Re: Delayed Treatments for Prostate Cancer


"george conklin" <george@xxxxxxx> wrote in message
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"george conklin" <george@xxxxxxx> wrote in message
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The issue is to what degree surgery, by any technique, is going to
do much for a patient. You point to a 3% difference over 10 years
as a major victory, even while the big studies, much delayed, are
just getting started. One has been going 10 years with no results
announced yet.

NEJM V347(11) from Sept 2002:
studied 700 men with prostate cancer. Median f/u of 6 years (not
adequate for prostate cancer studies) showed an improved disease
specific survival - a decrease from 8.9% to 4.6% which is a 48%
reduction.


So, go tell government to get rid of the PIVOT studies since
everything has been decided. 700 men? And from that pitifully small
number you are going to treat millions? Horrid.

We have the studies that we have. It's not easy to RANDOMIZE men to
treatment vs. no treatment. Only time will tell what PIVOT shows.

NEJM V352(19) from May 2005
Same group with longer followup, now out to 8 years (still not
adequate). Showed that "radical prostatectomy reduces disease
specific mortality, overall mortality, and the risks of metastasis
and local progresssion". Overall survival was improved by 22%. Not
3%...... but 22%. That was statistically and is clinically
significant.


3% of a sample turns into 22% 'reduction.' A committee had to
decide what the men really died of, since there were multiple causes.
Just a few differences in committee opinion would have changed the
result since you are dealing with a small sample. You know that too,
but you cannot fool the whole world with nasty posts. I still view you
as once reason why research into female cancers is so advanced
compared to men. Neither is all that good, but women have been
politically active against attitudes like yours.

22% improvement in survival. Bitch all you want - that's what the data
shows - a 22% improvement in survival after just 8 years of followup.


Look you continually fail to realize you cannot construct life tables
with disease-specific mortality with a sample of 700 and expect stable
results. 22% is based on only 3% of the sample, with a committee
having to decide who died of what, since it was often unclear. Politics
is obviously involved too. It is pitiful that treatment procedures for
millions are based on as few as 20-25 possible deaths in a sample of
700. You may like the results, but it is a scandal that never ceases to
amaze me. At the individual level, would you tell a patient that he had
a 3% chance in 10 years of having a better outcome of doing nothing? I
doubt it. You want the income first, the faith second, and your belief
system is in always doing something. Others might not make that choice,
but as the article on overtreatment showed, the cultural norms are
always to do something, even if it won't help. The system is set up for
that, and it is reinforced by the culture. You are a good example of
faith-based outcomes.

You're off your rocker again. You think organizing a randomized
controlled trial of 700 patients to surgery vs. no surgery is a simple
thing?

Only in the medical business are millions treated on the basis of a tiny
sample.

What alternatives do we have?

You say, "It is too much bother to keep track of all outcomes."

No, actually I did not say that. It is, however, impractical.

Yet billions of $$$ are spent on treatments; virtually nothing on
outcomes. You really do NOT want to know, do you?


That's a
huge number for that kind of study, which is the best study that can be
done. We have the data that we have. We'd all like to have more more
more data on lots of things, but we don't.

Billions for treatments; nothing for results.

The study I posted was not an inexpensive adventure. Nor was it easy to set
up and execute.

Sad, scandal and horrible, but you say that is the deck? YOU make the
deck up. You can change it. But the
AMA is a bill collecting organization. Science? Maybe now and then, but
not often.

The AMA has nothing to do with this conversation.

So we play the cards we're dealt. In
the case of prostate cancer, we have the best studies done in the world
showing a 22% improvement in overall survival with surgery vs. no surgery
after 8 years.

I have no confidence in a life table constructed on 3% of the initial
sample with a total N of 700.

Good for you. People with a half a brain understand an N of 700 in a
randomized controlled trial of randomizing PEOPLE to treatment vs. no
treatment is not a small undertaking and the results of which are actually
quite good and meaningful and far better than your N of zero.

That number will almost suredly increase with time due to
the nature of prostate cancer. That's not "faith based" that's EVIDENCE
based. Period.

Evidence? Your evidence is so limited it is simply unreliable.

It was a well done study with the highest level of evidence that a study can
produce. Aside from the evidence proving indisputably that surgery for
prostate cancer leads to a longer life expectancy, there is always the
common sense factor based on tumor biology.

You HOPE it is correct because you believe it ought to be, but when
committees have to decide who died of what, and you are dealing with a few
dozen cases to prove your point, I am left wondering where the billion of
dollars for treatment went with so little evaluation. Life is not a deck
of cards. The deck is created for research by politics, and the deck is
anything you want to make it. Right now the money is not in even
attempting evaluations which include large-scale evaluation. We have know
for years that surgery is three or four times more common in some parts of
the country than in others, but the death rates from prostate cancer are
about the same in all regions. This would be based on large populations,
not a pitiful few.



.

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