Re: Delayed Interventions


"Leonard Evens" <len@xxxxxxxxxxxxxxxxxxxxx> wrote in message
news:Vu6dnWIe67xEunvZnZ2dnUVZ_vudnZ2d@xxxxxxxxxxxxxx
George Conklin wrote:
"Leonard Evens" <len@xxxxxxxxxxxxxxxxxxxxx> wrote in message
news:dLSdnfuYx8LtcXjZnZ2dnUVZ_omdnZ2d@xxxxxxxxxxxxxx

George Conklin wrote:

With news reports out that the Journal of the National Cancer Institute

has

found that delayed intervention for prostate cancer is better than
overtreatment, links to the August 16 journal site require you to PAY

for

the article. Has anyone posting here paid or has a university

subscription

to the journal? What about some details? News reports are pretty bad

on

the details.



I tried accessing it through Northwestern, but they don't have anything
from that Journal newer than February.

I found the abstract using Medline/Pubmed and it says the following

--------------------------------------------------------------------

BACKGROUND: The frequently indolent nature of early-stage prostate
cancer in older men and in men with low- or moderate-grade tumors and
the demonstration that the survival benefits of radical prostatectomy
are primarily among men younger than 65 years have led to concerns about
prostate cancer overtreatment. METHODS: Using data from 13 Surveillance,
Epidemiology, and End Results registries, we performed a retrospective
cohort study of 71,602 men who were diagnosed with localized or regional
prostate cancer between 2000 and 2002. We quantified the incidence of
initial curative therapy (i.e., surgery or radiation therapy) among men
with lower-risk cancers as defined by their limited likelihood of either
dying from expectantly managed prostate cancer or achieving a survival
benefit from local therapy. Stratified analyses and multinomial logistic
regression models were used to quantify the absolute and relative rates
of curative therapy among men in various age-grade strata. All
statistical tests were two-sided. RESULTS: We identified 24,405 men with
lower-risk prostate cancers and complete data for the first course of
treatment. Initial curative therapy was undertaken in 13,537 of these
men (55%); 81% of treated men received radiation therapy. The likelihood
of curative therapy, relative to expectant management, varied
statistically significantly among lower-risk age-grade strata (all
P<.05). Assuming that initial expectant management is appropriate for
all lower-risk cancers, 2564 men (10%) in this population-based sample
were overtreated with radical prostatectomy and 10,973 (45%) with
radiation therapy. CONCLUSIONS: These data quantify a target population
for whom greater use of expectant approaches may reduce overtreatment
and improve the quality of localized prostate cancer care.

-------------------------------------------------------------

As you can see, they identified a large number of 'low risk' cases
diagnosed between 2002 and 2006. They don't give a definition in the
abstract of 'low risk'.


I got the entire article and read it. They do define risk in the
article.



Also, since it is much to soon to know what

actually will happen to these men, they did not report observed data on
results.


This has been the problem with all prostate cancer research:
long-term
results with some kind of control group.

Well there is the Swedish study of Holmberg, et. al. But I agree that
it may not be applicable to the US context.


I read that too. Clinical studies often do not pan out in the larger
population with average-style medicine. But even then, the PIVOT studies
from the USA are not out yet and have (so far) nothing to report. But the
Swedish study suggests that after more than 10 years a 3% difference in
mortality...very little.





(Keep in mind that for truly low risk prostate cancer

patients, the likelihood of dying of the disease within 5 years is
essentially zero.) So they relied on some models of what might be
expected in such cases, and assuming also that expectant management was
an appropriate choice for all of them, tried to estimate the degree of
overtreatment.

As best I can see, this is all highly conjectural. For older men today,
competent urologists don't by and large overtreat low risk cancers.


The article states the opposite, since most low-risk cancers ARE
treated.



How did you get the article? I would like to see the figures.

We have full rights to local libraries at with the Triangle interlibrary
system.



According to experts like Walsh and Scardino, such patients should not
ordinarily be treated, and the urological society's guidelines clearly
don't encourage it.

Usually everyone is treated, on the average. The article shows a strong
cultural bias towards treatment under all circumstances. Actually it is
intereting reading.

In particular, aggressive treatment to cure such
cancers should be reserved for men with at least a 10 year life
expectancy. Scardino does say that men with more aggressive tumors
should probbly be treated even if their life expectancy is about 5
years, but that is another matter.

There is a cite in the article that those with the most aggressive tumors
get more benefit, maybe. If you read all the cites, you might as well take
out a seat at a medical library and spend a few days.


I think the issue there is
maintaining quality of life, not necessarily expecting a cure.

You really should read the article. I checked with a friend at Duke who
does such research tonight and he told me that some of the details of
government-funded research and where it is located. Original unedited
manuscripts are not considered copyrighted and MUST be placed on an
open-source site. I don't know about this article. What with .pdf files
these days, even if a medical library stops paying fees, they lose access.
In the old days, the old journals did not disappear from the shelves if a
new subscription was not entered. Public libraries will disappear under the
new systems unless great care is taken. In the meantime, the web site
charges $28 to view the article for which the authors receive nothing and
the publisher gets it all, and government pays for the research. It is a
very BAD system. There are open access journals now, about 2,000 of them,
and it may increase in the future. Sweden has the DOAJ and I of course am a
member of that and even EBSCO has picked us up. But of course we are not
medical.....



.

Relevant Pages

  • Re: Delayed Interventions
    ... overtreatment, links to the August 16 journal site require you to PAY ... prostate cancer between 2000 and 2002. ... of curative therapy among men in various age-grade strata. ... of curative therapy, relative to expectant management, varied ...
    (sci.med.prostate.cancer)
  • Re: Delayed Interventions
    ... overtreatment, links to the August 16 journal site require you to PAY ... prostate cancer between 2000 and 2002. ... of curative therapy among men in various age-grade strata. ... of curative therapy, relative to expectant management, varied ...
    (sci.med.prostate.cancer)
  • Re: Delayed Interventions
    ... The frequently indolent nature of early-stage prostate cancer in older men and in men with low- or moderate-grade tumors and the demonstration that the survival benefits of radical prostatectomy are primarily among men younger than 65 years have led to concerns about prostate cancer overtreatment. ... We quantified the incidence of initial curative therapy among men with lower-risk cancers as defined by their limited likelihood of either dying from expectantly managed prostate cancer or achieving a survival benefit from local therapy. ... The likelihood of curative therapy, relative to expectant management, varied statistically significantly among lower-risk age-grade strata. ...
    (sci.med.prostate.cancer)