you be the judge - new statement coming out against pca screening.

[c palmer]

http://www.cnn.com/2011/10/06/health...ing/index.html

knowledge is power - growing old is mandatory - growing wise is optional
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
http://community.webtv.net/PALMER_ENT/doc

[Jean]

And I believe this is the same group that said women didn't need mammograms.

Jean

"c palmer" wrote in message
news:[email protected]..

http://www.cnn.com/2011/10/06/health...ing/index.html

knowledge is power - growing old is mandatory - growing wise is optional
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
http://community.webtv.net/PALMER_ENT/doc

[Magnus]

That was stated in the first sentence of the article.

On 10/7/2011 10:45 AM, Jean wrote:
> And I believe this is the same group that said women didn't need
> mammograms.
>
> Jean
>
> "c palmer" wrote in message
> news:[email protected]..
>
> http://www.cnn.com/2011/10/06/health...ing/index.html
>
> knowledge is power - growing old is mandatory - growing wise is optional
> "Many more men die with prostate cancer than of it. Growing old is
> invariably fatal. Prostate cancer is only sometimes so."
> http://community.webtv.net/PALMER_ENT/doc

[safire]

X-no-archive: yes On 10/7/11 4:52 PM, in article
LmEjq.1581$[email protected], "Magnus" <[email protected]> wrote:

> That was stated in the first sentence of the article.
Jean probably didn't read that first sentence. To understand the conclusions
of evidence-based medicine reading is a necessary skill. Notice that Jean's
"belief" is a non sequitur.
>
> On 10/7/2011 10:45 AM, Jean wrote:
>> And I believe this is the same group that said women didn't need
>> mammograms.
>>
>> Jean
>>
>> "c palmer" wrote in message
>> news:[email protected]..
>>
>> http://www.cnn.com/2011/10/06/health...ing/index.html
>>
>> knowledge is power - growing old is mandatory - growing wise is optional
>> "Many more men die with prostate cancer than of it. Growing old is
>> invariably fatal. Prostate cancer is only sometimes so."
>> http://community.webtv.net/PALMER_ENT/doc
>

[Jeff]

I'm not sure how it could be achieved but I wonder if screening could be
more effective with much more thorough DREs.

I realise the danger of generalising from the particular but like most
men I had regular DREs from family Drs over the years. About 10 seconds
of discomfort and it's over. Thye last of those DREs showed in Dr's view
"slightly enlarged prostate"

In an abundance of caution I was referred to a good Urologist. That DRE
must have lasted 3 or 4 minutes (felt like hours!!). Very uncomfortable
but that found much more sinister factors and predicted pretty well what
the biopsy would show and where it would show it.

I'm not suggesting my family Doc was in any way negligent - the exam was
similar to what I'd received pretty well annually for around 20 years
but I have to wonder if I'd had a DRE from that Urologist in earlier
years if the PCa would have been detected earlier.

[I.P. Freely]

Everyone's overlooking the unintentional but key factor ... a single
word ... in this new recommendation: *healthy* men don't need PSA checkups.

Well, DUH! If I'm healthy, I don't have cancer, thus don't need my PSA
checked. However, if the only means of verifying that I'm healthy, i.e.
do not have cancer, is a PSA check, then I demand my right to give a
vial of blood and have my rectum violated to determine whether I am, in
fact, healthy. Of *course* a PSA check is not going to save a healthy
man's life, but by golly it saves thousands of sick men's lives every
year. And what's the best marker to find out which men are sick with PC
while they're still curable? PSA.

That's just dumb. The problem is not too many PSA checks; the problem is
too many doctors and patients overreacting to elevated PSAs.

I.P.

[Alan Meyer]

On 10/08/2011 01:21 PM, Jeff wrote:
> I'm not sure how it could be achieved but I wonder if screening could be
> more effective with much more thorough DREs.
>
> I realise the danger of generalising from the particular but like most
> men I had regular DREs from family Drs over the years. About 10 seconds
> of discomfort and it's over. Thye last of those DREs showed in Dr's view
> "slightly enlarged prostate"
>
> In an abundance of caution I was referred to a good Urologist. That DRE
> must have lasted 3 or 4 minutes (felt like hours!!). Very uncomfortable
> but that found much more sinister factors and predicted pretty well what
> the biopsy would show and where it would show it.
>
> I'm not suggesting my family Doc was in any way negligent - the exam was
> similar to what I'd received pretty well annually for around 20 years
> but I have to wonder if I'd had a DRE from that Urologist in earlier
> years if the PCa would have been detected earlier.

