21 Comments
Mar 20, 2023Liked by Buzz Hollander MD

Usual thorough evaluation, difficult topic

Expand full comment

The gamble is; will l die of something else before I die of prostate cancer. If I were overweight, a heavy drinker, junk food junkie, that didn’t work out religiously, I would bet I don’t die of prostate cancer. Whoopi.

Expand full comment

It's still just math. 0% of us are getting out of here alive, cancer or not. I'll skip the medical nightmare and just go on living in peaceful bliss until I quit warming your planet for whatever reason. We're putting too many resources into keeping old people alive {temporarily} in a world with too many people

Expand full comment

If covid was by design it was genius. Look at the average age of death. The outliers were just collateral damage

Expand full comment

Granted, an anecdotal "study" of a sample of one isn't worth much, but the process from my positive PSA to an MRI and CT scan (done the same day), to implanting fiducials, to four Cyberknife radiation sessions, as of three years later, completely eliminated my prostate cancer.

Observation though: I live in Cary, NC. A couple of big hospitals here, and a lot of docs. The first doc I went to was a surgeon and the only option he offered was surgery. His description of the possible consequences of that scared me off entirely--I decided not to treat the cancer and let it do as it would. Fortunately, a friend of mine is a nephrologist, a graduate of the UNC medical school about 30 miles away, and he gave me a bigger picture: the Cary medical culture, at least regarding prostates, is way behind the times; if you want "modern," go to UNC.

The moral of this story isn't the question "Should We Stop Treating Most Prostate Cancers?", it's that those who treat prostate cancer should stay up to date on the treatment options. So far as I know, there are no Cyberknife machines in Cary, but that's no excuse for the docs in Cary not to know about the availability of Cyberknife, or other forms of prostate cancer treatment, at UNC-Chapel Hill or elsewhere.

Expand full comment

I’m a 12 year survivor with no treatment.

Expand full comment

The data used by the government health task force to give their recommendations has been rereviewed and found to be flawed.

PSA screening saves lives.

If people do not want to be screened and are afraid of evidence based active surveillance that’s an individual decision.

Making it for them is more based on ego than having a patient centered approach .

Almost every day I deal with a delay in diagnosis because PSA screening was not performed and rectal exams were either not performed or inadequately performed.. Especially in younger and older patients whose prostates were ignored.

The 12 year build up of undiagnosed now incurable prostate cancer is just now becoming apparent.

Just like Einstein supposedly said, doing the same thing over and over again and expecting a different outcome is the definition of insanity; going. Back to 1985 where over 70% of Prostate cancer presented metastatic is plain old foolish.

By 2005 well over 95% of Prostate Cancer was diagnosed organ contained.

Studies from Europe were pioneering who to watch and when to intervene ,

Things were really looking good until a group of non Urologist got out of their lane and here we are. Back to the future.

James A Betti MD FACS past Vice Chair Lahey Health Dept of Urology

Expand full comment

Zero out prostate cancer? Easy… Just kill all male children before puberty, and no one will die of prostate cancer ever again. /sarc

Expand full comment

Treatment may not decrease OVERALL mortality rates, but it certainly decreased MINE.

Call me selfish, I guess... lol

Expand full comment

Are you sure treatment decreased your mortality rate? It is impossible to determine what WOULD have happened if you’d pursued a different course of action, e.g., treatment vs non-treatment. Oncologists only give probabilities, such as 1% chance of recurrence with radiation vs 80% chance of recurrence without (the exact probabilities I was given for my throat cancer).

Expand full comment

If we talk about cancers that are generally more aggressive within someone's life expectancy, it is clearly a fallacy to base individual decisions on population averages. It is especially misguided when the public health screening recommendations are based on cost. If universal mammograms cost more than isolated breast cancer treatment, the public health doctor of cost accounting will come out against screening. But nobody gets 1% breast cancer. For the individual, it's binary. You should get screened even if everybody's screening costs too much. Prostate cancer is different. Another way of making Dr Hollander's point is that prostate cancer isn't binary in the way other cancers are. This complicates the individual decision.

Expand full comment

Health screening recommendations, like everything else, must factor in cost. If cost were not an issue, why not get a full-body MRI or PET scan every year? Or run thousands of lab tests on a daily blood draw? The only way cost is NOT an issue is if everything were free, which would require all doctors and diagnostic techs to work for no compensation, all medical devices be manufactured at zero cost, and so forth. Everything is a cost/benefit calculation, just like which car to buy or which restaurant to go to for dinner.

Expand full comment

No doubt if you're a public health official, consider cost. But if you're an individual, those recommendations are often contrary to your best interest. Go ahead if you want making your own decisions on population averages (you know, we average one breast and one testicle). I'm gonna figure out a way to pay.

