http://www.medscape.com/viewarticle/7448...ews&spon=7

Kind of interesting article on the topic. Hope our health care system doesn't go the way of the Brits one day.

Can't log in. Copy and paste the article.

Linking based on request, my opinion will follow.

June 17, 2011 — New data from the United Kingdom show that prostate cancer kills half of the men diagnosed with this disease, and challenge the notion that prostate cancer patients "are more likely to die with, rather than of, their disease," according to the researchers.

The situation is much different in the United States, where recent estimates suggest that only about 15% of men diagnosed with prostate cancer die from this disease.

The main reason for this huge difference is the high uptake of testing for prostate-specific antigen (PSA) in asymptomatic men in the United States, and the low uptake in the United Kingdom, say experts on both sides of the Atlantic.

Both situations are described as extreme by those on the other side. British researchers say that routine PSA testing in the United States is picking up disease that might be clinically insignificant, leading to overdiagnosis and overtreatment of prostate cancer. American researchers argue that PSA testing is picking up prostate cancer at an earlier stage of disease, when it is still treatable and curable, which results in the much lower mortality rates.

"If you are screening too aggressively, there is no question that you will overtreat, but the other end of the spectrum is that you have a cancer that is very curable but you still end up having half of the patients dying of the disease because they are presenting at late stages" said Brantley Thrasher, MD, FACS, professor of urology at the University of Kansas in Kansas City, who acts as a spokesperson for the American Urological Association.

"I would rather have the potential — and I emphasize the potential — for overtreating than swing the other way and lose all of these patients to a disease that is curable," Dr. Thrasher explained in an interview with Medscape Medical News.

New British Analysis

The new British data come from an analysis of 50,066 men diagnosed with prostate cancer between 1997 and 2006 from the Thames Cancer Registry, which covers a population of 12 million in South East England. Subjects were followed to the end of 2007.

During that period of time, there was little uptake of PSA testing in asymptomatic men in the United Kingdom.

The situation is different in the United States, where there is a high uptake of PSA testing, and has been for some time, lead researcher Simon Chowdhury, MD, consultant oncologist at Guy's and St Thomas' NHS Foundation Trust in London, United Kingdom, told Medscape Medical News.

Dr. Chowdhury presented the findings at the 2011 Meeting of United Kingdom Association of Cancer Registries and National Cancer Intelligence Network (NCIN), held in London.

The analysis found that prostate cancer was the cause of death in 49.7% of the men who had been diagnosed with the disease. The other causes of death were cardiovascular disease (17.8%), other cancers (11.8%), pneumonia (7.5%), and other causes (13.25%).

Prostate cancer remained an important cause of death even when the data were analyzed according to age, cancer stage, and first treatment, the researchers note.

Prostate cancer was the cause of death in 74.3% of men who had stage IV cancer at diagnosis, in 46.4% of all men 75 years and older, and in 31.6% of all men who underwent radical prostatectomy.

Our findings challenge the commonly-held view that most men with prostate cancer will die with the disease, rather than from it.
"Prostate cancer was the underlying cause of death in a substantial proportion of men," the researchers conclude, "and remained an important cause of death in all subgroups, including those treated with curative intent and older men."

"Our data show that a high proportion of men with prostate cancer die from the cancer," commented study author Henrik Møller, BA, BSc, MSc, DM, FFPH, professor of epidemiology at King's College London, and director of the Thames Cancer Registry. Dr. Møller, who is also head of analysis and research at the NCIN, added: "Our findings challenge the commonly-held view that most men with prostate cancer will die with the disease, rather than from it."

Setting of Low PSA Testing

The British researchers point out that their findings pertain to settings where there is a low uptake of PSA testing in asymptomatic men. In such a setting, "our findings challenge the notion that prostate cancer is a negligible problem in any subgroup, as defined by age, stage, or treatment," they note.

Dr. Chowdhury explained in an interview with Medscape Medical News that PSA testing was introduced in the United Kingdom in the early 1990s, but it is not routinely performed in asymptomatic men.

