General Petraeus has Prostate Cancer

[gp0560]

Hmmm. Your doctor isn't quite toeing the official line with respect to colonoscopy screening. Colonoscopy detects pre-cancerous lesions years before they become cancerous, and can catch early cancers before they spread. It's overall a slow process, but, unlike prostate cancers, colon cancers usually DO cause trouble for the person who has it. The official recommendation from the USPSTF (the most evidence-based, not special-interest driven of the recommendations) states:

 

* The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.

Grade: A Recommendation.

* The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient.

Grade: C Recommendation.

* The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.

Grade: D Recommendation.

* The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer.

Grade: I Statement.

Unicorn, thanks, I'll ask my doctor about this.

 

Meanwhile, what does a difference in the grade of the recommendation really mean?

[Guest]

I had a colonoscopy this week - one polyp found and removed with the recomendation for further such exams every two years.

 

I am curious as to why routine screening is not recommended between ages 76 & 85 and any screening is not recommended after 85. Does the cancer really grow so slowly that you'll die of age before it kills you? Very confusing.......

 

The reason that when colonoscopy is used for colon cancer, it can be done at 10-year intervals is that there's over 10 years between pre-cancerous polyps to cancer. Colonoscopy has a 1:1000 risk of colon perforation (in a low-risk patient). So at 76 and up, the risk of harm exceeds the odds the patient will benefit.

[Guest]

Unicorn, thanks, I'll ask my doctor about this.

 

Meanwhile, what does a difference in the grade of the recommendation really mean?

 

"A" evidence means there is little doubt but that it's true because there are multiple randomized clinical trials (not just case-control studies) that provide evidence for the recommendation.

"B" evidence means the evidence is strong but not iron-clad. Usually it means one large RCT, or a few small RCT's, or maybe even very convincing case-control studies.

"C" evidence usually indicate what most experts think from a logical standpoint, but hasn't really been proven

"D" means we know the intervention is harmful and should not be done (such as screening the elderly 70-75+ for prostate cancer)

"I" means we simply have no idea.

[gp0560]

Grading

 

Thanks again, Unicorn, for your help. You get an A!

[Guest greatness]

well

 

This is what you will probably find on the internet but you have to be careful interpreting this on your own because there are some changes since 2001.

 

Grade Definitions

 

Strength of Recommendations

 

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

 

A.— The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

 

B.— The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

 

C.— The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

 

D.— The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

 

I.— The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

 

Quality of Evidence

 

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

 

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

 

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

 

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

 

Internet Citation:

 

U.S. Preventive Services Task Force Ratings: Grade Definitions. Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/ratings.htm

 

 

But there are some changes... Published in Annals of Internal Medicine, July 17, 2007, Volume 147, No. 2, p. 134.

 

Summary of Recommendation and Evidence

 

The USPSTF will continue to assign a letter grade to signify its assessment of the level of its recommendation. The grade will be based, as before, on the USPSTF's assessment and synthesis of the overall evidence and the magnitude of net benefit (benefits minus harms). The evidence will no longer receive an overall assessment of "good," "fair," or "poor"; rather, the product of the evidence assessment and synthesis by the USPSTF will be expressed as levels of certainty. This change in terminology is intended to add precision to the description of the recommendation- making process and does not indicate a change in the process of evaluating the evidence. In brief, certainty represents the USPSTF's judgment about the overall evidence of net benefit. The Task Force's recommendation letter grades are explained in Table 1 on page 132.

 

While the USPSTF continues to use the same letter grades as it used in the past, some of the wording has changed. The description of an A recommendation no longer contains the word "strongly"; therefore, the A and B recommendation language is now the same. The USPSTF intentionally wanted to emphasize the importance of offering interventions with A and B recommendations, rather than distinguishing them on the basis of the certainty and magnitude of net benefit. The wording of the grade C recommendation represents perhaps the most important change in tone. The previous grade C recommendation read: "The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation." The new version will read: "The USPSTF recommends against routinely providing X service for Y population. There may be considerations that support providing the service in an individual patient."

