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Medical Forum / Diseases and Disorders / Prostate Cancer / May 2006British Study - No Benefit From Radical Treatment for Low Gleasons
There's a provocative study in the British Journal of Cancer, April 2006. See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html It looked at other studies (that is, it did not do direct research on men with PCa, but analyzed data published by others.) It looked at the 15-year survival rates for men aged 55 to 59 at time of diagnosis, and for men aged 55 to 75. It grouped them by the Gleason scores found at time of diagnosis: under 7, at 7, and above 7. The study concluded that "the probability of 15-year mortality from prostate cancer appears strongly dependent on grade, particularly so for men who are younger at diagnosis. For example, for men aged 55-59 years at diagnosis, the projected 15-year prostate cancer mortality is 0%, 31% and 72% for men with Gleason scores <7, 7 and >7, respectively. For men aged 70-74 years at diagnosis, the 15-year prostate cancer mortality is projected to be 2%, 9% and 28% for men with Gleason scores <7, 7 and >7, respectively." In other words, for men under 60 with a Gleason score under 7, there is almost no risk of dying from prostate cancer during the following 15 years, so radical treatment would add zero years of life expectancy. For men under 75 with low Gleasons, the mortality risk from PCa is only 2%. If the study is correct, these men have to balance a very small potential gain against the high probability of quality-of-life side effects from aggressive treatment. By contrast, the study found, for those with Gleasons higher than 7, the risk of dying from PCa during the 15 years after diagnosis is substantial: 72% from men under 60, and 28% for those in their early 70s. So these men have a much higher potential benefits from radical treatment. "The projected overall survival benefit from curative treatment appears similarly dependent on Gleason score and age at diagnosis. For example, for men aged 55-59 years at diagnosis, the absolute 15-year survival benefit from curative treatment is 0%, 12% and 26% for men with Gleason scores <7, 7 and >7, respectively. For men aged 70-74 years at diagnosis, the 15-year overall survival benefit is projected to be 1%, 3% and 6% for men with Gleason scores <7, 7 and >7, respectively." In another section they write: "The 15-year mortality from low-grade, screen-detected prostate cancer in men aged 55-74 years at diagnosis, who elect conservative management, is projected in our central model to be 1%, and the absolute 15-year survival benefit of curative treatment, less than 1%. The absolute survival benefit for radical treatment is predicted to be greater in men with high-grade disease." They point out that "the results of the model should be interpreted with caution, since the original data upon which it is based cannot necessarily be assumed to be generalisable more widely." With this caveat, the conclusion is attention-getting. For younger men with Gleason scores under 7, there is zero benefit from surgery, etc., in terms of additional life expectancy during the first 15 years. For men aged 70 to 75 with Gleasons under 7, there is a 1% gain in 15-year survival. A chart that accompanies the article shows that about 20% of those under 59 at diagnosis will die of other causes during the following 15 years. For those aged 65-70, that jumps to 40%, and for those 70 to 75 it is 60%. The authors believe the study indicates that radical treatment for PCa is being targeted to the wrong group: younger men with lower Gleason scores, who will get minimal benefit. A wiser strategy would be to reserve the more aggressive forms of treatment for those with higher Gleason scores. "While the outputs of the model must be interpreted with caution, they may have important implications for targeting treatment to those patients who stand to benefit most. Specifically, the absolute survival benefit of radical treatment is predicted to be greater in men with high-grade disease, whereas current clinical practice preferentially targets radical treatment to patients with low-grade prostate cancer." Alex So let's assume I'm diagnosed with a Gleason score of 6 at age 55. I assume from the study that they decide not to do anything. By the time I reach 59 my PCa has spread and I now have a Gleason of 8 and my projected 15-year prostate cancer mortality is 72%. Did I make the right decision at age 55?? The British Public Health system undoubtedly saved money on the whole, but what was the impact on their patients? > There's a provocative study in the British Journal of Cancer, April 2006. > See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 70 lines] > > Alex > So let's assume I'm diagnosed with a Gleason score of 6 at age 55. I assume > from the study that they decide not to do anything. By the time I reach 59 > my PCa has spread and I now have a Gleason of 8 and my projected 15-year > prostate cancer mortality is 72%. Did I make the right decision at age 55?? 1. Authoritative researchers still debate whether Gleason ratings change with time. 2. If I feel "they" aren't being thorough and honest, are choosing my fate based solely on their Hippocratic oath or tx costs, and/or don't understand and consider my priorities in great detail,"they" don't get to make decisions about MY life. "They" SHOULD educate me so *I* can make good decisions. Because very few of them meet even one of those criteria, let alone all three, their job is reduced, IMO, to briefing us on the basics (very few do even that, it seems from some of the stories and questions we see here), honest appraisals of and additions to our findings and decisions, and close scrutiny of the literature pertinent to OUR specific case. 3. Subsequent changes may lead to new decisions, but they don't invalidate prior decisions based on YOUR case of cancer, YOUR priorities, existing data and opinions, and existing statistics. 4. We don't make ANY decisions based solely on ANY single study. Even the most robust single study is worth no more than tiebreaker status, if that. I.P. > 1. Authoritative researchers still debate whether Gleason ratings change > with time. Do you have any of those references handy? I can't quite imagine why someone would think that Gleason doesn't change as the cancer becomes more advanced. TIA, laurel >> 1. Authoritative researchers still debate whether Gleason ratings change >> with time. > > Do you have any of those references handy? I can't quite imagine why > someone would think that Gleason doesn't change as the cancer becomes > more advanced. TIA, laurel No, but I've read and asked many sources because of my initial doc's possibly fatal two-year delay in alerting me to my rising PSA, and the scales seem well balanced; for every "expert" who thinks G may increase I've found another who thinks it doesn't. None seems very convinced or convincing either way. I.P. Hi I.P...Most of what I've read suggests that the tumor cells mutate further over time and the GS increases. The timeframe for these changes is variable. Here are a couple of recent references on the subject...Ron American Urological Association Annual Meeting May 21 - 26, 2005 San Antonio, Texas, USA Publishing #: 1003 Presentation Title: Progression Of Biopsy Grade In Men With Prostate Cancer Managed By Watchful Waiting Author Block: Jonathan R Osborn*, Gerald W Chodak, Vijaya Moranka, Chicago, IL; Hyung L Kim, Los Angeles, CA; Ximing J Yang, Chicago, IL Introduction and Objective: Only a small portion of men with Gleason 4-6 prostate cancer (CaP) treated by watchful waiting will die of their disease within 15 years, however prediction of this subset is difficult. We assessed if changes in pathologic tumor grade on repeat prostate biopsies could help identify patients that should undergo definitive therapy following watchful waiting Methods: Men with clinically localized CaP treated by watchful waiting by one physician (GWC) were advised to undergo repeat biopsies every 1-2 years after initial diagnosis. Clinical and pathological features, including repeat serum PSA levels and Gleason scores were recorded. The probability of developing a Gleason score >6 was determined. Results: 40 men with clinical stage T1c-T2b disease and Gleason 4-6 tumors on initial biopsy were followed for a median of 61.0 months after diagnosis (range 6-153). The median and mean age at diagnosis was 70.5 and 68.3, respectively (range 41.0-80.1). Patients underwent up to 7 repeat biopsies between 1.2 and 151.4 months (median 26.4 months) after diagnosis. Thirty-five percent (14/40) of the patients showed an increase in biopsy grade to Gleason 7 or greater. Three progressed to Gleason 7 within 2 years, 4 progressed between 2 and 4 years, and 7 progressed at greater than 4 years from initial diagnosis. Among patients showing progression, 4 continued with conservative therapy, 4 chose androgen ablation, 1 had a radical prostatectomy, 1 had brachytherapy, 3 opted for a combination of therapies and 1 has not yet decided. Of 12 men with more than 1 year of PSA results prior to the Gleason 7 biopsy, 7 (58.3%) had a PSA rise of >2.0 ng/mL within a year of progression. In contrast, 14/26 (53.8 %) had a rise of more than 2 ng in the year prior to a biopsy when there was no change in the biopsy grade. Seven patients (25.9%) underwent definitive local or systemic therapies without histological progression beyond Gleason 6. Median length of follow up (to curative treatment, or most recent PSA measurement) was 61.0 months (range 6-153). Conclusions: In men managed without local or systemic treatment for CaP, the risk of progressing to a Gleason score of 7 or greater on repeat biopsy is approximately 35% of those followed for more than 4 years. A rise of >2 ng/ml in the year prior to the biopsy failed to identify the patients with an increase to Gleason 7. Serial biopsies in patients undergoing watchful waiting may offer a good option for identifying men with more aggressive cancers who will need definitive therapy but changes in PSA was not a useful parameter Br J Urol. 1990 Mar;65(3):271-4 De-differentiation with time in prostate cancer and the influence of treatment on the course of the disease. Cumming JA, Ritchie AW, Goodman CM, McIntyre MA, Chisholm GD. University Department of Surgery/Urology, Western General Hospital, Edinburgh. There is little information on histological changes in prostate cancer during the course of the disease. We have studied 74 patients with carcinoma of the prostate who required 2 transurethral resections of the prostate (mean interval between resections 2.4 years). They constituted 18.4% of all patients with carcinoma of the prostate presenting to our clinic between January 1978 and April 1988. All tumours were staged by conventional methods and graded using the Gleason system. The Gleason sum score in those patients with tumour in both specimens increased in 49, remained constant in 12 and decreased in 7. Within this group were 34 patients who were treated expectantly. The mean Gleason sum scores in this group increased, with a concomitant increase in local tumour stage and development of metastases. Although this was not a randomised trial, there was no significant difference in survival between patients having "deferred" management and those treated immediately, either from time of diagnosis or from time of second resection. There was, however, a significant difference in the time to second resection, with the "deferred" group requiring repeat resection on average 1 year earlier. This study confirmed the concept of tumour de-differentiation with time and showed that this phenomenon occurs in both treated and untreated tumours. Although overall survival was not influenced by the type of initial therapy or its timing, local progression, as assessed by the need for further TURP, occurred earlier in those not receiving immediate therapy. > Hi I.P...Most of what I've read suggests that the tumor cells mutate > further over time and the GS increases. The timeframe for these [quoted text clipped - 3 lines] > American Urological Association Annual Meeting > May 21 - 26, 2005 > Conclusions: In men managed without local or systemic treatment for > CaP, the risk of progressing to a Gleason score of 7 or greater on [quoted text clipped - 4 lines] > identifying men with more aggressive cancers who will need definitive > therapy but changes in PSA was not a useful parameter That one is interesting in several ways: 1. As new data (2005), it may change some professional minds (some of the authors think it probably doesn't increase). 2. Its statistics seem sufficiently weighty to bear credibility (discouraging for me). 3. But it refutes other recent studies that showed PSAV > 2.0/yr => tenfold increase in likelihood of death by PC (encouraging for me). 4. Maybe more contradictory is its broad statement that PSA dynamics are not useful; other substantive recent studies say just the opposite, that PSA dynamics are extremely predictive. So who do we believe? Then there's > Br J Urol. 1990 Mar;65(3):271-4 > The Gleason sum score in those patients with tumour in > both specimens increased in 49, remained constant in 12 and decreased > in 7. Very old data, raising the question of why some authors today disagree with its findings. > there was no significant difference in > survival between patients having "deferred" management and those [quoted text clipped - 5 lines] > of tumour de-differentiation with time and showed that this phenomenon > occurs in both treated and untreated tumours. So I guess we don't care. But what's this "second resection" business? Did they just nibble away at the prostate back then (this was in RP's dark ages, mostly before Walsh pioneered nerve sparing)? > Although overall survival > was not influenced by the type of initial therapy or its timing, local > progression, as assessed by the need for further TURP, occurred earlier > in those not receiving immediate therapy. I guess this may answer my earlier implied question,"why do we care?" It implies we care because even though survival isn't impaired by delay, delay may make us sick sooner. In addition, asking Google whether Gleason grade or dedifferentiation changes with time still provides plenty of conflicting data and studies to sift through. I'll leave it to those who still have reason to care to do the sifting, but the bottom line still seems to include plenty of room for debate. I.P. >> Hi I.P...Most of what I've read suggests that the tumor cells mutate >> further over time and the GS increases. The timeframe for these [quoted text clipped - 25 lines] > >So who do we believe? I've had a one-off consultation to reflect on the wisdom of continued WW (referred by my RT consultant) with Parker, one of the co-authors of the report, and he's had me collect my PSA data over the last 2 years to establish PSAV so one must assume that there is still interested in this parameter. I'm booked to see him once more, after his hospital has reviewed my 2 biopsies (04/06), before returning to my usual coterie of local consultants. >Then there's >> Br J Urol. 1990 Mar;65(3):271-4 [quoted text clipped - 36 lines] > >I.P. How do we know the repeat biopsys hit the same site as the first biopsy. When know that prostate cancer is mutifocal, Therefore the second biopsey may just have hit a different cancer cell. The second sample may have hit a different more aggressive cell. We also know that often Gleason scores are under scored as a result of not sampling all the prostate. The only way of knowing the makeup of the prostate is by removing it and examining it under a microscope. All these studies sited are dealing with biopsey samples, therefore they are not that accurate in determining the true stage. > How do we know the repeat biopsys hit the same site as the first biopsy. > When know that prostate cancer is mutifocal, Therefore the second biopsey [quoted text clipped - 3 lines] > way of knowing the makeup of the prostate is by removing it and examining > it under a microscope. I think these are good points. I'll add to them that different pathologists looking at the exact same slides can come to different conclusions. My biopsy slides were separately evaluated by three different pathologists with the following conclusions: Quest Labs (giant low bidder HMO servicing lab): 3+3 Baltimore County General Hospital: 3+4 National Cancer Institute: 4+3 It makes you wonder. > All these studies sited are dealing with biopsey > samples, therefore they are not that accurate in determining the true > stage. Unfortunately, we can't remove the whole prostate twice in order to test the change in Gleason. Even if we could there would still be the problem of different pathologists. So there is no 100% reliable way of getting the information we want. Biopsies are the only recourse. So I guess the question is, are these studies better than nothing? I don't know the answer to that. We'd probably need to have multiple biopsies done on the same day and sent to two different labs (e.g., 24 needles instead of 12) and then see if the variation matches what the biopsies over time found. If it does, then we would suspect that the biopsies over time gave us false information. If the variation is much less, then maybe not. Alan > Quest Labs (giant low bidder HMO servicing lab): 3+3 > Baltimore County General Hospital: 3+4 > National Cancer Institute: 4+3 > > It makes you wonder. At the end of this newsletter, they always put a Gleason comparison chart. http://pcngcincinnati.org/2006/2006_04.htm I can see where there is some confusion between a high three and low four.  