The situation is different in the United States, where there is a high uptake of PSA testing, with reports that more than 50% of men older than 65 years of age are tested, and many of the men tested are asymptomatic. This PSA testing in asymptomatic men might result in overdiagnosis and overtreatment of prostate cancer, Dr. Chowdhury said, because "some of the prostate cancers that are picked up are small and some may be clinically insignificant."

Dr. Chowdhury noted that the ratio of prostate cancer deaths to prostate cancer diagnoses is very different in the 2 regions — about 1 to 6.0 in the United States (based on estimates from the 2010 SEER database, showing a diagnosis in 215,000 men and 30,000 deaths) and about 1 to 3.7 in the United Kingdom (based on 2008 Cancer Research UK data, which show that there were 37,000 diagnoses and 10,100 deaths from prostate cancer).

There is a difference in the stage of prostate cancer at diagnosis — some American reports suggest that about 80% of the disease is localized, whereas in the United Kingdom, although most disease is also localized, there is a higher proportion of cancers diagnosed at an advanced stage, Dr. Chowdhury explained. Widespread PSA testing picks up prostate cancer at an earlier stage, which might be less aggressive and less clinically significant, he said.

"Not a Trivial Disease"

This is an extremely important study.
"This is an extremely important study, which highlights the fact that prostate cancer is not a trivial disease for a large number of men in the United Kingdom who suffer from it," said Malcolm Mason, MD, head of oncology and palliative medicine at Cardiff University School of Medicine, United Kingdom. Dr. Mason is also chair of the UK National Cancer Research Institute's Prostate Cancer Clinical Studies Group, and was commenting in a statement issued by Cancer Research UK.

Particularly for men with advanced prostate cancer, their disease poses a significant threat to their health and their life.
"Particularly for men with advanced prostate cancer, their disease poses a significant threat to their health and their life, and the old notion that 'most men die with it, not of it' is simply not true."

Since that study was carried out, there have been a number of important advances in treatment, Dr. Mason noted. "It is possible that not all of the men in this study who died of prostate cancer would die of it today with modern treatment," he said. In addition, many more men are diagnosed at a much earlier stage; for these men, the outlook is excellent, even without treatment, he added.

Need for Earlier Diagnosis and Treatment

Dr. Thrasher agreed with the conclusion that prostate cancer is not a trivial disease. "This study highlights the fact that prostate cancer can be a deadly disease," he said. "It speaks volumes about what happens when the cancer is advanced and out of the confines of the organ — it will kill you."

These data add weight to the argument for screening for prostate cancer, he said. They reinforce the need for earlier diagnosis and earlier treatment of the disease, and although the PSA test has its problems, it does result in both.

"There is no question that this is happening in the United States; we are finding and treating prostate cancer earlier," he said.

Dr. Thrasher cited 2010 estimates, from the Cancer Journal for Clinicians,that there were 217,000 new cases of prostate cancer diagnosed in the United States and 32,500 cancer deaths, which gives a mortality rate from the disease of 15%. In the United Kingdom, the rate is 50%.

There is a similar situation in Japan, he noted, where there is no routine PSA screening. Dr. Thrasher explained that he recently had the opportunity to talk to Japanese urologists during a joint meeting of the American and Japanese urological associations in Hawaii, and they were saying that by the time they see prostate cancer, it has often advanced to a stage where it is inoperable and not suitable for radiation.

Dr. Thrasher acknowledged that routine PSA testing can lead to the overdiagnosis and overtreatment of prostate cancer that might not be clinically significant. "We are starting to see some pullback as a result of this," he said, and although it is slow to gain ground in the United States, there is more use now of active surveillance as a treatment option, he told Medscape Medical News."We are starting to do this, especially in older men with low-grade, low-volume disease," he said. "However, right now, that is not mainline, and it is not a standard of care," he emphasized: "It is one option."

