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Medical Forum / Diseases and Disorders / Prostate Cancer / January 2006Uncertainty prevails
Hello again Having been "in the Program" now for over 18 mths and on this NG for nearly the same time, I have concluded that "uncertainty prevails". 1. The original PSA test/s can vary and be flawed. 2. The DRE/s performed by the "educated finger/s" are usually under-staged and can only detect irregularities on the posterior side of the gland. 3. The TRUS Biopsies performed with Standard Greyscale Imaging are "shots" in the dark and many times the Cores sampled are not representative of the extent of the Tumour/s. 4. CT Scans and Full Body Bone Scans cannot detect Mets accurately. 5. Partin Tables and other Nomograms are doubtful predictors as their data are somewhat obsolete and non-representative of any particular patient. 6. Too many patients have opted for Surgery to "exorcise the Devil", only to discover the need Salvage Therapy. 6. My Professor of Radiation Oncology admitted to me "We just don't know! That's why we continue with Clinical Trials" I could go on and on, but I tend to agree with a guy who posted here some time ago who said it's all a "crap shoot" that has to be played out with the hand of cards you're dealt. What he means there is based on the above, we go with a Treatment Regime that is handed to us on the basis of what "falls through the sieve" There are a few measures I'd like to see to improve Dx and Tx decisions: 1. Improve TRUS Biopsy Sampling & Imaging by Power Color Doppler process. This shows the extent of the Tumour Involvement much clearer than the Greyscale. 2. Introduce PET scans in lieu of CT Scans up front. A PET scan can "see" Mets! 3. Look at complete development and approval of Immunotherapy as a total Tx. Immunotherapy harvests Cancer Cells, modifies them and re-injects them to KILL the remaining Cancer Cells. I'm sure a number of you could add or subtract from my beliefs and here is the place to do it. If we could all eventually agree on cutting out some of the crap and looking at some pro-active ideas we could plot a more Certain and expedient path to "Tx without tears for years". -- Reader to complete... -- Please reply to this ng as my email adress is fake: -- Regards -- CC Choice of Dr. is most important. I would be dead to this day. If I did not move ahead, and go for other diagnosis, and treatment options. I would have been radiated, (external beam) Wow....burn you for 3 to 4 weeks. I decided to go into this whole ordeal, and say no! I went to 2 other Drs. my stats were not that good. PSA 7 Gleason 3+5 Mri ok..... I got RP.....1999. (49 years)I am alive but do not guarantee my choice. I do not pee myself, and need a bit of viagra. 56 today.... > Hello again > [quoted text clipped - 50 lines] > > -- CC > 4. CT Scans and Full Body Bone Scans cannot detect Mets > accurately. True ... and a good reason for us to research and consider claims that the new CT/PET combination scan is far superior to either technology alone -- crucial, I suspect, for anyone (like myself) considering salvage radiation in their future. > 5. Partin Tables and other Nomograms are doubtful predictors as > their data are somewhat obsolete and non-representative of > any particular patient. Isn't obsolescence almost required for data to pass the time test? i.e., It's time-proven statistics, or knee-jerking to every new "finding". It strikes me as a legitimate dilemma. And while no one can claim large-population statistics DETERMINE any individual's outcome, they're infinitely better as a predictor than anecdotal "evidence" and the only valid decision data basis I can think of. > 6. Too many patients have opted for Surgery to "exorcise the > Devil", only to discover they need Salvage Therapy. "Too many"? That implies RT would have fried the devil in the first try. How often can we claim, let alone prove, that? > 2. Introduce PET scans in lieu of CT Scans up front. A PET scan > can "see" Mets! See above. > If we could all eventually agree on cutting out some of the crap > and looking at some pro-active ideas we could plot a more > Certain and expedient path to "Tx without tears for years". We can't easily change medical facts or influence the direction and speed of research, but we CAN influence the DISSEMINATION of PC knowledge -- of the values of early testing, individual research, and questioning one's doctors on such topics as tx timing, options, and SEs, among many others. I can't think of many other common, serious medical problems faced with the amount of personal understanding and involvement this malady requires. I.P. <snip> >> 5. Partin Tables and other Nomograms are doubtful predictors as >> their data are somewhat obsolete and non-representative of [quoted text clipped - 6 lines] >infinitely better as a predictor than anecdotal "evidence" and the only >valid decision data basis I can think of. Have a look at the dates the Partin Tables and the Sloan Kettering Nonograms were published.....somewhere over 15 yrs ago to my observation. If you now use a computer to do math, do you have to prove it on an Abacus? Surely some advances in Dx and Tx have been made in that period and therefore UPDATED