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Second Guessing

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

These types of reports always make me pause and wonder whether the early treatment actions that so many of us have taken--either RP, proton, radiation, HIFU, or some other therapy--were all unnecessary. All cancers aren't equal but sometimes we tend to view them that way. Good news is that all this treatment of low risk cancer has increased survival rates from 69% in 1975 to 99% today. No sense in looking back for those of us who have chosen treatment at an early stage, but I think this article underscores the validity of a physician monitored AS protocol.

From Urotoday.com:

CHICAGO, IL USA (Press Release) - July 26, 2010 - Most men who are diagnosed with prostate cancer appear to under undergo aggressive therapy, even if they have a low prostate-specific antigen (PSA) level and low-risk disease, according to a report in the July 26 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

More than 90 percent of all prostate cancers are diagnosed before the disease has spread to other parts of the body, and the five-year survival rate for these patients diagnosed with localized disease is almost 100 percent, according to background information in the article. The five-year survival rate from all stages of disease increased from 69 percent in 1975 to almost 99 percent in 2003. "The tremendous improvement in survival has been attributed to early detection and treatment," the authors write. "However, there have been concerns about the potential overdiagnosis and overtreatment of localized prostate cancer. Despite these concerns, some researchers argue that the prostate-specific antigen (PSA) level is associated with a continuum of cancer risk and recommend lowering the 4-nanogram per milliliter threshold for biopsy."

To determine current risk profiles and treatment patterns of men with prostate cancer and PSA levels below this threshold, Yu-Hsuan Shao, Ph.D., of the Cancer Institute of New Jersey, New Brunswick, and colleagues used data from the Surveillance, Epidemiology and End Results system. Of 123,934 men with newly diagnosed prostate cancer from 2004 to 2006, 14 percent had PSA levels of 4 nanograms per milliliter or lower. "The patients in these cases were less likely to have high-grade cancer, and more than half were classified as having low-risk cancer," the authors write.

"Despite their lower risk of having clinically significant disease, treatment rates for men with PSA values of 4.0 nanograms per milliliter or lower were comparable to those of men presenting with PSA values between 4.0 and 20.0 nanograms per milliliter." More than 70 percent of men with PSA values lower than 20 nanograms per milliliter had their prostates removed via radical prostatectomy or had radiation therapy. "Radical prostatectomy was performed on 44 percent of men with PSA values of 4.0 nanograms per milliliter or lower, 38 percent of men with PSA values between 4.1 and 10.0 nanograms per milliliter and 24 percent of men with PSA values between 10.1 and 20 nanograms per milliliter. Radiation therapy was performed on 33 percent of men with PSA values of 4.0 nanograms per milliliter or lower, 40 percent of men with PSA values between 4.1 and 10.0 nanograms per milliliter and 41.3 percent of men with PSA values between 10.1 and 20 nanograms per milliliter," the authors write.

The authors suggest that if the threshold PSA value for biopsy were decreased from 4.0 to 2.5 nanograms per milliliter, the number of men with abnormal PSA levels would double to approximately 6 million. "Estimates suggest that 32 percent of men with abnormal PSA levels would be diagnosed as having prostate cancer from their needle biopsy," they write. "Based on the results in the present study, 82.5 percent of these 1.9 million men would receive attempted curative treatments, while only 2.4 percent would have high-grade cancer. However, no evidence suggests that delaying biopsy until the PSA level reaches 4.0 nanograms per milliliter would result in an excessive number of potentially non-curable disease cases."

"These results underscore the fact that PSA level, the current biomarker, is not a sufficient basis for treatment decisions," the authors conclude. "Without the ability to distinguish indolent from aggressive cancers, lowering the biopsy threshold might increase the risk of overdiagnosis and overtreatment." (Arch Intern Med. 2010;170[14]:1256-1261.

lewvino's picture
lewvino
Posts: 1010
Joined: May 2009

It is great to read of the five-year survival rate from all stages of disease increased from 69 percent in 1975 to almost 99 percent in 2003.

For me I am glad that I treated when I did since my doc labelled borderline aggressive...Shown by the 4+3 Gleason and then positive margin found at surgery.

