NCI: 5 of 6 Men May Not Need Treatment for Pca

Dear All,

Somebody brought up a topic a few days ago which may have very
significant implications for a lot of people, so I think it deserves
its own post. I am referring to a msg which referenced an abstract
from Urology Times about Gleason scores trending upward over the
years. The article referred to a study by the NCI in which researchers
took slides of diagnostic prostate tissue from former patients and
examined how they had been classified originally (between 1990-92),
and then gave them to pathologists to grade in 2002-2004 The study
showed that the average gleason score had gone from a 5.9 to a 6.8, a
difference of .85, almost a whole percentage point.

This is what some researchers call "grade migration" or "grade
inflation". In other words, the biological composition of the cancers
that are being examined has not changed, but the ratings have. This
phenomenon is real, and it has implications in a number of areas, most
relating to newly diagnosed patients. It may concern:

* your long-term prognosis, possibly
* the way you and your doctor evaluate treatment decisions
* your decision whether to have treatment at all
* the information from the studies you and your doctor rely on

I got my info from an article in the Journal of the National Cancer
Institute, which originally reported this study. ("Prostate Cancer
and the Will Rogers Phenomenon", Albertsen, et al, Journal of NCI,
Vol. 97, No. 17, 9/7/05.)

http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=abstract

This paper outlines the basic facts. But what I would like to
communicate to you is info from an editorial in that same issue of the
NCI Journal about the subject discussed. (Editorial, "Stage
Migrations and Grade Inflation in Prostate Cancer: Will Rogers Meets
Garrrison Keillor", Thompson, et al, JNCI, 2005...)

http://jnci.oxfordjournals.org/cgi/c...ull/97/17/1236

Here are some conclusions that from the NCI study:

1) A subset of people, mostly those currently diagnosed with G6 or
(to a lesser extent) G7-grade tumors, will have a more optimistic long-
term prognosis when using older nomograms, such as the Partin Tables.

2) Because "grade inflation" has occurred, the clinical outcomes of
treatments reported for Pca patients today may be misleading. For
example: a tumor that 30 years ago was rated a 5 is now most likely
rated a 6 (Grade 5's almost never appear in clinical practice today,
acc. to the authors), *in spite of the tumor being histologically
equal* (fancy term for the tumors being the same), this will distort
the picture, because there will be an equal long-term survival rate
for a G6 and a G5. Therefore, it would appear that outcomes are
improving. However, this is an artificial result.

3) The good news is that survival rates for *all tumor grades* have
increased. I am looking at a chart of these outcomes, and I see a
significant increase in the 8's and a dramatic increase in long-term
survival for the 10's.

Where I am going with all this is that Gleason grade inflation and
it's consequences have led to an "insidious" overdiagnosis and
overtreatment of patients, according to the authors of the JNCI
editorial. I will let the experts do the talking. Here are the
excerpts (my comments in brackets).

[Artificially High Outcomes for Recent Tx]

Why does grade inflation in prostate cancer matter? There are two
reasons. First, although this methodology is utterly invalid,
investigators frequently compare results of treatments between two
series of patients, whether examining improvements over time with a
specific therapeutic modality or making comparisons between
modalities.

**If assignment of Gleason score is changing over time, then, given
that tumor grade has an overwhelming impact on outcome, it is obvious
that any more *recent* treatment will demonstrate improved outcomes
due simply to grade inflation. Thus, if there are any differences in
*years of diagnosis* of patients, such a comparison will be fatally
flawed.**

[Overdetection and Overtreatment]

..**We are more concerned that grade inflation is a component of the
more insidious phenomena of overdetection and overtreatment of
prostate cancer.**

Currently, about 50% of men in the United States have a prostate-
specific antigen (PSA) test annually, and about 75% of men have had a
PSA test. [From NCI report: Since the arrival of the PSA test, "the
reported incidence of low-grade cancers has declined. And even though
most men now present with localized disease, their tumors are rarely
graded < 6 ". So tumor grades are rising even though people are
being diagnosed (much) earlier.]

*Despite a 3%-4% lifetime risk of prostate cancer death, more than 17%
of men in the United States will be diagnosed with prostate cancer
during their lifetime.*

By contrast, the lifetime risk of being diagnosed with prostate cancer
in the 1970s was about 10%.

What has fueled this dramatic increase in diagnosis?

[Are tumors significant?]