 

"The concept of the close balance of benefits and harms from the previous version (the italicized sentence in the preceding paragraph) is now captured by a new summary statement in the rationale section of the new recommendation statement: "There is at least moderate certainty that the net benefit is small." This change is meant to indicate that although there is evidence of a small net benefit, the USPSTF has judged that this net benefit is too small to justify routine implementation of the service in the target population.

 

When the USPSTF cannot estimate the magnitude of benefits or harms with any certainty, it assigns a grade of "I" to indicate that there is insufficient evidence to support a recommendation for or against provision of the service. In the new format, this grade will be associated with a statement, not a recommendation, because the USPSTF is not issuing a recommendation for the use or nonuse of the particular service. The USPSTF is aware of the conundrum faced by clinicians who must decide whether to offer a service in the face of insufficient evidence. If such services are used, clinicians and patients should understand that there is uncertainty about expected benefits and harms. A future paper in this series will discuss domains in which the Task Force plans to provide information to clinicians to inform both their conversations with patients and their decisions."

 

 

 

 

To simplify...

 

 

Grade Definition Suggestions for Practice

 

A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.

 

B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

 

C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.

 

D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.

 

I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

USPSTF Levels of Certainty Regarding Net Benefit

 

Level of Certainty*

Description

 

High: The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

 

Moderate: The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: the number, size, or quality of individual studies inconsistency of findings across individual studies limited generalizability of findings to routine primary care practice lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

 

Low: The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:

the limited number or size of studies important flaws in study design or methods inconsistency of findings across individual studies gaps in the chain of evidence findings not generalizable to routine primary care practice lack of information on important health outcomes. More information may allow estimation of effects on health outcomes.

 

Please visit

 

http://epss.ahrq.gov/ePSS/search.jsp for more info...

[Guest Merlin]

Reading all the above one might think that prostate cancer is not dangerous. Actually, it is the second highest cause of cancer deaths in men, as I recall. It depends upon how aggressive the particular cancer is, which the pathologist determines by viewing the biopsy under microscope.

One of the problems with prostate cancer is that the answers are very unclear. Should I be treated or should I wait? If I am treated, which type is best--surgery, external radiation, seeding, freezing. Again there are no clear answers as there are side effects to all.

 

If you want to know what a biosy feels like, "thump" your middle finger against the palm of your other hand. It is a strong but painless bump. The doctor usually applies a novacain or lydocain (sp?) gel with his finger first. Not a bad idea to take a couple of tylenol before hand. Not aspirin, advil or aleve, as they can increase bleading. After several thumps, there is a slight ache in the prostate but it does not last long.

[Guest]

I'm actually at a medical conference right now. One of the speakers summarized all of the studies, which so far have shown more harm than good. He read from an editorial written by the head of the American Cancer Society (I can try to find the reference later if people are interested) which called for a recommendation to stop prostate cancer screening. The speaker said "It's time to drive in the death nail to prostate cancer screening!" to which the audience cheered. I personally think the jury is still out, and it's not unreasonable in someone with a life expectancy over 20 years, as long as the screened man understands that all studies so far have shown more harm than good (life expectancy was actually a tiny bit shorter in the screened group, although not significantly, although the harm was more significant). As I said previously, the studies are still continuing.

[Guest greatness]

Two clinical trials

 

Was Dr. Brawley talking about two recent clinical trials of PSA? They were both reported in March 26 issue of the New England Journal of Medicine.. However it has been suggested that a longer follow-up should be considered in the US trial. Are there any other clinical trial to solidify his argument? He was arguing against PSA test since 90s so it is not a surprise that he said that in an editorial. He has a lot of supporters on this matter.

[Luv2play]

. One of the speakers summarized all of the studies, which so far have shown more harm than good. .

 

Are these studies all American studies or do they include studies of men who live in countries that have universal medicare that is funded by the taxpayer? For men under 65, who in most countries can expect to live another 20 years or more if they are otherwise healthy, prostate cancer, left untreated, is a serious threat to that longevity.

