Prostate cancer: LA Times commentary

[Guest guest]

From the Los Angeles Times

Opinion

Prostate cancer screenings: a second opinion

Doctors are rethinking the value of the tests because the disease is

rarely a killer and the treatment can do serious harm.

By H. Gilbert Welch

April 1, 2009

I probably have prostate cancer.

There's no need to feel sorry for me -- so do about half the men my

age (I'm in my mid-50s). We doctors have learned this from

microscopic examinations of the prostates of men who are autopsied

following an accidental death. And the older men get, the more likely

it is that they have prostate cancer. Autopsies of men in their 70s

have found that about 80% of them had the disease.

I almost certainly won't die from prostate cancer, however. The

lifetime risk of prostate cancer death for American males is only

about 3%. So, although the prevalence of the cancer may sound

alarming, 97% of men will die from something else.

These two observations have forced doctors to rethink what it means

to have this cancer. Some have envisioned the problem to be like an

iceberg. In the past, we only saw the part of the iceberg above the

waterline -- the cancers that caused disease and death. With early

detection, we can see below the waterline -- and there are a lot more

cancers there. Many of these will never cause problems. They would

have been better off undiagnosed.

But doctors can't tell who is better off undiagnosed. We can't

reliably distinguish between prostate cancers that will never cause

symptoms and those that are deadly. So we tend to treat everyone. The

bulk of men who are treated won't benefit from it, because there is

nothing to fix. But many of them will be harmed. Treatment causes

significant side effects in about 30% of those treated, most commonly

a decline in sexual function, leaking urine and/or rectal irritation.

That's why prostate cancer screening is such a challenging issue.

Yes, it may save some men's lives, but it will harm many others along the way.

Two weeks ago, we learned more. The results of two large, randomized

trials of prostate cancer screening were published. The studies

represented an enormous research effort: almost 20 years of work,

involving more than a quarter of a million men and many millions of dollars.

Yet there is still some uncertainty whether screening saves any

lives. The European study said yes; the U.S. study said no. That in

itself tells you something: If there is a benefit, it is undoubtedly

small. In contrast, researchers in the 1960s were able to

convincingly demonstrate the benefit of treating very high blood

pressure by studying about 150 men over a two-year period. Why were

they able to do this with so few men so quickly? Because the benefit was huge.

I believe there probably is a benefit to prostate cancer screening.

But it is accompanied by a substantial human cost. Let's assume the

European study is right. Its data give us some idea of the magnitude

of the trade-off: For every man who avoids a prostate cancer death,

about 50 are treated needlessly (some of my colleagues might say the

number is closer to 30, others might say it's closer to 100).

Being 50 times more likely to be diagnosed and treated needlessly

than being the one man who avoids a prostate cancer death doesn't

strike me as a good gamble. To the extent I have control over my

cause of death, avoiding a prostate cancer death isn't my top

priority (I'm more concerned about a lingering cognitive decline in a

long-term care facility.) And death is not the only outcome that

matters to me. I place considerable value on not being medicalized

and suffering the side effects of treatment any more than I need to.

But it doesn't matter what I think about the trade-off. What matters

is what you think.

American men have been engaged in prostate cancer screening for

almost two decades with relatively little effort given to

communicating the trade-off between the benefit and the potential

harm of unnecessary treatment. The time has come to make that

trade-off clear. There are a lot of bad arguments out there for

screening. They include:

* Doctors who tell you they don't want to go back to the era when all

their prostate cancer patients had advanced disease. It is true that

the typical prostate cancer patient in the past had advanced disease.

But we now know that the primary reason these patients now seem so

rare is that they are being diluted by the many new prostate cancer

patients who would have never been diagnosed in the past -- the

majority of whom had cancers that weren't destined to progress.

* Media messages that highlight the tremendous improvements in

survival. It is true that over the last 50 years, the five-year

survival for prostate cancer has increased more dramatically than any

other cancer (from less than 50% to almost 100%). But we now know

that these numbers too are largely an artifact of over-diagnosis --

diagnosing a lot of men with prostate cancer who were never destined

to die from the disease.

* Friends, family, acquaintances or celebrities who " owe their life "

to screening. There are now a lot of men who appear to be in this

group. But once you understand the problem of over-diagnosis, you

recognize an alternative explanation: They never needed treatment in

the first place. Some have labeled this the popularity paradox of

screening: The more over-diagnosis screening causes, the more people

who feel they owe it their lives and the more popular screening becomes.

There is no imperative to be screened, or not screened, for prostate

cancer. The only imperative is that men be informed about the

consequences of either choice.

H. Gilbert Welch is a professor of medicine at the Dartmouth

Institute of Health Policy and Clinical Practice. He is the author of

" Should I Be Tested for Cancer? Maybe Not and Here's Why. "

[Guest guest]

I will give another rather personal opinion in rebutal to the article.

In late July of 2005 I was diagnosed with advanced PCa at age 55.

PSA 419 with liver mets(confirmed with biopsy). Stage IV with a dismal

prognosis.Gleason 9.

I understand the author's theoretical opinion on the subject , and maybe from a

statistical point of view he is correct. On the other hand when one is in the

minority 3 % with advanced disease , it does make the prospect of having had

routine screening more attractive.