I think this is a common problem. Even urologists are not immune. I
had a rather brutal 5 second exam by the first urologist I saw and he
found nothing. A lengthy and much more careful exam by a radiation
oncologist found two hard spots in the prostate which she thought were
evidence of tumors. Without saying what she found she asked her
resident to examine me. He found the same two spots in the same two places.

I never had any desire to see or be treated by that first urologist again.

Alan

[Jeff]

On 09/10/2011 3:37 PM, Alan Meyer wrote:
> On 10/08/2011 01:21 PM, Jeff wrote:
>> I'm not sure how it could be achieved but I wonder if screening could be
>> more effective with much more thorough DREs.
>>
>> I realise the danger of generalising from the particular but like most
>> men I had regular DREs from family Drs over the years. About 10 seconds
>> of discomfort and it's over. Thye last of those DREs showed in Dr's view
>> "slightly enlarged prostate"
>>
>> In an abundance of caution I was referred to a good Urologist. That DRE
>> must have lasted 3 or 4 minutes (felt like hours!!). Very uncomfortable
>> but that found much more sinister factors and predicted pretty well what
>> the biopsy would show and where it would show it.
>>
>> I'm not suggesting my family Doc was in any way negligent - the exam was
>> similar to what I'd received pretty well annually for around 20 years
>> but I have to wonder if I'd had a DRE from that Urologist in earlier
>> years if the PCa would have been detected earlier.
>
> I think this is a common problem. Even urologists are not immune. I had
> a rather brutal 5 second exam by the first urologist I saw and he found
> nothing. A lengthy and much more careful exam by a radiation oncologist
> found two hard spots in the prostate which she thought were evidence of
> tumors. Without saying what she found she asked her resident to examine
> me. He found the same two spots in the same two places.
>
> I never had any desire to see or be treated by that first urologist again.
>
> Alan

So, although we would all like to see a definitive lab test developed,
is the situation that there is a good (very good?) screening test that
is also cheap, not being properly utilised?

[safire]

X-no-archive: yes On 10/7/11 5:02 AM, in article
[email protected], "c palmer"
<[email protected]> wrote:

> http://www.cnn.com/2011/10/06/health...ing/index.html

From NY Times Magazine article "Can Cancer Ever Be Ignored" (behind
paywall), discussing Brawley, Ablin (who discovered PSA and calls the test a
public health disaster and "hardly more effective than a coin toss"),
Catalona and others:

"³Imagine you are one of 100 men in a room,² he says. ³Seventeen of you will
be diagnosed with prostate cancer, and three are destined to die from it.
But nobody knows which ones.² Now imagine there is a man wearing a white
coat on the other side of the door. In his hand are 17 pills, one of which
will save the life of one of the men with prostate cancer. ³You¹d probably
want to invite him into the room to deliver the pill, wouldn¹t you?² Newman
says.

Statistics for the effects of P.S.A. testing are often represented this way
‹ only in terms of possible benefit. But [David] Newman says that to
completely convey the P.S.A. screening story, you have to extend the
metaphor. After handing out the pills, the man in the white coat randomly
shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving
them impotent or incontinent.

Newman pauses. ³Now would you open that door?² He argues that the only way
to measure any screening test or treatment accurately is to examine overall
mortality. That means researchers must look not just at the number of deaths
from the disease but also at the number of deaths caused by treatment."
>

[Paul]

On Thu, 6 Oct 2011 22:02:33 -0500, [email protected] (c palmer)
wrote:

>http://www.cnn.com/2011/10/06/health...ing/index.html
>
>knowledge is power - growing old is mandatory - growing wise is optional
>"Many more men die with prostate cancer than of it. Growing old is
>invariably fatal. Prostate cancer is only sometimes so."
>http://community.webtv.net/PALMER_ENT/doc

I'd say that the best thing one can do is consider family history (if
available) in conjunction with screening results. To reiterate for the
newer group members, my mother's father died of PCa when he was 92 and
that would've been great if that was all the history I had. In fact if
that was it, I may have certainly opted for watchful waiting. That
said my father's father died of it at 79 and my Dad died of it at 73.
I figured if I did nothing I would've made my late 60s at best.

