Today, the New York Times reported on a “troubling new report from the Agency for Healthcare Research and Quality (AHRQ), which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no treatment emerged as superior to doing nothing at all. [my emphasis]
“When it comes to prostate cancer, we have much to learn about which treatments work best,” said agency director Carolyn M. Clancy. “Patients should be informed about the benefits and harms of treatment options.”
The Times went on to quote the agency saying “Considerable over-detection and over-treatment may exist.”
I have written about this issue here and here; Niko has written about it here.
I am not going to repeat what we have said in the past. But let me emphasize that the AHRQ looked at practically every treatment now being used:
“The agency review is based on analysis of 592 published articles of various treatment strategies. The studies looked at treatments that use rapid freezing and thawing (cryotherapy); minimally invasive surgery (laparoscopic or robotic-assisted radical prostatectomy); testicle removal or hormone therapy (androgen deprivation therapy); and high-intensity ultrasound or radiation therapy. The study also evaluated research on ‘watchful waiting,’’ which means monitoring the cancer and initiating treatment only if it appears the disease is progressing.”
The agency goes on to warn that “all active treatments cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction.”
Finally, the Times points out that while “one study has shown that men who choose surgery over watchful waiting are less likely to die or have their cancer spread, another study found no difference in survival between surgery and watchful waiting.” Moreover—and this is important—“few patients in the study had cancer detected through P.S.A. tests. As a result, it’s not clear if the results are applicable to the majority of men diagnosed with the disease.”
If the cancer is detected without a P.S.A. test, then this presumably
means that the patient has experienced symptoms—and his cancer may no
longer be “early-stage.” By contrast, in the U.S. most men are
diagnosed via a P.S.A. test and are asymptomatic—thus they may be in a
better position to “do nothing” while watching to see if the disease
progress.
The article drew many comments from readers. Below, is one that I found
particularly interesting. With a family history of prostate cancer,
this patient made a very difficult decision. But it sounds as if he is
happy with his choice. And, of course, if check-ups show that his
cancer is progressing, he can always decide to seek treatment.
February 5th, 2008 11:31 pm
I am a 58 year old who recently discovered through PSA screening and a
subsequent 8 needle prostate biopsy, that I have prostate cancer
(Gleason Score 6 & a T1C). My father died from prostate cancer at
the age of 67 before there was such a thing as PSA testing, and there
is certainly evidence today of a genetic link.
My initial inclination was to undergo a radical prostatectomy. Cut It
Out! My urologist certainly pointed me in that direction. I proceeded
to read extensively on the topic. I interviewed a top radiation
oncologist and a top (robotic) surgeon. Both acknowledged the
probability (but no guarantee) with my stage of diagnosis that I could
take some time to decide on a course of action before they would think
that a radical local procedure was essential. Further study revealed
that the 10 year survival rate, and for that matter the 15 year
survival rate according to some well documented and published studies
is no better for prostate surgery, radiation or watchful waiting (no
prostate localized procedure) +/- 1-3%.
That’s a pretty amazing statement!
I’ve since learned more, and have embarked on a serious effort to
starve my prostate cancer of fuel through implementation of a rigid
macrobiotic diet. In a day, I cut out animal protein (except modest
intake of fish), all dairy products, caffeine, eggs and hydrogenated
vegetable oils. I do not smoke, nor do I consume alcohol or drugs.
Color me motivated! The side benefits of this are amazing. I’ve reduced
my weight by almost 10%. I no longer need to take blood pressure
medication. I am sure that my next blood work will reveal that my
cholesterol has dropped considerably. My belly fat has melted away, and
I get many comments on how trim I look. I am more energetic. I have
started to exercise more. The initial BPH type symptoms that I had
(urinary urgency and frequent urination at night) have improved
dramatically. I embarked on this course with the logical arguments for
it posed by Roger Mason in his book “The Natural Prostate Cure”
(download via www.youngagain.org or available on Amazon and elsewhere).
I have come to believe that it is within the realm of possibility to
recover from prostate cancer; or to get into remission through diet.
I’m intent to prove my approach with the desired results in a year’s
time. Wish me well.
Technically, my regime, from those listed in the article is the one
termed “Watchful Waiting”. But mine is not a passive process, and with
my dietary approach and close monitoring, “Active Surveillance” is the
more appropriate terminology.
If you or a loved one have a diagnosis of Prostate Cancer it’s
imperative to learn as much about it as possible before having any
radical local procedure (imo), all of which have substantial risks
associated with them and dubious surety of improved outcome. Read the
John Hopkins Prostate White Paper for a good overview.
