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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2005Interesting
Friday, February 11, 2005 NEW YORK (Reuters Health) - The mortality rates for most men diagnosed with prostate cancer in the United States are no higher than those in the general population, a new analysis shows. "The bottom line is that most men diagnosed with the disease today can expect to live as long as, or longer than, men their age without the disease," two editorialists comment. The value of prostate specific antigen (PSA) screening in reducing prostate cancer mortality is still in question, Dr. Hermann Brenner and Dr. Volker Arndt of the German Center for Research on Aging in Heidelberg report in the Journal of Clinical Oncology. Widespread use of the PSA test in the US since the late 1980s means many more men are living with a diagnosis of prostate cancer, the physicians point out. They used "the recently introduced period analysis methodology" to evaluate 5- and 10-year survival rates for 183,484 men diagnosed with prostate cancer between 1990 and 2000 included in the Surveillance, Epidemiology and End Results Program (SEER), a large US database. Overall, relative 5-year survival rates for prostate cancer patients were 99 percent, and 10-year survival rates were 95 percent, Drs. Brenner and Arndt found. "That is, excess mortality compared with the general population was as low as 1 percent and 5 percent within 5 and 10 years following diagnosis, respectively," they explain. For the two thirds of men with well or moderately differentiated localized or regional prostate cancer, there was no excess mortality at all. The researchers note that it is possible that earlier diagnosis might not in itself mean longer survival. The question of whether PSA screening does in fact reduce mortality from prostate cancer must be answered by large-scale clinical trials, which are currently underway, they add. In an accompanying editorial, Dr. George Wilding and Patrick Remington of the Comprehensive Cancer Center at the University of Wisconsin in Madison write: "Given the many uncertainties about this disease, this information alone will be helpful for clinicians and their patients when discussing treatment options and when considering what life will be like living as a prostate cancer survivor." SOURCE: Journal of Clinical Oncology, January 20, 2005. Do you realize that if there was any merit to that study, that would mean that the medical community in this country is misleading us for there personal gain. Either that or are using us as guinea pigs. >Do you realize that if there was any merit to that study, that would mean >that the medical community in this country is misleading us for there >personal gain. Either that or are using us as guinea pigs. I'd go with the guinea pigs or lab rats! I'm in a clinical trial... -- Reader to complete... -- Please reply to this ng as my email adress is fake: -- Regards -- CC >>Do you realize that if there was any merit to that study, that would mean >>that the medical community in this country is misleading us for there [quoted text clipped - 3 lines] > > I'm in a clinical trial... Another point I should have mentioned is that there are clearly subpopulations who are going to benefit from PSA screening followed when indicated by treatment. That might include men with more aggressive cancers, for example. > -- Reader to complete... > -- Please reply to this ng as my email adress is fake: > > -- Regards > > -- CC On February 18, Leonard Evens wrote, in pertinent part: > Another point I should have mentioned is that there are clearly > subpopulations who are going to benefit from PSA screening followed when > indicated by treatment. That might include men with more aggressive > cancers, for example. That would be me. Regards, Steve J > Do you realize that if there was any merit to that study, that would mean > that the medical community in this country is misleading us for there > personal gain. Either that or are using us as guinea pigs. See my comments. Prostate cancer is a complex disease, and almost any oversimplified statement about it is going to be wrong. If your life expectancy was less than ten years, and your doctor recommended aggressive treatment, you have a complaint. That is all there is to it. > Friday, February 11, 2005 > [quoted text clipped - 23 lines] > as low as 1 percent and 5 percent within 5 and 10 years following diagnosis, > respectively," they explain. You'll excuse me for being a literal minded mathematician, but what these studies show is that if you only plan to live ten years, then there is no point is aggressively treating your prostate cancer, at least in most cases. It appears that Drs Brenner and Arndt, in making a statment not restricted in time, are drawing conclusions that are not supported by the data they have. To see the relevance of my objection, note that it is standard practice today not to recommend aggressive treatment for men with an expected lifetime of less than 10 years. So the study reenforces that