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Posted By : NKinney - 3/3/2015 11:02 AM
Married, caucasions with high socioeconomic status are at the highest risk of PC overtreatment.
 
 
Surprised?

Posted By : halbert - 3/3/2015 11:20 AM
Nope.
Age at Diagnosis: 56
PSA:3.3(lowered by saw palmetto)-pre 2012 <1.0, 2013 2.0, 2014 3.3
Biopsy: 3 of 12, G3+3, all on LT side, 20%, 5%, 3%
Clinical Stage T1C
Malignant Melanoma 2006 (2 sites, 1A in situ and 1B, no lymph involvement)
Bone Scan, CT scan negative for spread
RALP on 2/17/15
No EPE, 20% organ involvement, g3+4 final

Posted By : NKinney - 3/3/2015 2:48 PM
Tony Soprano learns what a "wallet biopsy" is:  https://www.youtube.com/watch?v=O7CVXO2pBLc
 
 
 

Posted By : ASAdvocate - 3/3/2015 6:31 PM
A key finding from that article:

"The rate of aggressive treatment among all men with indolent prostate cancer was 64.3%"

Well, that certainly is high, and probably reflects the natural impulse to "get the thing out, and get this over with".

On the other hand, that statistic would have one-third of the men choosing some form of AS or just ignoring treatment. I'll guess that number is up substantially from a few years ago, when intervention was considered the only safe course of action.
DOB: May 1944
December 2010: PSA 3.4 biopsy negative, HGPIN
March 2012: PSA 4.4 biopsy abnormal cells, HGPIN
April 2012: Prostate MRI w/coil, suspicious/indeterminate
July 2012: Biopsy <5% 1 of 14 cores, 3+3; T1c
Enrolled in AS program at Johns Hopkins
September 2013 PSA 3.7 biopsy: < 5% 3 of 14 cores, 3+3
OncotypeDX: 86 percent chance of PCa remaining indolent
Sept 2014: Biopsy negative.

Posted By : halbert - 3/3/2015 9:21 PM
OK, I'm going to be really dense here. The word "overtreatment" gets thrown around in here a great deal, and nobody bothers to define what it means. I am well aware that from the mid-80's (when PSA came in to common use), and about 2000 or so, there were a lot of men given surgery based mostly on PSA, who probably didn't need it.

Since the ACS guidelines came out a few years ago, and with all the publicity around it, there appears to be a lot more sanity around treatment options today compared to 15 years ago. There is also what sounds like hair-splitting, but it really isn't: AS IS a treatment. Non treatment would be: "go home and come back in a year".

So, my question is, what is the definition of over-treatment, in today?

I also note, relative to the OP, that married white males in upper socioeconomic status are more likely to have quality health care and medical insurance. Therefore, we are more likely to be getting screened.

Last, I suggest that in some ways, an individual will only know if they were 'overtreated', if the treatment is proven to have been unneeded. It's a bacwards look, not a forward look.
Age at Diagnosis: 56
PSA:3.3(lowered by saw palmetto)-pre 2012 <1.0, 2013 2.0, 2014 3.3
Biopsy: 3 of 12, G3+3, all on LT side, 20%, 5%, 3%
Clinical Stage T1C
Malignant Melanoma 2006 (2 sites, 1A in situ and 1B, no lymph involvement)
Bone Scan, CT scan negative for spread
RALP on 2/17/15
No EPE, 20% organ involvement, g3+4 final

Posted By : celebrate life - 3/3/2015 11:27 PM
Halbert, I can see where you're coming from. I just read a thread where Peter DA said that the most aggressive PCa sometimes produces little or no PSA, so anything above a 1 or 2 needs a biopsy to establish if there are cancerous cells or tumors. I'm a proponent for early detection, as I think my husband's doc was negligent in that dept, so the only "over treatment" would logically be following biopsy. So I would encourage all men to get a baseline psa at 50 or younger and if it rises, poke and pinch the wallet!
Husband age 56
Dx: PC with widespread Mets to bones and nodes 11/2010
PSA @ dx nearly 1900 Gleason 4+5
Docetaxel 1/17/12
Zytiga7/9/12
xofigo 7/18
Smarium 153 5/10/13
Xtandi 9/15/13
Cabazitaxel 2/21/14
Zytiga 10/15/14
Ongoing since dx: denosomab and Luprolide
Begin RT to sacrum X 10 1/13/15
PSA 1/15 increased to 100
PSA 130 2/15End Zytiga
Pilot study DRibbles vaccine approved to participate!