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, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum <snip> > All these studies sited are dealing with biopsey >samples, therefore they are not that accurate in determining the true >stage. If you research on all of the pre-dx to the dx methods, you'll conclude it's all like "pinning a tail on the donkey" whilst blindfolded. First and foremost, why would a Tumour obligingly present itself on the posterior side of the Prostate, so the Uro's "Educated Finger" can give him feedback to make an initial Staging? Answer: Nothing to do with Gravity, but that's as far as he can reach from the rectum Then with a TRUS Biopsy, no matter how many needles are used and how many Biopsies are done they're still digging in the same "potato patch" as the Uro did. In truth, Tumours are not regular in shape, size or position. If you could get a 3D image on one in the capsule pre-treatment, it would possibly resemble an Octopus with many sinister tentacles reaching out in various directions, and in some cases, penetrating the capsule. (Colour-Doppler imaging gives a better picture of this.) The post-surgery pathology reveals a lot of this, as they open it out and slice it up like Salami. The Tumour trails appear like blobs of fat in each slice (as in Salami.) Having said all this, it's all we have to date and we must run with it and live with any possible consequences. Hopefully, some better dx techniques (already done) will be approved and adopted, if they don't pose a big threat to the "Bottom-Line" of the existing ones. -Happy Hypotheses -- Reader to complete... -- Please reply to this ng as my email adress is fake: -- Regards -- CC >So let's assume I'm diagnosed with a Gleason score of 6 at age 55. I assume >from the study that they decide not to do anything. By the time I reach 59 >my PCa has spread and I now have a Gleason of 8 and my projected 15-year >prostate cancer mortality is 72%. Did I make the right decision at age 55?? By my reading, the statistics suggest that a gl6 at 55yrs is unlikely to become an 8 at 59 yrs - a non-zero probability true, but low in any case. Whether or not one finds oneself in the unfortunate minority 4 years later can't possibly impact on the initial rationale. In any case active surveillance would prescribe radical intervention at gl7 (I gather there are some in the 3+4 camp and others in the 4+3). >The British Public Health system undoubtedly saved money on the whole, but >what was the impact on their patients? The research is hardly likely to have been undertaken as a cost-cutting excercise! >> There's a provocative study in the British Journal of Cancer, April 2006. >> See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 70 lines] >> >> Alex >>So let's assume I'm diagnosed with a Gleason score of 6 at age 55. I assume >>from the study that they decide not to do anything. By the time I reach 59 [quoted text clipped - 9 lines] > at gl7 (I gather there are some in the 3+4 camp and others in the > 4+3). If I were doing watchful waiting I think I'd want a PSA test every 3 months and set age/PSA cutoff points above which I'd seek treatment. For example if I were under 70 and my PSA reached 10 I think I'd certainly want treatment, unless I were suffering from some other fatal disease. It would be a terrible mistake to read one of these studies and conclude it's okay to skip treatment because I'll be alive 15 years from now and don't expect to live longer. That is waiting without watchfulness. It would mean that if you are in the low probability high-risk group you won't find out until it's too late. Alan >>>So let's assume I'm diagnosed with a Gleason score of 6 at age 55. I assume >>>from the study that they decide not to do anything. By the time I reach 59 [quoted text clipped - 14 lines] >if I were under 70 and my PSA reached 10 I think I'd certainly want >treatment, unless I were suffering from some other fatal disease. I've been having 3 monthly. I guess I'd go along with the PSA=10 or even less and may soon be persuaded to do so. >It would be a terrible mistake to read one of these studies and >conclude it's okay to skip treatment because I'll be alive 15 years >from now and don't expect to live longer. That is waiting without >watchfulness. It would mean that if you are in the low probability >high-risk group you won't find out until it's too late. Well I think that's why WW has been largely superceded in the UK by active surveillance. > Alan Call me crazy, but how do they know for sure if the Gleason Score is a 6 or higher? From a biopsy? I think to assume that a biopsy can accurately predict actual pathology Gleason Scores, you are really rolling the dice. Taking a biopsy as fact of actual Gleason grade, and basing to treatment or not to treat on those biopsy results alone is risky business. B.A. Interesting study. Unfortunately it has been reported that many gleason scores are understated. Irrespective of this study, I think it will be very difficult for men in their 50's to put off treatment. I was in in the below age of 60 over gleason 7 group...so the decision was a bit easer. I opted for aggressive treatment, even though the odds for a cure were quite low. However, having gone through chemo, RRP, radiation and a few cycles of Lupron/casodex, I do wonder if I'd be in the same spot with hormonal treatment alone. But there is no looking back on these types of decisions. Robert > There's a provocative study in the British Journal of Cancer, April 2006. > See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 70 lines] > > Alex > having gone through chemo, RRP, radiation > and a few cycles of Lupron/casodex, I do wonder if I'd be in the same spot > with hormonal treatment alone. But there is no looking back on these types > of decisions. Maybe that's a strong incentive for ADT, if appropriate, simply because we CAN usually "look back on it", i.e., try it and walk away if it's unacceptable. Try THAT with anything else besides WW. I.P. I'd agree except ADT does not offer a cure...just a delay. In a small percentage of high gleason cancers, RRP and Radiation do result in a cure. As long as one understands this and what the side effects are, it is a reasoned, if not reasonable, decision. Of course one with cancer usually will gravitate towards a potential cure even when the odds for success are quite low. A bit of a conundrum... Robert >> having gone through chemo, RRP, radiation and a few cycles of >> Lupron/casodex, I do wonder if I'd be in the same spot with hormonal [quoted text clipped - 6 lines] > > I.P. > I'd agree except ADT does not offer a cure...just a delay. In a small > percentage of high gleason cancers, RRP and Radiation do result in a cure. > As long as one understands this and what the side effects are, it is a > reasoned, if not reasonable, decision. Of course one with cancer usually > will gravitate towards a potential cure even when the odds for success are > quite low. You're right, of course. I hadn't even considered that he meant "ADT alone" as a SOLE tx. I assumed he meant "alone after initial tx failed". I.P. > Unfortunately it has been reported that many gleason scores are > understated. Assuming assessment of cores is consistent throughout (which, of course, it is not), when you poke a prostate with 6, 8, 12, 20 needles, you're going to end up with only a percentage of the prostate tested. One or two cores might show cancer and that cancer might show a Gleason of, say, 7. However, when they get the whole thing on a lab table, they might find that the needles did not go through higher Gleason cancer just millimeters away. Usually, they've only missed cancer one level higher. Sometimes, it's only a 3+4 turning into a 4+3. But, obviously, it can go much higher with really unlucky needle vs cancer placement. Based on this, Gleason can always go up, but should not go down. 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, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum There is also the consistency of pathologists who evaluate Prostate Cancer. I've read (sorry I don't have the source) that many pathologists undergrade PCA and that it is recommended that a 2nd evaluation be done by a pathologist in a cancer treatment center who sees a lot of PCa. This happened to me... I originally was diagnosed with a Gleason 7 cancer, but after review by a pathologist at Mass General Hospital this was changed to an 8. >> Unfortunately it has been reported that many gleason scores are >> understated. [quoted text clipped - 11 lines] > > Based on this, Gleason can always go up, but should not go down. > happened to me... I originally was diagnosed with a Gleason 7 cancer, but > after review by a pathologist at Mass General Hospital this was changed to > an 8. Us too. Our original Gleason was a 4+3(7) from Mayo Clinic, 2nd opinion 3+4(7) from Oppenheimer Labs, and the total % was <1% in one core, <5% in another core, with 8 cores free of cancer or any concerns. The pathological staging after RP was G9, with extensive cancer throughout the prostate and extracapsular. I can't recall if it was 4+5 or 5+4, because as far as I'm concerned, there's no essential difference. I may be wrong, but I see Gleason scores as equivalent to earthquake measurements--the danger increases exponentially, so there is a world of difference between a 6 and a 7. By the time you get up into 9s, so what. The mountain is shook apart. Continental shelves have collapsed. Geologic plates have splintered. If we had another prostate, and had to go through this again, I wouldn't hang so much hope on a biopsy being accurate. > The pathological staging after RP was G9, with extensive cancer > throughout the prostate and extracapsular. I can't recall if it was [quoted text clipped - 4 lines] > into 9s, so what. The mountain is shook apart. Continental shelves > have collapsed. Geologic plates have splintered. You oringinally reported 4+5, if that is of any help. But I agree that the difference is that Steve is standing on a shelf with three toes and if it were 5+4, he'd only be supported by two. But, don't get too discouraged. They seem to be building a tower at the bottom of the crevice and it's coming up to his level seemingly faster than what we originally estimated. 