but doens't change it. However, the study results don't help men with expected lifetimes of 15, 20, or more years decide what to do. I am reminded of the early Sweish studies which showed no benefit from aggressive treatment of prostate cancer. It turned out that they just hadn't followed the men long enough. Later studies showed a significant difference for the same men when followed longer. People should always remember that any statisitcal study only tells you something about a population similar in characteristics to the sample studied. It is dangerous to generalize to the general population, which may differ in important characteristics. > For the two thirds of men with well or moderately differentiated localized > or regional prostate cancer, there was no excess mortality at all. [quoted text clipped - 3 lines] > fact reduce mortality from prostate cancer must be answered by large-scale > clinical trials, which are currently underway, they add. Yes, and they must be followed for a sufficiently long period of time. If they cut it off too soon, their results may be of limited use. > In an accompanying editorial, Dr. George Wilding and Patrick Remington of > the Comprehensive Cancer Center at the University of Wisconsin in Madison > write: "Given the many uncertainties about this disease, this information > alone will be helpful for clinicians and their patients when discussing > treatment options and when considering what life will be like living as a > prostate cancer survivor." Maybe? But if your doctor tells you not to worry about prostate cancer on the basis of this study, you should ask him just what he thinks the likelihood of your having advanced metastatic prostate cancer is 15 years down the line. And ask him on what basis he draws that conclusion. > SOURCE: Journal of Clinical Oncology, January 20, 2005. On February 18, Leonard Evens wrote, in pertinent part: > But if your doctor tells you not to worry about prostate cancer on the > basis of this study, you should ask him just what he thinks the > likelihood of your having advanced metastatic prostate cancer is 15 > years down the line. And ask him on what basis he draws that conclusion. Wham! Right on! Regards, Steve J So I guess what the study is really saying is that once you reach a plateau of 10 years with a 95% survival rate that your precentages must drop rapidly from that time on. Sounds like more speculation to warrant earliar treatment. > So I guess what the study is really saying is that once you reach a plateau > of 10 years with a 95% survival rate that your precentages must drop > rapidly from that time on. Sounds like more speculation to warrant earliar > treatment. I'm not sure what you mean by speculation. But I think it is incorrect to suggest that doctors are making their decisions simply to drum up business. The problem now, as it has always been, is to try to catch the cancer before it has metastasized. It is uncertain just when any particular cancer will metastasize if left untreated, and it will depend a lot on the specifics of the case. For example, generally higher Gleason score cancers will metastasize sooner, but of course not always. The doctor faces the same dilemma the patient does. If he finds the cancer at a stage where he thinks he can cure it, should he treat it and have the patients face possible side effects. Or should he wait until there are obvious signs of the disease at which point the disease can only be controlled for a limited period of time? There is lots of evidence that prostate cancer will progress if left untreated. For example, a recent Swedish study compared men who were treated by radical prostatectomy with men followed by watchful waiting. Men had been assigned randomly to each of the two groups in the study. They don't do routine PSA testing in Sweden, so these men were presumably at least 5 years further along when they were diagnosed. They were followed for an average of 6 years, which is probably too short to show all effects. There was no apparent statistically significant difference in deaths due to all causes in this period, but suprisingly---to me at least, because of the short followup---there was a significant difference in deaths due to prostate cancer. More important, the men in the watchful waiting group has greater incidence of symptoms of metastasis. That suggests rather strongly that if these men were followed longer, they would show greater death rates both due to prostate cancer and overall. The natural history of prostate cancer is not completely understood, but on the other hand, it is not a completely blank slate either. Urologists believe on the basis of the available evidence that most cases of prostate cancer detected clinically by current techniques will eventually progress. What is not well understood is which ones will progress and how fast that will happen. In spite of this, there are some guidelines, and doctors don't automatically treat all cases of prostate cancer. For example, men with an expected lifespan of less than ten years are, according to the