 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / Diseases and Disorders / Prostate Cancer / August 2006The "PCa is slow growing" myth
While I rarely post these days, I scan the group regularly. What really annoys me, and has done for the 6 years (when I was 60) since I joined the "club" is the oft repeated comment, often reported as coming from medical practitioners that "PCa is slow growing ...". From this follows sometime inappropriate or ill-advised recommendations. Some PCa is slow growing, but that's not the case with all PCa. In my case I was never told this, but in 2000 books on PCa was full of such advice and suggestions about "watchful waiting". I said back then, and repeat now: waiting for what -- death? Because of the proliferation of this advice, I very nearly decided to wait for a while and see what developed. My biopsy revealed 3mm of Gleeson 3+3 in one of 12 cores. A very small percentage that probably confirmed the wisdom of waiting. Within in weeks I changed my mind and opted for RRP which was performed three months later. The post-op path confirmed the Gleeson, but added two worrying factors which contradicted the belief that all PCa is slow-growing. 1. The margins were clear, but one by significantly less than 1mm. That's too close to be comforting. 2. The overall assessment reported: Extensive PCa throughout the prostate. I know that biopsies are selective, but from minimal involvement to extensive involvement in 3 months?? That indicates either an incompetent biopsy (which I do not for a moment accept) or a PCa which grew a damn site faster that thought likely/possible. I know of a person whose biopsy indicate several positive cores, each with minimal degrees of PCa. Two weeks later he had his laproscopic surgery. Post-op path reported no clear margins with a real possibility of escape from the capsule. These are just 2 cases. I'm sure that there are many more instances where the post-op path reported on a surprisingly growth and spread of PCa. Regardless of the age of the patient, I believe that it is dangerous for medical practitioners to suggest to people that PCa is slow growing. It might even be incompetent or negligent to do so. Laproscopy must assault the body less than the RRP techniques, so there might now be less concerns about the effects on older men. Note to medical practitioners: explain the effects of PCa. Outline the possible treatments. Make your recommendstions and explain your reasonings, but do not raise what are often false hopes that waiting is a realistic form of treatment. Sorry for the rant, but it really burns me up to hear about men suffering needlessly. Ray Walsh Perth, Australia Here is an expert opinion on this issue: http://www.urology.jhu.edu/newsletter/newsletter.php?var=84.php&id=8 >While I rarely post these days, I scan the group regularly. What really >annoys me, and has done for the 6 years (when I was 60) since I joined the >"club" is the oft repeated comment, often reported as coming from medical >practitioners that "PCa is slow growing ...". From this follows sometime >inappropriate or ill-advised recommendations. Some PCa is slow growing, but >that's not the case with all PCa. >Ray Walsh >Perth, Australia > Here is an expert opinion on this issue: > > http://www.urology.jhu.edu/newsletter/newsletter.php?var=84.php&id=8 I remember seeing a doctor about a problem and worrying if it was cancer. She said she couldn't tell, she'd have to refer me to a specialist. Then she said, "Hmmm, let's see. Our specialist is really booked up right now. We can't get appointments for the next three months. I'll put you down for three months from now. But don't worry, this is a slow growing cancer. You'll be okay until then." It's that lack of urgency that is infuriating. You feel that you have a life threatening disease, but nobody but you is excited about it. You're put in line behind folks with runny noses and bruised elbows (or the urologic equivalents.) I have the greatest respect for Dr. Partin - a man whose scientific and statistical skills both far exceed mine. However, in spite of his conclusion that, on average, there are no ill effects from waiting for treatment, there must be some individuals for whom waiting is a mistake. Presumably there is one particular tumor cell that travels through the blood stream, attaches to some other site, and begins to grow and divide, and that must happen at one particular instant in time. There must be some patients for whom that instant in time falls between diagnosis and treatment. No one wants to be the guy to whom that happens. Alan >>Here is an expert opinion on this issue: >> [quoted text clipped - 25 lines] > There must be some patients for whom that instant in time > falls between diagnosis and treatment. What Partin says he did was to compare the results for men diagnosed between 1989 and 1994 and all treated by Patrick Walsh. He found no significant differences in long term cancer control rates for men who waited different times before treatment, varying from less than 2 months to over a year. What that means is that if there were differences, they were so small that they were hidden in the general noise. That doesn't mean that it doesn't sometimes happen that earlier treatment can make a difference. But it does mean that the likelihood of that happening is pretty low and that, probably, it isn't worth worrying about. Remember that you regularly ignore low risk possibilities in your daily life. For example, every time you get in your car, you could end up dead as the result of a traffic accident. It also doesn't mean