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, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum > By the time you get up > into 9s, so what. The mountain is shook apart. Continental shelves > have collapsed. Geologic plates have splintered. Has anyone seen any data differentiating 8s from 9s from 10s? For now I'm assuming 8 isn't as bad as its "8-10 club" cohorts as long as it's based on 4+4s, not 5+3s. I.P. I was diagnosed "over detected" in the words of the paper) via PSA+biopsy at age 47. I opted for RRP. Left untreated, I might very well have lived for another 15 years (to age 62). At age 62, my father was diagnosed (by manifest symptoms) with PCa. Roughly two very unpleasant years years later he was dead from it. Assuming I followed in my father's footsteps, I would have validated the "no value in treatment" hypothesis of the paper's authors by surviving initial diagnosis for 15 years without treatment. I'd still have died unpleasantly in my early 60's though. Studies like this never mention this sort of thing. Caveat emptor. Oh, and I am having *extreme* difficulty believing that ~0% of the men in the "young" age group died of PCa within 15 years of dx, given the gross inaccuracy of biopsy plus Gleason grading by randomly selected pathologists. SignaturePeter Headland >I was diagnosed "over detected" in the words of the paper) via >PSA+biopsy at age 47. I opted for RRP. Left untreated, I might very [quoted text clipped - 6 lines] >surviving initial diagnosis for 15 years without treatment. I'd still >have died unpleasantly in my early 60's though. Maybe, but why do you cast that as a certainty? >Studies like this never mention this sort of thing. Caveat emptor. Studies like this are like most studies; general surveys and statistics. A study which included the dreadful details of your father's death would need also to include for balance the serendipity of those who did nothing and died of something other than PCa. >Oh, and I am having *extreme* difficulty believing that ~0% of the men >in the "young" age group died of PCa within 15 years of dx, given the >gross inaccuracy of biopsy plus Gleason grading by randomly selected >pathologists. > why do you cast that as a certainty? I don't. Note that I used the word "assuming". I was explaining why the terms of the study don't tell the whole story and using two real world cases to show different outcomes resulting from treatment. Do you disagree with my comments? SignaturePeter Headland >> why do you cast that as a certainty? > [quoted text clipped - 3 lines] >and using two real world cases to show different outcomes resulting >from treatment. Do you disagree with my comments? Sorry, I'd overlooked your 'assuming'. Yes, I think I do disagree but maybe I've misunderstood. From my viewpoint this is a survey structured much like any other, providing summary results and expressed in the language of probability. The individual seeking to establish a strategy for himself can only do so on the basis of averages and trend. Isn't that true? Could you give me some idea of how you feel the study might have been modified (or alternatively presented) to accommodate your two different outcomes in a way which would be meaningful for those trying to make sense of it? From what I can see, your father's case would be counted, for example, in a survey like the Scandinavian study where dx was made on the basis of clinical symptoms. Your own results, and mine, would figure, typically, in the Marsden study (or another study like it) some way down the line since your dx, like mine, was based on screening. The two surveys represent two different stories based on clinical and screen detected dx respectively. > The individual seeking to establish a strategy for himself > can only do so on the basis of averages and trend. That was my point - you have to understand the limitations of a study like this. On the face of it, it seems to say "don't bother to treat your PCa if it is <=G6". My illustration was meant to show how that might not be smart for some men. I don't think it would have been smart for me to leave my cancer untreated once detected, because I could have died unpleasantly of PCa after, let's say, another 17 years without in any way contradicting the findings of the study. Of course, maybe I could have waited for 10 years before getting treatment - there's no way to know. Fortunately I am continent and ED is slowly diminishing, so I don't have much to regret. Indeed, it's arguable that early treatment reduces the risk of ED (younger men heal better, and there's lower chance of nerve involvement early on). I don't trust the NHS on these matters - they are far too biased towards saving money. Poor cancer outcomes in the UK relative to many other countries (France does much better, despite also being a social healthcare system) was one of the reasons I moved to the USA 5.5 years ago. Both my parents died of cancer, so I didn't like my odds (still waiting for my mother's colon cancer genes to get me - I have already outlived her). As things worked out, I think moving over here counts as one of the few really smart decisions I have ever made. SignaturePeter Headland >> The individual seeking to establish a strategy for himself >> can only do so on the basis of averages and trend. > >That was my point - you have to understand the limitations of a study >like this. What other kind of study could there possibly be? >On the face of it, it seems to say "don't bother to treat >your PCa if it is <=G6". Yes. But 'don't bother' is emotive and inaccurate. It's your personal bias. >My illustration was meant to show how that >might not be smart for some men. I don't think it would have been smart >for me to leave my cancer untreated once detected, because I could have >died unpleasantly of PCa after, let's say, another 17 years without in >any way contradicting the findings of the study. The Marsden team advocate AS, with PSA monitoring and biopsies when PSA velocity or absolute value suggest it. If you'd remained at gl6 for 17 years then, yes, there would be no intervention (unless you wanted it!). If you reach gl7 - you're advised (subject to the usual age/morbidity criteria) to intervene. The key result from the research is that patients at gleason 6 have very good prospects. >Of course, maybe I could have waited for 10 years before getting >treatment - there's no way to know. Fortunately I am continent and ED >is slowly diminishing, so I don't have much to regret. Indeed, it's >arguable that early treatment reduces the risk of ED (younger men heal >better, and there's lower chance of nerve involvement early on). It's good that things have worked out as you would want them. >I don't trust the NHS on these matters - they are far too biased >towards saving money. How did it save money? You can (as it appears you have) choose to ignore or mistrust the results. You can still elect to have all or any of the treatments that were available before the published results at the NHS's expense. In fact the whole project clearly produced a net deficit to the NHS. The study will have cost money. >Poor cancer outcomes in the UK relative to many >other countries (France does much better, despite also being a social [quoted text clipped - 3 lines] >outlived her). As things worked out, I think moving over here counts as >one of the few really smart decisions I have ever made. > >That was my point - you have to understand the limitations of a study > >like this. > > What other kind of study could there possibly be? You know that, I know that, but not every man reading this newsgroup will understand it. That is why I posted a counterpoint for the benefit of such men who may well draw the "emotive and inaccurate" conclusion. > >On the face of it, it seems to say "don't bother to treat > >your PCa if it is <=G6". > > Yes. But 'don't bother' is emotive and inaccurate. It's your personal > bias. I really, really hate it when people presume to know what my "personal bias" is based on a few words in a newsgroup posting. If you think through the point I was trying to make, you will see that obviously I personally don't think that is what the study says. As I said, I think it is how some people who may read this news group may take it and I felt it worthwhile to place the study in context for the benefit of such people. That's what we're all here for - to help oters interpret information and make their own decisions. > The Marsden team advocate AS, with PSA monitoring and biopsies when > PSA velocity or absolute value suggest it. That's fine. I am not questioning your choice of action. The study data were not from men who followed such an active regime, though, so I don't see why you bring that up in this context. BTW, I don't know why you say that Watchful Waiting is not the same thing as Active Surveillance? > The key result from the > research is that patients at gleason 6 have very good prospects. That just doesn't seem to tie in with other studies. For example, a very recent post to this group showed that states that have legislation promoting aggressive PCa screening and treatment have better survival rates than those that do not. > >Of course, maybe I could have waited for 10 years before getting > >treatment - there's no way to know. Fortunately I am continent and ED [quoted text clipped - 3 lines] > > It's good that things have worked out as you would want them. Indeed. That doesn't mean I think everyone should do what I did. At diagnosis I hoped to live at least another 33 years (to age 80); I think the chances were very high that I would have needed treatment for PCa at some time during that 33+ years. The trade-off then became waiting for disease progression to make treatment more urgent and thus gaining more guaranteed SE-free years, or maximising my chances of preventing metastases at the potential cost of more years of SEs. Given my age and health, plus access to one of the world's best specialists, the risks from surgery were really quite low. I also believed that my father's case history was relevant; it is very likely that he had similar disease