tables/nomograms could be fed the newer Data, showing different outcomes. I would also like to see the "core" data range expanded some to cover any major pre-existing ailments. I would be more than willing to endorse these if you could point me to them. -- Reader to complete... -- Please reply to this ng as my email adress is fake: -- Regards -- CC > "I.P. Freely" wrote: >>Isn't obsolescence almost required for data to pass the time test? i.e., >>It's time-proven statistics, or knee-jerking to every new "finding". > Have a look at the dates the Partin Tables and the Sloan Kettering > Nonograms were published.....somewhere over 15 yrs ago to my > observation. > Surely some advances in Dx and Tx have been made in that period and > therefore UPDATED tables/nomograms could be fed the newer Data, > showing different outcomes. Yup, and I presume that's happening as we type. So in 15 MORE years -- the time it takes for PC to run its course and provide valid end-point closure -- today's new data may be the basis for valid conclusions for our sons. IOW, that 15-year lag between input and "reliable" output is determined by PC maturation speed, not computer speed. I can think of two solutions to that problem: 1. Speed up the progression of PC (maybe feed it a little extra T and don't treat it?), or 2. Mathematically model the medical progression (not the statistics) of PC so doctors can predict the course of individual cases of PC. (Far-fetched? Nope, just futuristic. We already do that with such diverse things as global and local weather and nuclear weapons development.) I.P. > ... <Very interesting summary elided > ... > There are a few measures I'd like to see to improve Dx and Tx [quoted text clipped - 3 lines] > process. This shows the extent of the Tumour Involvement much > clearer than the Greyscale. I had an endo-rectal MRI which also showed the tumor pretty well. It was a literal pain in the a.s, but probably no worse than the biopsy. > 2. Introduce PET scans in lieu of CT Scans up front. A PET scan > can "see" Mets! I think this and the color doppler are coming. Real Soon Now. > 3. Look at complete development and approval of Immunotherapy as > a total Tx. Immunotherapy harvests Cancer Cells, modifies > them and re-injects them to KILL the remaining Cancer Cells. Unfortunately, immunotherapy isn't that easy. One huge problem is that the human immune system has a built-in detector for cells that belong to one's own body. Cancer cells have the biomarkers for self that renders them safe from our immune systems. What some immunotherapies are trying to do is to target one of the intermediate metabolic products that are unique to cancer cells. Determining what those products are, that they are in fact unique to the cancer development pathway, that they can be destroyed by immunocytes, that the immunocytes can actually get at them (hard to do if they're only found inside cells that are proof against the immune system) and that the immune cells can be trained to detect them - are all very, very hard problems. Progress is being made, but it's slow and painstaking and requires huge amounts of very basic research. And remember that experimenting on people is not allowed until you've already gone through years of theoretical work, in vitro studies, mouse studies, and maybe higher animal studies. I fear that we're years away from proven, reliable, immunotherapy treatments - though some of the ones in clinical trials now may at least prove beneficial even if they're not cures yet. Alan In reply to Clarence Crow on Immunotherapy" <snip> >> 3. Look at complete development and approval of Immunotherapy as >> a total Tx. Immunotherapy harvests Cancer Cells, modifies [quoted text clipped - 22 lines] >treatments - though some of the ones in clinical trials now may >at least prove beneficial even if they're not cures yet. In Australia, we have a few Clinical Trials up and running using Dendritic Cells - see: http://www.prostate.org.au/dendritic.htm There are already some very encouraging endorsements from participants in the Trials promising life extension of several years by eliminating both Primary and many Secondary Tumours (Mets.) I don't say we are "there" yet, but we're damn close! -- Reader to complete... -- Please reply to this ng as my email adress is fake: -- Regards -- CC > Hello again > > Having been "in the Program" now for over 18 mths and on this NG for > nearly the same time, I have concluded that "uncertainty prevails". There is certainly a lot of uncertainty, but often that uncertainty can be quantified. Most important, uncercertainty does not mean there is no information. It is inevitable in medicine that there are going to be uncertainty, but we can't let that paralyze us when making decisions. > 1. The original PSA test/s can vary and be flawed. That is true. But a high PSA which leads to a needless biopsy is not a disaster. Biopsy is a relatively safe procedure. More serious is prostate cancer which doesn't lead to an increase in PSA. The data I've seen suggests that such cancers tend to be less aggressive, but certainly some of them of them can be very aggressive. That is why urologists recommend both PSA testing and DRE. The more serious question