I am not a doctor. I have absolutely no idea whether this diet is going
to have any effect on whether or not his cancer progresses. But it does
sound as if it is good for his overall health. And it gives him
something positive to think about. Most importantly, I think everyone
should take the advice that he offers at the end.
If you are diagnosed with early-stage prostate cancer, you need to
recognize the fact that medical science just doesn’t have any clear
answers at to what you should do next. As the National Cancer Society
says, there is no evidence that any treatment will alter the course of
the disease. This is why you need to learn as much as possible about
the “substantial risks associated” with various treatments and the
“dubious surety of improved outcome.”
For some people, watchful waiting (a.k.a. “active surveillance”) may be
psychologically impossible. That is something that only the patient
can decide. But common sense suggests that, at the very least, you
should give yourself time to consider it. Prostate cancer usually moves
very slowly—you don’t have to rush into treatment.
Once again, beware of oversimplifying. The original article from the AHRQ (which all should read) has as its main point that few good quality trials have been performed to compare these treatments, including watchful waiting. It doesn’t mean there isn’t a best treatment, just that we don’t know what it is yet. However, here’s the important sentence:
“Data from RCTs indicate that men with Gleason scores of 8 to 10 were more likely than men with Gleason scores of 2 to 6 to have evidence of biochemical recurrence, regardless of whether treatment was radical prostatectomy alone or combined with androgen deprivation therapy.”
In other words, a Gleason score of 8 or higher does NOT qualify for watchful waiting. Just want to make sure the lay reader understands that critical point.
As far as what to do for men with lower Gleason scores and low volume or low stage cancers, yes – treatment choice is a conundrum due to few adequately performed comparative effectiveness studies – not a rare event in modern medicine.
Bev M.D.
I don’t simplify. And I
did read the whole report–plus the executive summary published Feb 5. (See footnote at end of pargraph you quoted from.)
Apparently you didn’t. If you had you would find this sentence just before the sentence you quote:
“Analysis of one randomized trial concluded that disease-specific mortality at 10 years for men having Radical Prostectomy compared with Watchful Waiting differed according to age but Not Based On PSA level or Gleason Score. ”
In other words, the researchers are saying, very clearly that Watchful Waiting IS appropriate for patients with a higher Gleason score because the rate of mortalites with Watchful Waiting does Not Vary According to Gleason Score.”
So the section ends: “Men with Gleason scores 8-10 were more likely to have biochemical recurrence than men with Gleason scores 2-6, Regardless of Type of Treatment.”
In other words, men with higher Gleason scores are more likely to have a recurrence–no matter what treatment they chose.
Treatment doesn’t affect reccurrence. So why would a man with a high Gleason score choose a treatment which exposes him to the risk of life-changing side effects –if it’s not going to prevent the recurrence?
You also write The article “doesn’t mean there isn’t a best treatment, just that we don’t know what it is yet.”
This is what the article actually says: “Differences in development of disease and survival due to treatments are unlikely to occur for many years . . .”
They are not saying “but we know that eventually one of these treatments will turn out to be The One.”
They are saying that at this point we don’t have enough information to say if one of these treatments is more effective than another–or if any of then is more effective than Watchful Waiting–especially when you consider the risks vs. benefits. (Note that they list Watchful Waiting as a treatment–which it is.)
They also constantly refer to the fact that the majority of American men find out that they have cancer through a PSA test–very early on, when they have no symptoms and the tumor is small. As a result, the reserachers point out, these men are much more likely to survive 20 years–without treatment–then men in other countries where the cancer is detected later when it is larger and there are symptoms.
And if they never had the PSA test, most would never know they had cancer. They would die with it, but not from it. (Autoposies show that a very large percentage of elderly men have prostate cancer–but unless they had the PSA test, they never knew it.)
This is why the American Cancer Society and the National Cancer Insitute no longer recommend that doctors send men of a certain age for PSA testing.
Finally, Bev, I’m not sure why you continue to suggest that my posts are simplifying.
I realize you are a doctor, and I’m not–but you seem to be trying to use that “M.D.” to undermine my credibility.
This isn’t helpful. The tactic leaves my reader’s wondering –“Hey if Maggie is wrong about that fact–I wonder how of the rest of this blog is wrong?”
Other readers argue with me about particular points, have different values, ask for more evidence, etc. Very few suggest that I’m just “simplifying” or flat out wrong–except for the occasional conservative ideologue who suggests that Niko and I are Communists!
