Re: Delayed Treatments for Prostate Cancer


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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?


Given the current money-oriented sytem, probably not much. You have
to work in a seriously-flawed environment. I once as an ob/gyn if he kept
track of outcomes and he said to me, "Who is going to pay for that?" That
pretty well sums up the current system, which follows the money, not the
result.


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

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


It need not be impractical. But given the current organization of
medicine, it may be. But it need not be.



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.


Compared to the total amount spent on treating prostate cancer, it is a
small drop in the bucket.



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.


Yes it does. It supports the current social organization of medicine
and is directly responsible for most of the laws outlawing alternative modes
of providing care. It also accepts the idea of treating millions on the
basis of a few test cases and does nothing to change the system.


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.



The policy results end up being based on about 20 people. A life-table
constructed from 700 people is a serious joke.


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.


And now we are back to the core: common sense!!! What you call common
sense. Thank you for revealing your bias. The major advances in science
come from getting rid of common sense for FActs. Actually what you have is
an old theory, that cancer can be cured by cutting away at a visible tumor.
But as you know, most of the time it fails, but as you also note, every now
and then it has some delaying effects. And that is all you can offer, until
real scientists figure out the biology of cancer, and then it will be
controlled by medication. The only dramatic progress in cancer has come
from childhood leukemias and other fast-growing cancers.



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.




Don't you realize how sad the study you like to quote is? Out of 700 or
so, about 20+ can have life prolonged by surgery. Maybe the PIVOT studies
will reveal more, but it is not likely. But emotionally if they come out
and say that the benefit of a huge economic outlay is very, very small, you
are going to have fits. Most American men would too, so you keep focusing
on the very, very few who may be helped. Is this science? No, it is
policy. And policy and science are only very remotely related.


.

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