Certainly, since 1985, the primary impetus has been PSA testing.
Previously it was axiomatic that, whereas autopsy studies showed high
rates of prostate cancer in men who died of other causes, prostate
biopsy simply did not detect these small tumors.

**With the publication of the results of the PCPT study ("Prevalence
of Pca Among Men with PSA <4", NEJM, 2004, abstract is free), ... most
authorities recognized that clinically insignificant cancers are
indeed found with prostate biopsy **(10).

[90% of Men with Organ-Confined Pca Get Treatment]

** One large cohort study has found that more than 90% of men with
organ-confined prostate cancer currently opt for treatment (11).

[**5 out of 6 men may not need treatment**]

* With growing data that as many as five of every six men diagnosed
with prostate cancer (i.e., a 3% risk of death but a more than 17%
risk of diagnosis) may not need treatment and the evidence that
treatment adversely affects quality of life, why is it that so many
men opt for treatment?*

*One reason may be our risk-averse society. (We put labels on to-go
coffee cups that say "don't spill this on you-this beverage is hot.")

[Watchful Waiting Comparing Historical Gleason Scores is Inaccurate?]

* Another reason, however, may be the application of outcomes of
watchful waiting for prostate cancers of decades ago to a patient's
tumor today with its current Gleason score.

For example, a common reference in counseling patients is a previous
report from Albertsen (12). In that study, 767 men diagnosed with
prostate cancer between 1971 and 1984 were watched without treatment.
The primary determinants of risk of cancer death were age and Gleason
score, with risk of cancer death for a Gleason 2-4 tumor being 4%-7%
at 15 years compared with 42%-70% for a Gleason 7 tumor (12).

[I'm not sure what they mean. Are the old tumor grades still
meaningful? Practically speaking, the 2-5 category does not exist
today. The actual average increase over time for *all* tumor grades
has been .85; they have increased by almost a percentage point.
However, "this does not" apply across the board; mostly it affects the
lower-grade ca's))]

Similar conclusions have been reached in other series (13)

*The application of these historic outcomes to today's patient almost
certainly leads to a greater propensity for active treatment in lieu
of surveillance.*

[Unreliable Info?]

* Albertsen et al. have successfully drawn our attention to the
complexity of interpreting prostate cancer outcome data with their
demonstration that comparisons of outcomes among different groups of
patients receiving different treatments at different institutions and
over different periods will be fraught with very serious errors and
are fundamentally unreliable.

[Scarcity of Information for Patients Dx]

What is the answer to this morass of data that is faced by a quarter
of a million men in the United States annually? The mundane question
of "Doctor, what is the best treatment for my cancer?" (a question
that will not go away in the next 20 years) will be answered only
through clinical trials.

[Improved Outcomes for RP Px]

*One of these trials was recently completed; it demonstrated improved
survival and reduced risk of prostate cancer death with radical
prostatectomy compared with surveillance *(14).

These benefits must be balanced against changes in urinary and sexual
function with treatment

**and the recognition that 10-year data show that the number of
individuals needed to treat to prevent one adverse outcome ranges from
4 to 20.

[If I understand this correctly, it is mindblowing! It means that to
save one man's life (prevent adverse outcome), 4-20 men will be
needlessly treated.]

[Most Studies Focus on *High-Risk* Subjects]

Other trials are ongoing, but many more are needed because most have
focused on high-risk subjects-an important group-but one that
represents the **minority of patients currently diagnosed in the
United States.

*One key focus must be the development of large studies to track men
over time, merging pathologic and clinical data with

[The Future: Biomarkers to Pinpoint Pts Who Will Benefit from
Treatment]

What they really need to focus on is identifying ** biomarkers of
tumor aggressiveness to ultimately predict which tumor requires
treatment and which treatment is optimal for a specific tumor. **

Will Rogers mused about the effects of Okies migrating to California
on the average intelligence in both states. Garrison Keillor reflected
on Lake Wobegon, "where all of the women are strong, the men are good
looking, and the children are above average." Against the backdrop of
the growing challenges of prostate cancer, perhaps our current
assessment might be,

***"That's where we are in the United States today, where all the
biopsies are necessary and all cancers require treatment, as all have
Gleason scores above 5."***

Good Luck to you All.

Leah

I'd be very curious to hear our mathematician's (Leonard's) take
on this study.