I work pretty hard to get my facts right–as a trained jouranlist I know how to fact-check.
I’ve written a book about healthcare filled with medical details, I read medical journals and wrote about technical details of medicine when I was at Barron’s–where many of our readers were doctors.
No one has ever written in to say: “She got that fact wrong.” We never had to run a retraction. There aren’t any errors that I know of that I need to fix in the next edition of my book.
This isn’t to say I never make a mistake–just to say that I’m very careful about facts.
Finally, in this case, I have gotten my information both from medical research and from talking to doctors in the area. Honest urologists have told me what I know about prostate cancer.
Since urology isn’t your specialty, they might well know something you don’t know.
Maggie;
Notice I did not even address the issue of PSA tests in my comment. That is entirely another issue. As for men with prostate cancer of Gleason score 8 or higher, I would like you to give me a reference that indicates that watchful waiting is an acceptable form of treatment – unless the patient is 95 or something. These high grade tumors are aggressive, and I don’t want to you give some poor man reading this the excuse to not seek treatment.
I did read the sentence you cited regarding PSA score, but it goes against my clinical experience. It is possible that there were too few men with those high scores to assess meaningfully. I am just saying, watch out for generalizations.
If it makes you feel better, I do think you are one of the better informed and researched journalists. However, like many I have encountered, you seem to get a bee in your bonnet, like PSA tests and Gardisil, which I believe introduces an unconscious bias in your reporting on those issues. One must always keep an open mind, which is why I haven’t commented on your statements about either Gardisil or PSA (reread my comments if you don’t believe me) – the evidence either way is just not there yet. And this has personal impact for me as I am trying to decide whether to recommend whether my 17 yr old daughter should get Gardasil. I just don’t know yet.
Maggie;
Just an addendum to note that, as Dr. David Eddy (the “father” of evidence based medicine) remarked in an interview (which I cannot find), there is evidence – and then there is the interpretation of that evidence, which is inevitably subject to the heuristic factors affecting those interpreting it. Our discussion is a good example of that.
Sorry; a correction to my 2nd to last comment. “I did read the sentence you cited regarding PSA score” should have read “….regarding Gleason score”.
Men diagnosed with prostate cancer don’t necessarily need to rush for treatment, according to the current issue of Harvard Men’s Health Watch.
http://www.health.harvard.edu/newsletters/treating-prostate-cancer.htm
Bev M.D.
You write “I did read the sentence you cited regarding PSA score, but it goes against my clinical experience.”
In other words, you are saying that you know better than the AHRQ–the agency responsible for monitoring quality–which came to this conclusion after examining hundreds of studies . . .
All I can say is that I am glad that you are not my husband’s urolgoist. (BTW –I take it you are an urologist? )
AHRQ, recognizes that one has to “interpret” studies, but it also recognizes that we can no longer afford to have doctors practicing “lone ranger medicine” based on their “intuition” or personal interpretaion of their clinical experience.
As I said in my last post, while I’m not a doctor, at this point, I have enough knowledge to be invited to speak to groups like the Massachusetts Medical Association and the Texas Medical Association about issues like overtreatment, PSA testing, overdiagnosis, the need for shared decision-making etc.–based largely on my book.
Usually I am the only person speaking who is it not a doctor, but my work seems to be recognized and accepted by some of the best minds in American medicine–Berwick, Wennberg, Schroeder, etc.
The book was very well reviewed in Health Affairs.
I hate to boast–it’s embarrassing. But I want to reassure readers that what you see on this blog is accepted by those at the forefront of evidence-based medicine–your condescending comments notwithstanding (“If it makes you feel better, I do think you are one of the better informed and researched journalists . . but you seem to get a bee in your bonnet . . ”
Bev, I don’t wear a bonnet.
There is, understandably, some resistance to new information within the medical community. Some older doctors have a hard time accepting the fact that the ideas that have guided their practice for a long time are, in fact, wrong.
It’s worth noting that, in some instances, doctors in other countries have been quicker to recognize the holes in some theories.
For example,many doctors in the U.K. have long recognized that there is no proof that high cholesterol causes heart disease. I’ll be writing about that today.
And Canada does not pay for PSA testing because, as a doctor heading the shared-decision making program in Ottawa told me: “There’s just no evidence that it saves lives–or even gives men one additional day of life.”
As a long recent article about controversies in treatment of Prostate cancer published in this country puts it: “In short, no conclusive body of medical literature indicates that screening for this disease alters outcome.” This is also what the National Cancer Institute says.