I'm on top of this disease now with God's help. I have no metastasis and a low

PSA currently , but the statistics say I should be in a pine box 6 ft

underground.

As one male to another , don't be a fool , have the screening !

>

> From the Los Angeles Times

>

> Opinion

>

>

> Prostate cancer screenings: a second opinion

>

> Doctors are rethinking the value of the tests because the disease is

> rarely a killer and the treatment can do serious harm.

> By H. Gilbert Welch

>

> April 1, 2009

>

> I probably have prostate cancer.

>

> There's no need to feel sorry for me -- so do about half the men my

> age (I'm in my mid-50s). We doctors have learned this from

> microscopic examinations of the prostates of men who are autopsied

> following an accidental death. And the older men get, the more likely

> it is that they have prostate cancer. Autopsies of men in their 70s

> have found that about 80% of them had the disease.

>

> I almost certainly won't die from prostate cancer, however. The

> lifetime risk of prostate cancer death for American males is only

> about 3%. So, although the prevalence of the cancer may sound

> alarming, 97% of men will die from something else.

>

> These two observations have forced doctors to rethink what it means

> to have this cancer. Some have envisioned the problem to be like an

> iceberg. In the past, we only saw the part of the iceberg above the

> waterline -- the cancers that caused disease and death. With early

> detection, we can see below the waterline -- and there are a lot more

> cancers there. Many of these will never cause problems. They would

> have been better off undiagnosed.

>

> But doctors can't tell who is better off undiagnosed. We can't

> reliably distinguish between prostate cancers that will never cause

> symptoms and those that are deadly. So we tend to treat everyone. The

> bulk of men who are treated won't benefit from it, because there is

> nothing to fix. But many of them will be harmed. Treatment causes

> significant side effects in about 30% of those treated, most commonly

> a decline in sexual function, leaking urine and/or rectal irritation.

>

> That's why prostate cancer screening is such a challenging issue.

> Yes, it may save some men's lives, but it will harm many others along the way.

>

> Two weeks ago, we learned more. The results of two large, randomized

> trials of prostate cancer screening were published. The studies

> represented an enormous research effort: almost 20 years of work,

> involving more than a quarter of a million men and many millions of dollars.

>

> Yet there is still some uncertainty whether screening saves any

> lives. The European study said yes; the U.S. study said no. That in

> itself tells you something: If there is a benefit, it is undoubtedly

> small. In contrast, researchers in the 1960s were able to

> convincingly demonstrate the benefit of treating very high blood

> pressure by studying about 150 men over a two-year period. Why were

> they able to do this with so few men so quickly? Because the benefit was huge.

>

> I believe there probably is a benefit to prostate cancer screening.

> But it is accompanied by a substantial human cost. Let's assume the

> European study is right. Its data give us some idea of the magnitude

> of the trade-off: For every man who avoids a prostate cancer death,

> about 50 are treated needlessly (some of my colleagues might say the

> number is closer to 30, others might say it's closer to 100).

>

> Being 50 times more likely to be diagnosed and treated needlessly

> than being the one man who avoids a prostate cancer death doesn't

> strike me as a good gamble. To the extent I have control over my

> cause of death, avoiding a prostate cancer death isn't my top

> priority (I'm more concerned about a lingering cognitive decline in a

> long-term care facility.) And death is not the only outcome that

> matters to me. I place considerable value on not being medicalized

> and suffering the side effects of treatment any more than I need to.

>

> But it doesn't matter what I think about the trade-off. What matters

> is what you think.

>

> American men have been engaged in prostate cancer screening for

> almost two decades with relatively little effort given to

> communicating the trade-off between the benefit and the potential

> harm of unnecessary treatment. The time has come to make that

> trade-off clear. There are a lot of bad arguments out there for

> screening. They include:

>

> * Doctors who tell you they don't want to go back to the era when all

> their prostate cancer patients had advanced disease. It is true that

> the typical prostate cancer patient in the past had advanced disease.

> But we now know that the primary reason these patients now seem so

> rare is that they are being diluted by the many new prostate cancer

> patients who would have never been diagnosed in the past -- the

> majority of whom had cancers that weren't destined to progress.

>

> * Media messages that highlight the tremendous improvements in

> survival. It is true that over the last 50 years, the five-year

> survival for prostate cancer has increased more dramatically than any

> other cancer (from less than 50% to almost 100%). But we now know

> that these numbers too are largely an artifact of over-diagnosis --

> diagnosing a lot of men with prostate cancer who were never destined

> to die from the disease.

>

> * Friends, family, acquaintances or celebrities who " owe their life "

> to screening. There are now a lot of men who appear to be in this

> group. But once you understand the problem of over-diagnosis, you

> recognize an alternative explanation: They never needed treatment in

> the first place. Some have labeled this the popularity paradox of

> screening: The more over-diagnosis screening causes, the more people

> who feel they owe it their lives and the more popular screening becomes.

>

> There is no imperative to be screened, or not screened, for prostate

> cancer. The only imperative is that men be informed about the

> consequences of either choice.

>

> H. Gilbert Welch is a professor of medicine at the Dartmouth

> Institute of Health Policy and Clinical Practice. He is the author of

> " Should I Be Tested for Cancer? Maybe Not and Here's Why. "

>

>