is whether or not PSA testing is effective a lowering development of metastatic prostate cancer and death from prostate cancer. This is a contentious issue with evidence in both directions. It is also difficult to control enough variables to do a meaningful test. Finally, it is important to realize that the answers you get depend on the questions you ask. If you aks whether from a public health point of view, PSA testing is effective for controlling prostate cancer in the population at large, that is not the same thing as asking whether for any individual man, PSA testing is to his personal advantage. > 2. The DRE/s performed by the "educated finger/s" are usually > under-staged and can only detect irregularities on the > posterior side of the gland. Again, an abnormal PSA will lead to a possibly unnecessary biopsy, not a disaster. Some cancers will be missed through both PSA testing and DRE, but the great majority will be found that way. > 3. The TRUS Biopsies performed with Standard Greyscale Imaging > are "shots" in the dark and many times the Cores sampled are > not representative of the extent of the Tumour/s. See below. > 4. CT Scans and Full Body Bone Scans cannot detect Mets > accurately. > 5. Partin Tables and other Nomograms are doubtful predictors as > their data are somewhat obsolete and non-representative of > any particular patient. The uncertainty in the data in the Partin Tables is specified. It is fairly large, but that doesn't mean the Partin Table predictions are irrelevant in making decisions. Of course any statisitcal information is not necessarily going to apply to any particular patient. It just gives you an estimate of probabilities. Let me be concrete. In my case, (T1c, PSA 4.5, Gleason 7=3+4), the Partin Tables showed a likelihood of 5 percent of finding cancer in the seminal vesicles or lymph nodes. That would have been the most serious outcome because if that had happened there would have been a strong likelihood that cancer has already spread to distant sites and it may have been that surgery was not warranted. As one person, I could not guarantee that I was not the one in twenty to whom this would happen. However, the odds were that I was one of the nineteen out of twenty to whom for whom it would not happen. As best i can tell, there really is no additional information which could have been used to determine whether I was in the small minority or much larger majority in this matter. Given that we make decisions every day based on probabilities, this sort of thing is not unusual. Usually our expectations are borne out, but on occasion we are unlucky and they aren't. > 6. Too many patients have opted for Surgery to "exorcise the > Devil", only to discover the need Salvage Therapy. What to you mean by "too many"? In one sense, any is too many. But it is not as though essentially all patients who choose surgery need radiation salvage therapy. It depends in part on the nature of the cancer, which often can't be determined until post op pathology. A more serious problem is that some men find after surgery or after surgery plus radiation that it turned out their cancers has spreaad beforehand and the treatments did not work. But this happens in a relatively small minority of cases. If surgery seems the best choice for you at the time, it would be irrational to not choose it because it might not work. Consider the case of a man in his early 50s who has a PSA over 10 and a positive DRE. Surgery for him is going to be far from certain in providing a cure, but it might still be his best bet under the circumstances. > 6. My Professor of Radiation Oncology admitted to me "We just > don't know! That's why we continue with Clinical Trials" [quoted text clipped - 6 lines] > Regime that is handed to us on the basis of what "falls through the > sieve" I geuss it is the old adage about whether the glass is half empty of half full. Before the development of modern methods of diagnosing and treating prostate cancer, a diagnosis was close to a death sentence. We are far from an effective cure which works almost all the time for almost all men, but we are a lot better off than men in the 70s and 80s were. > There are a few measures I'd like to see to improve Dx and Tx > decisions: [quoted text clipped - 21 lines] > > -- CC >If you aks whether from a >public health point of view, PSA testing is effective for controlling >prostate cancer in the population at large, that is not the same thing >as asking whether for any individual man, PSA testing is to his personal >advantage. Can you explain why this might be? (A friend managed to pick up the Scardino book btw - hope to get my head well and truly stuck in next week - thanks for the heads up) "rosbif" asks why >>If you aks whether from a >>public health point of view, PSA testing is effective for controlling >>prostate cancer in the population at large, that is not the same thing >>as asking whether for any individual man, PSA testing is to his personal >>advantage. Because there are always exceptions to statistical "rules". Example: The average lottery player or extended warranty buyer loses. Some individual players and buyers win. I.P. > "rosbif" asks why >>>If you aks whether from a [quoted text clipped - 6 lines] > Example: The average lottery player or extended warranty buyer loses. Some > individual players and buyers win. Agreed, but I've never understood how anyone 'plays' the lottery. There's no game involved, no skill ... not even any time spent or entertainment. Mary > I've never understood how anyone 'plays' the lottery. > There's no game involved, no skill ... not even any time spent or > entertainment. Maybe that's why it's often and aptly described as a stupidity tax. I.P. Oops. Should have read ahead.  