Prostate Cancer Taskforce Finding

[tjscott0]

One thing about screenings that I always wonder about is that all the recommendations come from a group comprised entirely of those that benefit economically from the tests: product manufacturers and specialized doctors. Do nothing or do simpler tests would be a severe blow their core business.

I recommend you read any of Dr /Nortin Hadler's books.

He talks about the medicalization of the aging process. That to be "well" is not to be without symptoms of morbidity. It is abnormal escape heartburn, heartache, headache, or backache. That to be well is being able to cope with morbidity.

Medicalization is the process by which the morbidity is framed by the personas a medical iliness for which medical treatment could or should be sought. Medicaliztion superimposes a scientific idiom of distress on the common sense. Common sense is n ot common.....it is a sense that is highly susceptible presuppositions, magical thinking, and market pressure. to

He introduced me to the concept of Type II Medical Malpractice.

Type II meical malpractice is doing something to patients very well that is not needed in the first place.

I would also recommend reading "Overtreated" by Shannon Brownlee.

She tells the story of how the federal gov't attempted to drive down doctor fee costs in the medicare program. The federal & state gov't ramped up medical education spending. By 1973 they had double the number of medical school graduates being produced annually. Doctors, being very smart, 1) started becoming specialists in higher numbers as the fees were greater or 2)provide more health care to their patients generating more income. Remember medicare isn't market based. It pays however much treatment is provided. And as a third party is paying; the patient could care less what the ost is.

 

[lightspeed]

There is no doubt there are men who are diagnosed with prostate who are treated that never needed it. The problem is identifying who needs treatment and who doesn't. Doctors have to make a best guess based on the aggressiveness of the prostate cancer, how fast the psa is rising, the man's overall health and life expectancy. No doctor in the US wants to tell a man he does not need treatment than have it show up metastatic in the bones 10 years later.

Prostate cancer deaths, or lack of impact on prostate cancer deaths, is the wrong endpoint. How many patients who do not get screened develop a significant prostate cancer and subsequently go on androgen deprivation therapy (chemical castration) would be a better measure. These men that are missed having early prostate cancer and present with more advance stages still may die of something else but have poor quality of life.

There was a time when we did not have the PSA for screening. Men would be diagnosed with prostate cancer after it grew so bulky in the prostate it was incurable, or invaded the bladder and rectum, or spread to the bones and lymph nodes. Maybe to reduce healthcare spending, we should go back to those days and when patients show up like that, castrate them (much cheaper than chemical castration with drugs).

 

[tjscott0]

There is no doubt there are men who are diagnosed with prostate who are treated that never needed it. The problem is identifying who needs treatment and who doesn't. Doctors have to make a best guess based on the aggressiveness of the prostate cancer, how fast the psa is rising, the man's overall health and life expectancy.

Due to malpractice attorneys; I think doctor will err on the side of aggressive treatment.

Low-risk prostate cancer treated aggressively | Reuters

Many men with low-risk prostate cancer get aggressive treatment, increasing the risk of serious side effects, U.S. researchers said on Monday.

They said more than 40 percent of men who fell below the current standard for getting a biopsy had their prostates removed surgically, and a third had radiation therapy.

They argue that current efforts to lower the threshold of what is considered an abnormal prostate cancer screening test would add significantly to the number of men who are overtreated for cancers that might never harm them.

 

[TromboneAl]

To anyone who feels that the PSA saved his life (or the life of a friend or spouse), it probably did, and you should be grateful.

But here's the part that most people cannot seem to understand: A test which involved a flip of a coin could also save your life. If by random selection, you were chosen to get a biopsy, and cancer were detected, your life could be saved. But the problem is that the PSA isn't much better than a flip of the coin, so it results in unnecessary risk to those who do not have cancer (or have the slow-growing type).

The message is essentially: "the number of lives lost by not PSA testing is not worth the cost of the testing.".

You meant "The number of lives saved by PSA testing is not worth the cost of the testing."

But that is clearly not the message, unless by "cost" you mean the cost in lives and life-changing injuries.