The big question that comes to my mind is: If only one out of
five or six men diagnosed will die of the disease, does that mean
that only that one needed treatment?

Here are some countervailing factors:

1. A man was not treated, developed symptoms, including painful
and debilitating symptoms, but died of something else before the
cancer could kill him. Would he have been better off with
treatment?

2. A 65 year old man is diagnosed. He would have died of cancer
at age 80, but suffered a heart attack and dies at 75. However
he didn't know he would suffer a heart attack and hoped to live
to 85 or 90. Should he have sought treatment at age 65?

3. Two men are diagnosed with identical Gleason at age 60. Both
have the same PSA doubling rate at the time of diagnosis. Both
have the same staging. 15 or 20 years later, one dies of
prostate cancer and the other is still relatively healthy. But
there was no way to tell which one would die since their disease
markers were the same (I presume this happens.) What should have
been done?

I guess what I'm getting at is, If we can't tell whether we would
die of something else before we had a chance to die of prostate
cancer, and if we know that definitive treatment must be
undertaken at an early stage or never, what should we do?

A lot must depend on our personal assessment of our future, our
odds, and our fear (or lack thereof) of the side effects of
treatment.

Knowing that the odds are good that many of us would die of
something else before our cancer killed us helps us make a more
informed choice, but it doesn't point clearly to the correct
decision.

Alan

"Alan Meyer" wrote in message
news:EfWdnVyxYa6JL1vYnZ2dnUVZ_vCknZ2d@comcast.com. ..

>
> I'd be very curious to hear our mathematician's (Leonard's) take
> on this study.
>
> The big question that comes to my mind is: If only one out of
> five or six men diagnosed will die of the disease, does that mean
> that only that one needed treatment?
>

Well, I'm not a mathemetician but this study is beginning to sound a lot
like a societal cost/benefit analysis of the subject. If "society" spends
the money to treat six men to only save one, how much is that one life worth
to "society" (not to the man or the man's family)? Is is cheaper "overall"
to not treat all six. Is this where all this is headed?
--
JerryW

Please respond to group; email address is not valid

2/11/04 PSA 2.6, Suspicious DRE (age 62)
2/23/04 Biopsy: Gleason 3+4=7, T2a, left lobe
5/18/04 RRP, Path: Gleason 4+3=7, T2c, both lobes
Fully continent by 9/04
PSA <0.1 since

I agree with you Alan.
I do however have to say this has been the hardest health decision of my
life.
When my artery plugged I got a stent. No indecision or second thoughts.
With this I've decided to go with the Da-Vinci, but it has been very
difficult to sort thrugh all of the different claims and numbers.
Thank God for the internet and all the kindhearted people posting their
experiences.

Ron
Alan Meyer" <ameyer2@yahoo.com> wrote in message
news:EfWdnVyxYa6JL1vYnZ2dnUVZ_vCknZ2d@comcast.com. ..
>
> I'd be very curious to hear our mathematician's (Leonard's) take
> on this study.
>
> The big question that comes to my mind is: If only one out of
> five or six men diagnosed will die of the disease, does that mean
> that only that one needed treatment?
>
> Here are some countervailing factors:
>
> 1. A man was not treated, developed symptoms, including painful
> and debilitating symptoms, but died of something else before the
> cancer could kill him. Would he have been better off with
> treatment?
>
> 2. A 65 year old man is diagnosed. He would have died of cancer
> at age 80, but suffered a heart attack and dies at 75. However
> he didn't know he would suffer a heart attack and hoped to live
> to 85 or 90. Should he have sought treatment at age 65?
>
> 3. Two men are diagnosed with identical Gleason at age 60. Both
> have the same PSA doubling rate at the time of diagnosis. Both
> have the same staging. 15 or 20 years later, one dies of
> prostate cancer and the other is still relatively healthy. But
> there was no way to tell which one would die since their disease
> markers were the same (I presume this happens.) What should have
> been done?
>
> I guess what I'm getting at is, If we can't tell whether we would
> die of something else before we had a chance to die of prostate
> cancer, and if we know that definitive treatment must be
> undertaken at an early stage or never, what should we do?
>
> A lot must depend on our personal assessment of our future, our
> odds, and our fear (or lack thereof) of the side effects of
> treatment.
>
> Knowing that the odds are good that many of us would die of
> something else before our cancer killed us helps us make a more
> informed choice, but it doesn't point clearly to the correct
> decision.
>
> Alan
>