A pretty clear cut decision for me but for many men, it may not be
that simple. To this day I cannot see how the knowledge gained from a
blood draw and a DRE can harm someone.

--
PSA @ 45 yrs. = 4.7 02/06/2007
Biopsy 03/16/2007 G7(3+4),T1c
RLRP 06/12/2007 G7(3+4),T2cN0M0 Neg margins
PSA 07/16/2007 = <0.1
PSA 09/12/2007 = <0.1
PSA 12/18/2007 = <0.1
PSA 03/12/2008 = <0.1
PSA 06/12/2008 = <0.1
PSA 12/12/2008 = <0.1
PSA 06/12/2009 = <0.1
PSA 06/12/2010 = <0.1
PSA 06/12/2011 = <0.1

[I.P. Freely]

Paul wrote:
> To this day I cannot see how the knowledge gained from a
> blood draw and a DRE can harm someone.

Unnecessary panic and unnecessary treatment are the risks.

I.P.

[Alan Meyer]

On 10/9/2011 7:32 PM, Jeff wrote:
> On 09/10/2011 3:37 PM, Alan Meyer wrote:
>> On 10/08/2011 01:21 PM, Jeff wrote:
>>> I'm not sure how it could be achieved but I wonder if screening could be
>>> more effective with much more thorough DREs.
....
>
> So, although we would all like to see a definitive lab test developed,
> is the situation that there is a good (very good?) screening test that
> is also cheap, not being properly utilised?

It's my understanding that the panel recommended against screening with
digital rectal exams as well as against PSA testing.

In addition to the general screening problems mentioned by the panel, I
wonder how many doctors are really competent to perform a DRE. I should
think that, in order to be competent at it, a doctor has to practice
examining a number of healthy prostates and a number of unhealthy ones.
Ideally, he would be able to stick his finger up one butt, feel
around, then try another, then back to the first, then back to the
second, etc., and be questioned by a urology expert, until he really
understands what he's feeling.

If we lined up 100 general practitioners and gave them a number of men
to test, I wonder how many of them would get the right answers. For
that matter, if we lined up 100 urologists, how many would get it right?

There are going to be some cases where it's obvious that the prostate is
diseased, but most cases are probably not so obvious.

Alan

[Alan Meyer]

On 10/10/2011 6:21 AM, safire wrote:

>> http://www.cnn.com/2011/10/06/health...ing/index.html
>
> From NY Times Magazine article "Can Cancer Ever Be Ignored"
> (behind paywall), discussing Brawley, Ablin (who discovered PSA
> and calls the test a public health disaster and "hardly more
> effective than a coin toss"), Catalona and others:
>
> "³Imagine you are one of 100 men in a room,² he says.
> ³Seventeen of you will be diagnosed with prostate cancer, and
> three are destined to die from it. But nobody knows which
> ones.² Now imagine there is a man wearing a white coat on the
> other side of the door. In his hand are 17 pills, one of which
> will save the life of one of the men with prostate cancer.
> ³You¹d probably want to invite him into the room to deliver the
> pill, wouldn¹t you?² Newman says.
>
> Statistics for the effects of P.S.A. testing are often
> represented this way - only in terms of possible benefit. But
> [David] Newman says that to completely convey the P.S.A.
> screening story, you have to extend the metaphor. After handing
> out the pills, the man in the white coat randomly shoots one of
> the 17 men dead. Then he shoots 10 more in the groin, leaving
> them impotent or incontinent.
>
> Newman pauses. ³Now would you open that door?² He argues that
> the only way to measure any screening test or treatment
> accurately is to examine overall mortality. That means
> researchers must look not just at the number of deaths from the
> disease but also at the number of deaths caused by treatment."

