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Tuesday, February 25. 2014
"Decisions, decisions, decisions!" This often is spoken in a mixture of ennui and smug irony for decisions such as "should I buy the Audi, the BMW or the Lexus?" But this piece is nothing like that, it is about the general confusion and questionable value of our medical establishment.
The three "decisions" are apt because the diagnosis and treatment of three major illnesses have been called into question in the past year and this is disconcerting if not alarming. If you are unfamiliar with the work of Dr. John Ioannidis I recommend you find him on the web. His view of the state of medical research is summarized as "Lies, damned lies and medical research."
The original quote actually was by the British prime minister, Gladstone: "There are three kinds of lies, lies, damned lies and statistics."
The recent study out of Canada declaring the value of mammograms in women under fifty without value is noted. One doctor at Sloane Kettering has already balked and we have yet to hear from the Susan Komen foundation. The other disqualifying report identified antidepressant medication as simply placebo with no valid clinical evidence to the contrary. As a clinician my experience does not support that position, but there are facts that are hidden from us. For example, the FDA requires two "positive" studies to approve a medication for the treatment of a condition. That there may be six negative studies is not required to be revealed to us, and, as Ioannidis points out, many of the "successful" studies measure the new product against drugs that are known to be less than effective, if effective at all.
But it is prostate cancer I want to focus on. To PSA or not to PSA, that is the question. (Excuse me Prince Hamlet.) I have learned a great deal about this question from a man whom I have known for many years and who has had prostate cancer diagnosed. There was a series of articles in the popular press questioning the need for and value of the PSA test around the time his PSA began to increase incrementally. "You will more likely die with the prostate cancer than from the prostate cancer." This is very reassuring, unless you have witnessed a patient or a relative die the excruciatingly painful death of metatstatic prostate cancer.
The concerns expressed, in our behalf, is that the PSA can lead to biopsies which can be painful and prone to serious complications. While I am not a urologist, I can say I have seen one man who complained of persistent pain following a biopsy. That is all. What most of the articles failed to make reference to is something called the Gleason Score, an assessment of the aggressiveness of the tumor's malignant cells. The numbers of the score range from low to high but what you need to know is that a score of Seven is at the dividing line of could be serious and is serious. Eight and up are without question serious. Without that information one cannot make sensible judgements about how to proceed and one can only have that with the prostate biopsy. You can see the circularity of this process. With that information in hand one is then given a menu of treatment choices to consider. Watch and wait, radiation, surgery - robotic and standard supra-pubic surgical removal of the prostate gland, proton beam treatment, cyberknife, aggressive sonic ablation - more than most doctors, let alone lay people, can assess when in a state of some anxiety. Every treatment brings its own list of complications and ill consequences. "5%" risk of whichever one sounds reassuring but, if it is you who experiences that ill consequence it is 100%.
And what is most important is, as my friend learned, there is no evidence that any treatment is superior to any one of the other treatments and there may never be a study to pit one against the other to determine which is best. He chose surgery and has done well now for a few years. His PSA is zero and hopes it will remain that way. So, we ponder these three conditions, each afflicting roughly 10% of the general population, and we are asked to act or not act on the basis of flawed and insufficient information. What else are we missing?
Makes you think, doesn't it?
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My father in law almost died of sepsis following his biopsy - in his mid-80s. 12 days or something in the hosp and ICU.
I am a three time cancer survivor, the first was prostate in 2001 with a succesful surgery that thank God left all of my parts working. I had just above a Gleason 7 at 57 years old and it had come on fairly rapidly. Regular PSA tests can give a rate of change which can be important in recognizing how aggressive the cancer is.
I have had kidney dance a couple of time since then that was detected on follow up of my prostate cancer. I am a happy camper and thankful for a good urologist who has kept me going on part of one kidney so I can watch my grandkids grow up.
The biopsy has some discomfort but it was OK and I put off my first surgery until after the opening of dove season and I was in a deer stand on opening day a few months later. So now I am in bonus, overtime and life is good.
"The recent study out of Canada declaring the value of mammograms in women under fifty without value is noted."
Catchy, but that's NOT what the study showed.
Aside from the design flaws and biases in the study - mammography is known to have reliability problems in 40-49 year age group due to breast density - the study did NOT show that mammograms in women under 50 are without value. Its authors concluded that mammograms plus physical exam (usually by a trained nurse) was no better than exam alone.