The very real benefit from PSA testing — finding prostate cancer at an earlier stage of disease, when it is still curable, which saves lives — has to be weighed against the potential for overdiagnosis and overtreatment, and the potential for anxiety from routine testing, he concluded. These latest data from the United Kingdom show that when there is no PSA testing, "you are losing about half your patients to the disease, and so it lends credibility toward leaning the other way," he said.

2011 Meeting of United Kingdom Association of Cancer Registries and National Cancer Intelligence Network (NCIN): Abstract 86. Presented June 16, 2011.

[CLOSE WINDOW]Authors and DisclosuresJournalist Zosia ChusteckaZosia Chustecka is the News Editor for Medscape Oncology. A pharmacology graduate based in London, UK, she has edited and written extensively for publications aimed at clinician audiences. Her work has been recognized by the British Medical Journalists Association, and most recently she was the recipient of the 2010 National Press Foundation Cancer Issues Fellowship. She can be reached at zchustecka@medscape.net.

Disclosure: Zosia Chustecka has disclosed no relevant financial relationships.

I use medscape often, but it is free for a reason, and the profit whores are way too apparent in this article.


The very real benefit from PSA testing — finding prostate cancer at an earlier stage of disease, when it is still curable, which saves lives

WTF?

Pharma and lab companies hate the concept of lead time bias. Just because cancers diagnosed at an early stage are likely to have a better outcome, does not mean screening for those cancers with a test will lead to better outcomes. See, smokers and chest xrays, or smokers and chest CTs, or EVERY study involving PSAs compared to standard care. The diagnosis rate is always higher, but the mortality rate tends to be the same.

Quote:Just because cancers diagnosed at an early stage are likely to have a better outcome, does not mean screening for those cancers with a test will lead to better outcomes

Would you please explain that a little more? It seems that you are saying that IF you screen early, and cancer is found, you are likely to live longer; BUT, screening for those same cancers won't help you live longer.

I am confused. I am 64 and because I had a finger wave and sigmoidoscopy when I was 40, I am still alive. They found 2 polyps, then went ahead and did the colonoscopy and they found 27 total polyps. I have had so many colonoscopys since then that I am now on a first name basis with my doctor. Now I have one every 3 1/2 years and I have a PSA blood test every year. I am hoping I get the early warning, so that I might not check out too soon.

Perhaps I should have been more clear. My family has a strong history of colon cancer, so my ass is gonna swallow a camera when I turn 40, sooner if I see blood in the toilet. Screening for colon cancer is extremely cost effective, and often life saving. Colon cancer found early by the screening methods we have available extends lives.

Prostate cancer is a completely different discussion. People with a high PSA are more likely to have prostate cancer. OK. The last article I linked said people with early stage cancer are more likely to live longer, as compared to advanced stage. That seems completely intuitive, but it does not mean earlier diagnosis and treatment extends how long the patient lives. The problem we have now is we can't predict which prostate cancer will leave the capsule and which will stay at home, and we have no test that will determine if your prostate cancer will kill you. So why try to find it early if there is no benefit?

I've already had 3 upper and lower GI's done in about the last 8 years. And I turned 46 yesterday.

I have chronic acid reflux/heartburn which I take Prilosec for daily. Other than that, they have found nothing and given me a clean bill of health.

What I hate, is that because of the economy, I have cheap health insurance (an HSA with a $5,000 deduct). Cost me over $1,000 to find out I'm basically fine. Did find out I'm anemic, but that's not a big deal.

(06-18-2011 06:46 PM)glacier_dropsy Wrote:  Perhaps I should have been more clear. My family has a strong history of colon cancer, so my ass is gonna swallow a camera when I turn 40, sooner if I see blood in the toilet. Screening for colon cancer is extremely cost effective, and often life saving. Colon cancer found early by the screening methods we have available extends lives.

