Re: 10% of PC deaths occur to men under the age of 65

[Guest guest]

Sam, What he says is accurate. He uses the word “occasionally” and this does not mean all. The men with the type of aggressive disease that he is talking about are not normally caught on a yearly PSA test. We do need better ways to identify aggressive cancers earlier and also to identify slow growing cancers so that appropriate men can be more comfortable delaying treatment. I have not looked at the percentage of men under 65 who die with prostate cancer but I thought the percentage was higher so if your percentage is correct, that could be good news. Means younger men with prostate cancer are living longer. I am sorry that you feel that you were ignored by local urologists. The age that screening should begin is a matter of great debate. If you want to be upset about anyone look at the screening recommendation that ACS publishes. Unless a man is at risk because he is part of an at risk group they recommend beginning screening at age 50. Or maybe be upset with USPSF who say there is a lack of evidence for screening at the current time. Rather than attacking one researcher it is more constructive to engage in working for clarification of guidelines and trying to get ACS more inline other organizational guidelines. Kathy From: ProstateCancerSupport [mailto:ProstateCancerSupport ] On Behalf Of Georgia SamSent: Tuesday, November 23, 2010 7:04 AMTo: prostatic-diseases-treatments; ProstateCancerSupport ; HCT-PCA Subject: 10% of PC deaths occur to men under the age of 65 There is something I find particularly irritating about the following statement hidden away in an otherwise good commentary on active surveillance (AS) [ Klotz L. Active surveillance for prostate cancer: patient selection and management. Curr Oncol. 2010 Sep;17 Suppl 2:S11-7. PubMed PMID: 20882126; PubMed Central PMCID: PMC2935703 -- http://www.ncbi.nlm.nih.gov/pubmed/20882126 ] " Of course, patients are occasionally diagnosed with advanced disease at a young age and die rapidly of aggressive prostate cancer. These outliers are likely not helped by screening because of time bias (screening tests preferentially identify slower growing cancers); they generally have high-grade disease at the outset and represent a very small proportion of prostate cancer patients. " This is actually dead wrong. About 10% of ALL prostate cancer fatalities will occur to men under the age of retirement (65).I know all about this because I was Dx'd at the age of 49 after being ignored by the local urologists. It has crossed my mind more than once that I was consistently ignored for nearly a year because they thought I would die pretty quickly anyway, and a follow-up to my referral and rapidly rising PSA was not worth the bother. Yes I feel angry with Klotz on behalf of all those young men with serious disease who he is proposing that we just ignore. On that count the Klotz article is very damaging and some redress must be made. I don't know how exactly, because comments like his will be taken up by cash strapped health care providers who are looking for ways to reduce overheads, such as costs of population screening. I guess men will have to become more knowledgeable about their own bodies, and INSIST on testing and obtaining a definitive diagnosis in spite of the doctors pooh-poohing them.To write off this group as Klotz appears to be doing is a travesty of science (they are not " outliers " they are 10% of PC deaths), and of fairness to these men (more than any other group they need definitive treatment). This is a group for whom screening, early detection and timely treatment will clearly produce benefits. The challenge is to devise ways for population screening that return less false positives (leading to overtreatment). However, to meet that challenge we must not dump the idea screening altogether at the cost to these men who seem doomed ! http://www.ncbi.nlm.nih.gov/pubmed/208821261. Curr Oncol. 2010 Sep;17 Suppl 2:S11-7.Active surveillance for prostate cancer: patient selection and management.Klotz L.Screening for prostate cancer using prostate-specific antigen (psa) has been appealing. However, the significant associated decline in prostate cancer mortality comes at the cost of a very high rate of diagnosis, and many patients with indolent, non-life-threatening cancer are exposed to the risk of significant side effects from radical treatment. Most men with favourable-risk prostate cancer are not destined to die of their disease, even in the absence of treatment. The challenge is to identify the subset that harbour more aggressive disease early enough that curative therapy is still a possibility, thereby allowing the others to enjoy improved quality of life, free from the side effects of treatment. This article reviews current research into active surveillance in favourable-risk disease and some of the issues that arise when prostate cancer is monitored rather than being treated immediately.PMCID: PMC2935703PMID: 20882126 [PubMed - in process]-- Sam.For your delectation and edification:-http://poetryfromtheprostrateyears.com/

[Guest guest]

> Georgia Sam wrote:

>

> There is something I find particularly irritating about the

> following statement hidden away in an otherwise good commentary

> on active surveillance (AS) [ Klotz L. Active surveillance for

> prostate cancer: patient selection and management. Curr Oncol.