Expand full comment
author

I'd need a lot more time to really back up my thoughts here, but my suspicion is that most recommendable screening programs end up cost effective or at least so if you assign value to extra years lived -- mostly because systemic cancer treatment for advanced cancers in this country is so expensive and outcomes so dim. The programs with so few saves as to not save money probably run into these same issues as we see with prostate cancer screening - it's not clear you really wanted to know in the first place, most of the time. Quarterly MRIs and monthly labs would not only cost a ton and drive people crazy, they would lead to so many false positives and unnecessary work-ups that enough bad things would happen to probably counteract any screening benefit. Thankfully I trust we will never have data to support or refute this claim :)

Expand full comment

The recommendation to save money by not diagnosing turns the whole millennial history of medicine on its head. What if Hippocrates had taken this advice? Remember that in many cases he could only diagnose, but not offer effective treatment. But the whole subsequent progress depended precisely on those diagnoses. Medical reforms designed to save money, generally cost both money and lives. Was this ever the approach of the great pioneers like Harvey, Jenner, Pasteur, Lister, or Jonas Salk?

Expand full comment

Asking questions like this will lead to ALOT of missed boat payments. Shame on you.

Expand full comment

The problem with a non-Urologist pretending to be one is they come to the conclusion they wanted to have. In the study mentioned a good percentage of patients that were followed expectantly eventually had either surgery or Radiation, and that is what made the life expectancies the same.

America tried the author's approach for the last 13 years and now prostate cancers are being dx at an incurable stage. It is always better to make informed decisions rather than put one's head in the sand.

It is also best to understand the natural course of a disease and not pretend you are an expert at something you are not.

Expand full comment
author

I am quite familiar with the argument that lowered rates of PSA screening after the USPTF's flip-flop has increased the rate of metastatic disease at presentation. That is the known and primary risk of less screening and/or aggressive treatment! PSA advocates are fond of noting that "advanced disease rose by 50% in 14 years!" which sounds impressive (from the VA study: https://jamanetwork.com/journals/jamaoncology/fullarticle/2797845) However, the absolute #s are small - 2.5 men per 100,000. OK, tiny, given that TWENTY-FIVE THOUSAND of that 100,000 might be expected to be told they have a positive PSA test if screened annually. Hand-waving and credentialism aside, the question remains: how much damage do we want to tolerate to bring about a small amount of good? Unquestionably, we want those 0.025% of men to benefit, but not if we cause substantial harm to 2%. My read on the evidence is that being serious about screening those at highest risk is probably the best balancing of harm and benefit. By all means, offer counter-points supported by data if you disagree!

Expand full comment
Mar 20, 2023·edited Mar 20, 2023

I’m not sure that I would “shrug off” a large, well run study like this.

Certainly prostate cancer care has changed over 20 years, but this study, which has been published before at earlier phases, is a useful confirmation of the validity of less aggressive prostate cancer care for men with low risk cancers.

And I agree that Unfortunately, when it comes to PSAs, MRIs, biopsies, etc there is no silver bullet for delineating which people will truly remain “low risk” without meaningful progression, metastasis and morbidity with perfect precision. It’s a game a probability and there are chances of both good and bad outcomes with any approach.

But it is useful to know that men with low risk cancers (mostly Gleason 6, and all PSAs <20) did fairly well (and had similar rates of mortality) even if they didn’t intervene early. Further, there was a nearly 10-fold higher chance that men in this study would die of something other than prostate cancer over the 15 year followup.

That’s useful knowledge, even if it is based upon 20 year old treatment protocols.

Expand full comment
author

I may have been a little uncharitable in my assessment, especially in concluding that only 25% of the "active monitoring" group were winners (ie surviving the study w/o cancer treatment) -- I suppose the additional 20% who *died* w/o cancer treatment also won that bet, even if not in the way they probably would have chosen. However, my point is that the headlines overstate the significance of the trial, especially since it's likely (but not certain) that someone w/ a Gleason 4+3 being steered towards treatment in 2023 is more likely to have an aggressive cancer than the average person in the "active monitoring" cohort in 1999, esp since they were usually Gleason 3+3, a relative no-brainer to not treat these days. Maybe you could use this to support waiting to treat a Gleason 3+4... maybe... but really the numbers in that cohort are so small from the trial, I'm not sure that would be justified; and I don't think urologists are treating a lot of those folks in 2023, anyway. The question that really interests me is whether this "new era" with genetic tests, pelvic MRI, IsoPSA, etc will lead to less overtreatment and improved cancer mortality numbers in a long term trial; it sure seems possible, but time will make anyone a skeptic about such things!

Expand full comment

Definitely I would agree that this study is most relevant to Gleason 6, not 7, as I believe 3/4 of cases were Gleanson 6, which is likely to heavily bias the data set towards this lowest risk group in terms of outcomes. For Gleason 7 alone I don’t have access to the full 15 year study to know if they stratified to this group and whether the trial was powered for the Gleason 7 population in isolation.

Expand full comment