Lives saved < Lives lost + Injuries sustained

Another way:

For 3,000 men tested:

3 will have their lives extended
1 will die
129 will have a permanent life-changing injury.

 

[lightspeed]

For 3,000 men tested:

3 will have their lives extended
1 will die
129 will have a permanent life-changing injury.

True, but the more important question is what happens to the men who are not screened and diagnosed with early prostate cancer. Not the number of prostate cancer deaths, which is the only endpoint evaluated in these studies, but...
--how many unscreened men show up with advanced, incurable prostate cancer and go on androgen deprivation?
--what is the quality of life in patients presenting with advanced prostate cancer living the rest of his life on androgen deprivation?

 

[lightspeed]

Due to malpractice attorneys; I think doctor will err on the side of aggressive treatment.

Totally agree. Watchful waiting is much better accepted in some of the European nations, by patients and doctors. Doctors in ALL European countries rarely get sued. The average medical student graduating in the US today will get sued 3 times in his or her career. And those law suits, even if the doc is not successfully sued, last years and are very demoralizing, maybe practice ending. The malpractice cost for a doctor in France, Germany for an entire year is what the malpractice cost for a doc in the U.S. of the same specialty for a week. But this is thread drift....

 

[grasshopper]

I have blood drawn for my annual physical every year, why not include a PSA.

 

[TromboneAl]

I have blood drawn for my annual physical every year, why not include a PSA?

A. Because chances are it will do you more harm than good.
Q. How can getting more information do me harm?
A. Because the information is unreliable.
Q. Well I'd rather know than not know.
A. You will not "know" based on the PSA score, you will only "maybe know."
Q. Well that's better than not knowing, isn't it?
A. No, because it may lead you down a dangerous road.
Q. Well, I'll decide that after I get the PSA result, isn't that best?
A. No, because at that point you will not be able to make a rational decision.
Q. What's the worse that could happen just by my getting my PSA?
A. You could spend your life impotent and wearing a diaper even though you never had a type of cancer that would have ever done you any harm.
Q. How's that thing of not posting on controversial health topics going for you, Al?
A. Not well.

 

[JOHNNIE36]

Really some interesting reading and thought provoking questions, which I will leave for my doctor. At present, I have never had an elevated psa blood test. My doctor insists on a digital exam also, saying the psa test is not conclusive on it own. At age 76, my doctor says we will continue the annual psa test along with the other normal blood checks and the digital exam. If something turns up, we wll address it at that time. At my age he would be leaning toward doing nothing and so would I.

My brother just underwent robotic surgery for removal of the prostate. At this time it's not been determined if additional treatment is necessary.

 

[BigNick]

Due to malpractice attorneys; I think doctor will err on the side of aggressive treatment.

That; plus the economic interests of all the billable treatments; plus the fact that patients don't want to get cancer, because the guys with cancer are visible, unlike the 40,000-100,000 (take your pick) Americans who die in hospital each year from something that they didn't go in with.

Oh, and plus the fact that the majority of medical professionals don't understand (or, in some cases, have never heard of) Bayes' Theorem.

 

[Mulligan]

Really some interesting reading and thought provoking questions, which I will leave for my doctor. At present, I have never had an elevated psa blood test. My doctor insists on a digital exam also, saying the psa test is not conclusive on it own. At age 76, my doctor says we will continue the annual psa test along with the other normal blood checks and the digital exam. If something turns up, we wll address it at that time. At my age he would be leaning toward doing nothing and so would I.

My brother just underwent robotic surgery for removal of the prostate. At this time it's not been determined if additional treatment is necessary.

As I mentioned in a previous post, I am in the camp of not wanting to get tested. Right or wrong I am worried about a wrong decision than finding out. I have read that something near 70-80% of men over 80 had prostate cancer at death, but did not die from it. I wonder if my current age is clouding my perception. At 47 now, I would be thrilled to know I had the opportunity to live to be 76. But once Im in my 70s Im sure I would want to live into my 80s. I wonder if I suffer from some leftover teenage invincibility ideas in my head that this will not happen to me. I know I don't want to even do the test, but I also fall into Al's line of thinking that I will make poor decisions with the information and would have been better off to not know at all.