> 2010 Sep;17 Suppl 2:S11-7. PubMed PMID: 20882126; PubMed

> Central PMCID: PMC2935703 --

> http://www.ncbi.nlm.nih.gov/pubmed/20882126 ]

>

> " Of course, patients are occasionally diagnosed with advanced

> disease at a young age and die rapidly of aggressive prostate

> cancer. These outliers are likely not helped by screening

> because of time bias (screening tests preferentially identify

> slower growing cancers); they generally have high-grade disease

> at the outset and represent a very small proportion of prostate

> cancer patients. "

>

> This is actually dead wrong. About 10% of ALL prostate cancer

> fatalities will occur to men under the age of retirement (65).

....

Sam,

I'm not sure, but I think Klotz may actually be agreeing with

you, or at least not disagreeing. I think he may be saying not

that screening is a bad idea but that it gives us misleading

information about results.

Let's take some extreme examples to show what he means by " time

bias " .

Patient A has an extremely aggressive cancer. His PSA is in

the normal range at time T1. Only six months later, at time

T2, his cancer has already gone metastatic. A PSA test given

any time before T1 would raise no alarm bells. A PSA test

given after T2 would ring the alarm, but is too late to save

him.

Patient B has a slow growing cancer. His PSA is normal at T1.

It begins to grow slowly due to a slow growing local cancer.

Over the next several years, his gradually rising PSA is high

enough to alert his doctor that something is happening, but

it's not too late to treat him. For any T2 up to several

years after T1, screening will work for him.

Due to this phenomenon, paradoxically, annual or bi-annual

screening works best for the guy with the more indolent disease.

It's not that it doesn't work for the aggressive cases, but it

doesn't work as well. It finds fewer of them in time to save

their lives. It also appears to work better than it does because

it identifies lots of men who will not die of cancer.

See: http://en.wikipedia.org/wiki/Length_time_bias

Now as for what to do about it, I'm not sure. Screening more

often is possible and reduces the time bias but that has negative

effects too.

Screen men who are too young and you will get only false

positives, not true ones. Screen men too often and you will get

lots of noise from prostatitis or other temporary non-cancer

factors. Screen them too old or too seldomly and you miss deadly

cancers.

I don't know the answer to the question. I don't think that pure

statistics can tell us.

Should 500 million airline passengers take off their shoes every

time they board a plane because one deranged and bumbling young

man had some kind of explosive in his shoe?

Should we all be scanned with x-rays or groped by guards because

another deranged young man had a bomb in his underwear?

Personally I like your own conclusion:

> The challenge is to devise ways for population screening that

> return less false positives (leading to overtreatment).

> However, to meet that challenge we must not dump the idea

> screening altogether at the cost to these men who seem doomed !

It's going to take a lot of additional basic science to get us

there.

Alan

[Guest guest]

Kath and Alan,

Thanks for your response. Just a quick reply. I am not going to copy

what you wrote because my text editor chops it about and messes it up

pretty badly. [ Its probably worth just going back to the original

text in the event anyone is interested.]

What I wanted to say was Kath, I had difficulty recognising my post in

your reply which I found quite stilted. Then I realised of course over

there you guys are suffering from a bad case of screening fatigue.

This is something we haven't experienced in the UK because for decades

the NHS has had a do-nothing policy toward population screening for

prostate cancer.

This has resulted in a worse prognosis for younger men with aggressive

disease. I can promise you it is not an " occasional " sort of thing -

all you need to do is look at the survival stats and see for yourself.

The UK has one of the worst records in the developed world for PC

survival.

You seem to be churning something over about how you deal with the

next round of screening stakes with your political masters. That is

not a problem in my neck of the woods where we have to come to terms

with under diagnosis and under treatment for lack of screening. I fear

that if there is too extreme a reaction then you'll end up with a

bunch of young guys left out in the cold for want of basic treatment.

Just a thought.

--

Sam.

For your delectation and edification:-

http://poetryfromtheprostrateyears.com/