stage to me when he was 47, so it is not that big a stretch to think that I might well have experienced the same progression (this is, I know speculation, but since PCa has an inherited genetic element, one might reasonably hypothesise that it's progression may also be inherited - I'd be interested to know of any studies on that). > >I don't trust the NHS on these matters - they are far too biased > >towards saving money. > > How did it save money? I don't much trust studies comissioned by the NHS in the same way as I don't much trust studies comissioned by drug companies or makers of medical equipment. The NHS has a strong incentive to "prove" that cheap or no treatment is just as good as expensive treatment just as much as the commercial enterprises have an interest in proving that their expensive product is far better. A study that allows them to persuade men with G6 PCa that they don't need tretament obviously saves them treatment costs (especially since I strongly doubt those men will all get the adirable level of monitoring you are receiving). > You can (as it appears you have) choose to > ignore or mistrust the results. As I have stated, I have some reservations about the results. Only a fool "trusts" the results of any individual study of this kind. Since I have no decision to make there's no question of "ignoring" or otherwise. > You can still elect to have all or > any of the treatments that were available before the published results > at the NHS's expense. Obviously not since: 1. I have no prostate. 2. I am not an NHS patient. But I know you meant "one can". :-) > In fact the whole project clearly produced a > net deficit to the NHS. Not if they use it to justify continuing their shameful policy of discouraging PSA testing or they use it to discourage men with alleged G6 disease (see comments elsewhere on the inaccuracy of biopsy analysis) from getting treatment. If I still lived in the UK, I would be undiagnosed right now due to NHS policy on PSA testing. I only got my PSA tested because I live in a part of the USA where, given my family history, my GP (primary care physician) told me I should get tested. In the UK, I would have had no chance of AS or anything else (being undiagnosed in the first place). Just a little time bomb waiting to go off. That's what happened to my father and look where it got him. The one thing I think we should all be able to agree on is that early (no later than age 40; I suspect 35 would be better) PSA screening and PSAV tracking for all men would be just as valuable as breast cancer screening. No-one should ever die young from PCa, yet men who develop it young are at high risk because they are not screened early enough if at all (RIP Curt). SignaturePeter Headland >> >That was my point - you have to understand the limitations of a study >> >like this. [quoted text clipped - 4 lines] >will understand it. That is why I posted a counterpoint for the benefit >of such men who may well draw the "emotive and inaccurate" conclusion. So far, I've seen nothing in this thread that suggests the "emotive and inaccurate" conclusion is anything but uniquely yours. >> >On the face of it, it seems to say "don't bother to treat >> >your PCa if it is <=G6". [quoted text clipped - 4 lines] >I really, really hate it when people presume to know what my "personal >bias" is based on a few words in a newsgroup posting. Yes there's so much to hate in this world isn't there? Not only do I not know what your personal bias might be vis-a-vis your broader "attitude to all things" - I'm not even interested in it. I refer specifically to your use of the term "don't bother" in the context of the report. It's emotive and inaccurate. The bias screams from what follows. >If you think >through the point I was trying to make, you will see that obviously I [quoted text clipped - 3 lines] >such people. That's what we're all here for - to help oters interpret >information and make their own decisions. I can only tell you again you've introduced a slant which is transparently false and implies - even if you didn't mean it to do so - a cavalier attitude on the part of the research project which it doesn't deserve. Far from clarifying anything you've muddied it. >> The Marsden team advocate AS, with PSA monitoring and biopsies when >> PSA velocity or absolute value suggest it. > >That's fine. I am not questioning your choice of action. I'm not discussing my choice of action. I'm discussing, or trying to, the report and it's ramifications, as I've understood them. > The study data >were not from men who followed such an active regime, though, so I >don't see why you bring that up in this context. Because the report is aimed at helping those diagnosed to make a decision based on today's strategy. If the figures contained in this report reflect a laissez-faire approach post-dx then clearly the results when combined with a regime of AS will be even better. >BTW, I don't know why you say that Watchful Waiting is not the same >thing as Active Surveillance? Because they are not the same. A google search should clear that up. >> The key result from the >> research is that patients at gleason 6 have very good prospects. > >That just doesn't seem to tie in with other studies. It doesn't seem to? Or you don't want it to? > For example, a >very recent post to this group showed that states that have legislation >promoting aggressive PCa screening and treatment have better survival >rates than those that do not. Have you any details? A link? >> >Of course, maybe I could have waited for 10 years before getting >> >treatment - there's no way to know. Fortunately I am continent and ED [quoted text clipped - 35 lines] >treatment costs (especially since I strongly doubt those men will all >get the adirable level of monitoring you are receiving). You're suggesting orruption of data or methods? You're in cloud cuckoo land. >> You can (as it appears you have) choose to >> ignore or mistrust the results. [quoted text clipped - 3 lines] >have no decision to make there's no question of "ignoring" or >otherwise. But clearly there is a question of mistrust. You say "only a fool trusts" ergo you're either that fool or you mistrust. Why mince words? >> You can still elect to have all or >> any of the treatments that were available before the published results >> at the NHS's expense. >Obviously not since: > [quoted text clipped - 3 lines] > >But I know you meant "one can". :-) I beg your pardon, I hadn't realised you were a pedant :-) >> In fact the whole project clearly produced a >> net deficit to the NHS. [quoted text clipped - 3 lines] >G6 disease (see comments elsewhere on the inaccuracy of biopsy >analysis) from getting treatment. That is a travesty. >If I still lived in the UK, I would be undiagnosed right now due to NHS >policy on PSA testing. I only got my PSA tested because I live in a [quoted text clipped - 3 lines] >Just a little time bomb waiting to go off. That's what happened to my >father and look where it got him. In 1992 my father had an RP but died in any case 6 years later of a stroke. Naturally his PCa put me on an alert and I have been tested till my ears burst in every conceivable way and under the auspices of the NHS. I can only assume you are bent on continuing to spin a fiction. >The one thing I think we should all be able to agree on is that early >(no later than age 40; I suspect 35 would be better) PSA screening and >PSAV tracking for all men would be just as valuable as breast cancer >screening. No-one should ever die young from PCa, yet men who develop >it young are at high risk because they are not screened early enough if >at all (RIP Curt). Oh dear. You seem determined to engage in an aggressive argument with me; your comments are becoming increasingly personal. I decline to participate so I hereby agree that I am a worthless worm and fool and you are absolutely right about everything. I'd still like to know what the differences between Watchful waiting and Active Surveillance are, though. If you don't want to explain, just don't reply at all - I don't need any more of your aggression, thanks. SignaturePeter Headland (apologies if any of my messages appear twice - I think I'm having server problems) >Oh dear. You seem determined to engage in an aggressive argument with >me; your comments are becoming increasingly personal. I decline to >participate so I hereby agree that I am a worthless worm and fool and >you are absolutely right about everything. Of course not. But I don't think I can single handedly take the credit for raising the temperature.. >I'd still like to know what the differences between Watchful waiting >and Active Surveillance are, though. If you don't want to explain, just >don't reply at all - I don't need any more of your aggression, thanks. for something like this I would use "watchful waiting vs active surveillance" in the search field since 'vs' begs the result. It gives you, for example:- http://psa-rising.com/med/ww/05.html > I don't think I can single handedly take the > credit for raising the temperature. Please point out anywhere that I questioned your motives or decisions, suggested you were a fool, accused you of bias, distortion or lies, or in any other way insulted you personally. I don't think you will find any aggressive or confrontational language in any of my posts either. If disagreeing with you constitutes raising the temperature, then I suppose I must plead guilty, but otherwise, I think you are being unfair. OK, I must admit that some people just find