On Jun 16, 2:03 pm, safire <saf...@telenet.com> wrote:
> Kadafi wrote:
> > Article in 6/15 NY Times titled
>
> > "New Take on a Prostate Drug, and a New Debate"
>
> > "http://www.nytimes.com/2008/06/15/health/15prostate.html?_r=1&sq=pros..."
>
> > Here is a quote of the first several paragraphs of the article which
> > talks about Proscar (Finasteride). Actually, I think Proscar has been
> > around for a while so the drug is not new but the conclusions in the
> > article may be new.
>
> Not just "not new"; Proscar's patent protection has expired. That's why
> it's available as a generic.
>
>
>
>
>
> > "For the first time, leading prostate cancer specialists say, they have
> > a drug that can significantly cut men’s risk of developing the disease,
> > dropping the incidence by 30 percent.
>
> > But the discovery, arising from a new analysis of a large federal study,
> > comes with a debate: Should men take the drug?
>
> > Prostate cancer is unlike any other because it is relatively
> > slow-growing and while it can kill, it often is not lethal. In fact,
> > most leading specialists say, a major problem is that men are getting
> > screened, discovering they have cancers that may or may not be
> > dangerous, and opting for treatments that can leave them impotent or
> > incontinent.
>
> > So should healthy men take a drug for the rest of their lives to avoid
> > getting and being treated for a cancer that, most often, would be better
> > off undiscovered and untreated? Is it worth risking a chance that
> > unanticipated side effects may emerge years later if millions of men
> > with no prostate problems take the drug?
>
> > Some prostate cancer experts say the answer is yes. Any man worried
> > enough about prostate cancer to be screened might consider it, they say.
>
> > The drug, finasteride, is available as a generic for about $2.00 a day,
> > and millions of men safely take it now to shrink their prostates, its
> > approved use. "
>
> Your quote did not include the opinion of Dr. Christopher Logothetis, of
> the M.D. Anderson Cancer Center: “Most of the time, treatment wouldn’t
> help and may not be necessary. But the reality is that people are being
> operated on.” Note what he says: "most of the time". Does that mean
> that for every ten patients treated, at least five are treated
> unnecessarily?
The article in the Sunday Times was by Gina Kolata, who has been
writing what I consider biased articles about prostate cancer for
years. She has a tendency to quote skeptics about the value of PSA
testing and treatment for early prostate cancers as though they
represented the consensus among experts on the subject. In the
current article, there is the quote from Logothetis, which I certainly
think is misleading at best and a total misrepresentation at worst.
She also quote Albertsen, who was once a leading authority, but I
think it is questionable as to whether he still is. he has
increasingly become skeptical about PSA testing and treatment,
although his own data, I think, doesn't really support his
conclusions. She also quote Scardino, but not about the issues that
the other quotes raise.
Except for this bias, the article does address a real quandary about
the use of finasteride as a means to decrease the risk of prostate
cancer. Earlier studies had found that finasterise decreased the
overall risk of porstate cancer but appeared to increase the risk of
aggressive cancer. That made it something of a bad bargain as a way
of avoiding prostate cancer---Scardino had previously raised that
point. But the current, more careful study, showed that finasteride
decreased the risk for all types of PC by aobut 30 percent. In the
article she mentions that whereas originally Scardino though the use
of finasteride was a mistake, he now thinks that it may be a good
idea.
But still questions remain. The problem is, as usual, that PC is a
very complex disease, and one difficulty is that Kolata doesn't
understand the complexities.
Let me go through the relevant issues.
First there is the question of whether or not early PC needs to be
treated. Statments that in the great majority of cases it need not
be, while literally ture, are highly misleading. There is no
evidence whatsoever that I've ever seen that proves that prostate
cancer won't eventually kill you PROVIDED YOU DON'T DIE OF SOMETHING
ELSE FIRST, and of course before that it will seriously affect your
life either directly or because of the side effects of HT, the only
currently accepted treatment for metastatic PC that has moved to
distant sites.
A large number of PC cases are detected in older men, many of whom die
before the PC can seriously impact their lives. So it may be
literally true that most men "die with the disease rather than of the
disease", but the question for any man so diagnosed is whether or not
he is one of "most men" for that purpose. If he has a life
expectancy exceeding ten years, he probably isn't. Presently, there
seems to be aconsensus among urologists at least that men with life
expectancies of more than ten years should be treated, either by
surgery or radiation in an attempt to cure the disease. I know of
no current evidence which has proved that to be false. If any thing,
the recent Swedish studies show that even somewhat older men are
better off with RP than with WW.
There are of course some men who are being treated needlessly for PC,
but again there hasn't been any conviincing evidence establishing how
many such cases there are. I've seen estimates of 15 percent to 40
percent. More important, a specific man has to decide what the odds
are for him, since, again, he may not be "most men". For example, at
age 67, I had a T1c, PST 4.5, Gleason 7 = 3+4 diagnosis. I was in
good health and thus a candidate for treatment. The lower PSa
suggested a lower isk of developing metastatic disease any time soon,
but the Gleason 7 suggested it was high enough that it was a risk I
didn't want to take, e.g., Albertsen's results show that a Gleason 7
case like mine can easily metastasize within 5-10 years. I have gone
now 8 of those 10 years, and I am still going strong, so estimates of
my life expectancy were accurate. The treatment has been successful
in that my PSA so far remains undetectable, and the side effects
haven't made that much difference to my life, i.e., I am not
incontinent, and i can get erections when needed with
Viagra,
sometimes even without it. . But I won't say the treatment has been
totally cost free. Since it is entirely possible that my cancer would
have never have become a problem, I might have been better off doing
nothing. That is not something I spend time worrying about.
The problem with the skeptical attitude, reflected by Kolata in her
articles, is that it looks at the situation only from the point of
view of a public health authority trying to make a decision about
costs and benefits about a policy. But that is a very different
question from how things look from the perspective of an individual
man. The argument goes something like thiss. If a case is
detected, it will invariably be treated. I question that since it
assumes men can't make rational deicisons and that doctors will always
overtreat given the choice. I think it is far better to try to
educate both physicians and patients about the issues and hope they
will make rational decisions than to preclude their having the
opportunity to do so. They then assert that the majority of cases
detected didn't really need treatment, but as I've noted above, no
current research established that except for older men. They then go
on to exaggerate the possible side effects of treatment, and they
conclude that the harm will exceed the benefit, and so the policy
should be rejected. As I've pointed out there are several impoortant
gaps in this argument. It does show that most older men---and the
defintion of "older" keeps progressing---probably shouldn't be treated
aggressively for prostate cancer, and perhaps should not even be
tested. Walsh, for example believes that. But for younger men, the
situation is very different. For a complex disease like PC, you need
a complex policy.
So Kolata spends time in her article talking about how people who
adopt this attitude think about use of finasteride. Should you for
example advocate the use of finasteride, not because it reduces the
risk of prostate cancer, but instead just because it will reduce the
number of cases which are treated needlessly? That is getting to
convoluted for men. I prefer Scardino's attitude, which is much more
straitforward. Does it help or hurt given that there may be some
unseen consequences of the use of the drug down the line.
The whole thing is complicated, of course, because finasteride is
currently in common use to treat BPH in older men and even to treat
baldness. I have been bald since I was 18, so I think the latter use
is frivolous, but if men are willing to risk long term consequences so
they will be more appealing, so they think, to the opposite sex,
perhaps we shouldn't worry so much about men who use it to reduce
their risk of prostate cancer.
"New Take on a Prostate Drug, and a New Debate" 
Linear Mode