guidelines, supposed to be treated by watchful waiting followed by hormone therapy if necessary. Also, in some cases of men in their late sixties or older, Gleason 6 cases with other positive signs may be followed by watchful waiting even if they have longer expected lifespans. Walsh recommends that in his book, and Walsh is usually considered an advocate of aggressive early treatment of prostate cancer. It is not unusual to treat something because it might be a problem more than ten years down the line. For example, doctors are now suggesteing treating high blood pressure if the systolic pressure exceeds 130. My blood pressure has been normal most of my life, but in recent years it has been going up and now needs to be treated. Even at my age, it is unlikely I would feel the effects for ten years. Now treating blood pressure may seem trivial to you compared to treating prostate cancer, but I can say it makes a much bigger difference in my daily life than my surgery for prostate cancer did. Following a low salt diet, for example, requires very careful attention to what is in one's food. I've had to give up foods I've always enjoyed. I haven't done the research, but I would be surprised if there weren't many other forms of cancer which won't kill the patient for at least ten years. > The doctor faces the same dilemma the patient does. If he finds the > cancer at a stage where he thinks he can cure it, should he treat it and > have the patients face possible side effects. Or should he wait until > there are obvious signs of the disease at which point the disease can > only be controlled for a limited period of time? I think doctors' dilemmas are strongly loaded towards survival, not SEs, whereas many patients have other agenda. And although you didn't intend it this way, that "have the patients face possible side effects" sounds like the doctor, rather than an informed and involved patient, gets to dictate the treatment. Not preaching to you, Leonard, just encouraging newbies like myself to get involved. I.P. Leonard, Please don't take me wrong. You are probably much more read than I am and probably have much better retention than I do. However, when I read something, I try to always keep the big picture in mind when assesing an article. What I noticed about your above statment was that you addressed the problem as to try and catch the cancer before it metastasizes. Then further down, you state that the natural history of cancer is not completely understood. It's felt that most cancers will progress but it's unknown as to which ones and how fast. I believe the study was trying to consider localized well defined cancer tumors, Stage 1 and 2 and not the more aggressive tumors. We can't lump them all together. They are suggesting a more conservative approach to the earliar stages probably to avoid the SE of aggressive treatment without the benefits that one might obtain from treating more advanced cases. I believe it is a mistake to assume that everyone diagnosed with PCA whether treated or not will progress to metastasized desease in there lifetime. I believe that proposition is what drives many to treatments that might be unnecesary and even more harmful than the normal progression would be. Ron S > Leonard, > Please don't take me wrong. You are probably much more read than I am and [quoted text clipped - 7 lines] > I believe the study was trying to consider localized well defined cancer > tumors, Stage 1 and 2 and not the more aggressive tumors. Those are the ones I was talking about. I believe there is strong evidence that given time many of those will metastasize. What isn't known is which ones will or how to tell when it is about to occur. > We can't lump > them all together. They are suggesting a more conservative approach to the > earliar stages probably to avoid the SE of aggressive treatment without the > benefits that one might obtain from treating more advanced cases. I believe > it is a mistake to assume that everyone diagnosed with PCA whether treated > or not will progress to metastasized desease in there lifetime. Personally, I believe that many men currently being treated today would, if not treated, never have to face metastatic disease. But, the point is that many will, and there is no good way to distinguish easily between those that will and those that won't. > I believe > that proposition is what drives many to treatments that might be > unnecesary and even more harmful than the normal progression would be. > Ron S Suppose for the sake of argument that a man in his 50s has a diagnosis of prostate cancer at stage T1c, Gleason 6, and PSA less than 10. How small does the chance of metastasis during his lifetime have to be before it is a risk worth taking: 50% 30%? 