me irritating without being able to point to anything specific, but I choose to believe that is their problem. :-) >> differences between Watchful waiting and Active Surveillance > http://psa-rising.com/med/ww/05.html Well, at the risk of drawing your wrath upon me yet again, what I see there and in related links is the Royal Marsden people creating a specific rather narrow definition of WW precisely in order to differentiate it from the protocol they have dubbed AS. I found other links that treat the two terms as synonymous, so I don't think we can say that the RM's definition of WW goes unquestioned. Semantic quibbling aside, the RM monitoring protocol is clearly right up there at the very best end of what anyone who is not going for immediate treatment should expect and I am sure some of those who claim they are providing WW do fall short of that, so the new name "Active Surveillance" does seem like a good idea for a variety of reasons. I object to the RM's assertion that WW did not involve transition to aggressive treatment in the face of evidence of disease progression. I accept that that may have been the case in some places, but I think it is an insult to many urologists to suggest that they were all so cavalier. I am afraid some of the RM statements to the press about AS (if accurately quoted) came across as rather too much like marketing spiel for my tastes, but I will put that down to natural evangelism of what they clearly believe will revolutionise PCa management. The problem I have with this whole field is that there are so many voices all claiming to have the best way to manage PCa. Surgeons recommend surgery, oncologists recommend radiation, a few recommend a special hormone regime, RM recommends AS. They all cite studies that "prove" what they say. Any one of them may be right, but none of us truly knows which. If I were still in the UK, I would have been very reluctant to have RRP (because I have yet to see any evidence that RRP is done well by anyone in the UK). But I don't know if I would have the nerve to go with the RM's protocol - I really wanted to "cut it out and be done with it". Having seen at close quarters what the end-game is like, I can't imagine I would have dealt well psychologically with living with the disease untreated. Of course, living where we used to (rural north Staffordshire), I likely wouldn't have gotten a referral to the RM's progam anyhow. If I understand you correctly, you requested PSA testing and easily overcame the "first read this leaflet" hurdle? When I said I would be undiagnosed today, it is not because I believed I would have been refused PSA testing, just that I wouldn't have known to ask for it in the first place, and my doctor (if she followed what I understand to be NHS policy) would not have suggested it. When I say the NHS discourages PSA testing, I mean that they do not recommend it for screening purposes and they make patients who request it do a mini-counseling thing (don't know whether GP's do that verbally or just hand over a leaflet) which tells them that it may not be worthwhile to get tested (which I think is highly questionable advice based upon misinterpreted data). Contrast that with the aggressive promotion of pap smears and breast cancer testing (about which many reservations might also be expressed, BTW). Of course the NHS may have changed its ways since I last looked into this. As previously noted, I think every man should be routinely screened from age 40 (I'd actually prefer 35). I don't mean annually - 5 year intervals watching PSAV seems like the best protocol in younger men. Done in bulk it would be cheap. Until the NHS starts doing that, I will continue to criticise it. Actually, I'd also like to see all cancer survival rates in the UK greatly improved - at present they are scandalously low compared to what has been demonstrated elsewhere to be possible elsewhere. -- Peter Headland > I don't think I can single handedly take the > credit for raising the temperature IP's comments got me to wondering whether you took my comments to the effect that "only a fool trusts any single study" as accusing you of being a fool. They were not intended that way. I believe that your PCa management decisions were made after careful consideration and consultation and were based on a great many factors. So far as I know you were not even aware of the study we are discussing when you made those decisions, but even if you were, I doubt you would have made that single study the sole basis of your decision. There is a difference between throwing all your trust in a single study (foolish) and taking a study into account as part of a broader decision-making process. Despite my reservations, I should be delighted if the study were 100% correct in it's evaluation. Since my Gleason score was 6, I was extremely unlikely to die of PCa in the next 15 years, PLUS I had the bugger cut out, which must further lower my already low risk. My glass is always resolutely half full in these situations. SignaturePeter Headland >> I don't think I can single handedly take the >> credit for raising the temperature > >IP's comments got me to wondering whether you took my comments to the >effect that "only a fool trusts any single study" as accusing you of >being a fool. Not at all - as mentioned in my reply to IP it was the *trust* issue I was concerned with and since you categorically refused to be drawn on whether you trusted the study or not, and yet were happy to assert "only a fool trusts" (I took that to be a generality anyway) I presented you with your own petard, i.e. if you were not a fool then you must by implication 'not trust'. It was the only way to pin you down. > They were not intended that way. I believe that your PCa >management decisions were made after careful consideration and [quoted text clipped - 4 lines] >between throwing all your trust in a single study (foolish) and taking >a study into account as part of a broader decision-making process. I think we can move on from the 'fool' business, clearly neither of us is one. A new study might conceivably supercede if it takes into account new unconsidered factors. But it surely goes without saying that it's wise to look at all the angles. >Despite my reservations, I should be delighted if the study were 100% >correct in it's evaluation. Since my Gleason score was 6, I was >extremely unlikely to die of PCa in the next 15 years, PLUS I had the >bugger cut out, which must further lower my already low risk. My glass >is always resolutely half full in these situations. > it's wise to look at all the angles. and wiser still not to bet our life on any one of them. I agree Peter sounds overly paranoid about the NHS (or any study source with any reason for bias), but I also agree that 0% is tough to believe, especially given the gross distortions, hasty assumptions, and broad categorizations in the "cause of death" blank on death certificates. I.P. > (apologies if any of my messages appear twice - I think I'm having > server problems) [quoted text clipped - 15 lines] > > http://psa-rising.com/med/ww/05.html Or one could just look at http://www.prostatecancerwatchfulwaiting.co.za/RM.html , which confirms that this is not only semantics, not even general Britspeak, but one dang hospital's own semantics. i.e., One UK hospital decided to declare the WW term passe and use AS to mean what the rest of the world calls WW. i.e., close PSA monitoring but no tx . . . yet. Of course, US sources still use the WW term quite freely, to mean close PSA monitoring but no tx . . . yet. Jeez, guys. We're talking about bonnets vs hoods, loos vs bathrooms, WCs vs toilets, tires vs tyres here. I.P. > Jeez, guys. We're talking about bonnets vs hoods, loos vs bathrooms, WCs > vs toilets, tires vs tyres here. > > I.P. Get the torch, I need to find the flashlight. > The bias screams from [Peter's] >> If you think >> through the point I was trying to make, you will see that obviously I [quoted text clipped - 3 lines] >> such people. That's what we're all here for - to help oters interpret >> information and make their own decisions. 1. I've read it several times and see zero indication of bias. Its only declarative statements are: A. I don't think the study says . . . B. Some people may take it [this way] C. . . . worthwhile to put it in perspective D. We're here to help others . . . 2. Who DOESN'T have biases? At least he states his openly in >> I don't trust the NHS on these matters - they are far too biased >> towards saving money. >> I don't know why you say that Watchful Waiting is not the same >> thing as Active Surveillance? [sez Peter] > Because they are not the same [sez rosbif] >> I'd still like to know what the differences between Watchful waiting >> and Active Surveillance are. Oh, Peter . . . several differences are SO obvious: WW contains 15 letters, AS contains 18. AS would come first in a dictionary. WW is more common in the literature -- because it has existed far longer. Maybe "watch" comes from Greek roots, "Surveil" from Latin. AS is the more proactive-sounding term. Besides, rosbif used the terms interchangeably himself: > I've had a one-off consultation to reflect on the wisdom of > continued WW. [my doc] had me collect my PSA data over the > last 2 years to establish PSAV . . . I'm booked to see him > once more, after his hospital has reviewed my 2 biopsies , > before returning to my usual coterie of local consultants. Isn't that AS, even though rosbif calls it WW? >> For example, a >> very recent post to this group showed that states that have legislation >> promoting aggressive PCa screening and treatment have better survival >> rates than those that do not. > > Have you any details? A link? Today's newspapers. >> I don't much trust studies commissioned by drug companies or makers of >> medical equipment. > You're suggesting corruption of data or methods? You're in cloud > cuckoo land. How about how a study's questions/objectives are phrased? These two hypotheses differ by night and day: "Does our new uber-drug repel pink elephants?" vs "How many PC pink elephants do people on our uber-drug see?" As for whether a corporation or researcher might corrupt data or methods for personal gain: ***D***U***H!!!