 

In the US, with private insurance, screening for prostate cancer and any subsequent treatment represents a lucrative income for the medical establishment. In Canada, which has single-payer health coverage, prostate screening is not covered by the government plan unless you already suffer from prostate cancer. Individuals must pay if they want to be screened. Doctors can recommend testing but there is a financial disincentive to following up. I wonder whether this results is any differences between the rates of testing in, say, the US and Canada.

[Guest greatness]

It is based on

 

One of the recent clinical trials is based on the European study ( from 7 countries)...

 

 

Are these studies all American studies or do they include studies of men who live in countries that have universal medicare that is funded by the taxpayer? For men under 65, who in most countries can expect to live another 20 years or more if they are otherwise healthy, prostate cancer, left untreated, is a serious threat to that longevity.

 

In the US, with private insurance, screening for prostate cancer and any subsequent treatment represents a lucrative income for the medical establishment. In Canada, which has single-payer health coverage, prostate screening is not covered by the government plan unless you already suffer from prostate cancer. Individuals must pay if they want to be screened. Doctors can recommend testing but there is a financial disincentive to following up. I wonder whether this results is any differences between the rates of testing in, say, the US and Canada.

[Guest greatness]

"Dr. Phil Kantoff, who is director of the Lank Center for Genitourinary Oncology at Dana Farber Cancer Institute and a professor of medicine at Harvard Medical School": The ERSPC study started, once again, over 15 years ago, and it involved a much larger group of patients, 182,000 patients. A much more heterogeneous study. It was conducted at seven different countries. They

defined a core population of men, of about 162,000 men, who were between the ages of 55 and 69. And this is the

group that they reported on.

The men were randomized to either screening with PSA, on average every 4 years, and a digital rectal exam twice

over that period of time. In contrast to the PLCO study, the threshold, for the most part, of doing a biopsy was 3,

which was less than the PLCO study, which standardly had 4 as the cutoff, although there was variability from

country to country in terms of the criteria for doing the biopsy. The median follow-up in this study was 9 years,

slightly less than the PLCO study.

There were about twice as many cases of prostate cancer diagnosed in the experimental arm, the screened arm, than

in the nonscreened arm, speaking to the, although not documented, less contamination in the ERSPC study than in

the PLCO study. In absolute numbers, there were 326 patients who died of prostate cancer in the nonscreened arm

as compared to 214 patients who died of prostate cancer in the screened arm, which calculated out to be a 20%

reduction in mortality, with a median follow-up of 9 years.

 

Lee, Thomas H., Kantoff, Philip W., McNaughton-Collins, Mary F.

Screening for Prostate Cancer

N Engl J Med 2009 360: e18

[Guest greatness]

hmm

 

Is this what he read from???

 

CA Cancer J Clin 2009;59;264-273; originally published online Jun 29, 2009;

Otis W. Brawley, Donna P. Ankerst and Ian M. Thompson

 

 

 

He read from an editorial written by the head of the American Cancer Society (I can try to find the reference later if people are interested) which called for a recommendation to stop prostate cancer screening.

[Luv2play]

[quote=greatness;624407 The ERSPC study started, once again, over 15 years ago, and it involved a much larger group of patients, 182,000 patients. A much more heterogeneous study. It was conducted at seven different countries. They

defined a core population of men, of about 162,000 men, who were between the ages of 55 and 69. And this is the

group that they reported on.

The men were randomized to either screening with PSA, on average every 4 years, and a digital rectal exam twice

over that period of time.The median follow-up in this study was 9 years,

There were about twice as many cases of prostate cancer diagnosed in the experimental arm, the screened arm, than

in the nonscreened arm,

.In absolute numbers, there were 326 patients who died of prostate cancer in the nonscreened arm

as compared to 214 patients who died of prostate cancer in the screened arm, which calculated out to be a 20%

reduction in mortality, with a median follow-up of 9 years.

 

Lee, Thomas H., Kantoff, Philip W., McNaughton-Collins, Mary F.

Screening for Prostate Cancer

N Engl J Med 2009 360: e18

 

This study suggests that screening is a good thing, with a reduced mortality rate. Where are these other studies getting their data from?