20% 10% 5% ? Personally, if it were below 5%, I might consider it. If it were as high as 20%, I wouldn't want to take the risk. I don't want to belabor the point, but at present there is no way to separate out those cases which will never progress sufficiently to bother the patient from those that will. There is also no easy way to decide when the risk has increased sufficiently to merit treatment. Just how would you follow such men, and what criterion would you use to decide treatment is necessary? > I don't necessarily disaggree with what you are saying for the most part. However I tend to believe that especially here in the US, the conclusions from most studies are skewed towards aggressive cancers. Had it not been for the PSA test, how many men would have known they had pca and would have died from other problems before the cancer would have ever caused a problem. When many of these studies are compiled, they often include data from from pre-psa patients that were more advanced that bias the results. There is now way to tell how many men never new they had pca before unless it was aggressive. It's similar to alzhiemers. There is still no way to determine if a person is suffering from the disease without an autopsy. 80% that were diagnosed were eventually found to be negative. And most never get an autopsy anyway. I don't believe we should be in a such hurry to treat low risk patients and do more monitoring because of the SE and QOL issues. I believe many diminish these SE and QOL issues. ... > I don't believe we should be in a such hurry to treat low risk patients > and do more monitoring because of the SE and QOL issues. I believe many > diminish these SE and QOL issues. "More monitoring" seems to me to be the key element in your recommendation. The waiting tools we have now - PSA and DRE, maybe occasional biopsies, are useful but not perfect. We know that PCa spreads slowly. But we also know that there must be some point when it establishes itself outside the prostate and curative treatment become futile. What we don't know is exactly when that point is, and exactly what the early warning signs are, i.e., early enough signs that we are certain that we have time to schedule treatment. It seems to me that as the diagnostic tools get better and better, your advice will become more and more cogent. But in the meantime watchful waiting has something in common with Russian roulette. Five empty cylinders and one with a bullet. Are you willing to spin the cylinders and pull the trigger? Or is one chance out of six enough to face the radiation or surgery? And is there really only one bullet in that gun, or could there be two or three? Alan > You'll excuse me for being a literal minded mathematician, but what > these studies show is that if you only plan to live ten years, then > there is no point is aggressively treating your prostate cancer, at > least in most cases. My uro-doc said that if I didn't receive treatment, he thought I'd live 10 maybe 12 years. He staged me T1, Gleason 7=4+3, biopsy in only one of a dozen cores. The rad doc did his electronic imaging and called it T3, possible capsule penetration, tumor located on the "front" making it hard for the uro-doc to DRE it. The rad doc gave me 8, maybe 10 years if untreated. So, yeah, with a PSA 10+ and an aggressive, high-grade tumor, if I only plan to live 10 years, why did do the 8 months of Lupron, 25 IMRT sessions, and the 97 Palladium-103 seeds. I'm 58 now so 10 years puts me at 68. You are a statistic of one! I have gotten where I do not read most of the printed material as it is out of date. And, a realization that treatment approved by the FDA is one thing and treatment in a Phase II trial is another...... At 56 my numbers mirrored yours No Spam.......PSA 6.8, Gleason 7 (4+3) and a T1. I too have Palladium seeds and 25 sesions on a Peacock - IMRT. A year later, PSA was 25.3 with probably mets to T2 & L3. After Eligard and six months of chemo, PSA is .5 and bone scans are clean. So at 58, it is too early to say if complete reversal yet. All I do know is that everythig is headed in the right direction. As far as lifespan, I was told that 3-5 years before chemo and a minimum of 10 years with it with 30% considered cured with new bone re-growth to damaged areas. But my philosophy after a .1% probability of finding an aneuryism with a blood clot attached to it accomplished, that each day is a bonus.......... So, as a "statistic of one", I rejected standard published statistics......:) Mike > > You'll excuse me for being a literal minded mathematician, but what > > these studies show is that if you only plan to live ten years, then [quoted text clipped - 14 lines] > IMRT sessions, and the 97 Palladium-103 seeds. I'm 58 now so 10 > years puts me at 68. > You are a statistic of one! > [quoted text clipped - 20 lines] > > Mike Good morning Mike, What was your PSA trend? Mine was: 10+ Pre treatment 1.3 after 3 months on Lupron 0.8 after the IMRT started (it was probably the Lupron) < 0.1 after 7 months of Lupron, 2 month after the seeding and IMRT. My next PSA is in March. We'll see. But yeah, stats are just numbers and not the real world. Thanks, -- I think that you have great numbers......Me, not very typical and very strange. I never had a drop after primary treatment. Pretreatment - 6.8 six months after seeding and 3 months after IMRT - 9.3 PSA every month for next 