 

[Zero]

Rereading that article, I really wish Rich-In-Tampa would address this assertion.

"The problem is that even with staging and grading of tissue samples, there is no way to know for sure which cancers detected through screening are likely to kill a man and which could be left untreated and unnoticed for decades."

I cannot believe that is true.

 

[donheff]

I suspect that many of us who are inclined to forgo the tests at this point are also in the camp that would carefully evaluate the likelihood of significantly extending quality life years before agreeing to aggressive treatment of illnesses like lung cancer. For some of us, nothing seems worse than death, for others extending a miserable life (or needlessly imposing misery) weighs heavier on our minds. Neither side is right or wrong.

 

[tjscott0]

I wonder if I suffer from some leftover teenage invincibility ideas in my head that this will not happen to me.

Yeah I don't feel much different than when I was 18. But it always startles me went I see that 61 yr old fart staring back at me in the bathroom mirror.<LOL>

More & more as time passes; I catch myself saying to myself "I used to be able to do do that."<G>

 

[Zero]

I suspect that many of us who are inclined to forgo the tests at this point are also in the camp that would carefully evaluate the likelihood of significantly extending quality life years before agreeing to aggressive treatment of illnesses like lung cancer. For some of us, nothing seems worse than death, for others extending a miserable life (or needlessly imposing misery) weighs heavier on our minds. Neither side is right or wrong.

Hey, you must be talking to my best friend, he asked me the same question yesterday. His question was; "5 years of blissfully unaware life doing what you like, versus 15 years of knowledge of health issues and fighting to stay alive one more year."

 

[meierlde]

The question being asked by the panel is simple does the benefit outweigh the harm for society as a whole. Clearly it does for some folks, and not for others. Ultimately if you are spending societies money either thru insurance or medicare cost effectiveness becomes an issue.
It is just like one could build a car that would take a 200 mph crash and you could walk away, look at the formula 1 cars. However it would be prohibitively expensive, as carbon fiber bodies are built by hand.
As donheff says it partly depends on our attitude to heroic care versus hospice treatment.

 

[JOHNNIE36]

Rereading that article, I really wish Rich-In-Tampa would address this assertion.

"The problem is that even with staging and grading of tissue samples, there is no way to know for sure which cancers detected through screening are likely to kill a man and which could be left untreated and unnoticed for decades."

I cannot believe that is true.

I woulld like to hear from Rich also. Haven't seen (heard) from him in a while. It always seems like he can put an understanding to the situation. I just like way he always answered the posts.


Editing to add a thought. I have read and reread the posts and can't get over the idea from some of you that it's better to not know about a health care concern. Why? Because information may be more harmful than helpful. Why? Because the information can't be trusted. I guess I am missing something. I'm thinking, "why would my doctor prescribe a blood psa test if the information might be harmful"? I have a lot of faith in my doctor and for now I'll put my trust in him and not some writings by so called experts in the various fields. I've asked my doctor about these reports and he tells me he has read them also. He has always led me in the right direction. As for now, everything goes through him.

 

[Mulligan]

Hey, you must be talking to my best friend, he asked me the same question yesterday. His question was; "5 years of blissfully unaware life doing what you like, versus 15 years of knowledge of health issues and fighting to stay alive one more year."

This may in part be a reason for me not wanting to get tested. Otherwise, I would feel like John Wayne in one of my favorite movies, "The Shootist" as he didn't hang around for his painful death from cancer. Except that wouldn't work for me because I am no gunslinger and have no scores to settle

 

[TromboneAl]

Doctor A is smart and well-educated and opposes PSA testing.

Doctor B is smart and well-educated and is for PSA testing.

One of them is right, and one is wrong.

If you have blind faith in your doctor, you are essentially rolling the dice with your life, because what your doctor recommends is based on which doctor, A or B, you happened to end up with.

 

[Nords]

I should start off this post by promoting cheerful good news: studies have shown one of the best ways to avoid prostate cancer appears to be frequent sexual intercourse.
prostate health and ejaculation

I've told my spouse that she's welcome to do her share to help me rise (so to speak) above my family history...

First there is no family history of colon cancer.