Another man that I have spoken to a few times took to much time for treatment and has a Gleason 9. He told me it was his own fault for not taking prostate cancer serious ahead of time.

My father on the other hand I believe might of have treatment 1 to 2 years to early but then on the other side he is a 13 year Prostate cancer survivor.

That again is just the nature of this BEAST. So many variables that no model fits all. The final sentence says it all "These results underscore the fact that PSA level, the current biomarker, is not a sufficient basis for treatment decisions," the authors conclude. "Without the ability to distinguish indolent from aggressive cancers, lowering the biopsy threshold might increase the risk of overdiagnosis and overtreatment."

Larry

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

I think you're spot on, Larry. They need to figure out another marker to better classify PCa and which treatment ought to be followed. It would also be nice if they could break the demigrahpics down further...age group, ethnicity, stage correlated to PSA, Gleason, and so forth.

I tend to agree with you about the upstaging too and it seems to me (from reading all the posts) that upstaging after RP occurs more often than not. I have never seen a statistic on the percentage RPs that lead to a higher Gleason score after surgery than before. I suspect that the same percentages of higher grade cancer also exist in those that choose some treatment other than radiation but since the prostate isn't removed, we don't know for sure.

Another interesting fact associated with the favorable long term RP statistics is that about 30% of the men require some form of adjunct therapy after surgery yet survival rates show pretty much the same result for those who did radiation therapy as a mono-treatment.

The nuances of this disease are frustrating to say the least.

Glad your progress has been so smooth.

jminnj's picture
jminnj
Posts: 129
Joined: Nov 2009

I agree that there definitely needs to be a better, more definitive way to determine how agressive the cancer is. In my own case, my numbers were very low (2.9 atage 47 an only 1 core 10% positive). However at full biopsy 35% of the glad was cancerous. So I have no second thoughts on my treatement (DaVinci). Hopefully they come up with a better test

steckley
Posts: 100
Joined: Aug 2009

Kongo,

Thank you for the article ... as usual I think your insight is spot on.

If I'm reading the results correctly it looks like most guys are choosing to hit their cancers hard and early ... in general, I feel that for any type of cancer (ie. breast, ovarian, lymphomas, etc.) this is the correct approach.

For PCa, people argue that there are less agressive forms that do not need to be hit hard and early .... if only we could be "sure" (high confidence level) that we had a less agreesive PCa.

To me it doen't seem today's PSAs or scanning technologies can give us information that makes us "sure"... so "maybe" the masses are correct and hard and early is the best treatment philosophy.

That's where this forum is helpful, it gives newly diagnosed guys a place to ask questions so that they can try to figure out what is best for them.

Trew
Posts: 899
Joined: Jan 2010

Ok, you have a biopsy. I think the standard time before surgery after the biopsy is something like 6- 8 weeks to let the prostate heal. During that time my it appears that something changed in my prostate since the gleason moved from 8 up to 9 on the post-op biopsy report 8 weeks later. Maybe PSA levels need to be checked more often- maybe at least once a month after first rise is detected to see if there is a rapid increase or if the rate of increase is very slow. Seems like that would tell you something about the rate of cancer growth.

As for me, my PCa was already on its way out of the prostate and starting to get into the bladder neck. Delaying treatment in my case may have had very serious consequences.

I have also read that positive bladder necks have a higher rate of recurrance than other positive margin sites. But I think the uro who did my surgery expected the post-op biopsoy to show just what it did by the location of the core smaples from the first biopsy. So that tells a doctor something about the ca he is working with, too.

Hey, its all done now- I would just like to get a few other ordinary functions back ASAP. I guess I am moving on to other things and once again I have no idea what to think of all this.

randy_in_indy's picture
randy_in_indy
Posts: 495
Joined: Oct 2009

Had I not been with my GF at the state fair last year....I might be in advance stages of cancer today. I certainly feel I did not rush into treatment...even though I made my decision quickly and had treatement within two months of diagnosis (oct 27th 09 Davinci 12/29/09) After post op path report indicated I had 5% grade 5 and upgraded to 3+4 from 3+3...and from only thinking it was in right side to being less than 1mm from breaking out on both sides.

