| Leonard Evens 2004-10-04, 2:21 am |
| MB wrote:
> George:
>
> Let's cut the theory crap and get real practical:
>
> Got a question:
>
> Say you are 58 years old like me. Suppose all of a sudden your PSA starts
> rising. Mine is 2.2. It generally goes up by .1-.2 or so each year. Suppose
> next year it goes to say 4.0 and then they retest 4-6 months later and it
> goes to 4.8.
>
> What do you do???
>
> In my mind, a biopsy is in order. Something NEW is going on beyond my BPH.
> It may just be my BPH accelerating. but how do I know?
>
> What do you think? Len, what do you think?
Let's hope that doesn't happen. If your PSA weere to go up at that
rate, the most recent research (Catalona, et. al.) suggests that a
biopsy is very likely to show prostate cancer, and the cancer is also
likely to be aggressive.
But let me the Devil's advocate here. It is possible that in
circumstances like that it wouldn't make much difference if you were
treated. That is, it might be true that if the PSA were increasing
that fast, the probability of metastasis would be very high even with
treatment, and the treatment made no difference. In fact what the above
study showed was that the probability of recurrence after treatment
depended on the rate of increase in the year before. The study doesn't
quantify what decrease in metastasis rate might follow treatment.
To test this in a completely scientific manner, you would have to
collect a large number of men, do PSA testing on them, select those with
a high PSA rate of increase, and in that group randomly choose some to
be treated and some to receive no treatment. You would then have to
follow them for a long time. It would be at least 10 years or perhaps
longer. (Aggressive cancers tend to develop faster, so periods like 15
or 20 years might not be necessary.) If the metastasis rate in both
groups was essentially the same---meaning it couldn't be attributed
purely to chance---you would have to conclude that the treatment had no
effect. It can get even more complicated. There are other things you
can look at: the overall number of deaths within some period of time,
the deaths due to prostate cancer within that period of time, quality of
life considerations in both groups, etc. It is very hard to quantify
some of these factors and to compare them. Sometimes people interested
in proving a preconceived notion will select one or the other criteria
which is strongest in making their case, but to be objective one should
look at all the factors and try to come to a balanced judgement.
Now the problem is that this study will never be done. For relatively
nonaggressive cancers, it may be possible to do such a study, but few
doctors or patients are willing to stand still in the face of evidence
of an aggressive cancer. So they use other evidence, obtained by other
kinds of studies, which are not as definitive, to help them understand
the situation. Doctors who treat prostate cancer don't do so without any
scientific basis for what they do.
Some people, like George, argue that until it is proven by unassailable
methods that treatment, even in aggressive cases, is more effective than
non-treatment, the default ought to be to suspend judgement and not
treat. Their argument is that some of the men who are treated will
suffer significant side effects, and that is unnecessary misery for
them. I suspect George in his heart believes that in fact treatment is
ineffective, so it makes him angry that all that unnecessary
incontinence and impotence takes place. (He also doesn't know much
about the actual incidence of those things today with treatment using
the best techniques.) Others think that the treatment at least may be
partially effective, and perhaps they believe in their hearts that it is
highly effective. If so, doing nothing would a mistake.
So if you go by the science, in its current state, I think there is some
evidence that such cases should be treated, but it is very far from a
watertight case. The critics may prove to be right. That makes it very
difficult for a layman to make a decision.
Personally, here is how I would look at it. Fortunately, while my PSA
was increasing too fast, it wasn't in the high increase category. But
let's assume it was. The evidence shows that I have a cancer which is
likely to metastasize. If it does, I will have a variety of problems
which make the side of effects of treatment seem trivial. I've looked
at the likelihood of side effects of treatment and they don't scare me.
With a good surgeon, serious incontinence is highly unlikely.
Impotence is more likely, but it can be treated and doesn't mean an end
of my sex life. (I was impotent in fact for 18 months after RP, and my
sex life continued without significant interruption.) I don't know
that treatment will actually prevent metastasis, but I think from all
I've read that there is some chance it may prevent it or at least delay
it. So I would opt for treatment since it seems to me with all the
uncertainties that it is the better bargain. The fact that I am pretty
healthy and would otherwise expect a long comfortable old age also plays
a role.
I should add that there is not one single answer for all cases where
prostate cancer is diagnosed. It could be true that the effectiveness
of treatment in case with a very high rate of increase for PSA is
different than the effectiveness in cases with a modera rate of
increase. So beware of people who always say the same thing about
prostate cancer as if it were a simple disease which always must be
treated or never should be treated.
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