New prostate cancer test advice (Don't do it) overturns dogma

[Turborama]

Source: AP

By LAURAN NEERGAARD, AP Medical Writer – Fri Oct 7, 5:28 pm ET

WASHINGTON – Men finally may be getting a clearer message about undergoing PSA screening for prostate cancer: Don't do it.

They may not listen. After all, the vast majority of men over 50 already get tested.

The idea that finding cancer early can harm instead of help is a hard one to understand. But it's at the heart of a government panel's draft recommendation that those PSA blood tests should no longer be part of routine screening for healthy men.

The U.S. Preventive Services Task Force examined all the evidence and found little if any reduction in deaths from routine PSA screening. But it did conclude that too many men are diagnosed with tumors that never would have killed them and suffer serious side effects from resulting treatment.

Read more: http://old.news.yahoo.com/s/ap/20111007/ap_on_he_me/us_med_prostate_what_to_do

[snot]

1. I have questions about this that have not been addressed in the news I've seen so far.

My honey's first PSA, at age 50, was so high that, in combination with the other factors, there was a > 90% probability that the cancer had already spread beyond his prostate. He had the -ectomy, and only then were they able to determine that it had not in fact spread beyond his prostate; but if it had been left untreated, might it really not have killed him, if it had already progressed so far at his age? Are there NO forms of prostate cancer that are aggressive enough to kill someone if they've got it at age 50? I haven't heard this addressed.

Also, my honey had driven a Prius for 2 yrs, and I've read that a lot of Prius drivers have gotten prostate cancer or other cancers in or near their bottoms, supposedly because they're exposed to unsafe levels of electromagnetic radiation from the wires or whatever it is that conducts the energy from the battery in back to the engine in front. Another of our good friends who's the same age and also drove a Prius was also discovered to have an advanced case of prostate cancer.

The timing of discontinuing this test right when we are or should be increasing our use of electric cars seems unfortunate.

[truthisfreedom]

2. I doubt that the Prius is a source of anything dangerous to a prostate.

There's no reason why the design would need to have intensely changing magnetic fields occurring in cables going from the front to the back of the car. It's much more efficient to put the motor and battery in the same compartment.

[Tesha]

13. The Prius actually *DOES* have the main traction battery...

...located between the rear wheel wells just behind
the rear seat. Meanwhile, the traction motors and
their associated electronic controls are up front
in the engine compartment. And the main traction
power cable runs from the rear battery to the front,
but IIRC, it's tucked-in at the base of the left
floor pan box-beam, not directly under the driver's
seat.

Tesha

[AtheistCrusader]

3. The cabling for the battery pack in the prius doesn't run under the driver's seat.

Zero correlation.

[Tesha]

12. Roughly 100% of men would get prostate cancer if they lived long enough.

http://seer.cancer.gov/statfacts/html/prost.html

Today, the lifetime incidence of *DETECTED* prostate
cancer cases is 1 in 6 men with many more cases that
never get detected because they don't progress that
far before the man dies of other causes.

Lots of men drive Priuses. Lots of men get detected
prostate cancer.

Ignore the Prius thing.

Tesha

[madokie]

14. Rest assured that Prius isn't the cause of the prostate cancers

The wires are shielded by the metal body of the car so there is no electromagnetic radiation there to worry with. If they for some reason made the seat out of the wires that they run the electric through then maybe but it wouldn't be prostate cancer a guy would have to worry with but scorched butt would be. :-)
Sorry to hear about your husband. I just found out one of my friends who is the same age as me (63) has prostate cancer and he's going to let it run its course. I guess the doctors have convinced him that the bad outweighs the good in removing it.

[daleo]

19. The research says there is no difference in death rates between those tested and those not tested

Presumably this applies to the entire age range, including 50 year olds. There is a risk of death from treatments themselves (infections, surgical mistakes, etc) - apparently the risk of death from treatment is about the same as the reduction in deaths from treatments triggered by a positive test. There is no way to know ahead of time whether any treatment will be positive or negative.