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum >> I've never understood how anyone 'plays' the lottery. >> There's no game involved, no skill ... not even any time spent or [quoted text clipped - 3 lines] > > I.P. > Agreed, but I've never understood how anyone 'plays' the lottery. > > There's no game involved, no skill ... not even any time spent or > entertainment. It is not a game. It is a tax on the stupid. or "A tax on those who can't do math." >>Agreed, but I've never understood how anyone 'plays' the lottery. >> >>There's no game involved, no skill ... not even any time spent or >>entertainment. > > It is not a game. It is a tax on the stupid. > or "A tax on those who can't do math." And the superstitious and the greedy. Having been brought up in a bookmaking family I'm somewhat puritanical about all gambling, wanting something for nothing is not good. I saw my uncle, the actual bookie, go in ten years from having a tiny cold house heated by a paraffin heater, sitting on fruit boxes from the market, with a new baby, to that baby having a private education and his younger sister a horse, living in a splendid house with huge garden in a fashionable part of the city, on the edge of the countryside and taking foreign holidays - in the early 1950s. I don't begrudge my uncle, he and his wife worked extremely hard, but all their gains were from 3d and 6d bets from not well off punters. That said, we occasionally play cards with a daughter, for dried beans. They all go back into the jar at the end without a tally. If someone runs out during the game s/he borrows (aka steals) from a neighbour. Nobody loses anything. Mary >>>Agreed, but I've never understood how anyone 'plays' the lottery. >>> >>>There's no game involved, no skill ... not even any time spent or >>>entertainment. >> >> It is not a game. It is a tax on the stupid. > > or "A tax on those who can't do math." > [quoted text clipped - 19 lines] > > Mary You do realize that most vig is tax-free. The tax savings is enough to pay for the house, the horse, the vacations. >> > or "A tax on those who can't do math." >> [quoted text clipped - 27 lines] > You do realize that most vig is tax-free. The tax savings is > enough to pay for the house, the horse, the vacations. vig? Mary >> Agreed, but I've never understood how anyone 'plays' the lottery. >> >> There's no game involved, no skill ... not even any time spent or entertainment. > > It is not a game. It is a tax on the stupid. I once asked my brother why he played the lottery, given the odds against winning. He said, "I buy a lottery ticket on Monday for a drawing that occurs on Friday. Then I daydream all week about what I'll do with the money if I win. Where else can I get so much entertainment for a buck?" Alan > He said, "I buy a lottery ticket on Monday for a drawing that > occurs on Friday. Then I daydream all week about what I'll > do with the money if I win. Where else can I get so much > entertainment for a buck?" THAT is the best answer I've ever heard. >> He said, "I buy a lottery ticket on Monday for a drawing that >> occurs on Friday. Then I daydream all week about what I'll >> do with the money if I win. Where else can I get so much >> entertainment for a buck?" > > THAT is the best answer I've ever heard. Except that I wonder if he worries all week about crossing the road in case he's hit? Mary >"rosbif" asks why >>>If you aks whether from a [quoted text clipped - 8 lines] > >I.P. Sure, these are not so much exceptions as nominal predictions arising out of the established statistical results, i.e. if something proves in practise to show a 5% failure rate, then of course it means 'on average' (because a particular sample of 20 could still possibly show no failure) 1 of the 20 will fail - but that '1' isn't regarded as an exception - it was predicted and expected. (I did my UK degree in maths - I was a better algebraist than statistician by far but I did ok on the final papers). It seems to me that if the PSA test can be said to be effective in general then it must be effective also for the individual, irrespective of whether or not it shows up an undesired result for that one individual. Have I misunderstood? "rosbif" <asks > It seems to me that if the PSA test can be said to be effective in > general then it must be effective also for the individual, [quoted text clipped - 3 lines] > statistician. > Have I misunderstood? I think so. "General effectiveness" implies that the average bear (or PC case) is likely to behave like, well, the average bear (or PC case). "Effective for the individual" implies to the average individual -- who hasn't studied statistics -- that HE will be that average bear (or PC