 

I read another article that concluded in 2008 that PSA testing, which has only been used in the last 15 years, was coinidental with an overall reduction in prostate-caused deaths, whereas the death rate had been increasing in the 15 years before. This paper concluded that because of the recent controversy caused by "propaganda" as they termed it, fewer men were getting screened. It concluded that it may have been premature to call for reduced screening.

 

It would appear the controversy will continue.

[Guest]

This study suggests that screening is a good thing, with a reduced mortality rate. Where are these other studies getting their data from?

 

I read another article that concluded in 2008 that PSA testing, which has only been used in the last 15 years, was coinidental with an overall reduction in prostate-caused deaths, whereas the death rate had been increasing in the 15 years before. This paper concluded that because of the recent controversy caused by "propaganda" as they termed it, fewer men were getting screened. It concluded that it may have been premature to call for reduced screening.

 

It would appear the controversy will continue.

This is one of the studies that has led to an outcry to stop prostate cancer screening. If only 112 deaths are prevented in a group of 182,000 men, but more than that number are killed due to the screening, then screening is not worthwhile. This would be true even if there weren't any morbidity associated with inappropriate testing and screening, and there certainly is lots of morbidity associated with prostate cancer workup and treatment. What the public often doesn't understand is that there is a significant health cost (not to mention economic cost) to screening. This is a big money-making industry for a lot of urologists, but causes a significant amount of morbidity in patients. In order to understand the whole study, one has to read the entire set of results, not just the portion which agrees with one's point of view. One can't just say "112 were saved"--one has to know what happened to the other 181,888 patients!

[Luv2play]

If only 112 deaths are prevented in a group of 182,000 men, but more than that number are killed due to the screening, then screening is not worthwhile. !

 

What number of killed are you talking about? Not the ones included in this study. It showed 112 FEWER deaths in the screening arm than in the non-screened arm. If you are talking about other deaths in other groups, fine, but what does that prove? It doesn't invalidate what this study found. And this study covered 7 countries and a very large group over 15 years.

 

As I mentioned earlier, if other studies are based on US populations solely, I would question their applicability to people in other countries whose doctors don't have the monetary incentive US physicians have to conduct unnecessary tests and procedures to boost their incomes.

[gp0560]

Terminology

 

Can someone please explain in layman's terms what "morbidity" is? I'm pretty sure I understand only too well the meaning of "mortality," but the other term has always puzzled me.

 

Thanks in advance.

[Guest Merlin]

Morbidity does not, as the word suggests, refer to death. It refers to the side effects of the treatment. In prostate cancer treatment two big issues have prevailed. Prostate surgery, removal of the prostate, has historically involved cutting or damaging the nerves which control erections, and often resulted in impotence. Also often damaged are the muscles which control the sphinter which closes the bladder--resulting in incontence, the inability to avoid leaking. More recent developments have involved carefully sparing the nerves to avoid these side effects. Since PC affects more older men it is often hard to tell how harmful or effective the surgery is in avoiding these two side effects. Viagra etc help to avoid the impotence problem.

 

Other treatment modes including external beam radiation, seeding, freezing etc also involve the same side effects to some degree, plus some others. Seeding sometimes results in the creation of strictures in the eurethera, making it difficult or impossible to pee.

Radiation also often affects the rectal muscles resulting in anal incontinence and related problems.

Some patients randomly avoid these problems, others do not. The luck of the draw.

There is alas, no perfect treatment and the luck of the draw seems to prevail.

[Guest greatness]

US study

 

"DR. McNAUGHTON-COLLINS (a general medicine internist and health services researcher at Mass General Hospital and

Harvard Medical School): Sure, Tom. So PLCO, Prostate, Lung, Colorectal and Ovarian Cancer Screening study, is a large randomized trial from the United States. The prostate component was designed to determine the

effect of annual PSA screening and DRE on prostate-cancer–specific mortality. They enrolled about 76,000 men across 10 centers over the years 1993 to 2001. And the result, Tom: no mortality reduction with combined PSA and DRE screening over 11 years’ median follow-up."