Posted By : GOP - 3/4/2015 5:54 AM
Overtreatment is a guy who is worse off from the side effects of his treatment than he would have been if he'd chosen no treatment or a less aggressive one.
Diagnosed in October, 08. One sample of needle biopsy showed Gl 6. WW for 18 months. PSA went fro 4.3 to 6.1. Surgery scared the heck out of me. Mapping biopsy of 60 samples showed. 15 were GL6, 1 was GL7. Had LDR brachy on 10/ 4, 2010
First PSA post brachy on Jan. 6: 0.24
7/ 7, '11: PSA: 0.20
1/ 5, '12: 0.25
7/ 7, '12: 0.2
1/ 7, '13: 0.1
7/5, 13: 0.1
1/3/14: <0.1
7,5/14:<0.1
1,5/15:<0.1

Posted By : PeterDisAbelard. - 3/4/2015 6:45 AM
While we are talking about definitions, I am not sure I buy their definition of "Indolent Cancer" as "screening-detected, low-risk disease". I buy the whole "overtreatment" thing -- I acknowledge that it happens and that it is a big problem and one that is hard to deal with -- but it bugs me that in their eagerness to make their point they have tried to skip a step by defining words with a clear meaning to mean something else entirely. Most screening-detected, low-risk disease is indolent -- or more clearly, will prove to be so -- but some is not. There is a strong correlation but the ideas are distinct and the populations aren't entirely identical. The anxiety that drives men to seek treatment when they shouldn't do so is overheated but not illusory.

They also go on to define "PSA-detected, low-risk prostate cancer" as "(clinical category T1c, Gleason score<6, and PSA<10)". I suspect that the Gleason score < 6 part may be in error since, as far as I know, there hasn't been a notable rise in the treatment of men with Gleason scores of five or less.
62
Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012:
1)neg
2)neg,
3)positive 1 of 14 GS6(3+3) 3-4%, 2nd opinion GS7(3+4)
4)neg.
Mild Pre-op ED
DaVinci RRP 6/14/12. left nerve spared
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
24 mo ADT3 7/12 - 7/14
Adjuvant IMRT 66.6 Gy 10/17/12 - 12/13/12
Incontinent, Trimix, VED, (AUS Planned)
Forum Moderator - Not a Medical Professional

Posted By : halbert - 3/4/2015 6:54 AM
IMO, as the more sophisticated imaging tools become more common and widespread (and paid for by insurance), then overtreatment will go down. The hope, that I see, is that it will become truly possible to identify the low PSA but aggressive cancers, and treat them without also treating the truly indolent cancers.

I just don't think we're there, yet.

I suppose it's personal for me. By some definitions, I did not require treatment based on test results. I probably fall in that gray area.
Age at Diagnosis: 56
PSA:3.3(lowered by saw palmetto)-pre 2012 <1.0, 2013 2.0, 2014 3.3
Biopsy: 3 of 12, G3+3, all on LT side, 20%, 5%, 3%
Clinical Stage T1C
Malignant Melanoma 2006 (2 sites, 1A in situ and 1B, no lymph involvement)
Bone Scan, CT scan negative for spread
RALP on 2/17/15
No EPE, 20% organ involvement, g3+4 final