I doubt if Prius's matter, but as time goes we will see if a correlation becomes evident. Since the Prius produces less air pollution that other cars, widespread use of it probably would actually reduce cancer risk.

[still_one]

4. PSA is with other data points including DRE, velocity, and a new one which measures the urine after

a DRE. If multiple data points indicate a high probability, then a biopsy should be done

This smells like a cost savings bullshit, same as saying woman should not routinely get mammography, or people over 50 don't need colonoscopy unless there is a family history

I suspect it will be things like this that they will use to lower health care costs

I am very skeptical of this so- called task force

[Electric Monk]

5. old.news.yahoo.com = LBN?

:shrug:

[Turborama]

6. Regarless of the link's name, Fri Oct 7, 5:28 pm ET was within LBN's time limit @ time of posting it

Also, Yahoo's link works if you just take out the old. eg: http://news.yahoo.com/s/ap/20111007/ap_on_he_me/us_med_prostate_what_to_do

(I know this because I normally take it out to avoid confusing anyone, but forgot to this time)

[truedelphi]

7. My 86 yr old dad asked me if he should do anything about the prostate

Cancer his doctor had told him about.

"Well, what does your doctor say?"

"He says everything else wrong with me will kill me long before the cancer does. He also said if I undergo surgery for it I'll be incontinent."

"So he's against any surgery?"

"Yes, he is."

"Sounds about right to me."

He died four years later, continent till the end, and basically of a dozen serious consequences of living to be 90. (Emphysema being the biggest of the problems he had.)

Oh, and for anyone who worries about being pessimism causing a person to die early, he was the world's biggest pessimist!

[Chan790]

9. That sounds about right.

It's rather like the test that came back to tell us that my 91 year old grandfather was pre-diabetic. We said "Should we be concerned?"

"Well...considering that he's 91; blind; with poor-balance; has a heart condition that could kill him at any second; esophageal varices, strictures and narrowing all from 30 years of untreated GERD; and not a candidate for surgery for either? No. Just watch what he eats." (I need be clear...this wasn't insensitivity on the doctor's part...we were all aware of the health-condition of my grandfather.)

It seems the pessimistic ones do hang-on longer. Grandpa didn't want to outlive Grandma...he did by 17 years, cursing every day of it.

[Tuvok Obama]

8. Way ahead of ya

For once procrastination pays off

[freeplessinseattle]

10. my dear friend's life was saved by routine screening

just last year, and he participated in a new treatment study that worked! It was a hormone based treatment that basically put his body thru menopause-and while he had to be the one to find out that osteoporosis can be a side effect, heck, he's just happy to be cancer free.

[southshore]

11. Informed decision?

I guess just letting the patient have all of the information that they can get and letting THEM make an informed decision was too much of a stretch. Oh, I forgot the cost savings from no testing and the painful, but rather swift death from metastatic prostate cancer.

Follow the money.

[Th1onein]

15. First, do no harm....

Below is a study done on breast cancer patients, but there's no reason it would not apply to prostate cancer patients as well. Breast and prostate cancers are some of the slowest growing cancers in humans. Why not leave the body's immune system to battle them, instead of seeding the cancer with biopsies? There's a 50% increased chance of metastases after these procedures. Sometimes, it's just best to leave well enough alone.

Arch Surg. 2004 Jun;139(6):634-9; discussion 639-40.
Manipulation of the primary breast tumor and the incidence of sentinel node metastases from invasive breast cancer.
Hansen NM, Ye X, Grube BJ, Giuliano AE.
SourceJoyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, Calif, USA. [e-mail]

RESULTS: Of the 676 cancers, 126 were biopsied by FNA, 227 by large-gauge needle core biopsy, and 323 by excisional biopsy before sentinel lymph node dissection. Mean patient age was 58 years (range, 28-96 years), and mean tumor size was 1.85 cm (range, 0.1-9.0 cm). In multivariate analysis based on known prognostic factors, the incidence of SN metastases was higher in patients whose cancer was diagnosed by FNA (odds ratio, 1.531; 95% confidence interval, 0.973-2.406; P =.07, Wald test) or large-gauge needle core biopsy (odds ratio, 1.484; 95% confidence interval, 1.018-2.164; P =.04, Wald test) than by excision. Tumor size (P<.001) and grade (P =.06) also were significant prognostic factors.