 

Lee, Thomas H., Kantoff, Philip W., McNaughton-Collins, Mary F.

Screening for Prostate Cancer

N Engl J Med 2009 360: e18

 

This study suggests that screening is a good thing, with a reduced mortality rate. Where are these other studies getting their data from?

 

I read another article that concluded in 2008 that PSA testing, which has only been used in the last 15 years, was coinidental with an overall reduction in prostate-caused deaths, whereas the death rate had been increasing in the 15 years before. This paper concluded that because of the recent controversy caused by "propaganda" as they termed it, fewer men were getting screened. It concluded that it may have been premature to call for reduced screening.

 

It would appear the controversy will continue.

[Guest greatness]

Risk-Benefit Balance

 

<Risk–Benefit Balance>

 

DR. LEE: So, Mary, as you look at these studies and other data, do you see evidence that our fears that we might

harm patients with PSA testing might be realized?

DR. McNAUGHTON-COLLINS: I think that there is convincing evidence of harm, to answer your question, Tom.

The two studies together show marginal to no benefit across several years of follow-up at the cost to so many men of

overdiagnosis and overtreatment. So that deceptively simple PSA test inevitably leads to a cascade of biopsies, which

lead to prostate-cancer diagnoses, leading to aggressive treatments for those prostate cancers, leading to men

having substantial side effects from those treatments, urinary incontinence, sexual dysfunction. And the problem

being that, for many of these men, they suffer those downstream troubles for a cancer that was never, ever destined

to cause them harm in their lifetime.

So I think that that is a part of the problem. Once we can tell the indolent cancer that doesn’t need to be treated from

the aggressive cancer that does, I think the PSA screening controversy will diminish. And in the meantime, I think

the onus is on us, to maintain that healthy skepticism about a screening program that’s built on inconclusive data

on whether or not we are helping more men than we’re hurting.

DR. KANTOFF: I just want to agree with Mary in the sense that there’s a lot of uncertainty about the downside

effects, including getting a PSA and having the PSA anxiety, as we call it, associated with an elevated PSA, but not

having prostate cancer, the morbidity of the biopsy itself, the overtreatment. I would like to begin to dissociate the

whole process of PSA screening from treatment, because I do believe that many people who get diagnosed with

prostate cancer do not need to be treated. And that’s where much of the morbidity exists.

 

Thomas H. Lee, M.D., Philip W. Kantoff, M.D., Mary F. McNaughton-Collins, M.D., M.P.H.

[Guest greatness]

Clinical Practice

 

I wish I could post the video but you will need a subscription so here is the rest of the script.

 

 

DR. LEE: I’d like to ask each of you to summarize what you’re going to be saying to the patients, and friends and

neighbors, that you talk to about this topic in the weeks ahead. Mary?

 

DR. McNAUGHTON-COLLINS: So, Tom, I think I would advise, looking at these papers, caution to patients,

caution to physicians, and to neighbors and friends. I think that from my perspective, primary care physicians need

to, with our patients, fully acknowledge the ongoing prostate-cancer-screening controversy. We need to encourage

our patients to become informed, fully informed, to consider their preferences and values about their decision, this

PSA test. And we physicians can help them to know that there’s tradeoffs, that there are potential benefits and that

there are potential harms.

And so, for men in my own practice, for some men the PSA decision is the right one. We check that box on the lab

slip, and that’s the right decision for them. For many of my men, once they’re fully informed, they decide to forgo

the PSA test. And for those men, that is the right decision. So I think right now, we’re left with a shared decisionmaking

process that is crucial and that works well to help us achieve quality decisions and outcomes for men

considering PSA screening in 2009.

DR. LEE: Phil?

DR. KANTOFF: I think I’m not going to be saying a lot differently than what I was saying a week ago. What I

learned, what I confirmed from these studies is that the mortality from prostate cancer in screened populations, in

the first 10 years, is quite modest. And as a result of that, I more firmly feel that if somebody has a life expectancy of

under 10 years, one could conceivably forgo screening.