6 months ranged from 9-12 One year after seeding PSA jumped from 12 to 24 and then 30 and finally 32.3. I took my first shot of Lupron (22.5 mg). Two months later PSA was 7.6 or so and I started chemo. July - 3.0 - (Eligard - 22.5mg) August - 1.0 September - 1.0 - (Eligard - 22.5mg) October - 1.0 November - 1.0 - (Eligard - 22.5mg) December - 0.7 January - 0.5 - (Eligard - 22.5mg) February - 0.5 I actually have had my PSA tested every month since September 2003. > > You are a statistic of one! > > [quoted text clipped - 37 lines] > > -- > Overall, relative 5-year survival rates for prostate cancer patients were 99 > percent, and 10-year survival rates were 95 percent, Drs. Brenner and Arndt > found. My Response: No doubt the survival rate is a positive thing and does give cause for hope for many men. I guess that the lingering question about the actually benefit of PSA has some degree of validity but I personally don't buy into it. I'm a proponent of testing. >"That is, excess mortality compared with the general population was > as low as 1 percent and 5 percent within 5 and 10 years following diagnosis, > respectively," they explain. For the two thirds of men with well or moderately differentiated localized > or regional prostate cancer, there was no excess mortality at all. My response: Again good news BUT, of course, if your PCa poorly differentiated and you are in the 1 or the 5 % then it seems like 100% because you are the exception. Modern medicine, I guess, needs to focus on the most good for the most people but when dealing with PCa we need to focus on our own situation. In In 1998, with a PSA of 0.9 and what was described as a normal DRE I was told by a urologist that I had less than 1% chance of having PCa and a biopsy was not justified. In 1999 my PSA was still at 0.9. Less than 2 years later I was diagnosed with a high grade and aggressive PCa, PSA was 3.9, Gleason 4+4=8, Stage T3a, perinueral invasion. My PCa statistics moved rather quickly from less than 1% chance to 100% certain. Such is statistics. Such is life. My motto: If in doubt, check it out. > Suppose for the sake of argument that a man in his 50s has a diagnosis > of prostate cancer at stage T1c, Gleason 6, and PSA less than 10. How > small does the chance of metastasis during his lifetime have to be > before it is a risk worth taking: 50% 30%? 20% 10% 5% ? > Personally, if it were below 5%, I might consider it. If it were as > high as 20%, I wouldn't want to take the risk. That's exactly why I decided to have surgery. Sounds like you are writing about my clinical stats here. The difference is that after the surgery, the path report was a Gleason 7. After going through all I've been through after RP - if I get killed in a car accident before I get an erection - - I'll shoot myself... (lol) Paul > ... > Overall, relative 5-year survival rates for prostate cancer patients were 99 [quoted text clipped - 6 lines] > or regional prostate cancer, there was no excess mortality at all. > ... Here's what the National Cancer Institute says about survival: "Survival of the patient with prostatic carcinoma is related to the extent of the tumor. When the cancer is confined to the prostate gland, median survival in excess of 5 years can be anticipated. Patients with locally advanced cancer are not usually curable, and a substantial fraction will eventually die of their tumor, although median survival may be as long as 5 years. If prostate cancer has spread to distant organs, current therapy will not cure it. Median survival is usually 1 to 3 years, and most such patients will die of prostate cancer. Even in this group of patients, however, indolent clinical courses lasting for many years may be observed." (http://www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessional/page1) >>... >>Overall, relative 5-year survival rates for prostate cancer patients were 99 [quoted text clipped - 13 lines] > prostate gland, median survival in excess of 5 years can be > anticipated. This description is way out of date and probably based on the understanding of the natural course of the disease in the 80s. I believe that hese days, when prostate cancer is typically discovered through PSA testing, close to 100 percent of the patients with cancer confined to the prostate will survive for 5 years, treated or not. Median means half. So to say median survival is in excess of 5 years is quite an understatement. I think most urologists believe that before PSA testing, prostate cancer was typically diagnosed at least 5 years later than it is now, usually through DRE or explicit symptoms. It is also unclear from these statement whether they are talking about treated or untreated prostate cancer. > Patients with locally advanced cancer are not usually > curable, and a substantial fraction will eventually die of their tumor, [quoted text clipped - 4 lines] > indolent clinical courses lasting for many years may be observed." > (http://www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessional/page1)
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