CONCLUSIONS: Manipulation of an intact tumor by FNA or large-gauge needle core biopsy is associated with an increase in the incidence of SN metastases, perhaps due in part to the mechanical disruption of the tumor by the needle. The clinical significance of this phenomenon is unclear.

[BiggJawn]

16. I don't like this.

Shit, I'm sitting here wondering if I could have my pancreas yanked out to avoid pancreatic cancer. I'm already diabetic, so it's just basically freeloading, biding its time til it blows up and kills me anyway.

To me, this smacks of the cost-benefit numbers you'd pull trying to decide if it's worth it to replace the transmission in a 15 year-old car.

I think I'm more valuable than an old car.

Who benefits from "Whoops! Sorry, too late to treat it, get your affairs in order" prostate cancer besides the insurance companies who get to pocket more of your money?

[Gormy Cuss]

17. First it takes years to convince people that they need routine screening,

then it takes years to convince them when some screenings or screening intervals prove to be less effective than thought. There should be hard science data behind this recommendation -- if there isn't, it's hard to take it seriously.

One note from the link that I find interesting:

Yet the cancer society notes that in Western European countries where screening isn't common, 1 in 10 men are diagnosed and the risk of death in both places is the same.

[crim son]

18. Testing isn't cost effective.

My ex FIL didn't get tested and died in great pain of prostate cancer that spread to his bones - the usual path in that cancer.

I had a surgery to correct a defect in my esophagus. I went from extremely ill, unable to eat, in constant pain with uncontrollable asthma and heart palpitations to... normal. However I had to petition my physician to recommend it because the common wisdom was that it wasn't a good surgery. That made little sense to me so I did the research and found that the arguments against it were ALL based on economics. It isn't a permanent fix, some patients still had to take medication afterward and so it was routinely denied. Unbelievble, considering how utterly miserable I was for a year before my petition was finally granted. I've been well for the thirteen years since.

[Yo_Mama]

24. Yes, that's really what is going on

But population studies often don't detect the subgroup of patients that get the real benefit from various treatments, so these sorts of decisions really should be made on a much more individualized basis.

[Yo_Mama]

20. The real question is whether to treat cancers detected at an old age

Out of all three direct maternal male relatives (two uncles, one grandfather), my brothers had two that died of prostrate cancer that was highly malignant and spread throughout their bodies. So both my brothers are considered at high risk and they have to get PSAs every couple of years to check their number.

Both the uncle and the grandfather opted for no treatment when the cancer was diagnosed (they were pretty young in both cases) - both died horrible, prolonged and highly expensive deaths. I don't need to go into the repugnant details. Many cancers don't kill quickly, and a tumor on the spine is so unbelievably painful that you have to kill yourself or get it reduced.

Men who are at high risk should get this test. If the cancer is detected young they can get a biopsy and find out just how bad it is, then make the decision. Or if you have an elevated PSA you can wait a few months and see if it is going up. There are multiple options and these should be discussed with a knowledgeable physician.

Personally, if my husband's PSA goes up after 75 I won't worry too much. But EARLY prostrate cancer is another matter.

I think the recommendation is highly suspect because if you sorted out different age brackets you would come up with a different result. By lumping cancers detected after 75 (more common) with cancers detected in the 50s (rarer, but often more aggressive) the picture is very confused. The average male doesn't live to 85, so of course there won't be much of a difference in survival rates. If you did a good strong study on prostrate cancers picked up in the earlier years, you would see a 10 year survival rate difference.

I went in to my doctor's office today because we had a meeting set up after office hours about a new medical system we might try, and my doctor brought up this issue. He was highly negative about the recommendation and said that he felt that in many cases not to do the PSA was malpractice, and he'd use his own medical judgment. He said missing early, highly treatable cancers in younger persons was pretty much murder in his opinion, and that if he were ever forced to practice this way he'd opt to just retire.