In my opinion, I do think that there is going to turn out to be a reduction in mortality associated with PSA-based

screening, but what I also firmly believe is that not everybody diagnosed with prostate cancer needs to be

pigeonholed into a treatment paradigm. And we need to individualize, because clearly there are many patients who

are diagnosed with prostate cancer that do not need to be treated, can be observed safely, and will not die of their

cancer.

DR. LEE: I want to thank both of you, Mary McNaughton-Collins and Phil Kantoff, and thank our viewers for joining

us.

 

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

[MsGuy]

So what progress, if any, has been made in distinguishing aggressive prostrate cancers from the slow type? Any promising research out there?

[Guest greatness]

Let's wait until additional studies come out....

 

DR. KANTOFF:

 

Argument #1: In the PLCO study, the cutoff for doing a biopsy was 4 nanograms per milliliter. If we set up a study

right now, that probably would not be the criteria for doing a biopsy. It would probably be lower, or we would use

age-adjusted PSAs in order to trigger a biopsy. And of course, by using a higher criteria, you could miss some

potential cancers and potentially some lethal cancers.

 

Argument #2: The second issue with the study is the issue of contamination: 52% of the men who were in the nonscreened arm

had a PSA documented within the past few years in the study, as opposed to 85% in the screened arm. And as a

result of it, it’s not surprising to me that there was only a modest increase in the number of cancers that were

diagnosed in the screened arm, only 20%.

 

Argument#3: But I think the most problematic part of this study is the relatively short follow-up period — average follow-up of 11

years. But the number of outcomes were actually very modest. One tenth of 1% of the entire population actually died

of prostate cancer. Not surprisingly that the mortality for prostate cancer within the first 10 years is small, but with

the numbers that they generated of about 50 and 44 in each arm, it’s really hard to make a statement about

differences in outcomes given that limitation.

DR. LEE: Why don’t you tell us about the European study which came to a different conclusion?

 

DR. KANTOFF: The ERSPC study started, once again, over 15 years ago, and it involved a much larger group of

patients, 182,000 patients. A much more heterogeneous study. It was conducted at seven different countries. They

defined a core population of men, of about 162,000 men, who were between the ages of 55 and 69. And this is the

group that they reported on.

The men were randomized to either screening with PSA, on average every 4 years, and a digital rectal exam twice

over that period of time. In contrast to the PLCO study, the threshold, for the most part, of doing a biopsy was 3,

which was less than the PLCO study, which standardly had 4 as the cutoff, although there was variability from

country to country in terms of the criteria for doing the biopsy. The median follow-up in this study was 9 years,

slightly less than the PLCO study.

There were about twice as many cases of prostate cancer diagnosed in the experimental arm, the screened arm, than

in the nonscreened arm, speaking to the, although not documented, less contamination in the ERSPC study than in

the PLCO study. In absolute numbers, there were 326 patients who died of prostate cancer in the nonscreened arm

as compared to 214 patients who died of prostate cancer in the screened arm, which calculated out to be a 20%

reduction in mortality, with a median follow-up of 9 years.

DR. LEE: Mary, this study is probably going to be quoted by some of our colleagues as proof that PSA testing should

be used routinely. What’s your take on that?

 

 

DR. McNAUGHTON-COLLINS:

 

Argument#1: I think that there are limitations that deserve serious consideration. Firstly, the European study, as Phil said, it actually pulled together trials from different countries, but these different countries

used different protocols. It wasn’t a uniform study design.

 

Argument#2: Secondly, this study is an interim analysis, and it’s the third interim analysis. And so the result of the 20% mortality

reduction is only marginally statistically significant at 0.04, raising the question, which is curious, Tom, why stop now?

 

Argument#3: And thirdly, the numbers needed to screen, numbers needed to treat are high. The investigators themselves point out that to prevent one prostate cancer death, 1400 men need to be screened. But more problematic than that, about 48 men would need to be treated. So I think the European investigators have some additional studies coming out, analyses on quality-of-life implications, on cost-effectiveness. And those papers will help round out this point. And those are eagerly awaited. But I think, at this juncture right now, it does behoove us, I think, to maintain a healthy skepticism about a screening program such as this, because any effective screening program, we know, requires more than just effectiveness. We have to find out more about quality of life or cost-effectiveness.