patient). I fully understand that my decision to reject adjuvant ADT MAY bite me in the a.s if my PC is worse than the median or mean case, or MAY have been smart if my PC behaves better than the mean or median, but it's far more likely to behave in accordance with the fat part of the prognosis curve. That's one vote for using the fat part to make our decisons. (In my case, the fat parts of the ADT upside and downside curves made it quite clear that I was likely to lose with ADT; the hell with the far less likely end points.) Another vote for using the fat part, the "meat", of the curve is that our PC case is just as (un)likely to hit the left 3-sigma point (early reoccurrence) as it is the right 3-sigma point (cure), so we may as well discount those and work with the far more likely middle 9X% of the curve. OTOH, those unlikely end-points ARE useful. Example: if a pt values maximum longevity, potence, or any other aspect of PC or its treatment above all other considerations, he may elect to minimize or maximize his odds of encountering that particular part of the curve at all costs. He should thus base his decisions on the unlikely curve endpoints that optimize his own priorities. (e.g., Someone who fears bowel problems worse than death may avoid RT; someone who favors heartbeat at any cost may choose RP, RT, ADT, and chemo right up front.) I've had many heavy graduate courses in math and statistics, too, but they get real boring real fast in a diverse group. I.P. >>"rosbif" asks why >> [quoted text clipped - 23 lines] > that one individual. > Have I misunderstood? I think you are correct about that with a couple of provisos. If you don't have any onther information, and you know in general that the likelihood of something happening to you is one in twenty, it would be foolish to act as though it definitely was going to happen. One proviso would be that if for some reason you placed a very high negative value on that one in twenty event and relatively small postive values on the 19 out of twenty other events, then you might still, on balance choose to avoid the highly unlikely event. In other words, it is a problem is decision theory. You have to multiply each likelihood with the loss or gain associated with it to hlep you choose. You see this by asking yourself the following question. Suppose you know that with a Gleason 7 cancer, if untreated, your chances of getting metastatic prostate cancer within your lifetime are only about one in three, and the chances of your getting it if you have surgery are one in 20. (I just made those figures up. Don't take them seriously.) Would it be rational to choose treatment? I think it would be because I place a very high negative value on metastatic prostate cancer, even though the odds might be against it. (The actual figures I've seen suggest that metastasis within 5-10 years in such a case may be as high as 40 percent, and within 15-20 years much higher. But this is based on old data when prostate cancer was usually diagnosed later in its stage, so those time periods may have to be extended somewhat in the modern environment of PSA testing.) The other proviso, is that the usual estimates like those in the Partin Tables have error bars associated with them, and in some cases they are relatively large. That tells you something about how reliable those figures are, which might affect your judgement. Leonard always stuns me with his astute mathematical analysis. From THAT observation...I'll move to the lottery. :-) (I bet he could tell us PLENTY about THAT) For Mary, I.P., Steve K, and Dan...the lines are... "Ya gotta be in it to win it" and... "SOMEBODY'S gonna win...it might as well be YOU." :-) It's always amazing to see the 200 millon dollar winner buying houses and cars for his entire family. And to Mary...bookmaking is better cuz your uncle made HIS money on the "vig". :-) Best of health to all, Ron B. Chicago > For Mary, I.P., Steve K, and Dan...the lines are... > > "SOMEBODY'S gonna win... Yes, but they're winning YOUR money. > It's always amazing to see the 200 millon dollar winner buying houses > and cars for his entire family. Well, those things are VERY important, aren't they! > And to Mary...bookmaking is better cuz your uncle made HIS money on the > "vig". I'm English, I don't understand :-) Mary > :-) > [quoted text clipped - 3 lines] > > Chicago > > For Mary, I.P., Steve K, and Dan...the lines are... > > [quoted text clipped - 13 lines] > > Mary The vig, or more precisely, vigorish, is the percentage that a bookie or gambling house makes on each transaction. Since gambling is illegal and underground, bookies don't normally declare this income or pay income tax on it. Most folk fixate on the total dollars brought in. In actuality, the real benefit is that, on, say, a fifty thousand dollar vigorish income, an underground bookie doesn't pay the five thousand dollar tax that a merchant might. There's no sales tax, no income tax, nothing. Five thousand a year, 20 years, and the bookie has a hundred thousand dollars, tax-free. That's the benefit of working outside of the economy. > The vig, or more precisely, vigorish, is the percentage that a > bookie or gambling house makes on each transaction. Since gambling > is illegal and underground, Not in England. Mary When I jokingly mentioned the 'vig' on bets, Mary said: "I'm English, I don't understand :-)" The smiley face made me think that she knew what I meant. I wasn't being a 'smarty-pants.' Those comments about the lottery were U.S. phrases to get people to play. I find them a joke also. And...when I mentioned the 200 million dollar winners buying homes for everyone...that TOO was a 'tongue in cheek" remark because, as Mary so correctly pointed out...monetary things are so worthless compared to good health. kh helped to explain the 'vigorish.' It means that if you pick either side of a football match to bet on...you pay 'a little extra' (the vig)...which allows the bookie to win something no matter WHICH side wins the actual game. Now...in the U.S. ...the bookies make money from this. In the UK, I think betting is legal so the tax-free nature of the vigorish doesn't apply. None of this is really important...it's just cuz of Super Bowl week. :-) My best to all, Ron B. Chicago > When I jokingly mentioned the 'vig' on bets, Mary said: > > "I'm English, I don't understand :-)" > > The smiley face made me think that she knew what I meant. I didn't know what 'vig' meant, I was smiling because I thought that explaining that I'm English would automatically explain my dumbness ... and it would be allowed for by the charitable Americans. :-) > > I wasn't being a 'smarty-pants.' > > Those comments about the lottery were U.S. phrases to get people to > play. They're used here too for our national lottery. 'It could be you' on a poster with a large pointing finger is on posters and signs everywhere. It *couldn't* be me of course. We reckon we've made more than £1,000 though, by not spending £1 a week each in the last ten years. > And...when I mentioned the 200 million dollar winners buying homes for > everyone...that TOO was a 'tongue in cheek" remark because, as Mary so > correctly pointed out...monetary things are so worthless compared to > good health. That reminds me that when I say we've installed a solar water heating panel on the roof the first question almost everyone asks is, "How long will it take to pay for itself?" Well, I wonder how long it takes for a car, or holiday, or bar of chocolate or a pair of shoes or bottle of wine takes to pay back :-) I suppose that attitude is encouraged by people who encourage you to buy things like home insulation, they always give the payback times. There are other reasons though, money isn't everything. > kh helped to explain the 'vigorish.' > > It means that if you pick either side of a football match to bet > on...you pay 'a little extra' (the vig)...which allows the bookie to win > something no matter WHICH side wins the actual game. I wonder about the etymology of the word. > Now...in the U.S. ...the bookies make money from this. > > In the UK, I think betting is legal so the tax-free nature of the > vigorish doesn't apply. That's true.There will always be illegal books and gambling but most is licensed and even respectable - hence the national lottery. And solar panels :-) And even buying a new pair of shoes when you don't know if you'll be run over by a bus the day after! > None of this is really important...it's just cuz of Super Bowl week. I've heard of Super Bowl, no idea what it is though. Anything like cricket? ;-) Thank you, Mary Who's been to Chicago. That is, landed and took off from there on the way to SeaTac (sp?) in 1993. I looked out of the window and tried to be impressed by the Sears (?) tower because a son had told me I must. I always do what I'm told. <whistles> "Leonard Evens" <wrote > "I.P. Freely" wrote >> there are always exceptions to statistical "rules". >>Example: The average lottery player or extended warranty buyer loses. Some >>individual players and buyers win. > I think you are correct about that with a couple of provisos. If you > don't have any onther information, and you know in general that the > likelihood of something happening to you is one in twenty, it would be > foolish to act as though it definitely was going to happen. Certainly. That's why I pretty much ignore the fringes of the statistical curves, unless your next proviso applies: > One proviso would be that if for some reason you placed a very high > negative value on that one in twenty event and relatively small postive > values on the 19 out of twenty other events > In other words, it is a problem is decision theory. Yup. Got the tee shirt. But since most people don't, I try to reduce the explanations to plain English. Details get lost in the translation, but since PC information is fuzzy studies (i.e., "uncertainty prevails") anyway, details are less important than clarity and practicality, IMO. Marking a cut with a laser before cutting with an axe is more useful in academia than in Elba, Alabama. > I place a very high negative value on metastatic prostate cancer, even > though the odds might be against it. Me, too. But since adjuvant tx doesn't change met likelihood significantly but is virtually certain to alter one's SE profile, their risks (likelihoods times impacts) become comparable, with the latter often becoming dominant (according to the PCRI and others). > The