men need enlightening, not frightening ||March
- counselling and support necessary
touched on the question of anxiety and depression in E-Letter #6 in January 2012. These emotions
are so often associated with a diagnosis of prostate cancer and the aftermath
- the decisions making process, the wait for therapy, the period until outcomes
are finalized, the continuing monitoring.
There seems to have been very
little work done on this subject. One of the few studies with good data comes
from a companion study to the Holmberg randomized trial of surgery vs. watchful
waiting in Sweden. It found absolutely no significant psychological difference
between men who chase surgery and men who did not after five years. Worry, anxiety,
depression, all were equal between the two arms. While surveillance may be stressful
for some men, the reality is that most patients with prostate cancer, whether
treated or not, are concerned about the risk of progression. Anxiety about PSA
recurrence is common among both treated and untreated patient.
this reason, I feel that the recently published study Counseling and support associated with active surveillance:
highly necessary for some has wider implications than merely for men which
have chosen AS (Active Surveillance). The conclusion of this small study was that
"Educational support from physicians and emotional/social support should be
promoted in some cases to prevent poor QoL" (Quality of Life).
finding should be acknowledged on a much wider scale than merely men who choose
not to have immediate therapy. And men should also be much more aware of the fact
that they are not weak or alone in having concerns and anxiety. They should seek
professional help, preferably before such feelings slide into depression.
dividing line in prostate cancer diagnosis between "young men" and men
who are, well, not young men is usually put at age 55. About 10% of all
cases diagnosed are in men of aged 54 or less - about 60% in men aged 65 or older.
Diagnosed as I was at the youthful age of 54, I have always had some focus on
the subject of what young men should do when diagnosed - and if their choices
are significantly different. I don't think they are.
One of the reasons
most commonly advanced to support the view that young men need to take early and
immediate action is that the disease is more aggressive in younger men. Yet, like
many other aspects of this disease, there is simply no good evidence to support
the belief. A clear example of this occurred last year a "young man"
in his late forties mailed me to ask me for information on HIFU (High Intensity
Focused Ultrasound) which he was considering as the best option for his diagnosis,
which was one that fitted the"insignificant disease" criteria. I gave
him the information he was seeking, with the usual warning that most of the data
on HIFU was published by the manufacturers and was thus possibly not entirely
objective. Having done that I suggested that he went to the Choosing A Treatment page on the site.
did that and in due course told me that he was considering taking a "combo"
therapy of EBRT (External Beam Radiation), Brachytherapy and ADT (Androgen Deprivation
Therapy). In response to my query as to why he felt he needed such a high voltage
therapy he sent me a copy of the letter from the institution offering him the
treatment. It justified the suggested approach because young men had more aggressive
cancers. With his permission I wrote to the medical centre and asked them politely
if they could let me know where I could find the studies upon which this statement
was based. They promised to do so, but after several reminders I received a short
mail from the Marketing Manager saying that they could not give me references
to any published studies. The statement had been made based on their experience
at the centre.
I have in fact found two studies. One is based on data collected
before the PSA era and the second is from the period 1988 - 2003. Both studies
contained simular conclusions regarding younger men.
(a) there was very
little difference in the likelihood of younger men being diagnosed with high grade
(and therefore potentially dangerous) cancer. In fact the second study said younger
men were less likely than older men to have high grade disease
(b) in the
relative few young men who were unfortunate enough to be diagnosed with the aggressive
forms of the disease, the probability of a disease specific death was greater
than in older men. It was not clear whether this was because older men tended
to die of other causes at a greater arte than younger men.
I intend on
expanding on this subject in a piece on the site when I get around to it. If any
of you have any questions or input that will help me focus the piece better, please
Treatment Is Expensive, Is It Therefore Effective?
has always been some commentary about the cost and value of medical services.
Media releases are often denigrated by commentators as being spin put out by interested
parties. Insurers or governments are blamed for those stories suggesting that
costs are running away, too many expensive tests, too much use of inappropriate
therapies, over diagnosis, over treatment. On the other hand those who push for
more testing, more intervention, more use of the latest (and inevitably more expensive)
therapies are accused of feathering their own nests, either as practitioners or
suppliers of the therapies.
The truth is always difficult for any of us
to ascertain and probably lies somewhere between the opposing camps. I read two
articles which might seem rather oblique to this theme, but just shed some small
beams of light and added to my overall views.
The first was a piece in
a blog apparently written by a doctor in practise on one of the Hawaiian islands
- Playing Doctor Although the piece is not
prostate cancer specific Dr Plumer was diagnosed with the disease in 2000 and
found, as we all have that there was very little good data to help us make up
our mind what we should do. Why?
"I asked the physician who ultimately
became my treating physician in Georgia why it was so hard to get good comparative
data, and why people seemed so reluctant to be objective about the treatment they
offered. It's big money,he said. Each of the docs offered only a single treatment
modality - external beam radiation, seeds, prostatectomy, cryotherapy, and so
on. And everybody was so desperate to hang onto the big money in cancer treatment
that docs simply could not afford to have their business fall off substantially
if patients moved to a more appealing treatment, one which would be provided by
somebody else. Objectivity was an expensive luxury for docs maintaining a state-of-the-art
Nothing new about that, but what did attract
my attention was his remarks about late stage/end of life treatment v palliative/hospice
care. I have not had an opportunity to research this issue but it seems likely
that what Dr Plumer says is correct:
".... Medicare will pay for
any care a doctor orders, including all futile efforts at preserving fleeting
life at the end. On the other hand, Medicare pays a severely limited amount of
money for six months for a patient who elects hospice care... Here's where palliative
care has a role, the search for ... the best care possible, not simply the most
interventions. Right now if we simply insist on the next possible treatment, Medicare
will pay for it all, no matter how futile. On the other hand, if we actively make
a selection in favor of pain relief, comfort, support, and gentle death we swim
against the tide of technology, and we find that money available for our care
is limited and carefully doled out."
The second article may not
have much appeal because it deals with some statistical issues which too many
of us (and too many medical people) do not understand fully. It is Drug Trials: Often Long On Hype, Short on Gains.
I found it interesting because I have found it difficult to understand all the
excitement about the Abiraterone (Zytiga) and Provenge trials. It seemed to me
as I tried to come to grips with the media releases and commentaries that the
actual value of these very expensive therapies was tremendously variable and not
very large. Very little has been said about the negative consequences of these
therapies either, so it is difficult to establish a value. There is a quote from
Dr. Saltz in the piece that I think is pertinent:
" I'd like to
see us get away from the self-serving term of significant benefit, and
stress much more clearly when we are talking about statistical significance
- and explain to the public what that means. We should also move toward taking
a harder look at what constitutes a clinically significant benefit to the
Presumably the clinical significant benefit would take
into account the negative consequences as well as the positive potential.
news just to hand we have learned from Ann of the passing of Frank Streiff on March 6. Ann concludes
Prostate cancer stole his health but was never able to conquer his character.
thanks to all of you who responded positively to the E-Poll linked in the last
E-Letter. Although I was hoping to see at least a 50% positive response - that
would be 250 Yes votes. I'll take the 178 who did vote Yes as an affirmation that
there is some interest in continuing these missives.
Mark mentioned earlier
this week that we have had over 900 updates posted since he provided the slick
mechanism which makes that so much easier. I am always sorry to see the number
of Inactive stories grow - these are men who have not responded to our reminders
and who have not updated their story. If you're one of them, please go along to
Update Your Story and do it today.
If all's going well, it doesn't have to be a long update - the fact that you've
done it shows that you are alive - and will help to convince newbies that there
is indeed a life after their diagnosis.
News: Laser Focal Study Recruiting