Sspecifically in his "The Rate of recurrence in the PSA-Era was too
high" where does he get his numbers from? Do they appear accuate?

Article:
In general, the New Era strategy for prostate cancer is to screen and
possibly treat men earlier when the cancer is limited and weak.

The goal is to keep a patient's life as it was before the diagnosis
and ensuing treatment.

The dramatic reduction in the rates of recurrence from treatment of
this extremely dangerous disease, and the avoidance of the great harm
to quality of life that previously came with the use of long-term
hormonal therapies and experimental drugs, has made the New Era of
treatment the most prudent choice for patients.

The emphasis on early diagnosis and treatment in the New Era has also
opened up the realistic hope for much simpler treatment of the earliest
prostate cancer cells that are called high grade PIN (HGPIN).

While credible doctors have concerns regarding the potential risk of
overtreatment caused by earlier diagnosis, that concern should only
motivate us to be careful in our medical choices rather than to bypass
the new opportunities for best treatment.

A New and Different Strategy

The PSA-Era provided nerve-sparing surgery, and PSA screening (blood
test) thresholds set at 4.0ng/ml combined with DRE (Digital Rectal
Exam) testing, to detect prostate cancer when it could still be treated
with curable intent.

Over the last decade, if there was recurrence after treatment, it was
almost universally treated with hormonal therapies.

The New Era of treatment currently provides for:

Earlier screening beginning at age 40 (or 35 in some cases);
A PSA screening threshold of 2.5ng/ml with the potential of early
biopsy using 12 or more cores;
Emphasis on improved diagnostic techniques especially including the use
of PSA velocity and doubling time to guide the necessity for and the
type of treatment;
Emphasis on viewing surgery and follow-up high dosage radiation therapy
(usually IMRT at dosage levels over 70Gy), when required, as a
compatible pair of processes rather than only as opposing options;
Non-invasive treatment of patients with cancer-precursor high grade PIN
disease, when appropriate. Many men at age 50 have PIN. The presence of
"high grade" PIN (HGPIN) implies later cancer in almost half of
men. (This work is in-progress)

The decline in the death rates in the PSA-Era was NOT good enough

In 2005, 232,090 men will be diagnosed with prostate cancer, 30,350
will die of it, and about 1.6 million men are alive who have had a
positive diagnosis.

The total number of men dying each year from prostate cancer has
remained about constant over the last decade.

The "age-adjusted" death rate has been declining at a steady rate
of 4% per year since 1994. (Age-adjusted means that 4% more men per
year would have died had the treatments not been available.) PSA-Era
screening and treatment are given credit for this major achievement.

A death rate decline of 4% per year was too low to persuade all primary
care doctors and patients to follow the standard screening guidelines.
(CAA Journal for Clinicians 2005)

About 50% of men with health insurance under 65 years of age were
screened last year.
Above age 65, screening rates were about 60%.
Lack of health insurance or a fixed provider cause large decreases in
screening rates: usually to about 25%.
It has, unfortunately, often become a patient responsibility to ask for
screening and for the latest types of medical care. While education
about screening is important, the effectiveness of treatment must also
be improved.

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The Rate of recurrence in the PSA-Era was too high

Recurrence over the 10 years after treatment was much too frequent. On
average:

For Low-risk patients: normally PSA= 10ng/ml or less, and Gleason
Score= 6 or less, there was 20% recurrence.
Medium-risk patients: normally PSA between 10 and 20ng/ml, or Gleason
Score = 7, there was 50% recurrence.
High-risk patients: normally PSA greater than 20ng/ml, or Gleason Score
8-10, there was 66% recurrence.
Overall, the average recurrence rate was about 1/3 of the patients over
10 years, and this statistic is not nearly adequate, especially for a
man who typically has a potential 30-year lifespan ahead of him.

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Recurrence is feared by all patients

Recurrence is only an arbitrary marker of the rise in PSA after
treatment.

The worrisome aspect of recurrence is that it is related to the time
until metastasis (spread of the cancer), and metastasis usually implies
suffering and death.

Almost all prostate cancer patients have a Gleason Score (level of
aggressiveness) between 5 and 10. The Johns Hopkins result, 2003, were
that:

For the Gleason Score 5-7 patients, the probability of metastasis
varied between 16 and 25% at 7 years; and for the Gleason Score 8-10
patients, the probability of metastasis varied between 43% and 93% at 7
years after recurrence.

For those men who metastasized (usually those with more rapidly rising
PSA), the average time to metastasis was about 7.5 years after
treatment unless other intervening treatment is successful, and the
average time from metastasis to death was 6.5 years. Prostate cancer
can greatly shorten life, and recurrence is its marker for trouble.

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Hormonal and other drugs for recurrence

The "gold standard" of care for men with recurrence after surgery
or radiation therapy (i.e. men with advanced disease) has been hormonal
(or androgen deprivation) therapy (ADT).

The intent is to greatly slow down the growth of cancerous cells by
depriving the man of testosterone. Both injection of drugs like Lupron
and use of pills such as Casodex become part of a plan for stopping the
rise of PSA.

For many men use of ADT is effective. The problems are that ADT has a
set of side effects that many men view as unacceptably brutal, and even
if they are endured, in time, the cancer is likely to recur without
testosterone and the ADT will no longer work.

One alternative has been to use ADT temporarily to drive the PSA level
down to undetectable levels and then let the body recover. Some drug is
often used to sustain this "OFF" cycle as long as possible, and ADT
is only used again when the PSA rises to some level (PSA=4 is used by
Catalona).

This therapy is called intermittent androgen deprivation (IAD).

A new problem for IAD is that the process for picking one or more of
the several hundred drugs that are in development or early use that
might be suitable for cancer suppression during the OFF cycle, has not
been established. Availability of these drugs is also often an issue.

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The New-Era offers something better

The lowering of the PSA screening threshold to 2.5 does seem to help.

Dr. Patrick Walsh of Johns Hopkins published his 10-year results in the
PSA region 0-4ng/ml:

Of patients with Gleason Scores of 5-7, recurrence was between only 1
and 18 %. Compare this to 20-50% recurrence for low-to-medium risk
patients, above.
Of patients with Gleason Scores of 8-10, recurrence was only 37%.
Compare this to 66% recurrence for high-risk patients, above.
Dr. Catalona described cooperative use of adjuvant and salvage
high-dosage radiation therapy in a prior issue of Quest. The recurrent
patients usually had about an 80% chance of ending the recurrence with
those follow-up treatments.

In the new era using both therapies together:

Of patients with Gleason scores of 5-7: 96% or better, non-recurrence
Of patients with Gleason scores of 8-10: 80-93% non-recurrence
These results are with limited or no use of difficult hormonal
therapies.

While these results require further validation, at such high levels of
outcome success, the best choice for a patient to follow is the New-Era
approach for screening and treatment; and it's not even a close call.

http://www.drcatalona.com/quest/Spring05/quest_spring05_6.asp