Overtreatment? Catalona says that's exaggerating.

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Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/15/2009 10:06 AM (GMT -6)   
Bill Catalona made this presentation about over diagnosis and over treatment. Pretty eye opening. Catalona has performed over 5000 open RP's but that is not all he is famous for. As one of the top prostate oncologists in the world he is the father of the PSA test...happy reading...You can watch the presentation as well.

www.zerocancer.org/site/News2?page=NewsArticle&id=11119

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/15/2009 10:09 AM (GMT -6)   
Excellent report, Tony. He's quite a guy. That line of thinking is how I feel about the matter. Sounded real balanced to me.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/15/2009 10:11 AM (GMT -6)   
Watch the presentation...It takes about 45 minutes...

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/15/2009 10:13 AM (GMT -6)   
P.S.

It's almost like the other side wants you to believe that PC is because of testing, not the other way around. PSA testing doesn't make more PC appear, the cancers are there and growing whether a man knows about it or not. If a PSA test cost $1,000 a pop, perhaps there could even be a economic argument, but its a realatively low cost blood tests, and we know, it has saved thousand of lives over the years.

Don't know why people have to put a negative bias on a good thing. Guess they never dealt with PC first hand in their own bodies
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/15/2009 10:20 AM (GMT -6)   
Just a note. Most of these challengers come from the advocacy groups. ACS, for example, is not helping quell that sentiment. They spend 80% of their moneys on breast, colon, and lung cancers, and have a medical director, Dr. Otis Brawley, that has a bad attitude when it comes to prostate cancer...Common sense tells us otherwise...And this presentation does as well...

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 10/15/2009 11:53 AM (GMT -6)   
Excellent presentation; thanks for posting it. The problem is not with PSA screening; everyone should be screened; it's what you do with the information you get from the PSA. Even Cantalona's extremely low estimation that up to 20% of PC detected may result in overtreatment that's a lot considering the side affects and complications of the treatment. (most think it's a lot higher). If there were no side affects then treatment for everyone would be a no brainer. I think AS is still a valid option for a lot of patients whose biopsy reflects a low grade pc. I for one would never go on AS without a color doppler ultrasound and even an MRIS to confirm the biopsy results. I also think that the older you are the more sense AS makes. I think that treating every case of PC discovered is just as radical as saying that screening should not be done. Both arguments are at the extreme and there is a very large middle ground.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/15/2009 11:58 AM (GMT -6)   
I agree entirely with your above post, John, moderation is usally always the right path, not extreme views
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 10/15/2009 12:05 PM (GMT -6)   
The issue is not really whether men should get a PSA test - they should if they wish.
 
The heart of the matter is why, a generation after the introduction of the PSA test, we still don't have any good way to distinguish which detected cancers are going to metastasize and cause suffering and perhaps death and which detected cancers will stay in the prostate for the remainder of the patient's life (and hence treatment will only lead to unnecessary incontinence, impotence, etc.).
 
The reason is that urologists, radiologists, and cancer centers have no financial incentive to find an answer to that issue.  Since the advent of the PSA test, for example, the average income of a urologist has jumped immensely. 
 
Thus, it is not a surprise to learn that the money, time, and energy is going into finding better ways to operate and radiate - not whether most of the surgeries or radiation sessions are justified in the big picture.
 
Catalona's last slide is too ridiculous to merit comment.
 
Otis Brawley has written some very intelligent and thought-provoking articles and editorials recently.  For example, read online his editorial "Prostate Cancer Screening: Is This a Teachable Moment?" from the August 31st edition of the Journal of the National Cancer Institute.  Then get the two long-term studies and read them yourself.  The American study suffers from many methodological problems - one of them fatal, in my opinion.  The European study, while far from perfect, is much better and raises some very troubling questions.
 
To be clear: I strongly suspect that most of the men on this board correctly chose to have their PC treated.  I am still comfortable with my choice.  But one should not extrapolate from the unrepresentative sample of PC patients on this board that the "overdiagnosis - overtreatment" issue isn't a very real and troubling one. 
 
Now I'll stand back and wait to get flamed.
 
Zen9
 
    

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/15/2009 12:40 PM (GMT -6)   
en I think you may have taken my last post wrong. You are most welcome. your comments are too.

I don't think anybody questions any ones choice of AS. It is a very personal decision...

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/15/2009 4:06 PM (GMT -6)   
I think AS should be presented as a very respectable choice when dealing with PC. If we are talking about men with no PSA velocity issues, lower PSA readings in general, biopsies with real low numbers of positive cores, and low percentage of cancer present, and assume they have no serious family history of PC, I think they should be encouraged to try AS.

If their cancer is more prone to become agressive quicker, its ugly head will rear soon enough to make a sensible non-AS treatment choice.