***; see the headlines. >> As I have stated, I have some reservations about the results. Only a >> fool "trusts" the results of any individual study of this kind. Since I [quoted text clipped - 4 lines] > You say "only a fool trusts" ergo you're either that fool or you > mistrust. Why mince words? OK, maybe Peter should have said "gullible person" rather than "fool". BFD. > 'don't bother' [with tx for G<6] is emotive and inaccurate. > It's [Peter's] personal bias. All I read into that "don't bother" phraseology is a rephrasing of the study's finding: "for men under 60 with a Gleason score under 7, there is almost no risk of dying from prostate cancer during the following 15 years, so radical treatment would add zero years of life expectancy. For men under 75 with low Gleasons, the mortality risk from PCa is only 2%. If the study is correct, these men have to balance a very small potential gain against the high probability of quality-of-life side effects from aggressive treatment." Presented alone, Peter's "don't bother" would be inaccurate and misleading. But since the original study results were presented and discussed here for all to see, the purposes of saying "don't bother" struck me as brevity plus a little extra insight, not bias, in light of his stated assumption about his father's history. Folks, this whole PC world is fuzzy studies, not rocket science. Decimal points MATTER in the latter, but not in the former. Similarly, one trial can validate the latter (e.g., the first moon landing validated the physics and math), but not the former. Anyone who gets all het up over one freaking study is a fool . . . er, rather, is investing too much capital in a first-order approximation of fuzzy studies. I.P. >> The bias screams from [Peter's] In fact, IP, I typed >>The bias screams from what follows the "what follows" refers to the whole post, not the following paragraph which of course is harmless. I read the whole post before replying. (So please jump to.... >>> If you think >>> through the point I was trying to make, you will see that obviously I [quoted text clipped - 5 lines] > >1. I've read it several times and see zero indication of bias.= > Its only >declarative statements are: >A. I don't think the study says . . . >B. Some people may take it [this way] >C. . . . worthwhile to put it in perspective >D. We're here to help others . . . ....here) >2. Who DOESN'T have biases? At least he states his openly in > >> I don't trust the NHS on these matters - they are far too biased > >> towards saving money. (Which incidentally is neither interesting nor an indictment - it's a truism for any publicly funded agency which is enslaved to 'infinite' demand) Peter's bias is peppered here and there through the thread but when it's highlighted he's not happy.....he says:- >I really, really hate it when people presume to know what my "personal >bias" is based on a few words in a newsgroup posting - which so burns with righteous indignation as to effectively prime the reader into expecting unalloyed, determined neutrality. ...(and so on and so on..) >>> For example, a >>> very recent post to this group showed that states that have legislation [quoted text clipped - 4 lines] > >Today's newspapers. Yes, but you've clipped precisely the sentence which prompted my question. Here it is again:- [rosbif] >> The key result from the >> research is that patients at gleason 6 have very good prospects. [Peter] >That just doesn't seem to tie in with other studies. And you've chimed in with 'Today's newspapers'. We don't get your newspapers here so could you tell me what exactly the newspaper says which refutes (my rather simplistic summary of the report's gl6 data) "patients at gleason 6 have very good prospects" >>> I don't much trust studies commissioned by drug companies or makers of >>> medical equipment. [quoted text clipped - 7 lines] >see?" As for whether a corporation or researcher might corrupt data or >methods for personal gain: ***D***U***H!!!***; see the headlines. A corporation maybe. A publicly funded accountable body - very rarely - the political reverberations would be horrendous. An in-house Marsden report from a non-profit making 100% academic team - forget it. But I'd be interested in anything you have. Did you spot anything in the language of the report which might have raised an alarm, something ambigous? It seemed very simple to me and with not even the tiniest gap left for guile. But this is a central point since Peter has tried to generally undermine the veracity of NHS commissioned research. If anyone is seriously suggesting it was rigged, what would be the mechanism and how might it percolate through the research hierarchy, in one direction as command, the other as reward. A nod and a wink? Brown envelopes stuffed with currency? Mass promotion for everyone on board? It's ridiculous, the food of half-witted crazed delusionals rotting in various consipiracy fora. (Peter - I'd appreciate it if you could offer ANY examples of recent NHS commissioned research that have left you feeling uneasy. Just one would be a start. Just one.) >>> As I have stated, I have some reservations about the results. Only a >>> fool "trusts" the results of any individual study of this kind. Since I [quoted text clipped - 6 lines] > >OK, maybe Peter should have said "gullible person" rather than "fool". BFD. Well thank you for sweetening that for me, but who gives a duck's tit whether its a fool, a dupe, Mr Bamboozled,....It's the *TRUST* issue that matters here, not the dignity of the reader. Is the report to be TRUSTED or NOT. Is it authoritative? The answer to that question will hold good whether the scrutineer is Einstein or an earth-worm. > > 'don't bother' [with tx for G<6] is emotive and inaccurate. > > It's [Peter's] personal bias. [quoted text clipped - 14 lines] >struck me as brevity plus a little extra insight, not bias, in light of >his stated assumption about his father's history. No, I don't accept that. The nuance in "don't bother" is palpably discrediting to the report. But it's academic because "don't bother", frankly, is a new-born lamb to the sheep that would warrant a hanging. (later) >Folks, this whole PC world is fuzzy studies, not rocket science. Decimal >points MATTER in the latter, but not in the former. Similarly, one trial [quoted text clipped - 4 lines] > >I.P. quote:- "For example, for men aged 55-59 years at diagnosis, the projected 15-year prostate cancer mortality is 0%" Now that's just the whole point. 0% IS NOT FUZZY!!! And that is why the report needs to be taken seriously and checked against other data before being summarily ruled out!!! But here's what Peter really thinks and what took him a little time to confess:- >I don't much trust studies comissioned by the NHS in the same way as I >don't much trust studies comissioned by drug companies or makers of [quoted text clipped - 5 lines] >treatment costs (especially since I strongly doubt those men will all >get the adirable level of monitoring you are receiving). and then >Not if they use it (the study - ed) to justify continuing their shameful policy of >discouraging PSA testing or they use it to discourage men with alleged >G6 disease (see comments elsewhere on the inaccuracy of biopsy >analysis) from getting treatment. That is truly awful! It IS a travesty. Peter starts out by appearing doubting but reasonable, using fair but challenging language, talking about balance and then ends up with a full-scale trashing based on naive conspiracy theory. I await his account of any previous NHS skullduggery. How many gl6's will read Peter's interpretation and, like Doug Taylor's colleague, already nervous, run straight into possibly unnecessary Tx. Purrrleeese!!!. >>> The bias screams from [Peter's] > [quoted text clipped - 193 lines] > > Purrrleeese!!!. Is there like a CliffsNotes or Joe Six pack version of this post for the us in the attention deficient crowd? MikeinTexas Yup - RosBif is a patient of the folks at the Royal Marsden in the UK. Those folks co-authored a study (to show how dumb I am, I didn't realise the RM people were involved in that study until this morning). Some of us questioned various aspects of the study in various ways. Since then RosBif has become increasingly aggressive in defence of this study. He has never troubled to do that in respect of the numerous other studies that have been discussed and criticised here, but I would not dream of accusing him of bias, so you have to join the dots for yourself. SignaturePeter Headland >Yup - RosBif is a patient of the folks at the Royal Marsden in the UK. >Those folks co-authored a study (to show how dumb I am, I didn't [quoted text clipped - 5 lines] >not dream of accusing him of bias, so you have to join the dots for >yourself. (I think you've joined the dots for him