It turned out great for me....not using ED drugs for some time now...just pop one every once in a while for extra fun...totally continent and still a memember of the zero club....Still....I watch and wait thinking this could all change at some point down the road...as we are in battle with a very strange and sometimes mysterious beast with Pca.

Best to All!!!

randy in indy

gumbyrun's picture
gumbyrun
Posts: 58
Joined: Dec 2009

I saw the dip in the exports from India to the US but didn't make the connection. (Just pulling your chain.) Glad to hear all is on the up and up.
Mike

randy_in_indy's picture
randy_in_indy
Posts: 495
Joined: Oct 2009

I bought about 60 100mg of Viagra generic and still have about 30 left I think....I do use 1/4 pill because it gets a very good woody with lasting power...orgasms still are not as good as they once were...but there is still time for that to change I suppose... Glad you're getting on so well! Peace to all!

Randy in indy

Swingshiftworker
Posts: 1013
Joined: Mar 2010

What I take from this report is that most men are too quick to resort to surgery to remove the prostate when they get an early PCa diagnosis.

This doesn't mean that surgery is the "wrong" approach for a particular individual but, given the significant adverse risks of surgery -- namely incontinence & ED, as well as more serious problems associated w/PCa surgery, all of which have been well-documented here -- it seems that too many men are make the choice to "cut it out" rather to choose less risky forms of therapy, which may be equally effective with fewer potentially damaging side effects.

In my case, I've chosen to get CyberKnife treatment which, based on my research, appears to be the least detrimental form of treatment currently available for early PCa and I now expect to receive that treatment sometime in September. Notably, Kongo (who's opinion seems to be highly valued here) made that choice and has already received that treatment too.

When I joined this forum I noted a definite bias towards surgery and the point of my comment here is NOT to suggest that surgery may not be a suitable choice for certain PCa patients. I just want to caution early PCa patients lurking out there not to be so quick to jump on the surgical bandwagon and to recommend that they check out ALL of the available alternatives out there -- not just surgery -- and to choose the one that is best for them.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Swing, nice post and thanks for the complement although I am pretty sure there is a large group that wouldn't agree with you about the value of my opinion. In any event, I hope your CK procedure goes as smoothly as mine did.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

Kongo:

You're too modest.

I can't count the # of posts that I've seen hailing the value of your messages. I also can't recall anything that you've posted that I disagree with, including the choice of CK for treatment.

In any event, I have an appt to get the gold markers placed on 8/31 and just got a letter of authorization from BS for the entire CK procedure. So, looks like I'm on schedule to get it done in September.

UCSF uses a 4 day straight protocol, but will ask about doing it every other day as you previously suggested. Anything further to report on your experience?

I'm planning on traveling to Guadalajara for a couple of weeks in October after the treatment to celebrate my 60th b-day. Hopefully I will have a lot more than just my b-day to celebrate.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Glad that BC/BS is picking up the tab. I've read that in some states it's a problem. Only suggestions I would make is to start the low fiber diet a few days before your first treatment so that the prostate settles down and won't move so much from material in your colon. My protocol included a laxitive the evening before treatment and the ever popular fleet enema in the morning before getting zapped. Have some ibuprofen handy in case you feel some urgency. (I felt it briefly the final afternoon after treatment). You might want to leave with a Flomax prescription in case the swelling of the prostate after radiation causes a weaker stream. The other thing is to load up your iPod or whatever with some tunes then sit back and relax.

I envy you your birthday trip to Mexico. I'll be spending my 60th next month on an airplane flying home from an East Coast business trip. We are heading to the Big Apple for a week in early October (my wife's birthday) to take in some Broadway shows and revisit some of our favorite haunts there.

Keep us posted on how everything goes.

randy_in_indy's picture
randy_in_indy
Posts: 495
Joined: Oct 2009

Kongo is a very bright individual with a very methodical and pretty fail proof approach to this beast...many can learn much from following Kongo around in this thread. Kongo has contributed a vast amount of very good insight to all!

Off to work for me - getting my 10 year service award at the company today should be fun!

Randy in indy

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