as half of all men will get prostate cancer, but most won’t ever know because they’ll die of old age or something else before it shows up.
  7. Up to 3000 Kiwi men a year are diagnosed, and about 600 die each year, figures that have not changed much since the mid-90s when PSA testing came along (and there was a sudden rise in diagnoses at younger ages).
  8. So your chances of dying, statistically speaking only, are about one in five of those diagnosed, who in turn represent about 15% of the male population. So that’s about 3% of all men (but don’t rely on my maths – do some research of your own on the Ministry of Health website).
  9. Maori and Pacific Island men have much worse stats, which suggests they ought to be offered mass-population screening (like breast and cervical cancer) by the Government.
  10. Few, if any, governments in the world offer mass-population screening, saying there is too big a risk of over-diagnosis and over-treatment, that side effects of treatment are unacceptable if someone didn’t need treatment in the first place, and that PSA testing is unreliable.
  11. A lot of research is going into trying to establish whether PSA testing is effective, but so far the results are confused.
  12. A lot of research and money are going into new tests, drugs and treatments, especially in the US.
  13. The holy grail for researchers is a test that will tell if a prostate tumour is dangerous and needs treatment, or if (as in most cases) it’s so slow-growing (indolent) it can be ignored.
  14. The four main treatment options and their variations – surgery, external radiation, brachytherapy, drugs (hormone and/or chemo) – are highly effective to some degree or other, but all have their down-sides, such as urinary problems, impotence, bowel problems, depression, risk of a recurrence of the disease, etc.
  15. I know a lot about:
  • open surgery radical prostatectomy (because that’s what I had), but only so far as it affected me;
  • having a catheter. No problem in my case because the urology nurse who removed it knew what he was doing. And I’ve never had to self-catheterise myself, a tricky procedure, judging from the accounts some men give.
  • the importance of getting fit before and after the operation;
  • the need to change diet – to cut down on red meat, and increase intake of fine Central Otago pinot noir wines;
  • the importance of a supportive partner, friends and family;
  • not rushing back to work;
  • the need to avoid stress;
  • changing your views on life (buy a campervan!);
  • not rushing into resuming sex.

The danger of a little knowledge

I read new stuff about prostate cancer every time I check my Google Alerts and RSS feeds, and I’m regularly surprised by new slants on aspects I thought I was familiar with.

Prostate cancer has become one of the biggest medical industries in the world, no surprise given its high incidence (it’s the most reported cancer in most countries).

My “little” knowledge is indeed that.

But one advantage I have is an ability to translate the lexicon of the prostate industry into that of every man.

It’s what journalists can do, especially aging ones who get the idea into their heads that here, at last, is some good they can do.

Read the full My PC Adventure story HERE>

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URO TODAY:  An “uncertainty management” model developed for people being treated for breast or prostate cancer has been revamped for those who chose active surveillance when diagnosed with prostate cancer. READ MORE>

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URO TODAY: Watchful waiting may not be a wise choice for younger men diagnosed with low risk prostate cancer, a new study suggests.

Our pathologic findings and risk of biochemical recurrence after open radical prostatectomy question the wisdom of active surveillance in men with low-risk disease who have “long” life expectancies. READ MORE>

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UPI: Prostate cancer patients who refuse treatment don’t do as well as those who choose radiation treatment, US researchers found. READ MORE>

Researchers at Henry Ford Hospital in Detroit found the 10-year overall survival rate for men who chose “watchful waiting” was 51 percent. It was 68 percent for those who had radiation treatment.

URO TODAY: And those on active surveillance are often reluctant to proceed with treatment because they fear erectile dysfunction. READ MORE>

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URO TODAY: You’re a “low risk” prostate cancer patient – what treatment do you choose?

A panel of three doctors – expert in active surveillance, surgery and radio therapy – look at a 62-year-old with Gleason 6, 2/12 positive biopsy samples, small volume, PSA 0.09 and good sexual function. READ MORE>

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