Prostate cancer is a completely different discussion. People with a high PSA are more likely to have prostate cancer. OK. The last article I linked said people with early stage cancer are more likely to live longer, as compared to advanced stage. That seems completely intuitive, but it does not mean earlier diagnosis and treatment extends how long the patient lives. The problem we have now is we can't predict which prostate cancer will leave the capsule and which will stay at home, and we have no test that will determine if your prostate cancer will kill you. So why try to find it early if there is no benefit?

Doesn't "finding it early" imply that you have a better chance of identifying it when it is "early stage", and therefore make you "more likely to live longer"?

(06-20-2011 11:04 AM)bearcatjim Wrote:  

(06-18-2011 06:46 PM)glacier_dropsy Wrote:  Perhaps I should have been more clear. My family has a strong history of colon cancer, so my ass is gonna swallow a camera when I turn 40, sooner if I see blood in the toilet. Screening for colon cancer is extremely cost effective, and often life saving. Colon cancer found early by the screening methods we have available extends lives.

Prostate cancer is a completely different discussion. People with a high PSA are more likely to have prostate cancer. OK. The last article I linked said people with early stage cancer are more likely to live longer, as compared to advanced stage. That seems completely intuitive, but it does not mean earlier diagnosis and treatment extends how long the patient lives. The problem we have now is we can't predict which prostate cancer will leave the capsule and which will stay at home, and we have no test that will determine if your prostate cancer will kill you. So why try to find it early if there is no benefit?

Doesn't "finding it early" imply that you have a better chance of identifying it when it is "early stage", and therefore make you "more likely to live longer"?

I have no doubt that screening with PSA leads to earlier diagnsosis. But living longer from the time of diagnosis does not equate to living longer. If a cancer was going to kill me 10 years from the time it first developed, what do I care when the diagnosis is made. I can be diagnosed early and be aware I have cancer for a longer period of time, or diagnosed later and live a short time after diagnosis, but if my expiration date is the same regardless, what's the use? You also need to factor in the false positive rate (high PSA but no cancer) and how many people will be harmed by the treatments that may or may not be necessary. That is why a screening test needs to prove a reduction in mortality when comparing a screened population vs a not screened population. Just proving that people who are screened live longer from the time of diagnosis just proves that you diagnosed the cancer earlier, nothing more.

(06-20-2011 01:27 PM)glacier_dropsy Wrote:  

(06-20-2011 11:04 AM)bearcatjim Wrote:  

(06-18-2011 06:46 PM)glacier_dropsy Wrote:  Perhaps I should have been more clear. My family has a strong history of colon cancer, so my ass is gonna swallow a camera when I turn 40, sooner if I see blood in the toilet. Screening for colon cancer is extremely cost effective, and often life saving. Colon cancer found early by the screening methods we have available extends lives.

Prostate cancer is a completely different discussion. People with a high PSA are more likely to have prostate cancer. OK. The last article I linked said people with early stage cancer are more likely to live longer, as compared to advanced stage. That seems completely intuitive, but it does not mean earlier diagnosis and treatment extends how long the patient lives. The problem we have now is we can't predict which prostate cancer will leave the capsule and which will stay at home, and we have no test that will determine if your prostate cancer will kill you. So why try to find it early if there is no benefit?

Doesn't "finding it early" imply that you have a better chance of identifying it when it is "early stage", and therefore make you "more likely to live longer"?

I have no doubt that screening with PSA leads to earlier diagnsosis. But living longer from the time of diagnosis does not equate to living longer. If a cancer was going to kill me 10 years from the time it first developed, what do I care when the diagnosis is made. I can be diagnosed early and be aware I have cancer for a longer period of time, or diagnosed later and live a short time after diagnosis, but if my expiration date is the same regardless, what's the use? You also need to factor in the false positive rate (high PSA but no cancer) and how many people will be harmed by the treatments that may or may not be necessary. That is why a screening test needs to prove a reduction in mortality when comparing a screened population vs a not screened population. Just proving that people who are screened live longer from the time of diagnosis just proves that you diagnosed the cancer earlier, nothing more.

Well, nobody gets treated because of a high PSA. A high PSA (or any screening test) leads to more conclusive tests (imaging, biopsy etc).