that none of these men had their cancers recur. It just means that the likelihood of that was just as high for those who were treated immediately as for those who waited. Finally, it is possible that another larger study might detect small but significant differences, but that wouldn't change the conclusion that the differences, if they exist, are pretty small. A more serious question is whether or not the sample was large enough, about 100 men, to be able to distinguish any differences depending on the aggressiveness of the cancer, e.g. on Gleason score. Scardino, for example, recommends not wating a whole lot of time for Gleason 7 or worse cancers. On the other hand, he is not talking about waiting several years to be treated. That is an entirely seprate question, and it still hasn't been established how safe watchful waiting is when compared to immediate treatment. > No one wants to be the guy to whom that happens. > > Alan > While I rarely post these days, I scan the group regularly. What really > annoys me, and has done for the 6 years (when I was 60) since I joined the [quoted text clipped - 19 lines] > I do not for a moment accept) or a PCa which grew a damn site faster that > thought likely/possible. You probably made the right decision for you. But I don't think the two findings you report above necessarily suggest that the cancer was close to spreading. The great majority of prostate cancers are in the peripheral zone so they are all pretty close to the capsule. Also, it is very common for cancer to arise at different sites and the biopsy may miss many of them. So, in my admittedly inexpert opinion, the post surgical results don't support either of your conclusions about the competence of the biopsy or rapid growth of the cancer. To me, the one factor arguing most strongly against WW in your case was your age. If you had been 70, the case might have been stronger with an apparently small Gleason 6 cancer. But of course, as with everything in prostate cancer treatment, there are no guarantees. You are taking a chance no matter what you do. The decision is based on both your estimate of the odds and also the price to you of making the wrong decision. > I know of a person whose biopsy indicate several positive cores, each with > minimal degrees of PCa. Two weeks later he had his laproscopic surgery. [quoted text clipped - 9 lines] > body less than the RRP techniques, so there might now be less concerns about > the effects on older men. It generally is slow growing, but physicians should certainly tell their patients it sometimes grows quite fast. Ideally, the physician should tell the patient his/her best estimate of the odds of various outcomes, but unfortunately, most patients can't deal well with quantitative estimates. This is true even of people who are relatively sophisticated in such matters. It is hard to be objective when it is your life that is at risk, but perhaps that is just the time you should try your best to do so. > Note to medical practitioners: explain the effects of PCa. Outline the > possible treatments. Make your recommendstions and explain your reasonings, [quoted text clipped - 6 lines] > Ray Walsh > Perth, Australia Docs were taught years ago that carcinoid tumors -- the rare form of colon cancer that would have killed me if PC met scans hadn't discovered it -- was generally benign and slow growing. They now know it is often deadly, and mine grew from non-existent (via colonoscopy) to life-threatening size in just 3 years, long before my next colonoscopy was due. Wear your hip boots and thinking cap when reading medical literature, talking to doctors, and cruising the internet. I.P. > Wear your hip boots and thinking cap when reading medical literature, > talking to doctors, and cruising the internet. Just shows to go you, ... anecdotal evidence is the only reference you can trust. ;-) > > While I rarely post these days, I scan the group regularly. What really > > annoys me, and has done for the 6 years (when I was 60) since I joined the [quoted text clipped - 40 lines] > estimate of the odds and also the price to you of making the wrong > decision. My father was a good candidate for WW. He had a very bad case of heart failure and the Pca was far down the list of concern. Dalej.  SignatureEmail: dalej2@mac.com > It generally is slow growing, but physicians should certainly tell their > patients it sometimes grows quite fast. Ideally, the physician should [quoted text clipped - 4 lines] > at risk, but perhaps that is just the time you should try your best to do > so. That Leonard, neatly encapsulates the issue. I know of your interest in statistics, but there is a point when statistics become pretty meaningless to the individual. I recall my surgeon saying as we discussed treatment options, that the mortality rate as a result of RRP (not PCa) was less than 0.05%. If you are part of that minority, the stats are meaningless to you, but of "interest" only if you are not part of that small group. [I make no claim, one way or the other as to the accuracy of his claim. > but physicians should certainly tell their patients it sometimes grows > quite fast. Ideally, the physician should tell the patient his/her best > estimate of the odds of various outcomes, By omitting this information, physicians remove an important element from the patient's decision-making process. It is particularly so, when without knowing exactly what type of PCa is involved, the physician blandly states "PCa is slow growing". > but unfortunately, most patients can't deal well with quantitative > estimates. IMHO, very few