I understand the points being made here. If one in 500 treated
patients is killed by the treatment, and another 150 (30%) have
serious side effects, and only a few are saved, and we don't know
who will be saved and who won't, who will be killed and who
won't, and who will have serious side effects and who won't, then
are we doing the right thing?

I think the answer is, it depends. Here are some factors it
depends on:

1. How old are the patients?

If I remember correctly, the panel recommendations were based
on 10 year overall survival statistics, which were not
different for men with and without treatment.

But for men diagnosed early by annual PSA exam, the expected
lifespan without treatment is greater than 10 years. At 10
years, something like 99+% of patients are alive even without
treatment. But at 15 years the story is very different and at
20 years the prospects begin to look grim indeed.

I was diagnosed at age 57. My Dad lived to age 87. My
chances of living to 87 without PCa treatment were close to
nil. Now, conceivably, I have a chance.

So I agree that PSA testing after age 85, and maybe 80, 75, or
even 70, is useless or problematic. But what about for men
like me diagnosed at 57, or Steve Kramer who was diagnosed in
his 40s?

Consider also that men who survive even 10 years don't
necessarily survive symptom free. In some cases they may be
surviving with ADT, which has side effects of its own.

2. Can we reduce the odds of over treatment?

If we could distinguish the men needing treatment from the men
not needing treatment, the number of men killed by treatment
or suffering serious side effects could be reduced.

Dr. Epstein at Hopkins proposed a set of guidelines for
watchful waiting. If the guidelines were followed, some
number of men who have been treated in the past would not have
been treated. If one half of the diagnosed men are correctly
identified as not needing treatment, then the numbers of
treatment deaths goes from 1/500 to 1/1000 men. The
number of men suffering side effects goes from 150/500 to
75/500. The odds improve significantly in favor of the
patients.

3. Can we reduce the number of treatment failures?

Statistics show that cancer (and most other) treatments by
highly qualified and experienced experts is significantly
safer and more effective than treatment by average physicians.

If we could direct more patients to doctors who really know
what they're doing, at hospitals that have implemented proper
infection and other safeguards, I bet we could significantly
lower the rate of treatment failure, lower the number of
deaths due to treatment mistakes, and lower the number and
severity of side effects.

I understand the panel's position. They are arguing about
guidelines for the real world, not a more perfect world than
actually exists. They are assuming that death rates, side effect
rates, and treatment failure rates are held constant and saying
that, if they are, we're better off doing nothing.

Personally however, I would rather that we work towards better
medicine in that more perfect world, than just say that what we
have doesn't work very well, so let's give up and do nothing.

Public health experts might say that's all well and good but it
ain't going to happen. Let's base our recommendations on the
real world. They may be right but they haven't convinced me yet.

Alan

[Alan Meyer]

On 10/11/2011 6:46 PM, Alan Meyer wrote:

> ... I wonder how many doctors are really competent to perform a
> DRE. I should think that, in order to be competent at it, a
> doctor has to practice examining a number of healthy prostates
> and a number of unhealthy ones. Ideally, he would be able to
> stick his finger up one butt, feel around, then try another,
> then back to the first, then back to the second, etc., and be
> questioned by a urology expert, until he really understands
> what he's feeling.

This is an opportunity for some budding entrepreneur. We need
someone to manufacture a plastic butt with replaceable model
prostates. The instructor puts different prostate models in the
right position and the student has to stick his finger in and say
what he found.

Now if the plastic butt could also be made to squirm and say
"Ouch!" when presented with a ham fisted student with sharp
fingernails, then we'd really make some progress!

Alan

[Magnus]

On 10/11/2011 12:22 PM, I.P. Freely wrote:
> Paul wrote:
>> To this day I cannot see how the knowledge gained from a
>> blood draw and a DRE can harm someone.
>
> Unnecessary panic and unnecessary treatment are the risks.
>
And the treatment will invariably escalate... at some point your
physician is going to request a biopsy... "just to be sure" or possibly
"due diligence" (aka "malpractice avoidance") ... and at some point
there will be a positive indication and retests... because cancer cells
are just a fact of life as we age... And the positive result will drive
treatment discussions with uncertain benefit and certain SEs ... not to
mention side affects. And within a government run insurance program,
you'll incur mandatory treatments prescribed to avoid later, down the
road, complications...