and, between the lines, accused me of bias.....so were quits) Don't forget, I'm a relative newcomer here so wouldn't have had an opportunity to chip in on earlier studies, but if a contribution need only consist in saying "I don't believe it", then it's not anything I'd bother with. Incidentally, I'm not in the RM group, but was allowed a couple of consultations and a recheck of my biopsies with their own pathology dept. > Is there like a CliffsNotes or Joe Six pack version of this post for the us > in the attention deficient crowd? A dude dissed the gum'mint (pick one) and approximated two paragraphs with two words. Another dude resented both actions. Other dudes tried to bridge the gap. The details aren't worth your time, 'cause they're not on the test. I.P. > There's a provocative study in the British Journal of Cancer, April 2006. > See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 45 lines] > caution, since the original data upon which it is based cannot necessarily > be assumed to be generalisable more widely." That caution has to be taken very seriously, and perhaps it gives the game away. First, 15 years in not a long enough period of time for younger men. For example, that just gets a 55 year old man to 70. Second, here is some advantage in avoiding advanced prostate cancer even if one doesn't die from it. It is an unpleasant disease, and the side effects of HT are considerable. That has to be balanced against the possible side effects of treatment. Third, in England, men are not routinely screend for prostate cancer, so cancers may be discovered later. Also, the study population may differ significantly in other characteristics from a corresponding US population. One would guess that the US men, being screened earlier, would be even less likely to die of prostate cancer within 15 years from diagnosis, but that might be misleading for unknown reasons. Having said that, I think it is fairly clear that signficant numbers of men with Gleason 6 cancers are being treated aggressively for early prostate cancer which, if left untreated, would never bother them. The trouble is that we have no good way today to distinguish between these relatively benign cancers and more serious ones. The latter remark emphasizes the fact that results from a population study may not be too helpful when a particular man has to decide what to do in his own case. Still, in the category of sliver linings, my Gleason was 7 = 3+4, which removed any doubt about whether or not treatment was justified at age 67. > With this caveat, the conclusion is attention-getting. For younger men with > Gleason scores under 7, there is zero benefit from surgery, etc., in terms [quoted text clipped - 18 lines] > > Alex > my Gleason was 7 = 3+4, which > removed any doubt about whether or not treatment was justified at age 67. I'm not sure that would remove doubts for me. I guess it would HELP, in that I'd probably have ED anyway and less to lose, but it would complicate the ADT gamble by increasing the likelihood that even short-term ADT evaluation could "stick" after we quit. And your 3+4 is on the cusp of a lot of data, so it could break either way -- with the happy-go-lucky sixes or the screwed 8-10s. Maybe there's something to be said for us 8's: some of our decisions become easier. But . . . will our 4+4s break with the 7s or the 8-10s? So . . . which way did your 3+4 @ 67 push you? It's not doubt-free to me. I.P. >That caution has to be taken very seriously, and perhaps it gives the >game away. > >First, 15 years in not a long enough period of time for younger men. >For example, that just gets a 55 year old man to 70. but risk doesn't jump to 100% on commencment of 71st year. Presumably 20 year survival data will be available in 5 years time > There's a provocative study in the British Journal of Cancer, April 2006. > See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 8 lines] > cancer appears strongly dependent on grade, particularly so for men who are > younger at diagnosis. --SNIP-- Verrrrrrry interesting. After all the nit-picking that could be done, all the decimal point debates are settled, and more modern techniques are accounted for, it could be argued that this expands to initial treatment the applicability of the oft-seen statement regarding adjuvant treatment: pick your treatment according to the SEs you are willing to risk, in accordance with your Gleason level. But doing so refutes the study we saw last week -- based on data from much the same era as this one -- that 1990's-style RT was worse than WW and RP is far superior to both. So once again we are confounded by apparently contradictory data, from about the same era, which we can resolve -- if at all -- only by far more extensive examination of all the data, methodology, and statistics. i.e, we still can't draw useful conclusions, only vague generalities, no matter how specific a study's conclusions SEEM to be. And I'll never stop wondering where our grading puts us G8 pts -- just above the G7 stats or way up there in the middle of the G8-G10 stats. We seem to be left with three basic choices: trust our oncs 98% and press on, spend literally thousands of hours -- which few treatments are likely to return for the more aggro cancers -- doing our own research, or just pick everything based on SEs . . . presuming we can believe THAT research . . . then consider modifying our paradigm when aggressive clinical reoccurrence changes our priorities again. I.P. Why ignore the natural course of untreated prostate cancer? It has been almost ten years since this data was published in Sweden. Age and tumor grade (differentiation) had a significant impact in prostate cancer mortality. RalphV Abstract follows: In a retrospective study 6890 patients with prostate cancer from the North Swedish Cancer Register were analyzed according to cancer specific survival. Prostate cancer mortality was 40% in patients with well differentiated cancers, 54% in patients with moderate differentiated prostate cancer and 72% in men with low differentiated prostate cancer. Prostate cancer mortality was 80% in men younger than 60 years, 63% in men 60-69 years old, 53% in men 70-79 years old and 49% in men older than 80 years. Source: Damber JE, Gronberg H.[Mortality due to prostatic carcinoma in northern Sweden] Urologe A. 1996 Nov;35(6):443-5 PMID: 9064879 [PubMed - indexed for MEDLINE] > There's a provocative study in the British Journal of Cancer, April 2006. > See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 7 lines] > The study concluded that "the probability of 15-year mortality from prostate > cancer appears strongly dependent on grade, particularly so for men who are If I get it surgically removed at 55, I have a pretty good chance of a cure for as long as I may live. If I don't, I have a pretty good chance of it eventually spreading and not having any chance for a cure at all. Seems like a crystal clear choice to me. The only other consideration is if you think they'll come up with a non surgical cure in the next 15 years. are you willing to roll those dice is the real question. -- JK Sinrod www.sinrodstudios.com www.MyConeyIslandMemories >> There's a provocative study in the British Journal of Cancer, April 2006. >> See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html [quoted text clipped - 16 lines] >it eventually spreading and not having any chance for a cure at all. Seems >like a crystal clear choice to me. Longevity+SEs vs reduced (possibly!) life span+no SEs. It'll be crystal for some, a dilemma for others. >The only other consideration is if you >think they'll come up with a non surgical cure in the next 15 years. are you >willing to roll those dice is the real question. >There's a provocative study in the British Journal of Cancer, April 2006. >See http://www.nature.com/bjc/journal/v94/n10/full/6603105a.html Great. I spent last week worrying about dying because I got treated with IMRT instead of RP. Now I can spend this week worrying that I should not have been treated at all, and blew my sex life for the rest of my life for nothing. WTF? Good thing there are worse things in life (such as my business partner with ALS and a colleague who died of pancreatic cancer last week) or a guy could get really depressed with all the conflicting opinions and advice about being diagnosed with and then whether, when and how to be treated for PCa. > Good thing there are worse things in life (such as my business partner > with ALS and a colleague who died of pancreatic cancer last week) My SIL was a top artist for the textile industry with top name customers in New York and Paris. She had a view of the United Nations outside her window. Then, she developed a tumor at the base of her brain, had surgery and radiation and re-started her career. Years later, the radiation started taking its toll. She developed Raynauds (resulting in problems with her fingers). She also was losing her short term memory. She took a tape recorder to business meetings. But, her fingers lost their ability to produce. She came home and deteriorated. Eventually, she showed symptoms of and has now been diagnosed with CREST (Calcinosis, Raynaud's, Esophugus, Schlerodactyly, and Telangiectasia), a combination of five diseases that leave her with partial memory loss, total incontinence, occasional mini-strokes, and an inability to draw, write, tie shoes or dress, potty and dress herself. She is now 43 years old, sitting in a nursing home, re |
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