First, we already knew that mammograms have reliability issues in this age group. I'll give you credit - at least you defined the age group - many headlines have simply reported that mammograms are of no benefit.
Second, for many women, mammograms are the ONLY screening exam they receive. This study did not compare mammogram alone versus no exam. However, from many media headlines, one would assume that was the case.
Third, in most provinces, the exams were done by trained nurses - nurses that weren't rushed for time like US doctors. I'm willing to bet that the trained nurses did a better breast exam than many women receive from rushed US doctors. In terms of doctors versus nurses, it's unfortunate that the study makes no mention of the outcomes of women in Quebec (where docs did the exams) versus women in other provinces.
Many thanks for informing me of the Gleason. I've always thought of this site as especially excellent in bringing into focus lots of off-beat, often cultural, matters. I know I sound like Asian spam, but I'm for real. ;-)
Guidelines combined with tort lawyers are the problem. Unfortunately some in the medical world (those that populate many committees which I'm betting don't do a lot of patient care) love guidelines that benefit their specialty.
Good guidelines are like the Marines one where you forge ahead on a path to get you 70% of the way to your goal, then reassess.
As a 13-year survivor of aggressive prostate cancer, I dislike the current de-emphasis on PSA tests. I was diagnosed with prostate cancer -- as a result of the routine PSA test that was a part of a routine physical in the Army. The only reason my cancer was identified was the serendipitous timing of the very comprehensive lab-work conducted as part of that Army age-40 physical.
At first the elevated PSA values were assumed to be merely a result of infection. Two separate courses of antibiotics over a few months did nothing to affect the PSA values; indeed, follow-on values were climbing alarmingly 8.4, 8.7, 12.4, and 13.1 within the span of three months.
The biopsy showed a high Gleason and indicated an aggressive cancer throughout the entirety of my prostate tissue. A radical prostatectomy followed. Two years later, I had to undergo follow-on radiation therapy as the slow increase of my PSA values indicated that the cancer had not been entirely removed.
Since then my PSA is < 0.01; for practical purposes nil.
Had I not had a routine PSA, as part of my comprehensive age 40 physical, my prostate cancer would not have been discovered in time to affect the necessary surgery. I would have very likely, almost certainly, died painfully within a year. So I am a believer in the PSA as a useful test.
Note: Prior to my experience, no one in my family had experienced any prostate or testicular cancer. When my grandfather died at age 89, his prostate was naturally enlarged, but with no significant symptoms. My father, age 80, currently has an enlarged prostate, but no cancer.
I have encouraged my four sons to get regular testing, starting in their mid-30’s, as they are as likely at risk as was I – without any previous family history of the disease.
My dad had a miserable time after his biopsy and surgery due to an elevated PSA. Elevated PSA does not mean you have cancer, so no one should rush into invasive treatment until the pathology report is thoroughly explained. The Gleason score helps to identify an aggressive cancer that is likely to spread and kill you if left untreated. Some men with a low Gleason will still opt for treatment because their urologist knows nothing about "watchful waiting, and it doesn't pay the bills. I tried to convince my dad to just leave it alone (back in the mid-1990s) because his was non-aggressive and that he would not have to risk the surgical complications (which he had). He went with the urologist, so that was his choice.
On the breast cancer and mammograms - I had a questionable spot on a mammo 5 years ago. Was sent for a ultrasound, and then a biopsy because nothing was conclusive in that teeny tiny little spot in the middle of my breast (would have never felt it). The push was on for a lumpectomy+radiation at the least, or a mastectomy without radiation. All this was pushed at me without the oncologists even knowing the aggressiveness of my microscopic tumor. Mine ended up being very non-aggressive with 5% chance of recurring with estrogen-suppressing drugs and 10% without the drugs. No talk of watchful waiting for me. I am not going for mammograms any more (I am 66) - that may be dumb, but I believe that anything that is growing in there will die with me. If I am wrong, I will deal with it when the time comes. I am not interested in the one-size fits all that permeates most the Cancer Industrial Complex.
Souix: I stipulate to every point you make regarding watchful waiting and Gleason scores ("The Gleason score helps to identify an aggressive cancer that is likely to spread and kill you if left untreated." and "Some men with a low Gleason will still opt for treatment because their urologist knows nothing about "watchful waiting, and it doesn't pay the bills.").
Nevertheless, my personal example, a data point of one I grant you, is the opposite case. Without the opportunity to have a routine PSA lab when I was 40 - mind you with no history of prostate cancer or prostate problems in my family - my aggressive prostate cancer would have remained undiscovered until too late. Even with a radical prostatectomy, I had slowly metastasizing cancerous activity two years later that had to be treated with radiation.
