Subscribe to RSS Feed for recent updates
Subscribe to RSS Feed for recent updates









Prostate men need enlightening, not frightening March 2013
Anxiety - counselling and support necessary


We 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.

For 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).

This 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.

Young Men


The 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.

He 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 mail me.

If Treatment Is Expensive, Is It Therefore Effective?


There 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 treatment center."

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 patient. "

Presumably the clinical significant benefit would take into account the negative consequences as well as the positive potential.

Yana update
In 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.

My 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.
HIFU News: Laser Focal Study Recruiting
There were two items of news on the HIFU front which I have incorporated in the Treatment Choices page.

The first of these is the first long term study of outcomes based on data from Regensberg - HIFU outcomes in Germany after an average of 8 years of follow-up

The other refers to media reports in February that FDA permission was being sought for the Ablatherm procedure EDAP TMS submits data for approval of HIFU to US FDA

There is also a media release concerning a Phase I trial carried out by the University of Chicago. The results of the trial are sufficient to consider a further trial. You can read about the intial outcomes on the Treatment Choices page at Focal Laser Therapy Details of the Phase II study and eligibility are at MR Image Guided Focal Therapy in Prostate Cancer
Useful Links

Subscribe to this E-Letter

Past issues of E-Letters

Choosing A Treatment

YANA Survivor Stories If you want to see the latest stories and updates, choose the Updates link on this page

YANA Forum

A Strange Place An information guide to prostate cancer

Terry Herbert has been invited to join the Cure Panel Talk Show on Prostate Cancer on 28 March @ 6pm EST