physicians know their new PCa patient well enough to make that decision. These days I don't read the literature as broadly as you and other might, but while I have not seen anything that supports this claim, it is possible that such a survey has been done. Regardless, I would hope that few physicians would be patronising enough to take that decision on behalf of a patient. Stats are proven to to be useful. Unfortunately, their accuracy tends to depend on how likely a person might might fit into the broader group. e.g. If a statistical study says that 99.99% of a group will live for 20 years after the defined event, that figure is absolutely meaningless for the 0.01 who won't make it. :-) >> It generally is slow growing, but physicians should certainly tell their >> patients it sometimes grows quite fast. Ideally, the physician should [quoted text clipped - 8 lines] >statistics, but there is a point when statistics become pretty meaningless >to the individual. Where is that point, for you in particular? > I recall my surgeon saying as we discussed treatment >options, that the mortality rate as a result of RRP (not PCa) was less than >0.05%. If you are part of that minority, the stats are meaningless to you, >but of "interest" only if you are not part of that small group. [I make no >claim, one way or the other as to the accuracy of his claim. You describe the stats as 'meaningless' if you are one of the unfortunates, and 'of interest' if you are one of the luckier majority (in your quoted example at least, most survive the RRP). What is particularly odd here is that you evaluate the usefulness of the statistics on the basis of *outcome*. In fact this puts the chronological cart before the horse! We can only use statistics to make a decision PRE-outcome. It's only the compilation of statistics which is POST-outcome. This is the only way statistics can make themselves useful; as a decision making tool based on prior outcomes, not as a pretext for hand-wringing, nor as a post-decision reflection on whether the statistics were a good guide - although of course you can criticise the stats if they show unacceptable inconsistencies. No question, it's terrible news If you happen to be the 1 in 2000 who die from RRP, but it doesn't devalue the validity of the prediction arising from the statistics - in fact it confirms it. Nor does it impact on the usefulness of the statistics as a decision making tool - after all it's the only one we have. The proof of this is that without exception we demand the statistics and we act upon them. If the statistics are favourable we proceed, if they're not we either freeze or dither. The stats relating to PCa treatment seem particularly onerous to many because the statistical benefits/disbenefits are seen to be either too marginal or qualitatively confusing. >> but physicians should certainly tell their patients it sometimes grows >> quite fast. Ideally, the physician should tell the patient his/her best [quoted text clipped - 4 lines] >knowing exactly what type of PCa is involved, the physician blandly states >"PCa is slow growing". Obviously any physician who unequivocally says "PCa is slow growing" should be struck off since it appears some is and some isn't. Everyone has to take care not to mislead. Some reading the title of this thread might infer that "PCa is not slow growing". Current thinking seems to suggest that is yet another invalid generalisation. >> but unfortunately, most patients can't deal well with quantitative >> estimates. One can only do one's best with an 'average' - rejoice if the outcome is good, bemoan it otherwise. But if procedure A offers 99% success while B offers 25%, you will want to know this. Tragic for the one in 100 who failed the better procedure (and you can argue till the sun expires that he'd have had a better chance if he'd picked 'B') but to make this kind of observation is to be mischievous with time itself. It's pure hindsight. >IMHO, very few physicians know their new PCa patient well enough to make >that decision. These days I don't read the literature as broadly as you and [quoted text clipped - 8 lines] >after the defined event, that figure is absolutely meaningless for the 0.01 >who won't make it. :-) If the statistics are reliable and 0.01% fail to make it, then the 0.01% who don't make it are nothing less than a vindication of the statistics. Tragic but not meaningless. >>It generally is slow growing, but physicians should certainly tell their >>patients it sometimes grows quite fast. Ideally, the physician should [quoted text clipped - 12 lines] > but of "interest" only if you are not part of that small group. [I make no > claim, one way or the other as to the accuracy of his claim. As best I can tell, the claim is pretty accurate. Of course you are right that if you die as a result of surgery, then the fact that it was a rare incident doesn't help you. But I hope you will agree that it doesn't make a whole lot of sense to base your decisions on highly unlikely possibilities. 