That was 10 years ago.
The PSA test is useful for initial screening. Your points about what to do after the results are well taken, but I do not like the recent movement that downplays the utility of the PSA test just because it occasionally is followed by unnecessary procedures.
A routine PSA saved my life.
Serious question here. Have any studies been conducted comparing the rate of prostate cancer in men who frequently indulge in what I will call prostate exercise and those men who do not? I'm thinking maybe an underused muscle may tend to weaken over time and be more vulnerable? Just asking.
Here's my experience:
I had a slightly elevated PSA test. My doctor said wait till next year and see what happens. Next year's test was a couple of points higher. I was biopsied. The urologist found one small cluster of cancer cells, centrally located. He suggested "watchful waiting" as most prostate cancer cells are slow growing and statistically, it would likely not be the cause of my death.
BTW, the needle biopsy was VERY uncomfortable, like being stung over and over by insects. I was given a topical anesthetic, but it didn't seem to do a hell of a lot.
There were significant hazards and side-effects to all the available treatments. After a lot of research, I decided I wanted the surgery. I wanted the cancer out of my body.
My doc was a terrific surgeon. He was able to preserve the nerves, and I wasn't even incontinent, except for dribbling for a short while.
They examined the removed prostate. The lab tests revealed multiple clusters of cancer cells, with one of the clusters at the very edge of the prostate, but not yet in the capsule that surrounds the prostate. I have to think that had I elected "watchful waiting," the cancer would have escaped into the body and would be essentially incurable. At the time (this was in September, 2004), no chemo treatments worked on prostate cancer cells. I don't know if it's different now.
I'm coming up on ten years of being cancer-free.
It's a crap shoot. If someone elects an expensive surgery, and it turns out the cancer was not a threat, I can see how a bean counter would object. I'm very glad my doctor went along with my decision. I belonged to an HMO (Kaiser-Permanente), so I didn't have to fight with a separate insurance company about anything. Untreated, I'd probably be dead by now.
The PSA remains a useful way to see if further action is needed. What we don't - and can't - factor is the quality and experience of the treating physician. Clearly we are not equally skillful at what we do and even the best have complications. And if you go to the best is that the one who does the procedure or is it a resident?
One more thing. When I need to have something done by a colleague I have not known and they tell me they are going to give me "special" attention I urge them not to do that. Too often trying too hard causes them to throw off their "game" and swing too hard.
I'm may be faced with the decision to have a prostate biopsy. I've scoured the internet for possible 'silver bullet' cures short of traditional cut and burn therapies, and the contradictory evidence leaves one as confused as enlightened.
My urologist said one of the keys is the rate of rise of the PSA results over time. Since it's normal for the PSA to rise as we age, he's looking for sudden increases. But if there are no annual PSA tests, there is no history to track increases.
In my case, it has been rising over the last 4 years, then took a sudden jump last spring. I was retested and the PSA number dropped almost 2 points. Six months later it rose again-- to just below 4-- the mendoza line for biopsy. I've read that the number increases during the winter months and any increase slows during the summer. Something to do with D. And men north of the 40th parallel are more like to develop cancer than those in sunnier climates. Hmmm.
I've decided to forgo the biopsy and continue to monitor my PSA with annual tests, and the urologist is fine with that, but he did point out there is nothing magic about the number 4 and men do have cancer with numbers below 4.
It may be good public policy in the aggregate to forego PSA testing, unless you're the one whose cancer is missed.
As to supplements, a recent report by the Fred Hutchinson Cancer Center at the U of Washington claims to have found evidence that those taking fish oil supplements (specifically the DHA in the fish oil) have a higher incidence of aggressive prostate cancer. Go figure. I've been taking fish oil for the last 10 years to control my cholesterol. My cholesterol is fine, but my prostate may be toast.
The jury is still out. Another study showed a benefit - in terms of prostate CA - in men on a low fat diet who took fish oil. Also, the study you cite shows correlation, but not causation. Some question if it's the type of fish oil or maybe even the total fat, i.e. fish oil + other fats = total fat (if you're taking fish oil, reduce the other fats in your diet). Also look at other risk factors - if your a fat black guy with a family history of prostate cancer, fish oil might be a problem. Of course, you can't change your race or your family history, but you can lose weight. Hope this helps.