If you give a mouse a cookie...

[Gourd Dancer]

I agree with Dr. Andrew von Eschenbach (Past Provost at MD Anderson Cancer
Center, Urologic Oncology Fellow and subsequent Chair, President American
Cancer Society, Director of National Cancer Institute, etc.) The U.S.
Preventative Services Taskforce (which has zero Urologists serving) is going
to get people killed.

Gourd Dancer

"c palmer" wrote in message
news:[email protected]..

http://www.cnn.com/2011/10/06/health...ing/index.html

knowledge is power - growing old is mandatory - growing wise is optional
"Many more men die with prostate cancer than of it. Growing old is
invariably fatal. Prostate cancer is only sometimes so."
http://community.webtv.net/PALMER_ENT/doc

[Paul]

On Tue, 11 Oct 2011 09:22:03 -0700, "I.P. Freely"
<[email protected]> wrote:

>Paul wrote:
>> To this day I cannot see how the knowledge gained from a
>> blood draw and a DRE can harm someone.
>
>Unnecessary panic and unnecessary treatment are the risks.
>
>I.P.

I suppose that may be the case for some but one test should not be a
cause for panic. I agree that unnecessary treatment is something that
happens. The more cynical would say that there are a lot of Davinci
robots out there that need to be paid for. I would like to think its
simply uros giving poor advice to trusting patients.

--
PSA @ 45 yrs. = 4.7 02/06/2007
Biopsy 03/16/2007 G7(3+4),T1c
RLRP 06/12/2007 G7(3+4),T2cN0M0 Neg margins
PSA 07/16/2007 = <0.1
PSA 09/12/2007 = <0.1
PSA 12/18/2007 = <0.1
PSA 03/12/2008 = <0.1
PSA 06/12/2008 = <0.1
PSA 12/12/2008 = <0.1
PSA 06/12/2009 = <0.1
PSA 06/12/2010 = <0.1
PSA 06/12/2011 = <0.1

[frank curtis]

This is disturbing and frustrating to hear, of course, but can we
agree on one thing: if the screening advances to the point of biopsy
that shows cancer in, say, 50% of the cores, the screening results
should DEFINITELY be acted on?
Or is this study suggesting there may still be some reluctance to
recommend treatment even then?
Most of this study focuses on PSA and DRE only...I haven't read much
about biposy results.
Going with this line of thinking...then what percent of how many cores
found cancerous in a 12 sample biopsy should be acted on?

[safire]

X-no-archive: yes On 10/12/11 5:07 PM, in article
2102ce56-f897-45c1-b7de-839b172df7a4...oglegroups.com, "frank
curtis" <[email protected]> wrote:

> This is disturbing and frustrating to hear, of course, but can we
> agree on one thing: if the screening advances to the point of biopsy
> that shows cancer in, say, 50% of the cores, the screening results
> should DEFINITELY be acted on?
> Or is this study suggesting there may still be some reluctance to
> recommend treatment even then?

I think the study only deals with the question whether PSA testing is
beneficial or not, not with treatment decisions given a particular biopsy
result.
> Most of this study focuses on PSA and DRE only...I haven't read much
> about biposy results.
> Going with this line of thinking...then what percent of how many cores
> found cancerous in a 12 sample biopsy should be acted on?

The NCCN guidelines probably give an answer to that question or at least on
the basis of a Gleason Score. Notice that a biopsy may cover as little as 3%
of the prostate.

[Paul]

On Wed, 12 Oct 2011 08:07:13 -0700 (PDT), frank curtis
<[email protected]> wrote:

>This is disturbing and frustrating to hear, of course, but can we
>agree on one thing: if the screening advances to the point of biopsy
>that shows cancer in, say, 50% of the cores, the screening results
>should DEFINITELY be acted on?
>Or is this study suggesting there may still be some reluctance to
>recommend treatment even then?
>Most of this study focuses on PSA and DRE only...I haven't read much
>about biposy results.
>Going with this line of thinking...then what percent of how many cores
>found cancerous in a 12 sample biopsy should be acted on?