In the meanwhile, this group of men can enjoy a good season of no side effects and quality of life issues longer, and perhaps in some cases, forever.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/15/2009 4:50 PM (GMT -6)   
Actually AS is the next closest thing to resistance to PSA screening and those who advocate against it. But I think the point the doctor makes is that AS or any treatment should be a decision made by a patient who has been diagnosed and has all of the necessary criteria for AS before commencing. Without screening, and those against screening I believe is assuming that decision for others who do have prostate cancer but have not yet been diagnosed. Dr. Brawley recommends against PSA screening which I believe is flat wrong. This would put this idea ahead of providing options to the patient and that is unethical in my opinion. If PSA screening was stopped, then all cases of early prostate cancer go to the AS category without the surveillence. We don't need to do this for study reasons because before the PSA test, death by prostate cancer was more than double the rate it is today. I still say there is no such thing as over diagnosis. And there is not as much over treatment as has been reported by the media.

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/15/2009 5:35 PM (GMT -6)   
Tony, I agree with the sentiments of your very last post above. Well said.

Ohio, I know you often speak of the 12 known types of PC, and I know that is true ,but the vast majority of men with PC have
the most common variety. Ultra rare cancers are a special concern by their nature. That is how it was when I battle d porocarcinoma three different times in my past, was one of only 38 known cases in the US at that time. My oncologist at that time had one other patient with it, a female, and for extensive purposes, he was the expert with 2 cases.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 10/16/2009 4:07 AM (GMT -6)   
I think we can say truthfully that the variant types of PCa, especially if you ask someone like Bostwick will tell you it is very difficult for pathologists to identify these (he said so at a PCa meeting a while back when he was here in Michigan at a PCa meeting group), let alone the gleason scoring. So, probably in some cases the "normal" presentation case of PCa is actually not the normal case, as the patho-doc did not know or catch that. It is harder than you may think. Another piece of the jungle, not to mention ploidity testing (optional not widely done), and missed biopsies (you can have various Gleason scores going on inside your gland, I had 2 sets of 3 different Gleason scores that were "found" via 12/12 biopsy).

So, with this lack of knowledge and 'known' data, many patients get protocols based upon limited accurate data. So, yes it can be a mine field, twilight zone and jungle in this world of PCa....and it is.
 "I wouldn't join a club that would have me as a member" (Groucho Marx)


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 10/19/2009 10:18 AM (GMT -6)   

TC-LasVegas writes, "Dr. Brawley recommends against PSA screening which I believe is flat wrong. This would put this idea ahead of providing options to the patient and that is unethical in my opinion."

Actually, Dr. Brawley belives that "[t]he patient and physician should make a shared decision about screening."  CA Cancer J Clin 2009, 59:220-224.

Calling someone unethical is an extremely serious matter.
 
Zen9

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/19/2009 10:53 AM (GMT -6)   
Brawley does actively speak out against screening of any kind. I have seen his "official statements" where he has indicated a "shared" opinion, but I would gather more information about his actions in the public eye. When he tells a reporter that he won't ever have a PSA test, was that his "shared opinion" or only his? Perhaps he does not care?

From his year 2000 interview with PSA-Rising:
www.psa-rising.com/upfront/otisbrawleyfeb00.htm

From this years Oxford Press
jnci.oxfordjournals.org/cgi/content/full/djp310

I am quite familliar with Dr. Brawley's editorials and on air comments. He notes that PSA screening could be responsible for up 40% less mortality, but so could improved treatment. What we do know for sure is that early intervention has improved mortality, and what's the only way to get there early?

We know it is not by following the ACS guidelines on prostate cancer screening. Which clearly says "we do not recommend screening"...
www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_prostate_cancer_found_36.asp?sitearea=

Tony
Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
Hormone Therapy May '07 to September '09 ~ Currently off.
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (October 7, 2009): <0.1

My Journal is at www.caringbridge.org/visit/tonycrispino]
My InfoLink page is at Tony's Prostate Cancer InfoLink Page

STAY POSITIVE!

Post Edited (TC-LasVegas) : 10/19/2009 9:58:01 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/19/2009 11:38 AM (GMT -6)   
Tony, I read every link you just posted. Horrifies me. What is the real motivation for such an anti-PSA testing scheme? I must be dumb, because I can't comprehend the other side of this issue. They even admit that the death rate has gone done, and it may be because of testing, though they won't come out and give credit.

You would think that PSA testing was some hokey, expensive, invasive test to hear them talk. I must be missing something here.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 10/19/2009 11:39 AM (GMT -6)   

The two citations to Dr. Brawley that you chose to post clearly indicate that he advocates "informed or shared decision making" (Oxford Press) and "informed consent" (PSA-Rising); that there is no basis for criticizing any man who chooses to get tested (PSA-Rising); and that he categorically rejects any suggestion that he is "anti-screening" (PSA-Rising). 

