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prostate cancer treatment

Common Prostate Cancer Treatment Falls Short

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Much like breast cancer, there has been much controversy with prostate cancer “prevention” and treatment in recent years.

Mainstream medicine as well as the public health gurus all put all their bets on the PSA card when it came to prostate cancer “prevention.”  (For those non-regular-readers of the Rantings, I always surrounding the word “prevention” in quotation marks because mainstream medicine does little to prevent cancers–most of what they call prevention is really early detection.)

The research over the past few years has been leading away from using PSA as an effective means of preventing prostate cancer and saving lives.  Even the discoverer of the PSA test, Dr. Richard Albin, has clearly shown his opinion about the matter, stating that the test should never have been used for the early detection of prostate cancer.

The main concern with the widespread use of the PSA test to detect prostate cancer is that there are a large number of prostate cancers detected that never would progress to anything of substance.  This large chunk of men diagnosed with non-aggressive prostate cancer is pushed towards surgery, radiation and chemotherapy for a cancer that would never create harm.

You can see the problem here.

One of the common treatments given to prostate cancer patients includes a drug to block the action of testosterone, referred to as androgen-deprivation therapy or ADT.  The idea is, if we block the action of testosterone on prostate cells (regardless of where they may be in the body) they will not divide as rapidly and these patients should have a longer survival time.

But, like so much else in medicine, we take an idea that may sound good on the surface and run with it long before the research is done to confirm that it’s a good idea.

And sometimes this research takes a LONG time.  In the case of hormone replacement therapy for women, HRT was used for almost 50 years before the research trials found out it was a bad idea.  This was, of course, after the drug companies made billions of dollars on drugs like Premarin.

As a result, ADT therapy is a common drug approach used in men with prostate cancer, despite a list of side effects like weight gain, loss of sexual libido and heart disease.  Which brings us to this particular study.

In it, researchers looked at 66,717 Medicare patients 66 years or older diagnosed with prostate cancer from 1992 through 2009.  They were followed for 15 years (average follow up was 110 months) and broken out into high use and low use of ADT.  Here’s what they found:

  • ADT was not associated with improved 15-year survival following the diagnosis of localized prostate cancer.
  • Among patients with moderately differentiated cancers (more serious types of tumors), the 15-year overall survival was 20.0% in areas with high ADT use vs 20.8% in areas with low use (in other words, it made no difference).
  • The 15-year prostate cancer survival was 90.6% in both high- and low-use areas.
  • In poorly differentiated cancers (the worst type), the 15-year cancer-specific survival was 78.6% in high-use areas vs 78.5%, in low-use areas.
  • In this same group of poorly differentiated cancer, the overall risk of dying from any cause (not just cancer) over 15 years was 8.6% in high-use areas vs 9.2% in low-use areas (in other words, the group NOT using the ADT lived slightly longer).

Keep in mind that this is a very large study.  While no single study sets anything in stone, the fact that we have been using an unproven therapy for prostate cancers that might never have progressed that have significant side effects should make you wonder just how many other commonly used treatments in medicine are creating far more harm than good.

 

Low Grade Prostate Cancer–What Will Happen Under Obamacare?

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Anyone who follows my Facebook page will know that I have grave concerns over the Affordable Care Act and that I ultimately think it will fall flat on its face.  But my reasons may be different than most.

With all the research I read through and post articles about, it should be abundantly clear that our system of medicine is incredibly expensive and incredibly ineffective for today’s burden of chronic diseases.  We waste more money on stupid stuff like statins, blood pressure medications and countless surgeries.  More on this later.

On to this particular study.

There has certainly been controversy in the past few years on the dangers of overtreating breast and prostate cancers from aggressively pursuing screenings like PSA testing and mammography.  It has become clear that there is a significant harm from finding and aggressively treating cancers that never would have created a problem (the old adage about dying WITH prostate cancer instead of dying FROM prostate cancer.

To this end, researchers looked at treating low grade prostate cancer (prostate-specific antigen level <10 µg/L, stage ≤T2a, Gleason score ≤3 + 3) with brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy and compared this treatment with observation.

Here’s the details:

  • Active surveillance is a more frequent form of observation, including regular PSA tests, digital exams, ultrasounds and biopsies to keep an eye on whether the cancer is progressing.
  • Watchful waiting is much less intense, relying more on the development of symptoms or less frequent PSA testing.
  • Compared with active surveillance, watchful waiting provided 2 additional months of  life expectancy (9.02 vs. 8.85 years) at a savings of $15,374 ($24 520 vs. $39 894) in men aged 65 years.
  • The life expectancy was the same in 75 year old men with a smaller cost savings of $11,746.
  • As far as treatment, brachytherapy (the use of radiation implants) was the most effective and least expensive initial treatment.
  • If a treatment was known to lead to a more dramatic reduction in prostate cancer death (in other words, if a treatment was known to add lots of years of life rather than just a few months or a year), then treatment  became more effective than observation.
  • Active surveillance became as effective as watchful waiting in 65 year old men when the there was at least a 63% chance of the man progressing to treatment (basically, if the man was at a relatively higher risk, active surveillance was a better approach).
  • Active surveillance became as effective as watchful waiting when the quality of      life was 4% higher in men aged 65 years or 1% higher in men aged 75 years.
  • Watchful waiting remained least expensive in all analyses.

Overall, watchful waiting or active surveillance were more effective as well as FAR cheaper under a variety of clinical scenarios that can be laid out for the patient.

So how does this apply to Obamacare?  For a long time now, we US citizens have wanted our healthcare and we want it now.  Damn the evidence.  If a 40 year old woman wants her mammogram, she’s going to get it.  If a 65 year old male has a PSA of 8, he wants his prostate destroyed with radioactive seeds or have it taken out altogether.  If someone has a cholesterol of 230, he or she know, from the commercials, that they need a statin.

But as we gather evidence that suggests that a huge chunk of procedures that are currently done are not worth the cost and / or risk.

If Obamacare is going to be worth snot, it is going to have to deprogram us from our resource-heavy, benefit-low healthcare delivery system.  Most will view this as government getting it nose into our healthcare and making cuts, but the reality is that it is just good medicine.

Only time will tell how it all works out.