On Feb 4, 11:30?pm, "Alan Meyer" <amey...@yahoo.com> wrote:
> I'd be very curious to hear our mathematician's (Leonard's) take
> on this study.
>
By all means. And maybe you could corner some of the nerdy types at
the NCI and ask for their help? (Was going to append a note saying, I
did my best but don't rely on me, but people here already know I am
not a scientist.) I am going to post this in my other PC forums
because I know there are quite a few scientific types out there. They
all came out of the woodwork when people were arguing over whether 1
cc is equal to 1 mg (I think so), to lament the miserable state of
science education in this country and to bemoan the end of
civilization as we know it. But the full text of these articles is
available on line and I suggest ordinary mortals might want to read it
as well.

Leah

On Feb 5, 10:21�am, "JerryW" <jer...@seemysig.net> wrote:
> "Alan Meyer" *wrote in message
>
> news:EfWdnVyxYa6JL1vYnZ2dnUVZ_vCknZ2d@comcast.com. ..
>
> > Well, I'm not a mathemetician but this study is beginning to sound a lot
> like a societal cost/benefit analysis of the subject. If "society" spends
> the money to treat six men to only save one, how much is that one life worth
> to "society" (not to the man or the man's family)? Is is cheaper "overall"
> to not treat all six. Is this where all this is headed?
> --
> JerryW

There is no question that money is a big part of the "to screen or not
to screen" debate and that those who are against it are willing to
sacrifice some people. But I really don't think that's what the NCI
study is focusing on. What I take out of this is, that instead of
treating everybody (including those who may not need it) we should
direct our collective resources to treat the sicker/sickest men who
need it the most".

Leah

JerryW wrote:

> Well, I'm not a mathemetician but this study is beginning to sound a lot
> like a societal cost/benefit analysis of the subject. If "society" spends
> the money to treat six men to only save one, how much is that one life worth
> to "society" (not to the man or the man's family)? Is is cheaper "overall"
> to not treat all six. Is this where all this is headed?

Apparently, as evidenced by some HMOs' and gum'mint health care plans'
increasing tendencies to challenge big-ticket care for older or terminal
patients.

I.P.

> Dear All,

I just came across this, and thought it offered yet another
perspective on the difficulty of diagnosing and treating PC -- from
the British medical profession. I think these doctors are right on
the mark when they suggest that a multi-disciplinary approach should
be standard procedure. Hallelujah!

Sent: Monday, February 05, 2007 2:31 AM

Subject: [ProstateCancerSupport] Call for better prostate cancer
guidelines

Publisher: Ian Morgan
Published: 04/02/2007 - 11:05:07 AM

Taking the right decision is critical for patients

Better guidelines are needed to improve the treatment of men with
locally advanced prostate cancer, say researchers.

A survey of specialists found that strategies for managing this
vulnerable group of patients varied widely across the UK.

There were also differing opinions about the definition of locally
advanced prostate cancer (LAPC).

About a third of men diagnosed with prostate cancer have a tumour that
has started to break out but not yet spread to other parts of the
body.

Taking the right decision is critical for these patients, and can have
a major impact on survival.

A number of different approaches can be taken to treat LAPC, involving
both oncologists and surgeons.

They include "watchful waiting" - a system of careful monitoring
employed when a cancer is progressing slowly - radiotherapy, removal
of the prostate gland (radical prostatectomy) and hormone therapy.

The survey, which questioned 155 practising cancer specialists and
urologists, found that over half recognised the need for both to share
treatment decisions within multi-disciplinary teams.

However, almost as many still expected their own speciality to be
solely in charge.

A total of 41% of oncologists and 17% of urologists insisted that they
should take primary responsibility.

Although radiotherapy was considered the optimum treatment by most of
those questioned, 22% of urologists thought surgery was better.

Most favoured using drugs such as Zoladex that block production of the
male hormone testosterone in conjunction with radiotherapy. But there
was "significant variation" in the preferred duration of hormone
treatment and in the radiotherapy dose.

Oncologist Dr Heather Payne, from University College Hospital London,
and urologist David Gillatt, from Southmead Hospital, Bristol,
reported their findings in BJU International, the official journal of
the British Association of Urological Surgeons.

They wrote: "This survey suggests that there are still wide variations
in the management practices for locally advanced prostate cancer in
the UK, and between urologists and oncologists.