other proviso, is that the usual estimates like those in the Partin > Tables have error bars associated with them, and in some cases they are > relatively large. That tells you something about how reliable those > figures are, which might affect your judgement. And personal priorities may often override the error bars. If someone is absolutely determined to live to see his incubating first grandchild at any cost, he's going to grasp at every straw regardless of its likelihoods or non-lethal impacts. Is that even rational, let alone scientific? Absolutely, as it attempts to ride the coattails of every statistical curve he can find, including marinara sauce enemas twice a day if it adds 1 to the sixth decimal point of his prognosis. Other may recognize -- and care -- that the time spent cleaning up spaghetti sauce wastes more hearbeat that it gains. I.P. >>>"rosbif" asks why >>> [quoted text clipped - 3 lines] >>>>>as asking whether for any individual man, PSA testing is to his personal >>>>>advantage. I should have asked you what you meant by 'effective'.... >I think you are correct about that with a couple of provisos. If you >don't have any onther information, and you know in general that the [quoted text clipped - 13 lines] >20. (I just made those figures up. Don't take them seriously.) Would >it be rational to choose treatment? On the face of it seems to me that you've left out the statistics associated with the negative SEs of treatment in that question. Would they not be part of a rationale? If not then I would certainly go with surgery. (I hope I'm not becoming irritating - I'm just trying to work out my own 'rationale'....) > I think it would be because I >place a very high negative value on metastatic prostate cancer, even [quoted text clipped - 9 lines] >relatively large. That tells you something about how reliable those >figures are, which might affect your judgement. I don't know enough to comment here - hopefully Scardino's book will mention Partin tables? On January 28, rosbif wrote, in pertinent part: (snip) > I don't know enough to comment here - hopefully Scardino's book will > mention Partin tables? Or go directly to the Partin Tables on the Johns Hopkins University website: http://urology.jhu.edu/prostate/partintables.php Regards, Steve J "What are the facts? Again and again and again -- what are the facts? Shun wishful thinking, ignore divine revelation, forget 'what the stars foretell,' avoid opinion, care not what the neighbors think, never mind the unguessable 'verdict of history' -- what are the facts, and to how many decimal places? You pilot always into an unknown future; facts are your single clue. Get the facts!" --Lazarus Long >On January 28, rosbif wrote, in pertinent part: > [quoted text clipped - 3 lines] >Or go directly to the Partin Tables on the Johns Hopkins University >website: http://urology.jhu.edu/prostate/partintables.php thanks - will check those now. >Regards, > [quoted text clipped - 7 lines] >your single clue. Get the facts!" >--Lazarus Long > On the face of it seems to me that you've left out the statistics > associated with the negative SEs of treatment in that question. Would > they not be part of a rationale? If not then I would certainly go > with surgery. SEs are absolutely part of a first treatment choice rationale, and are virtually the primary -- some experts say sole -- basis for a second treatment choice. Surgery's relatively lower SE profile contributed very strongly to it as my first choice. And even though I got the short SE stick (I'm still in diapers at 15 months), I would do it again in a heartbeat. But that's just me ... and hundreds of thousands of others. I.P. >>>>"rosbif" asks why >>>> [quoted text clipped - 28 lines] > they not be part of a rationale? If not then I would certainly go > with surgery. Yes, that would also be part of the analysis. I wasn't trying to be exhaustive. In fact, given a competent surgeon, serious side effects like permanent incontinence are fairly unlikely. Few men are incontinent one year after surgery, and many of those who are can be helped by further treatment. But for men for whom any chance of incontinence is unaccpetable, surgery would be not a viable choice. Impotence is more likely, though by no means a certainty, and it need not preclude an active sex life. I was impotent for 18 months and used a pump during that time successfully. I have a friend who is still using a pump and finds it works for him and his wife. But there are men for whom the thought of impotence is so awful that they are willing to face death instead. Or course, metastatic prostate cancer and its treatment also kills one's sex life, so one must also factor that into the analysis. In principle one could set up a detailed decision tree with probabilities and costs associated with all choices. But no one actually makes decisions this way. Rational people try to keep everything in mind, and after some soul searching settle on something which clinches the decision for them. The point of educating oneself is not that you can behave complete logically in these matters but that you can avoid the worst kinds of mistakes. AQt some point you just have to make a decision which makes sense to you