Here are some stats on incidence by age:
http://prostate-cancer.emedtv.com/prostate-cancer/prostate-cancer-statistics.html

This page has stats on age at death of prostrate cancer:
http://prostate-cancer.emedtv.com/prostate-cancer/prostate-cancer-statistics-p2.html

Scroll down and look at the five-year survival rates separated by diagnosis at stage. You can't convince me that diagnosing this cancer early for people with a good chance of living 10 years otherwise isn't worthwhile.

Therefore I think the data as presented is somewhat dishonest - very few men would bother to seek extensive treatment for a cancer that wasn't causing them problems late in life. But that does not mean that giving PSA tests to men in their 50s and early 60s doesn't improve survival rates. Of course, if you are already very ill with something else, the picture changes.

Decisions such as these should be made clinically and individually.

Further, I believe that the studies done were designed to present a cost justification for NOT offering prostrate screening in some countries. US cancer survival rates have been running significantly above those of most European countries for some time. I don't know whether an unsubscribed user can "see" this Medscape article (reprint from 2007 Lancet Oncology), so I will quote the significant portion:
http://www.medscape.com/viewarticle/561737

Survival was significantly higher in the United States for all solid tumors, except testicular, stomach, and soft-tissue cancer, the authors report. The greatest differences were seen in the major cancer sites: colon and rectum (56.2% in Europe vs 65.5% in the United States), breast (79.0% vs 90.1%), and prostate cancer (77.5% vs 99.3%), and this "probably represents differences in the timeliness of diagnosis," they comment. That in turn stems from the more intensive screening for cancer carried out in the United States, where a reported 70% of women aged 50 to 70 years have undergone a mammogram in the past 2 years, one-third of people have had sigmoidoscopy or colonoscopy in the past 5 years, and more than 80% of men aged 65 years or more have had a prostate-specific antigen (PSA) test. In fact, it is this PSA testing that probably accounts for the very high survival from prostate cancer seen in the United States, the authors comment.

Further analysis of these figures shows that, in the case of men, more than half of the difference in survival between Europe and United States can be attributed to prostate cancer. When prostate cancer is excluded, the survival rates decreased to 38.1% in Europe and 46.9% in the United States. For women, the survival rate of 62.9% for all cancers in the United States is comparable to that seen in the wealthiest European countries (eg, 61.7% in Sweden, 59.7% in Europe), and the slightly higher survival in the United States was largely due to better survival for colorectal and breast cancer, the authors comment.

[daleo]

21. Side effects like impotence and incontinence are also hard on 50 year olds

There is plenty to consider. A younger man may benefit more than an older man from treatment, but the negative side effects also last longer and interfere with quality of life more acutely.

[Yo_Mama]

23. Of course they do

That's why it should be an individual decision.

Prostate cancer treatment is rather effective in early cancers. Here is a Scandinavian study:
http://www.medscape.com/viewarticle/750994

The difference between radiation treatment and watchful waiting really shows up. However with a median age at diagnosis between 67 and 68, you do not expect to see much of a 15 year mortality difference. But note 65% progression-free survival versus 36% for the radiotherapy group.

The reason why I would not be very aggressive with prostate cancer treatment if it is detected late is that you are buying many less years of life for the unpleasantness. For example, I have no intention of going through breast cancer screenings when I am 75.

Many men won't seek treatment. Those men who have decided not to shouldn't be forced to get PSAs. Men who would seek treatment should get them. It's up to the individual. Most men I have known detected by PSA have waited for a couple of months and had retesting and/or had other risk assessments done before even opting for a biopsy. In my admittedly limited experience, rapidly rising PSAs HAVE had a high predicting factor for aggressive tumors, and larger tumors have been far more aggressive.

If the cancer seems very static, or the PSA isn't going anywhere, or the PSA is high but free PSA is also high, then many men will choose the watchful waiting route. It's not as if Prostrate Cops kidnap you and perform a biopsy willy-nilly. Also, radiotherapy in early-stage cancers does appear to offer benefits comparable to more radical treatments and it often has less side effects.

