Re: Delayed Treatments for Prostate Cancer


"George Conklin" <georgeconklin1@xxxxxxxxxxxxx> wrote in message
news:iLiFg.10216$0e5.7283@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

"Skeptic" <bcs002b@xxxxxxxxx> wrote in message
news:9_8Fg.140629$1i1.122040@xxxxxxxxxxxx

"George Conklin" <georgeconklin1@xxxxxxxxxxxxx> wrote in message
news:_33Fg.5011$Sn3.149@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

"Skeptic" <bcs002b@xxxxxxxxx> wrote in message
news:2fQEg.904055$084.859533@xxxxxxxxxxxx
Are you talking about,
"Incidence of Initial Local Therapy Among Men With Lower-Risk Prostate
Cancer in the United States " ?

All that that article finds is that we are overtreating some men with
low
grade prostate cancer - something which we all know already.

A major journal does not publish articles about what is already known.

LOL... yes they do - all the time. Confirmational studies. They're
actually much easier to get published than are novel ideas. But hey,
thanks
for expressing your ignorance.

The study cited is based on real-world experience rather than from a
self-selected group of volunteers. That is always a difference.

Good to know for future reference - so from now on, whenever I cite a study
based on the SEER database, you'll have to accept it as strong evidence.

These are real-world outcomes, not those projected from a few hundred
self-selected men in a so-called 'clinical' study.

It was actually nothing more than a retrospective review, which is much
weaker than a randomized control trial would be.

Incorrect.

No, not incorrect. It was a retrospective study. If you don't agree with
that, then you don't understand the terminology being used.

It is everyone they could get ahold of,

It was a retrospective review of thousands of patients in the SEER database.

not a self-selected
group of volunteers, which gives unreliable results when applied to
general
populations.

What are talking by "self selected volunteers"? Are you suggesting that a
retrospective review is better evidence than a prospective study?

But until we
have a way to find out which men will die of prostate cancer and which
ones
will die of something else, overtreating is far better than not
treating.

This specific point is contradicted in the article itself. It
states,
"In particular, for some men with localized prostate cancer, the use of
'curative' therapy (.e., surgery or radiation therapy) may result in
substantial morbidity without a consequent survival benefits." (page
1134).
The 'quotes' around curative are in the original.

Indeed. Treatment may result in morbidity. Treatment may also result in
a
cure. We don't don't which patients get cured which is why we tend to
treat
rather than ignore prostate cancer. Why is that concept so difficult for
you? Is not treating an alternative? Sure. Each patient can decide
that
for himself. Most young patients with prostate once fully informed that
we
don't know if prostate cancer will kill them or not strongly - very
strongly - desire some form of treatment.

You sure hate research.

I do research. You criticize - mostly because you don't understand it.

Fully informed? Not by you. You push your
services hard, very hard.

You've never been in my clinic and never been counseled by me. You're
making ASSumptions, which are incorrect.

In the end, patients are hardly left much choice
unless they go out and read the literature. It is a cultural bias too to
push doing something, even if it provides many with only harm.


Also, "Given the cumulative health burden which is attriutable to
prostate
cancer and its associated therapies and the recognition that
unnecsssary
care is POOR-QUALITY CARE (emphasis added), efforts to better define
these
'upstream' determinants of initial expectant management are an
important
clinical and public health endavor." (p. 1138).

Which is what I've been saying - we don't know which patients will
benefit
most from treatment and this paper does NOTHING to help resolve that
problem.

Which is a total misreading of the paper. Did you actually read it or
are you just giving us your personal opinions which are not important at
this point?

George, if you read this article, it's probably the first medical journal
you've read in your life. As such, I didn't expect you to really understand
it. It's a lot of technical jargon and there are certain expectations made
by the authors about the target audience.

You are not the target audience. You are the target audience for the dumbed
down review offered by NBC news or whatever broadcast channel you mentioned
earlier.

Further and this applies to YOU:

It is also likely that some clinicians will disagree with our
classification
of lower-risk cancers with the general notion some prostate cancers
require
no initital intervention. For example, two studies (39,40) have used
similation techniques to demonstate that curative therapy benefits
healthy
men over 70 years. However, the survival gains projected by; these
data
were concentrated among patients with high-grade tumors who would not
be
classified as lower-risk in the current analysis." (p. 1138).

So, YES, the study did provide a control for who would benefit and you
know
it did since you read the study, right? Or did you? Tell us.

Of course, and I previously summarized in a post for you to understand.
Clearly I failed.

All you showed was your bias. The paper speaks for itself. I am sorry
you are so overwhelmed by your personal opinions. Why don't you give me a
cite of YOUR refereed work to see whether your personal feelings are
accepted by the field in general? What about a real cite, authored by
someone named Skeptic.

Because I don't care to toot my own horn and my publications have no
influence on the current debate topic. My bias is actually to be far less
aggressive with surgical intervention than the vast majority of my peers.
As such, my patients are fully informed about all of their options,
including active surveillance ("watchful waiting").

That must be the article you're talking about, since it's the only one
from
August that discusses this issue. That study is just another (of many
many
many) that is data mining from the SEER database. Their paper has
surprisingly little data in it.