Again, it is one thing to disagree (even strongly) with someone, quite another to charge someone with being unethical. 

I'll let you get in the last word - I have to get back to work!

Zen9


Post Edited (Zen9) : 10/19/2009 12:24:34 PM (GMT-6)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/19/2009 1:44 PM (GMT -6)   
David hits the point I am trying to make. The last link I included is clearly showing the confusion coming out of the ACS with regards to prostate cancer. It clearly says that the best way to deal with prostate cancer is with the early detection, and yet it also states that the ACS does not support screening in men.

1> Exactly how do you find asymptomatic early stage prostate cancer without PSA screening? A DRE? It would be just as easy to say that DRE's would cause the same concerns and don't help either. However, in the NEJM, the European study clearly supports screening is helping by as much as 20% in reduction in mortality, even the US study supports this though to lesser degree. And to far too many, Brawley is saying PSA screening does NOT save lives by saying it is misleading to say it does. To me that is a 100% false statement. One he admits to later in the same paper that PSA screening in fact does save 1 in 43. More on those NEJM things later.

2> Brawley states that testing should only be done when doctor and patient have had a thorough conversation about the test. My point is ~ Exactly what can be discussed to improve what he says is the problem with PSA screening? He also states that folks are saying that PSA testing absolutely saves lives and that he does not agree with that. PSA is a screening test, in itself it saves no lives. It is not a treatment. What it gives a patient is valuable information. The patient can make better informed decisions if AFTER the PSA test when the doctor does a great job explaining the ramifications. The fact is that many patients will require an intervention (remember the ACS says early detection is key). And without PSA screening how will they know that they have treatable prostate cancer?

One more tidbit on the NEJM screening controversy. Those studies clearly are flawed. They have one very huge common flaw. They both skip a younger generation of men. Neither study, nor the ACS, has screening information on men in their 30's and 40's. The question of if PSA screening can help younger men is widely accepted as plausible and likely.

Until such time, I will gladly take the world re-knowned word of Dr. Catalona ahead of Dr. Brawley when it comes to prostate cancer. He has quite a few more prostate cancer patients as I don't believe that Emory College has a world re-knowned prostate cancer program...ACS spends 80% of it's money on Breast, Lung, and Cervical cancers, and the rest on all of the others combined. But it's stature in the press is taken for way more than it's worth in prostate cancer. If anyone wants to donate to prostate cancer research because they have prostate cancer or know someone who does, perhaps they should be aware of this fact before they choose the ACS...

Please note: I respect Dr. Brawley for all the good work he does. But I personally find him to be too obtuse when it comes to prostate cancer and the only tool we have for early detection. As flawed as it is.

Tony

Tony
Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
Hormone Therapy May '07 to September '09 ~ Currently off.
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (October 7, 2009): <0.1

My journey is at: www.caringbridge.org/visit/tonycrispino

My InfoLink page is at Tony's Prostate Cancer InfoLink Page

STAY POSITIVE!

Post Edited (TC-LasVegas) : 10/19/2009 2:04:38 PM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/19/2009 1:57 PM (GMT -6)   
Tony,

You and I are on the same page in this discussion, you are just more technically eloquent to explain your position. In your point #2, hard to believe that a doctor and patient would have to discuss even having a PSA test. It's just another check mark on the blood draw order. It's no invasive, its not painful, the cost is neglible to include it. Not looking for a conspiracy theory (as I hate them as a rule) ,but still trying to figure out why this educated man, Dr. Brawley, have to skirt and talk in riddles about the one aspect of PC that is easy, get men tested, both DRE and PSA, get an early base line. If they are fine, great, no sweat. But if not, then thank God there is a reasonable means to dx. the prospect of PC way ahead of time, and if it is an agressive varient, then be able to give that poor man a ghost of a chance of a cure or at least pro-longing his life and quality of life much further out. How could anyone argue against that? I know I am preaching to the choir with you, that's cool.

But who are these highly educated ones really talking to? Is it just pride and academics to them? I am not too smart, really, so it seems to me, that to take the sides of this issue that they are spewing, they absolutley must not have much first hand knowledge of living with PC, having a loved one suffer through it, and even those 28K lives they snatched away by this beast every year. They must be far more interested in "being right" on paper, then on being right with the lives of us men who have PC. End of speech. Promise.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 10/19/2009 2:32 PM (GMT -6)   
David, I
think the motivation is two fold: one being cost of treatment and the other being quality of life issues, If it really takes 48 men being treated to save one life then both of these are significant. I don't know if it is truely the case, but Brawley and others believe it. If it is indeed fact then, at $40k per treatment it would cost nearly $2,000,000 to save one life in addition to the 47 men having side affects, some rather severe complications. I may not agree with it, but it is a valid argument.
Today everyone is looking at how to reduce the total cost of medicine to society; in this framework it makes sense that someone is looking at PC.
JY