"Improved consensus guidelines are required."

The survey found that virtually every specialist taking part gave a
different definition of locally advanced prostate cancer.

They included different tumour staging combinations, aggressiveness
measurements, and other diagnostic signs such as the pre-treatment
level of the blood test marker PSA.

"This suggests a need for clearer definitions of LAPC," the authors
wrote.

Prostate cancer is the most common male cancer in Britain. Each year
32,000 UK men are diagnosed with the disease, and more than 10,000 die
from it.

Chris Hiley, head of policy and research at The Prostate Cancer
Charity, said: "This survey quantifies important areas of uncertainty
in treatment that have worried doctors and their patients for some
time. The lack of consensus reported in this survey is what we'd
expect given the lack of good enough evidence that clinicians can draw
on, when deciding when and how best to intervene when prostate cancer
reaches this stage.

"Although some progress is being made, what men with prostate cancer
really need is more research into the treatment of locally advanced
prostate cancer to enable doctors to know when, and how best to
intervene in order to maximise the treatments' effectiveness and
reduce its side effects.

"In the meantime, this survey reminds us of the importance of multi-
disciplinary team working and good communication and guidance in the
management of locally advanced prostate cancer."

Copyright Press Association 2007

http://www.24dash.com/health/16061.htm




Mon Feb 5, 2007 2:40 pm


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Alan Meyer wrote:


SNIP

All those looks back from the year 2040 change the statistics and are
thus strictly mathematical exercises.

> I guess what I'm getting at is, If we can't tell whether we would
> die of something else before we had a chance to die of prostate
> cancer, and if we know that definitive treatment must be
> undertaken at an early stage or never, what should we do?

Just what we do now: do our homework, prioritize the potential outcomes
and their likelihoods, and choose our poison(s).

I.P.

On 04 Feb 2007, you wrote in alt.support.cancer.prostate:

> Dear All,
> [snip]
The study
> showed that the average gleason score had gone from a 5.9 to a 6.8, a
> difference of .85, almost a whole percentage point.
>
> This is what some researchers call "grade migration" or "grade
> inflation". In other words, the biological composition of the cancers
> that are being examined has not changed, but the ratings have. This
> phenomenon is real, and it has implications in a number of areas, most
> relating to newly diagnosed patients. It may concern:
>
> * your long-term prognosis, possibly
> * the way you and your doctor evaluate treatment decisions
> * your decision whether to have treatment at all
> * the information from the studies you and your doctor rely on
>

The upward movement in the GS is not alarming from my viewpoint except
where certain threshholds are passed. For example, A GS of 5 migrating to a
GS of 6 is not necessarily the end of the world. I don't think there is a
lot of difference between a 3+2 or a 3+3.The 3+2 might be more significant
if it is 3(51%)+2(49%) then 3(95%)+2(5%).
However, there is a big difference between a GS of 6 and the upward
movement to a GS of 7. Likewise I think the same can be said for a movement
from GS7 to GS8-10.
In Ontario where I live, we tend to depend upon OHIP(our medicare) to cover
expenses in a moajority of cases, even though many have separate plans
through work etc. If you are depending on OHIP then, a migration from GS6
to GS7 isa very important in that, here, you cannot get free coverage for
seeds (or brachytherapy) if the GS is higher than 6. A migration of GS in
this sense would eliminate one possible treatment option for these men.
[snip]
>
>
>
> Why does grade inflation in prostate cancer matter? There are two
> reasons. First, although this methodology is utterly invalid,
> investigators frequently compare results of treatments between two
> series of patients, whether examining improvements over time with a
> specific therapeutic modality or making comparisons between
> modalities.

Yes, I agree. Robotic laproscopic surgeons want their product to look the
best. Lapros theirs. Good old open RP uro's still maintain their
method is the 'gold standard' treatment. Radiologists theirs. Brachy
theirs. Oh, yeah, cryo's do too and now there are the HIFU's, can't forget
them.By the way, they all say don't forget to pay the bill on your way out.
Thanks.