A high Gleason score does predict that a man is more likely to die of the cancer. But we don’t know what we can do to alter that outcome. Anything we do involves shooting in the dark.
And since we do know that all treatments can lead to serious, permanent side effects (incontinence, impotence, difficulty with bowel movements), patients given full informaton about the risks, and how little we know about benefits often are not willing to risk those side effects–even if their Gleason is high enough to suggest that they have a 60 percent chance of dying of the disease.
(The percentage comes from the article on controversy)
The patient’s age is important in making the decision. Today, 50 is seen as a possible cut-off. IN other words, if you are 50, and have a high Gleason score, you are likely to live long enough to suffer the effects of the cancer and to die from it.
The problem is that if you choose treatment and endure side effects you will never know whether you would have been one of the 60% or even 70% in your cohort (similar age and similarly high Gleason score) who would have died of the cancer, or one of the 30% to 40% who died of somethinig else long before the cancer bothered you.
You will never have any way of knowing whether the treatment saved your life–or was totally unncessary. What you do know is that we have no evidence that the treatment you underwent saves the lives of men with high Gleason scores.
The problem is complicated by the fact that men under 50 are more likely to be very depressed at the thought of becoming impotent.
I have met men who were treated for the disesase, survived, never had any more trouble with prostate cancer, but were haunted by the fact that they will never know whether they become impotent or incontinent needlessly.
I have also written tn article quoting a higly respected urologist saying that the never intends to have a PSA test because, as far as he is concerned, it simply opens a can of worms for which there are no good answers.
With regard to your clnical experience, Bev, for a long time, American doctors have been treated as infallible. Patients, and policy-makers were never supposed to question an opininon based on an individual doctor’s “clinical experience.”
We know now that is a mistake. Increasingly, we are realizing that medicine is a team sport; doctors need to work together, looking over each other’s shoulders, and keeping up with the latest reserach.
To say “the doctors at AHRQ may have looked at hundreds of studies, but that doesn’t square with my clinical experience” borders on arrogance.
Greg-
Thanks much for the
link on the Harvard newsletter on prostate cancer.
I think that what is most imporant for men who are diagnosed is to understand is that they don’t need to panic. They have time. And if their doctors are pressing them to Do Something Now, they should seek a seond opinion.
Also, if your doctor is suggestng that he is quite certain that he has the life-saving treament, you should be very wary. An honest doctor will tell you that we just don’t know.
We really don’t know if any of these treatmens will save your life. AFter being diagnosed with cancer, this is s terribly bitter pill to swallow.
But patients should realize that “watchful waiting”–and avoiding the risks of the various terament–may well make more sense than exposing yourself to a treament when we have no evidence that it will save your life–or even give you an extra week
. Maybe it will; maybe it won’t. All that we know for certain is that all of the treatments carry the risks of very serious side effects.
Maggie;
Once again, you are pounding on PSA tests, which I never mentioned and do not know enough to discuss.
If it makes you feel better, we can declare that you “won” this argument – but I still didn’t see the reference I requested – just hearsay from doctors you have talked to. The AHRQ article’s statement is open to interpretation for the reasons I discussed – if only 3 men in the study had Gleason score 8 or higher, that’s not meaningful, is it?
Since neither you nor I are learning anything here, I think it’s best if I just stop reading your blog. Best wishes.
“Since neither you nor I are learning anything here, I think it’s best if I just stop reading your blog. Best wishes.”
Bev – I hope you don’t stop reading and contributing as I, for one, am learning plenty from everyone including you.
I had prostate surgery in 2004, not for cancer but for BPH, after seeking a second opinion. I get the PSA test every year as part of my corporate physical and probably couldn’t refuse it if I wanted to. In the course of the episode leading up to the surgery, I learned something important about second opinions. I asked my cardiologist (who is also my PCP) who referred me to the urologist I saw, whether I should seek a second opinion or not. He said I could if I wanted to. I did, and the second opinion urologist confirmed the opinion of the first.
After the surgery, my cardiologist made the following points: (1) it all worked out fine, (2) sometimes the second opinion doctor tries to steal the case, and (3) when he does his teaching rounds at the AMC that he is affiliated with and the medical students ask when is it appropriate to recommend a second opinion, his answer was: “if the patient brings it up.” While second opinions are a separate issue from shared decision making, I thought it was a very telling comment about the cultural reluctance of doctors to challenge or interfere with the judgment of a colleague, especially one they know and respect.
Barry–
I think it’s a major
problem when doctors are reluctant to have a patient go for a second opinion.