and then not look backwards. > (I hope I'm not becoming irritating - I'm just trying to work out my > own 'rationale'....) [quoted text clipped - 15 lines] > I don't know enough to comment here - hopefully Scardino's book will > mention Partin tables? "Leonard Evens" <wrote > But for men for whom any chance of incontinence is unaccpetable, surgery > would be not a viable choice. I think that's one place we could be of immense value to newbies making decisions, simply by educating people who think light to moderate urinary incontinence is a big deal. While I REALLY wouldn't want to fill big diapers twice a day as I once did, I've had mosquito bites that bothered me more than changing funny underwear every 24 hours simply because they're 24 hours old and may have a small teaspoon of dribble in them somewhere. I.P. > I think that's one place we could be of immense value to newbies making > decisions, simply by educating people who think light to moderate urinary [quoted text clipped - 3 lines] > they're 24 hours old and may have a small teaspoon of dribble in them > somewhere. I am with you, I.P. Maybe it's a matter of confidence or just pragmatics. However, you have to recognize that incontinence is the Number 1 depressor for most people with PCa. I do not understand why, but I can't argue with the fact. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05 PSA .07 .05 .06 .05 .08 Non Illegitimi Carborundum >>I think that's one place we could be of immense value to newbies making >>decisions, simply by educating people who think light to moderate urinary [quoted text clipped - 9 lines] > for most people with PCa. I do not understand why, but I can't argue with > the fact. The first time I peed in my pants after I was diaper trained was in my 60s. I had a pinched nerve in my neck and was in constant pain. As a result I was taking a lot of Vicodin, and I don't know if that contributed, but one day I didn't get home nearly in time and wet my pants thoroughly. I found the whole experience very upsetting and assumed there was something seriously wrong with me. My doctor calmed me down, and in the years following, before my diagnosis of prostate cancer, I had occasional problems of this kind, though not as bad. Often they would happen on very long bicycle rides or long walks. So I was prepared for such things after my surgery. Fortunately I was continent after about a month using pads. But to this day, I will use a pad if I know I am going to be out for a long time without a bathroom available. It is just a practical way of dealing with life's exigencies and I know it doesn't mean I'm in my second childhood. >>>I think that's one place we could be of immense value to newbies making >>>decisions, simply by educating people who think light to moderate urinary [quoted text clipped - 25 lines] > practical way of dealing with life's exigencies and I know it doesn't mean > I'm in my second childhood. I agree, it's not the end of the world. And it's a small price to pay for life. A beautiful young girl in my neurosurgical ward refused life-saving surgery because she wouldn't have her head shaved. That's an extreme example but illustrates the point. Where do you draw the line? My slight dysphasia (which means having to take Spouse as a prompt when I do public speaking) and a drooping eyelid are small prices to pay for being alive thirteen years after a craniotomy. My hair re-grew, that was a fascinating experience in itself. Oh - and I have stress incontinence, in common with many women of my age. It's not just poor old men who dribble :-) Mary >>If you aks whether from a >>public health point of view, PSA testing is effective for controlling [quoted text clipped - 3 lines] > > Can you explain why this might be? This could be for a variety of reasons. Looked at from the perspective of public health professionals, for example, it might be considered worthwhile allowing a certain level of metastatic prostate cancer, which is really very unpleasant, in order to avoid a much larger amount of undesirable consequences following directly or indirectly from a screening program. These would involve cost of procedures, emotional distress of patients, rare serious side effects of screening, unnecessary treatment for many relatively benign cancers, etc. However, from the point of view of an individual man, low level risks might be considered tolerable in order to avoid metastatic prostate cancer, if that is possible. How you might judge such risks depends on a variety of factors. One would be your age, because side effects of treatment might be less likely and also the time to develop metastatic cancer longer. If you have a family history of prostate cancer, you might be more inclined to do what you can to avoid it. Another might be how much you are willing to devote in time and mental effort to deal now with something which might not be a serious problem for many years. This is hardly an exhaustive discussion of the matter, but it will give you some idea of why there could be differences. > (A friend managed to pick up the Scardino book btw - hope to get my > head well and truly stuck in next week - thanks for the heads up)
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