0.05 percent is the same order of magnitude as the likelihood of being killed in an auto accident, but you don't decide never to enter a car because, if you died as a result, that the statistics wouldn't matter. Practically speaking, you just take reasonable precautions and ignore the possibility. What you should do in principle is to try to balance the cost to you of dying during the surgery to the hoped for benefit of avoiding advanced prostate cancer and dying of it. Actually, you should try to balance the costs and benefits of every possible decision and choose that which minimizes your loss. But few of us can engage in such a coldly rational analysis, even if we had completely reliable information, which we don't. Instead, we consider all the possibilities, ignore some because we just don't think they are going to happen, and try to roughly balance the others in some metaphorical rather than strictly numerical sense. Some one factor gains prominence in your mind and helps you make the decision. >>but physicians should certainly tell their patients it sometimes grows >>quite fast. Ideally, the physician should tell the patient his/her best [quoted text clipped - 4 lines] > knowing exactly what type of PCa is involved, the physician blandly states > "PCa is slow growing". I have to agree with you about that. >>but unfortunately, most patients can't deal well with quantitative >>estimates. [quoted text clipped - 5 lines] > few physicians would be patronising enough to take that decision on behalf > of a patient. I am not basing my statement on any survey. I based it on my reading about how human beings actually make decisions and the fact that few people have a better background for rational quantitative analysis than I do, yet when making my decision, I found it very difficult to see it in terms of pure logic. Perhaps, I am being arrogant, but I figure that if I have trouble doing it, someone not trained in quantitative methods is going to find it even harder. > Stats are proven to to be useful. Unfortunately, their accuracy tends to > depend on how likely a person might might fit into the broader group. e.g. > If a statistical study says that 99.99% of a group will live for 20 years > after the defined event, that figure is absolutely meaningless for the 0.01 > who won't make it. :-) Again, what you say is true, but unless there is some practical way to determine whether you are in that 0.01 percent minority, there is no way to factor that possibility into your decision making process. As a practical matter, with regards RP surgery, in fact, physicians don't recommend it for men with shortened life expectancies, and there is an implicit calculus there. Such men aren't likely to gain much, if anything, from the surgery. In addition, their risk of dying from the surgery, while still small, is higher than it would be for a healthier man, and given no clear benefit from the surgery, they shouldn't be subjected even to that low risk. "from minimal involvement to extensive involvement in 3 months?? That indicates either an incompetent biopsy (which I do not for a moment accept) or a PCa which grew a damn site faster that thought likely/possible." Ray, when you are coming up w/ hypotheses to explain a result, you need to come up w/ all of them or you are likley to reach the wrong conclusion, as you have here. As Leonard explained, even a competently executed biopsy can miss a lot or even the majority of the PCa. Your PCa did not spread appreciably in that period of time. PCa is slow growing AS COMPARED TO MOST OTHER CANCERS - that is what the term means. I screwed up and did not have a PSA until I was 51, and it was 30. The concensus among the many doctors I have conferred w/ is that I probably had PCa for 5 or more years. If it had been lung cancer or pancreatic, I'd be in the grave lo many years now. PCa cells do no rapidly reproduce - indeed, that is the reason that traditional chemo agents do not work very well for PCa - they attack fast-dividing cells. (That is why those chemo agents make you go bald - because hair cells are among the fastest dividing.) But even if your PCa did spread that quick, you could probably still go untreated and live 5 years or so. Not so w/ most other cancers. Bill Denton RP 2/12/02 PSA .96 Memphis I have heard the "slow growing" thing from the beginning of my journey. What I have not heard of is a test that pins down with certainty that a particular cancer in a particular patient at a particular time is not a threat to life. When they have that, give me a call. Other than that what they are talking about, they being men that know statistics but who do not have cancer, is that x percent would die of other causes if they did not seek treatment, and conclude that therefore the active treatment is unnecessary. Somehow "they" never seem to talk about the other side of the coin, i.e., the men that do die of prostate cancer who would have lived if they sought treatment instead of watchful waiting. Welcome to the wonderful world of prostate cancer. > While I rarely post these days, I scan the group regularly. What really > annoys me, and has done for the 6 years (when I was 60) since I joined the [quoted text clipped - 44 lines] > Ray Walsh > Perth, Australia > While I rarely post these days, I scan the group regularly. What really > annoys me, and has done for the 6 years (when I was 60) since I joined the [quoted text clipped - 44 lines] > Ray Walsh > Perth, Australia Yep, there is that window of opportunity that one does not want to miss. Dale j. SignatureEmail: dalej2@mac.com > Sorry for the rant, but it really burns me up to hear about men suffering > needlessly. Hey, Ray. No problem about the rant. Indeed, it reminded me of something I used to post about often. I was dx'd with PCa consuming 85% of my prostate at biopsy and Stage was T2c. Six weeks later, my prostate was complete consumed and Stage was T3. 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, 6/06 PSA .07 .05 .06 .09 .08 .132 .145 Casodex added daily 07/06 Non Illegitimi Carborundum
|
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2008 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.