Second of all, I'm no expert, but with almost every cancer, if you catch it early, your survival rate is much higher.

What am I missing?

(06-20-2011 02:45 PM)bearcatjim Wrote:  

(06-20-2011 01:27 PM)glacier_dropsy Wrote:  

(06-20-2011 11:04 AM)bearcatjim Wrote:  

(06-18-2011 06:46 PM)glacier_dropsy Wrote:  Perhaps I should have been more clear. My family has a strong history of colon cancer, so my ass is gonna swallow a camera when I turn 40, sooner if I see blood in the toilet. Screening for colon cancer is extremely cost effective, and often life saving. Colon cancer found early by the screening methods we have available extends lives.

Prostate cancer is a completely different discussion. People with a high PSA are more likely to have prostate cancer. OK. The last article I linked said people with early stage cancer are more likely to live longer, as compared to advanced stage. That seems completely intuitive, but it does not mean earlier diagnosis and treatment extends how long the patient lives. The problem we have now is we can't predict which prostate cancer will leave the capsule and which will stay at home, and we have no test that will determine if your prostate cancer will kill you. So why try to find it early if there is no benefit?

Doesn't "finding it early" imply that you have a better chance of identifying it when it is "early stage", and therefore make you "more likely to live longer"?

I have no doubt that screening with PSA leads to earlier diagnsosis. But living longer from the time of diagnosis does not equate to living longer. If a cancer was going to kill me 10 years from the time it first developed, what do I care when the diagnosis is made. I can be diagnosed early and be aware I have cancer for a longer period of time, or diagnosed later and live a short time after diagnosis, but if my expiration date is the same regardless, what's the use? You also need to factor in the false positive rate (high PSA but no cancer) and how many people will be harmed by the treatments that may or may not be necessary. That is why a screening test needs to prove a reduction in mortality when comparing a screened population vs a not screened population. Just proving that people who are screened live longer from the time of diagnosis just proves that you diagnosed the cancer earlier, nothing more.

Well, nobody gets treated because of a high PSA. A high PSA (or any screening test) leads to more conclusive tests (imaging, biopsy etc).

Second of all, I'm no expert, but with almost every cancer, if you catch it early, your survival rate is much higher.

What am I missing?

On your first point, it generally leads to a more conclusive and invasive test, called a transrectal prostate biopsy. I have seen otherwise healthy people end up in the hospital with sepsis from colonic flora after that procedure, it's a rare complication but it happens.

Now on to the part that makes prostate cancer screening so (currently) ineffectual. Many of those biopsies will find cancer. Standard treatment will likely involve some form of surgery, chemo, radiation, or hormonal therapy. The first three come with plenty of negative side effects, the last carries less. The problem is, a significant portion of the people treated (under our old guidelines) never would have died from their prostate cancer. That's a factor in why the data shows earlier diagnosis, longer time alive from time of diagnosis, but no "all cause" mortality benefit from screening versus not screening. Because we killed some folks by screening for a cancer that was never going to kill them, but our attempt at cure did.

Now think about how much money we spend ordering a (currently) useless screening test and how many surgeries and medications we pay for to make the average male live no longer than the poor saps in the UK that can't get their screening PSAs paid for. I would figure you cost cutting repubs would be all over this kind of government waste.

So, you're saying that if your doctor found your prostate cancer at a very early stage, you would stand no better of a chance at curing it than if he found it at an advanced stage? Is that right?

No, that is not right. I'm saying that screening for prostate cancer with PSA testing using the protocols and male populations that have been studied to date does not lead the men that have been screened to live significantly longer than the men that were not screened. Some will be diagnosed early and have their lives saved, others will see no benefit regardless of test result, some will be harmed by the screening process and subsequent treatment, and some will be false negatives that were missed by the screening.

So to whittle it down to my personal n=1 scenario. I don't want my doctor to screen me for prostate cancer with a PSA if I am asymptomatic.