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Posts Tagged ‘metastatic disease’

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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JUNE 20: CHRON.COM:  Annual prostate screening is not necessary for all men, but getting a baseline PSA test at age 40 is a good idea, says a University of Texas M.D. Anderson Cancer Center urologist. The recently reported long-term European study of PSA testing clearly showed that early detection can work:  “People talk about it showing you have to treat 48 men to prevent one death. That’s true, but there was also a 41 percent reduction in metastatic disease, which is incurable. That translates to treating about 25 men to prevent one death, which is much more in the realm of what you want from early detection.” READ MORE>

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JUNE 19: NEW PROSTATE CANCER INFOLINK: One of the major issues in the management of prostate cancer is the identification of early physical (as opposed to biochemical) evidence of metastatic disease. READ MORE>

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MAY 22: PROSTABLOG NZ:  How many questions did you ask your doctor when you got the news you have prostate cancer? A dozen? More?

I can’t remember now, even though it was less than six months ago, but I’m guessing it would barely have broken double figures, even by the time I was on my third visit to the urologist.

Did you know there are at least 28 queries you should probably make, and another 22 if you’re looking at brachytherapy?

I know this from an excellent new book on prostate cancer just published by the Michael Dattoli and his colleagues in Florida – The Dattoli Blue Ribbon Prostate Cancer Solution:  How to survive and thrive without surgery (February, 2009).

DattoliBk 1It’s a 260-page manual on the latest techniques for treating prostate cancer, most of it written by Dattoli, whose pen portrait in the back says he is “a board-certified oncologist with more than 20 years of brachytherapy experience and has performed thousands of prostate implant procedures…a noted author and speaker in this complex field of medicine.”

Aha, perhaps I hear you say:  he’s biased towards radiotherapy and hence the tilt at surgery in the book title.

Maybe. I’m hardly in a position to judge, being merely a humble prostate patient, although one who has done a fair bit of journalistic investigation into the topic during recent recovery “downtime”.

This book seems to me to be very thorough in its examination of prostate treatments, research, survival and success rates, issues and dilemmas, and refers to every branch of the burgeoning field of treatment I’ve so far come across.

The case he puts for radiotherapy/brachytherapy and combined drug treatments (if needed), in the second half of the book, seems convincing to me.

Essentially, he’s saying that advances in radiotherapy equipment and techniques make its use so accurate and effective that people with aggressive tumours and/or cancer that’s got out of the prostate box are better served by his approaches than surgery or some of the many experimental but unproven (long-term) therapies now on offer (in the US, anyway).

The book reinforces for me how crucial it is to discover prostate cancer at the earliest possible time, since it is one version of cancer that can conceivably be “cured” when discovered at its least developed and aggressive stage.

At that point, it seems surgery is still as good an option as Dattoli’s approach, although he attacks the notion that getting it cut out is an end to the matter. It may not be, even with contained, low-aggression varieties like mine.

The book explores, and partially dismisses, many of the newer approaches, such as cryotherapy (freezing the tumour), hyperthermia (heating it), HIFU (high intensity focused ultrasound), many new drugs (because there is no long-term research done yet) and most versions of surgery.

He strongly advocates the latest approach to radiotherapy – four dimensional (the fourth is motion) intensity modulated (rather than short, high dose) radiation therapy (4D IG IMRT) – which he uses at his clinic, the Dattoli Cancer Center and Brachytherapy Institute of Sarasota, Florida.

With this complex treatment mode, he says the centre can achieve a very precise radiation attack on the tumour(s) with little collateral damage and few long-term after effects (depending, of course, on the patient).

It sounds very expensive. Pictures in the book show space-age technology, which obviously doesn’t come cheaply.

In a couple of discussions in the book, Dattoli borders on the disingenuous when he says centres using other kinds of expensive gear push its efficacy partly because they have big investments to recover.

That said, his record seems impressive, and 14 years of results are highly praised in an “independent” review by Charles E. Myers Jr MD, founder and director of a body called the American Institute of Diseases of the Prostate:

“Many men with intermediate to high-risk cancer treated [by Dattoli] with radiation to the prostate gland and pelvic lymph nodes with external beam radiation and seeds remain free of disease out to 14 years…Radiation therapy is consistently more effective when combined with androgen withdrawal. Faced with these facts, I can only conclude that radiation therapy can kill prostate cancer stem cells or in some way arrest their ability to go on to establish metastatic disease.”

Even ignoring the book’s main thesis (the superiority of 4D IG IMRT), it contains usefully detailed outlines of all aspects of prostate cancer, written in superbly accessible language. Everything is explained and translated for the layperson.

That alone makes it worth the read, although it’s not a quick read, given the fact-heavy nature of the explanations.

It contains other helpful material, including a guide to the foods we should eat (out goes my four-red-meat-meals-a-week diet) and a rundown on the latest drugs being trialled and/or used.

As a footnote, I should add that nothing I read in this up-to-date resource on prostate cancer makes me think I made the wrong decision electing radical prostatectomy. For me, it still feels 100% the right way to go. I believe I was well advised.

Further footnote: I’m interested to know how many of the treatment techniques canvassed by Dattoli are available in NZ. I suspect we trail by a long way, but perhaps there’s some advantage to that: we can observe how various developments pan out in what is undoubtedly the prostate capital (well, country) of the world.

And those 28 questions? I’ve reproduced them here, for those many men in the future who are going to get the bad news:

 Dattoli 1

Dattoli 3Copies of the book can be obtained from:

Dattoli Cancer Foundation, 2803 Fruitville Road, Sarasota, Fl 34237, US.

They cost about $US23 with postage included.

Read a 15-page extract from the book where Dattoli discusses hormone therapy: HERE>

Go to the Dattoli website HERE>

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