Nonsense. It has all the data it needs, since it uses multivariate
analysis. You must be used to high-school data presentations.

Read the article again. They don't talk about overall survival, disease
specific mortality, PSA values/doubling time/velocity/etc., need for
additional treatment, morbidity from delayed treatment, etc etc etc etc
etc
etc etc. They present on table of results. That's it. In a relative
sense, that's VERY little data. If you ever read medical journals I
wouldn't have had to explain that to you.

I think it is obvious I read statistics quite well,

lol... uh, no.

and have read
numerous medical journals any time I feel like it.

Weren't you just griping that you had to pay to get access to a single
journal article? Uh, no, I don't think you read medical journals. Ever.

You seems to prefer
ignoring outcomes in the real world.

I am the real world you halfwit. I'm the one on the front line of this
issue. I see 40+ patients a week with prostate cancer. I have every level
of prostate cancer imaginable from the low volume disease with a low PSA and
favorable pathology on biopsy all the way to the metastatic prostate cancer
patients we are trying to keep palliated as best as possible from their
spinal cord compression and pathologic fractures.

That's real world. What you have is a largely ignorant understanding of the
issues at hand yet you try to pretend you know what's going on. Grow up.

Remember that the field has ignored
overall survival for the past 100 years and concentrated on things like
PSA

PSA has only been around for 20 years. But thanks for playing Yee Old
Ignorant One.

or tumor size, ignoring survival. Only now will studies such as the PIVOT
study look at mortality. And the Swedish study? 3% differences after 10
years? Only a few hundred people? This study looks at real world out
comes
on 72,000+. That is what it takes. Real world.

PIVOT has no results yet.

There have been several Swedish studies looking at prostate cancer, most of
them showing a survival benefit for treatment. There was one, for example,
that showed
"... researchers found that after complete follow-up, 39 (17 percent) of all
patients experienced generalized disease. "Most cancers had an indolent
[slow to develop] course during the first 10 to 15 years," the authors
write. "However, further follow-up from 15 (when 49 patients were still
alive) to 20 years revealed a substantial decrease in cumulative
progression-free survival (from 45.0 percent to 36.0 percent), survival
without metastases (from 76.9 percent to 51.2 percent) and prostate
cancer-specific survival (from 78.7 percent to 54.4 percent). The prostate
cancer mortality rate increased from 15 per 1000 person-years during the
first 15 years to 44 per 1000 person-years beyond 15 years of follow-up."
(JAMA. 2004; 291:2713-2719)

There have been other studies showing both disease specific survival and
overall survival as well.

The study we're talking about now did NOT EVEN DISCUSS overall or disease
specific survival. It is practically worthless.

At least they looked at a data file with 73,566 men, and not a few
hundred
self-selected men in a so-called clinical study. These were real-world
decisions.

Yep, a retrospective review of a well known database. And their
conclusion?
That some men are being overtreated but we don't know who and have no way
as
of now to determine that - information is well known already.

They provide a discussion of the criteria used. Why do you want to
ignore it?

They don't have hard criteria for who should and who should not be treated.
They can't - since they didn't look at survival.

Of course, younger guys are also the perfect age group to treat
surgically since a 55 year old man has almost 30 years left of life
expenctancy - and if the prostate is left to grow, it may well end up
killing him.

The authors even admit they have, essentially, nothing of substance.
They
state, "Given the substantial body of evidence supporting expectant
management as an evidence based option for the initial treatment of
men
with
lower risk prostate cancers, our data highlight the need to better
define
potential catalysts and barriers to the use of initial expectant
management
among CAREFULLY SELECTED PATIENTS [emphasis added] with new diagnosed
prostate cancer"

Uh huh... riiiight. There should have been an editorial reply of "no
***
Sherlock". And just how does one "carefully select" these patients?

The criteria were specified.

No - they do NOT come and say men with Gleason X and a PSA of Y with a
doubling time of Z and are DD years old should get treatment vs watchful
waiting.

They provide guidelines for age and tumor grade and SES as well. Are
you blind or something?

Ever hear of the Partin tables? This type of "guesswork" is no differnent.
The authors offer no clear guidelines. They can't - they have no data to do
so.

Ah,
why with a crystal ball of course. "You, Mr. S, will die of a heart
attack
in 9 years so no need to deal with your low risk prostate cancer right
now.
But you, Mr. L, will live a long and healthy life if we operate on
your
prostate before it goes metastatic".

Sigh. There's nothing new in this article. Nothing.

You only wish.

George, the stats and information around prostate cancer are well known.
The SEER database has generated dozens of other articles on prostate
cancer
(meaning the same patients have already been looked and reported on).
It's
common knowledge that treating every patient with prostate cancer results
in
over treatment of some patients. Common knowledge. This article
provides
no new information

Then write the journal and tell them that. I am looking forward to
reading your refereed response.

Feel free to write them. No need for me to - since anyone who has a faint
clue about prostate cancer already knew everything in that article. Yes, we
overtreat prostate cancer. No, we don't know how to avoid it.


.