All of those unpleasant side effects of treatment are much worse when aggressive cancers aren't treated pretty early, and the side effects of a cancer doomed to grow fast is going to be a hell of a lot worse than the treatment. To my mind, early PSAs often offer a way to assess significance of rising PSAs later, especially because early PSA levels tend to predict later PSA levels. You are really watching for the rapid rise. That's why I find this report somewhat frustrating. The European Randomized Study of Screening for Prostate Cancer did find a 20% mortality reduction with PSA testing after 9 years, but they set the PSA bar lower. This suggests that the real problem with PSA testing is that it is being used improperly - detecting aggressive cancers early enough to reduce mortality requires a more complicated methodology plus use of other testing to screen out a lot of the false positives without doing biopsies at too high a rate.

For men with the risk factors that my brothers have, more frequent testing beginning earlier and intervention at a lower PSA level apparently confirmed with a low free PSA rate, and monitoring for rapid rise at lower PSA levels backed by screening for other causes like inflammation almost certainly will reduce mortality and will produce better quality of life results via much earlier treatment that has less associated loss of function.

The bottom line is that one size does not fit all - that's the point I am making.

Most women will eventually get microscopic breast cancers if they live long enough. Most men will get microscopic prostate cancer if they live long enough. The cancers that will steal decades of life are the fast-moving ones that start earlier.

[daleo]

25. Money makes this a difficult area, like breast cancer screening

As with breast cancer screening, claims of evidence against screening can be seen as an excuse for cost cutting by governments or insurance companies. On the other hand, claims of evidence for screening can be seen as supportive of an expensive medical sub-industry and not necessarily in the public interest. The competing economic interests can make it difficult to interpret the scientific evidence objectively.

For myself, I tend to be cautious of screening programs for this very reason. But that's just me. Individuals have to decide for themselves and there is no easy answer.

[hedgehog]

27. My mother recently died of everything else (COPD, diabetes, heart disease etc)

at age 82 two years after having a mastectomy. She hated the entire idea of the surgery. I would have given anything at the time to be able to know for sure whether she really needed the surgery. What if breast tumors in 80year old women are so slow growing that they are of little concern? On the other hand, the tumor was not present on one mammogram but was found a few years later with the next scheduled mammogram, so it did grow during that time.

[hedgehog]

26. Just my wild ass guess, but I agree with what I think is your point -

use the PSA to detect fast growing cancers in young men, stop at say 65 or 75 because the cancers that arise at those ages are slow growing ones that don't kill. We need research to confirm this and determine the appropriate age.

[Nikia]

22. I'm glad that my father got tested for prostate cancer a t 50

His levels were high. The cancer was found and his prostate was removed. Luckily, it had not spread. If he had waited until he had obvious signs, it might have been too late.
A competent doctor will know how to communicate the screening results to the patient. If the patient does not want to go further, that is up to him.

[Fool Count]

28. While the scientific data are incontrovertible (PCA screening does not save lives),

in the comments following the NYTimes article on the subject commenter after commenter attack the researcher for reporting those results.
All attacks are based on a single argument - "It saved my (my loved one's) life, I (he) would have surely died if I (he) didn't do the test."
How do the scientific results square with those personal anecdotes? They don't. That's the problem with debunking any useless, but harmless,
medical procedure - any patient who underwent it is convinced that it helped (or even saved his life). Who wants to think that they went
through surgery for nothing? While there is no way of knowing otherwise in any individual case, the massive scientific studies clearly show that
it simply can't be the case for vast majority of patients. Of course, the results do not imply that all prostate cancers should be left untreated,
only that PSA screening provides no measurable benefit. Not all cancers detected as a result of PSA tests are treated, and not all treated
prostate cancers were detected using a PSA test. I certainly do want to know what is the overall efficacy of any medical procedure before
I decide whether to undergo it. And I want to have solid scientific data, not a bunch of personal anecdotes. Based on scientific data,
PSA screening does not make the cut and I am not doing it.