Posted By : Pratoman - 3/4/2015 7:12 AM
One mans over treatment is another mans erring on the side of caution. What's more important than the semantics, is that each man gets himself educated so they can differentiate between the two, and what each term means for HIM
Age 64 (in 2014), Father had PCa
PSA Feb 2006 - Nov 2014, PSA rose from .7 to 4.3
Nov 2012 - Biopsy - 14 cores all negative for PCa, 1 showed Hi Grade PIN
Nov 2014 BX 3 of 12 cores positive original pathology G6 10%, G6 20%,
G8 (3+5), 70%. Johns Hopkins second opinion, G3+5=8 downgraded to 3+3=6 @80%
Bone scan and CT Scan negative
Surgery with Dr Ash Tewari Jan 6, 2015
Post surgical pathology, stage T2c, bilateral disease, upstaged to G7(3+4)
5% of Prostate involved in Tumor
Organ confined, negative Margins, negative SV, negative lymph nodes (9) PNI positive
PSA 2/15 <.02
My story: www.healingwell.com/community/default.aspx?f=35&m=3297053&p=1

Posted By : clocknut - 3/4/2015 9:30 AM
What a strange study and what an odd conclusion. I don't question the numbers, but I do question the underlying assumptions.

Since married Caucasian men in high socioeconomic groups generally receive "the highest quality health care," one must assume that the authors consider all the other medical procedures men who meet those descriptors undergo to be medically necessary and free from overtreatment.

In other words, men who meet the authors' description often have procedures such as knee replacements, hip replacements, hernia repairs, and who knows what else, and all these are apparently automatically deemed "good medicine" and "appropriate" Isn't it fair to consider that the wealthy white married guy could have limped around for the rest of his life on a painful pair of legs, just like the poor man who couldn't afford that surgery? Was he "overtreated"? Lately, I've been reading that many knee surgeries, for example, provide no better relief than the passage of time and less invasive procedures might have offered. But, we don't sweat "overtreatment" when we think about knee surgery. For whatever reason, we only seem to worry about "overtreatment" when it involves the ability to get an erection.

Are there men who could have postponed prostate surgery, or who could have chosen a less aggressive treatment? I'm sure there are.

Are there women who could have avoided a mastectomy, or a double mastectomy and chosen a lumpectomy instead? I'm sure there are.

Are we to assume that all the cardiac by-pass surgeries that men in these categories undergo are entirely necessary? That all cardiac catheterizations are necessary? That these procedures couldn't have been deferred in favor of lifestyle changes or less aggressive therapies? I guess so.

Most of us choose some sort of cause or issue as the center of our focus. For some, it's global warming or environmental issues, for example, and they see everything through the filter of that way of thinking.

I can't escape the feeling that some have chosen "overtreatment" as the windmill against which they must wage combat, and when they think of prostate cancer, that's their center of focus.

I'm still inclined to give men the benefit of the doubt. If they're in the group described, they're probably not ignorant of the issues involved, and if they make the decision to sign on the dotted line for their treatment, I just don't consider it to be "overtreatment." It's what they chose. It's their choice. And isn't "a man's right to choose" something to be respected? His body, his choice.

I may disagree with that choice, but I'm reluctant to call it "overtreatment."

Post Edited (clocknut) : 3/4/2015 8:45:02 AM (GMT-7)


Posted By : MikeM53 - 3/4/2015 9:43 AM
GOP said...
Overtreatment is a guy who is worse off from the side effects of his treatment than he would have been if he'd chosen no treatment or a less aggressive one.   
I agree with this.

Age at Dx 53
Age now 55
PSA 3/18/13 = 6.4
Biopsy 3/27/13
3 of 12 cores positive (10%, 80%, and 60%)
Gleason Score 3+3
Started first SBRT treatment 9/03/13, finished on 9/13/13.
PSA 10/31/13 3.1
PSA 1/30/14. 1.6
PSA 5/12/14. 0.9
One year PSA 9/18/14. 0.8
See my SBRT journey in the thread below
http://www.healingwell.com/community/default.aspx?f=35&m=2818301

Posted By : halbert - 3/4/2015 11:55 AM
clocknut, exactly the kinds of thoughts I've been having. This is really a fundamental question of medical ethics. I have a hard time accepting the idea that most, if not all, medical professionals are urging unnecessary treatment so they can buy their next yacht or whatever.

The bigger issue, to me, is undertreatment of people at high risk because of their inability to pay. It kind of falls in a similar vein to the classic legal construct that goes something like this: I'd rather see 100 guilty men walk free than see one innocent one imprisoned.