I'm sure there are guidelines to be followed but the original question
was not the biopsy rather the PSA screening. In my case I had multiple
screenings done from the time I was 40 to 45. A sudden jump in one
year and no significant reduction when given Levaquin (IIRC) sent me
for the biopsy. I was a 3+4 Gleason at 45 years with a steep history
of PCa in my family.

I suppose that some might even question a biopsy as you really aren't
getting the whole gland with any certainty but at what point do you
just trust the science and stop trying to defy it? Even with the
biopsy, who's to say what PCa will stay encapsulated and which will
spread and at what rate?

This is why, as sure as I am of my decision and have no regrets, I
would never condemn someone else for waiting it out, but to completely
ignore the ability to have the information at hand strikes me as
foolish.

--
PSA @ 45 yrs. = 4.7 02/06/2007
Biopsy 03/16/2007 G7(3+4),T1c
RLRP 06/12/2007 G7(3+4),T2cN0M0 Neg margins
PSA 07/16/2007 = <0.1
PSA 09/12/2007 = <0.1
PSA 12/18/2007 = <0.1
PSA 03/12/2008 = <0.1
PSA 06/12/2008 = <0.1
PSA 12/12/2008 = <0.1
PSA 06/12/2009 = <0.1
PSA 06/12/2010 = <0.1
PSA 06/12/2011 = <0.1

[safire]

X-no-archive: yes On 10/13/11 1:56 AM, in article
[email protected], "Paul" <Paul> wrote:

>
> I'm sure there are guidelines to be followed but the original question
> was not the biopsy rather the PSA screening. In my case I had multiple
> screenings done from the time I was 40 to 45. A sudden jump in one
> year and no significant reduction when given Levaquin (IIRC) sent me
> for the biopsy. I was a 3+4 Gleason at 45 years with a steep history
> of PCa in my family.

I think the studies merely conclude that universal psa testing doesn't save
lives and that a psa test may not be beneficial for the average man. You
can't apply that conclusion to someone with a family Pca history and/or
symptoms.
>
> I suppose that some might even question a biopsy as you really aren't
> getting the whole gland with any certainty but at what point do you
> just trust the science and stop trying to defy it? Even with the
> biopsy, who's to say what PCa will stay encapsulated and which will
> spread and at what rate?
>
> This is why, as sure as I am of my decision and have no regrets,

Gambling in a casino is irrational. But people that walk a way with lots of
winnings justifiably have no regrets.
> would never condemn someone else for waiting it out, but to completely
> ignore the ability to have the information at hand strikes me as
> foolish.

[Dale j.]

In article <[email protected]>, Paul wrote:

> On Thu, 6 Oct 2011 22:02:33 -0500, [email protected] (c palmer)
> wrote:
>
> >http://www.cnn.com/2011/10/06/health...ing/index.html
> >
> >knowledge is power - growing old is mandatory - growing wise is optional
> >"Many more men die with prostate cancer than of it. Growing old is
> >invariably fatal. Prostate cancer is only sometimes so."
> >http://community.webtv.net/PALMER_ENT/doc
>
> I'd say that the best thing one can do is consider family history (if
> available) in conjunction with screening results. To reiterate for the
> newer group members, my mother's father died of PCa when he was 92 and
> that would've been great if that was all the history I had. In fact if
> that was it, I may have certainly opted for watchful waiting. That
> said my father's father died of it at 79 and my Dad died of it at 73.
> I figured if I did nothing I would've made my late 60s at best.
>
> A pretty clear cut decision for me but for many men, it may not be
> that simple. To this day I cannot see how the knowledge gained from a
> blood draw and a DRE can harm someone.

Nor I.

What is with this new war against screening for prostate cancer. Is it
money or what?

I'm thankful for that first PSA test I had in my late fifties. If I had
not acted on it I might be in a dire state today almost nine years
later.
--
Email: [email protected]

Eight years already, going on nine.