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/19/2009 6:08 PM (GMT -6)   
John, if those statistics were 100% provable and accurate, that would be one thing, but you have to admit that any sensible person would want to question the true motivation involved. We here all agree, what is needed is to know the difference between indolent and agressive, that is where the money could be saved in "overtreatment". Me, I am a dedicated right to life person, and regardless of the financial considertion, even if it is true, I would still value the life of the one that gets saved. If someone agrees to the position that its not worth the money, are they willing to sacrifice their own life, their sons, their father?

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 10/19/2009 6:35 PM (GMT -6)   
David,
These are tough questions and I don't have a clue about the answers; What's a life worth, $2mm, $10mm, $20mm? It's pretty obvious that most European countries have already made this determination and some day we will also have to. Is it worth saving one life if it means that 10 men will be incontinent, 20 will have ED, 1 or two have severe rectal proti***. I'm glad someone is asking the questions and thinking about it, even though I may not like the answers.
You are absolutely right; until we can distinguish agressive from indolant and as long as most doctors recommend treating every single case of PC uncovered we will continue to have these debates in the medical community.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/19/2009 6:45 PM (GMT -6)   
John, perhaps a medical compromise could work. I.E., if a man is dx with a low grade Gleason 6, 1 core/low % cancer, no family history, to be encouraged to use AS and see what the cancer is up to over time. Perhaps the primary treatment approval must be a little higher than it is now. If you have insurance, and you have a legitmate dx, most any health insurance will pay for operation or radiation.

Perhaps to get treatment on the first pass, you need to have a higher grade dx to begin with, in cases like these, waiting is proven dangerous.

This wouldn't be as good as the perfect test that doesnt exisit yet, but perhaps it could control some of the spirling costs involved, and perhaps there would be less men with incontinence, ED, worse that really didnt need to be treated.

Having a cancer DX shouldn't mean an automatic knee jerk reaction out of fear, I think most of here would agree to that premise.

And as you, and Zufas in particular bring out, perhaps before a primary treatment is approved, a consensus of opionions must be met, i.e. a surgical opinion, a radiation opinion, and a prostate cancer specific opinion. Getting any or all of the opinions would still be way cheaper than any of the primary treatment options.

When I was dx, if my uro/surgeon and a radiation oncologist agreed that AS was the most sensible choice, trust me, I wouldn't be going through all this prolonged hell that I have been dealing with for the last 11 months. Unfortunately, with my stats, treatment was legitmate from the beginning.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/09 met 2 rad. oncl, 7/09 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 - out  38 days, 9/14/9 - met 3rd rad. oncl.agree to start radiation, mapping on 9/21/9, 9/24 - mtg with uro/surg, 9/29- pre-op, 10/1 - 3rd corr. surgery - suprapubic cath/hard dialation, 10/5 - began IMRT SRT - 39 sessions/72 gys.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 10/19/2009 7:22 PM (GMT -6)   
Not screening because of the SE's and cost? That is precisely the ethics question I raise. The patient deserves the right to make his own decisions. I do not believe that it should be a joint decision between a patient and a doctor. The doctor should tell the patients what is available. He can tell them the upside and the downsides, and then get out of the decision process. If a doctor refuses, or refuses to give the patient the options, then he is having his own opinion or emotions getting in the way. I believe that a position against screening is a position against a patient being able to make his own decisions.

John, we are not at the points for I/C or ED yet. We are only at the point of a patients right to information in this discussion. Namely ~ whether he may have cancer or not. If a good job is done with providing him the options after his screening indicates an issue, then more patients will make better choices.

Tony
Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Gleason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
Hormone Therapy May '07 to September '09 ~ Currently off.
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (October 7, 2009): <0.1

My journey is at: www.caringbridge.org/visit/tonycrispino

My InfoLink page is at Tony's Prostate Cancer InfoLink Page

STAY POSITIVE!


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 10/19/2009 8:54 PM (GMT -6)   
Tony,
You don't have any disagreement from me on the need for screening. It's the need for treatment and the patient's right to information. They go hand in hand. I believe most doctors understate the case for AS in their low risk patients. I also think that a few more tests like color doppler and MRIS can also better identify true low risk patients; these are rarely recommended; yet doctors readily request bone and CT scans which are practically useless in this situation and are much more costly.
My only point is that low risk patients aren't getting the full story to make informed decisions, hence many are getting treatments that will do more harm than good. As long as this continues there will be guys like Brawley that focus on the screening instead of the decision to treat.
In the end it is the patient's decision; but I fear this will someday be taken away from us.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT

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