> [Overdetection and Overtreatment]
>
> .**We are more concerned that grade inflation is a component of the
> more insidious phenomena of overdetection and overtreatment of
> prostate cancer.**
>
> Currently, about 50% of men in the United States have a prostate-
> specific antigen (PSA) test annually, and about 75% of men have had a
> PSA test. [From NCI report: Since the arrival of the PSA test, "the
> reported incidence of low-grade cancers has declined. And even though
> most men now present with localized disease, their tumors are rarely
> graded < 6 ". So tumor grades are rising even though people are
> being diagnosed (much) earlier.]
>
> *Despite a 3%-4% lifetime risk of prostate cancer death, more than 17%
> of men in the United States will be diagnosed with prostate cancer
> during their lifetime.*
>
> By contrast, the lifetime risk of being diagnosed with prostate cancer
> in the 1970s was about 10%.
>
> What has fueled this dramatic increase in diagnosis?

Hmmmm, it would be interesting if we would be reading the same comments and
points if this article had been about breast cancer instead? (with no
disrespect to the ladies)
>
> [Are tumors significant?]
>
> Certainly, since 1985, the primary impetus has been PSA testing.
> Previously it was axiomatic that, whereas autopsy studies showed high
> rates of prostate cancer in men who died of other causes, prostate
> biopsy simply did not detect these small tumors.
>
> **With the publication of the results of the PCPT study ("Prevalence
> of Pca Among Men with PSA <4", NEJM, 2004, abstract is free), ... most
> authorities recognized that clinically insignificant cancers are
> indeed found with prostate biopsy **(10).

Unfortunately,there are more and more men with PSA <4 being diagnosed with
PCa. These 'clinically insignificant'cancers are only insignificant if a)
20 years down the road you are still with us, the PSA is under control, and
you have absolutely no signs of an active PCa; or b) you're the one doing
the statistics, but not the one with the cancer.

>
> [90% of Men with Organ-Confined Pca Get Treatment]
>
> ** One large cohort study has found that more than 90% of men with
> organ-confined prostate cancer currently opt for treatment (11).

Key word here is 'opt'!
>
> [**5 out of 6 men may not need treatment**]
>
> * With growing data that as many as five of every six men diagnosed
> with prostate cancer (i.e., a 3% risk of death but a more than 17%
> risk of diagnosis) may not need treatment and the evidence that
> treatment adversely affects quality of life, why is it that so many
> men opt for treatment?*
>
> *One reason may be our risk-averse society. (We put labels on to-go
> coffee cups that say "don't spill this on you-this beverage is hot.")

How about - 'Damn I'v got it, I don't want it so get it out!!!' What about
age - As stated before much younger men are being diagnosed (I had a GS7 at
58), and, regardless of any statistics, the odds of living longer by trying
to do something about lessening the PCa inside you seems awfully tempting,
regardless of the SE's.

[snip]

> What is the answer to this morass of data that is faced by a quarter
> of a million men in the United States annually? The mundane question
> of "Doctor, what is the best treatment for my cancer?" (a question
> that will not go away in the next 20 years) will be answered only
> through clinical trials.

IMO, until the clinical trial boys can come up with a definitive way to
determine whether or not a PCa of any GS is presently or going to be
aggressive, I would think that all of the treatments mentioned above will
be offered as a treatment.

> **and the recognition that 10-year data show that the number of
> individuals needed to treat to prevent one adverse outcome ranges from
> 4 to 20.
>
> [If I understand this correctly, it is mindblowing! It means that to
> save one man's life (prevent adverse outcome), 4-20 men will be
> needlessly treated.]

No, it doesn't say that. What it says is that 4-20 men CHOSE to be treated
when, in fact, they may not have needed to be. They CHOSE what they thought
was the best for them. For me the choice was simple, 'which treatment is
right for me?'.(As it turned out, I was NOT one of the 4-20, but 1,2 or 3)

[snip]

> What they really need to focus on is identifying ** biomarkers of
> tumor aggressiveness to ultimately predict which tumor requires
> treatment and which treatment is optimal for a specific tumor. **

Absolutely!!

> ***"That's where we are in the United States today, where all the
> biopsies are necessary and all cancers require treatment, as all have
> Gleason scores above 5."***
>
> Good Luck to you All.
>
> Leah

Unfortunately that is the case. In fifty years or so, there might be a shot
you can can take along with the measles and the flu that will prevent all
men from getting this unwanted beast (and women breast cancer). I know that
they are working on it. Until then, each man must decide what is best for
him - treat or not. If treat - then what treatment? In the end though,
regardless of GS, the patient should still get the right to decide.

Conrinued good results!

Russ