This tends to be a much bigger problem in the Northeast–where doctors are accustomed to working “solo” and don’t like the idea that medicine has become a team sport.
In other parts of the country ,particularly in the Northwest,where doctors have been practicing collaborative medicine for years (all the way back to the Mayo Clinic and Kaiser
Permanente) a doctor would be much less likely to bristle at the idea.
And I’m afraid that the reluctance about patients going for a second opinion has much less to do with
respecting colleagues than
with a fear that someone will “steal” your patient (and the cash that will come to you if you do the procedure.)
The whole notion that patients could be “stolen” suggests that they are property–not how I want to be viewed by my doctor. Doctors are supposed to be professionals: the people they treat are not customers or clients–they are patients.
As one young cardiologist said to me not long ago: “We’re not lawyers, you know. We’re physicians.”
Among the doctors I respect, it would be considered highly unprofessional to in any way discourage patients from getting a second opinion. And if a patient seems uncomfortable with a recommendation–or is anxious–it’s considered good practice to urge them to go for a second opinion.
Whoever does the procedure, you don’t want the patient to be anxious. It’s just not good for his/her health, and that should always be the first concern.
Prostate Cancer May Not Get Worse Immediately After Detection.
Prostate cancer patients are suggested not to treat the disease immediately after detecting it, because there are good chances that the disease won’t get worse.
Cancer Institute of New Jersey examined 9000 men of age 77 who were prostate cancer diagnosed between 1992 and 2002. All the patients chose either not to take treatment or to delay it. 72% percent of examined men who didn’t receive any treatment at all died from other diseases and age related causes. The rest of them (2675 people) delayed treatment for a decade.
The most known way of detecting the disease is prostate specific antigen (PSA) blood test that detects cancer much before symptoms occur. Researchers suggest that there is no need to start treatment immediately, because about 10-15% needed prostate biopsy and only 2-3% needed treatment.
What researchers suggest is called “wait and watch” – they should wait and get treatment only when symptoms get worse. This is because prostate cancer treatment side effects, such as sexual problems or bladder control problems, may be more threatening than the positive ones, especially in older adults.
One in six American men suffers from prostate cancer. There were 218890 cases detected in 2007, 27050 of those patients died from disease caused reasons. In this year about 220000 cases are expected to occur. However, according to this new research, the disease is not deadly and aggressive. It should not be treated until really needed.
Thanks Gregory–
Prostate cancer is a disease in which cancer develops in the prostate, a gland in the male reproductive system. It occurs when cells of the prostate mutate and begin to multiply out of control. These cells may spread from the prostate to other parts of the body, especially the bones and lymph nodes.
The idea of sitting around and doing nothing scares me. But i guess, with your doctor’s help, you have to make up your own mind.
Patients who were on Avodart or Dutasteride should refrain from donating blood for 6 months since there is a possibility of the blood being transfused to a pregnant female who might be carrying a male fetus.
Benign hypertrophy of prostate is associated with increased levels of serum ‘prostate specific antigen [PSA]’ which is a marker for carcinoma prostate, it is not considered to be a pre-malignant condition. This condition is diagnosed mainly by rectal examination and by ultrasonography.
Generic Levitra is an invention in the field of treatment of erectile dysfunction (ED) in men. The drug provided first time success and reliable improvement of erection quality for many men. A lot of people have get advantages from it. In fact the people having serious erection problem have got fruitful result.
You have a very informative blog,The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all,Thank you so much for bringing up this.
sphin
Once again, beware of oversimplifying. The original article from the AHRQ (which all should read) has as its main point that few good quality trials have been performed to compare these treatments, including watchful waiting. It doesn’t mean there isn’t a best treatment, just that we don’t know what it is yet. However, here’s the important sentence:
“Data from RCTs indicate that men with Gleason scores of 8 to 10 were more likely than men with Gleason scores of 2 to 6 to have evidence of biochemical recurrence, regardless of whether treatment was radical prostatectomy alone or combined with androgen deprivation therapy.”
In other words, a Gleason score of 8 or higher does NOT qualify for watchful waiting. Just want to make sure the lay reader understands that critical point.
As far as what to do for men with lower Gleason scores and low volume or low stage cancers, yes – treatment choice is a conundrum due to few adequately performed comparative effectiveness studies – not a rare event in modern medicine.
Hi Maggie,
I have a family history of cancer. My mom died of breast cancer and my brother had testicular cancer. I am a DES baby, so not sure what effect if any DES may have on the development of prostate cancer.
What are your thoughts?
Thanks, Ken Weiss
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