 

 

 

 

 

 

 

What number of killed are you talking about? Not the ones included in this study. It showed 112 FEWER deaths in the screening arm than in the non-screened arm. If you are talking about other deaths in other groups, fine, but what does that prove? It doesn't invalidate what this study found. And this study covered 7 countries and a very large group over 15 years.

 

As I mentioned earlier, if other studies are based on US populations solely, I would question their applicability to people in other countries whose doctors don't have the monetary incentive US physicians have to conduct unnecessary tests and procedures to boost their incomes.

[Guest]

Can someone please explain in layman's terms what "morbidity" is? I'm pretty sure I understand only too well the meaning of "mortality," but the other term has always puzzled me.

 

Thanks in advance.

 

Morbidity refers to adverse effects other than death. Since the prostate, which is located at the outlet of the bladder, makes almost all of what's in "cum" (less than 10% comes from the testicles), removing the prostate by any method makes him unable to cum. There is also, obviously, a good chance that the man whose prostate is removed will leak urine to some extent or another. The nerves which control erections also go along the prostate. Although a skilled surgeon can minimize damage to these nerves, erections are also often affected (although even if erections are OK, the man without a prostate still can't cum). Treatments which burn (i.e. radiation) or freeze the prostate are more likely to damage nerves which control erections, since the nerves cannot be protected the way they can during surgery. In addition, since the prostate is adjacent to the rectum, fecal incontinence can also be a complication (again, very rare with surgery, but more common with other methods of destroying the prostate).

[Mark Gordon]

Clients with Prostate Problems

 

I have every sympathy with guys who suffer from prostate problems and I've had a number of them as clients over the years. The complications I've encountered as a result of prostate cancer or its treatment have included:

 

1.Guys who could not get an erection, but still enjoyed some sexual activities.

2.Guys who could get an erection, but could not remain stiff enough for penetrative sex.

3.Guys who could get an erection, could orgasm, but could not ejaculate.

4.Guys who had difficulty reaching orgasm and who sometimes did and sometimes didn't.

5.A guy who had blood in his semen.

 

With the exception of the last one, these guys all explained what the complication was and how it affected them, either at the beginning or during our encounter. The guy who shot blood seemed to be as surprised as I was! I would certainly encourage any client who has prostate problems or any other health issues which might affect their sexual performance to be open with your escorts about this so that they can adapt to the situation.

[Luv2play]

The interviews with the American doctors was very revealing. In it it was acknowledged that the American study involved far fewer men than the European study, that it was conducted over a shorter time period and that 52% (OVER HALF) of the American men in the so-called non-screened group had had a PSA with the last several years of the study. This was referred to as "contamination". Well, I guess!

 

Another interesting point was that for every cancer identified, 1400 screenings would need to be done. Well, what's the big deal here? A DRE and a PSA are hardly strenuous exercises.

 

Another interesting point was that the European study was restricted to men of between 55 and 69 years of age. I think this is right. If screening turned up the need for a biopsy and then that shows cancer, these are the men who must consider whether they might live longer than 10 years and therefore benefit from treatment, even given the possible downsides.

 

Let's face it, if you were offered the choice of say, not being able to produce ejaculate at the age of 60 or over, or dying prematurely from prostate cancer, which would you choose? Of course there are other downsides, but my doctor says that age and general physical condition are factors in whether incontinence or impotence occur as a result of surgery. OF course, more recent advances in surgical techniques are also improving the outcomes.

 

I actually discuss this with my escorts now, telling them I have had a RP and that not to expect me to "cum" in the traditional way. I still experience orgasms, and I take Cialis to help with the erections. As a bottom, I don't look to be anally penetrating the escorts so that is not an issue altho it may be for some men who are primarily tops.

 

Last week, I was penetrated by an escort with an enormous dick and he said it felt good, that I was nice and tight but not constricted as a few of the men he had experienced who had had RP. I guess my doctor did a good job!