Every time I read a "not in my family" comment, I'm perversely relieved that my family medical history sucks.

Genetics loads the gun, but the environment pulls the trigger. If your family never pulled the trigger, then you've learned nothing about your genetic susceptibility. In addition, I've been exposed to dozens of environmental hazards over the years, and the reason I know this is because battalions of government agencies and litigious lawyers have told me about asbestos, ionizing radiation, atmosphere-control chemicals, and their ilk. But if you've never had that "benefit" of being informed, either, then how are you going to know when your life is at hazard?

I'd rather continue to have testing and seek knowledge.

When I need a decision, I'll "rational"ize it by subjecting it to a poll of the posters here.

One certain way to cut healthcare costs is not to do healthcare. Cutting our mammograms, PSA, PAP smears, Diabetes testing, blood pressure testing and colonoscopies would certainly reduce testing costs. Now the next logical step would be to reduce healthcare costs is to let everything just progress naturally, not treating either.
The message is essentially: "the number of lives lost by not PSA testing is not worth the cost of the testing.".

This sounds like it would raise the costs of hospice.

But I'm not sure. Let's try it on someone else's family members first...

It doesn't. It makes the whole process more expensive but more likely to be done.

So right now, we're carrying out selective evolution for people who are more likely to inflict colonoscopies on themselves, and the "demand" for virtual colonoscopies should literally die out in a few generations...

 

[meierlde]

Here is an article from CNN reporting that hospitals used free prostate screening to drum up more business. Prostate cancer screening's false promise - CNN.com
The hospital in question used the free screenings because they found that the 135 men who had the second stage payed for the screenings. I wonder how much much of the screenings, in particular the expensive ones are motivated by the fee for service system? Of course fee for service in principal is a conflict of interest.

 

[meierlde]

I
So right now, we're carrying out selective evolution for people who are more likely to inflict colonoscopies on themselves, and the "demand" for virtual colonoscopies should literally die out in a few generations...

Of course the question is the age of the person involved beyond the age of reproduction? when you die after that age it has no effect on evolution, your genes have either passed to offspring or not. May diseases that occur say after 50 have little evolutionary impact directly because the individuals affected have already reproduced. There might be a secondary effect in terms of helping or not helping the offspring, but is only secondary.

 

[lightspeed]

There seems to be the myth that treatment is life altering and leaves men impotent and incontinent on a regular basis. Everyone knows somebody that had a terrible time with treatment, but in reality most patients who undergo treatment are happy with their decision, whether it be surgery or radiation, and most would even choose the same treatment again when asked a year after treatment. The reality is, treatments are much better and safer than they were even 5 years ago. Permanent seed brachytherapy is an outpatient surgical procedure, patients are back to work in a day or two. IMRT is daily 10 minute appointments that patients can drive to every day. Robot assist prostatectomy requires 1 night hospitalization in most cases, and some surgeons are now considering sending patients home the same day. The terrible complications come from choosing the wrong treatment for a certain pt. Some are better suited for one type of treatment than others, and if treatment decision is individualized, there is very little risk of long-term, permanent life altering consequences. For example, for someone who is most concerned about sexual function, surgery may not be the best option. For someone with a large prostate and trouble urinating to begin with, I would not recommend seed implant, which causes a lot more long-term swelling. The problem is some doctors recommend only what they do.... usually they have a vested interested in their equipment, and that's when you get in trouble-- when you use one tool to fix all problems. Which is why second opinions are so important.

 

[Nords]

Of course the question is the age of the person involved beyond the age of reproduction? when you die after that age it has no effect on evolution, your genes have either passed to offspring or not. May diseases that occur say after 50 have little evolutionary impact directly because the individuals affected have already reproduced. There might be a secondary effect in terms of helping or not helping the offspring, but is only secondary.

Ooh, good point.

I keep forgetting that the Darwin Awards should be restricted to those who have not yet (knowingly) managed to procreate.

 

[Buckeye]

Although the annual PSA test is not recommended, isn't the annual DRE recommended?

Did we get to the annual PSA only because men don't like the annual DRE?

Is this a skill that has been lost or was never really good in a GP?