I'd rather see any number of men be overtreated (whatever that really means) than see one die of this horrible disease because he couldn't pay for treatment.
Age at Diagnosis: 56
PSA:3.3(lowered by saw palmetto)-pre 2012 <1.0, 2013 2.0, 2014 3.3
Biopsy: 3 of 12, G3+3, all on LT side, 20%, 5%, 3%
Clinical Stage T1C
Malignant Melanoma 2006 (2 sites, 1A in situ and 1B, no lymph involvement)
Bone Scan, CT scan negative for spread
RALP on 2/17/15
No EPE, 20% organ involvement, g3+4 final

Posted By : NKinney - 3/4/2015 2:15 PM

Don’t waste time or energy trying to re-define “overtreatment.” 

 

Understandably, re-defining provides a means for some to minimize the unpleasant notion of prostate cancer overtreatment.  Minimization is a common tactic involving denial coupled with rationalization in situations where complete denial is implausible.  (I’ve seen posts here at HW, believe it or not, which have sought to deny PC overtreatment by saying, “I’m not sure I buy into this whole ‘overtreatment’ thing” and have sought to rationalize the entire epidemic as a hoax.)  Minimization through re-definition serves to avoid acknowledgement, conscious confrontation and ultimately having to deal with a negative situation by reducing the perception, importance and impact of the events.

 

Rather than re-define, or guess, look it up.

 

This month’s (March 2015) Journal of the Association of American Family Physicians includes an editorial titled, “Improving Quality by Doing Less:  Overtreatment.”

 

I’ll simply copy and paste this portion of one sentence, “…overtreatment, which is defined as treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm.”


Posted By : NKinney - 3/4/2015 2:32 PM

BTW, the "Overtreatment" article by the American Family Physicians lists a number of other proceedures as examples of overtreatment, in addition to treatment of low-grade prostate cancer.  I believe clocknut took a cut at a list, but the AFP list includes:

Anticoagulation for a small, subsegmental pulmonary emboli

Arthroscopic surgery for knee osteoarthritis

A1C targets below 7.0%, especially for middle-aged and older patients

Medical therapy for moderately elevated triglyceride levels

Treatment of prehypertension and mild hypertension

Using the same low-density lipoprotein targets for low-risk patients as for high-and very high-risk patients

Vertebroplasty for painful vertebral compression fracture

 


Posted By : halbert - 3/4/2015 7:24 PM
Ok, I accept the definition of overtreatment. What I struggle with is that there does not seem to be clear delianation and lines of demarcation that define 'to treat or not to treat'. It's not as clear cut as many seem to want it to be. Statements about "an epidemic of overtreatment" that lack real information that states that a particular group of patients were clearly overtreated based on commonly accepted criteria at the time of treatment is opinion based, not fact based.

Fact is, the criteria for appropriate treatment are changing all the time, and whether we like it or not, the only way those criteria get tightened is in retrospect. We'll get there eventually.
Age at Diagnosis: 56
PSA:3.3(lowered by saw palmetto)-pre 2012 <1.0, 2013 2.0, 2014 3.3
Biopsy: 3 of 12, G3+3, all on LT side, 20%, 5%, 3%
Clinical Stage T1C
Malignant Melanoma 2006 (2 sites, 1A in situ and 1B, no lymph involvement)
Bone Scan, CT scan negative for spread
RALP on 2/17/15
No EPE, 20% organ involvement, g3+4 final

Posted By : NKinney - 3/5/2015 10:14 AM
halbert, while I agree that PC overtreatment is difficult to accurately size — current estimates are that there are somewhere be 1 and 1.5 million men living today in the US who have been overtreated for PC — that doesn't imply it's "not fact based."

And you are also correct that the understanding of who does or does not need treatment is evolving with time as the body of scientific knowledge grows with time. It was only a generation ago when detection capabilities were inferior to what we have today that (essentially) everyone was treated immediately. The biggest change, and the change that has sparked overtreatment, is that we are now detecting smaller and smaller traces of "natural aging" which we brand with the term "cancer."

Current new imaging techniques have highly refined the abilities of knowledgeable specialists to separate who does and does not need immediate treatment.

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