A doctor will always be able to find something wrong with you if you allow them to or complain enough. A doctor was educated to do something, and he/she wants to make you better, as that is why they sought out their profession. A doctor will try to fix that which they are a specialist of, and save the side effects for the next doctor, regardless of the quality of life issues, as they will convince themselves that they are saving your life. A doctor will give you pills, shots and surgeries as long as you have the insurance or money to pay for it. A doctor will say that there is nothing more that they can do for you after all the money is gone. If something goes wrong, the doctor will not take responsibility for it, but instead say, every body is different. A doctor will not guarantee their work, like a mechanic will, but instead blame the victim for their poor health. A doctor’s job is to make money for himself, his staff, his facility, the insurance companies and the pharmaceutical industry. A doctor will try to instill fear in the patient in order to convince the patient that they need the doctor and the medical institutions. A doctor is a person who must believe in their ability regardless of their ability. A doctor is a doctor no matter how they placed in their class. A doctor has emotional baggage. A doctor practices medicine, they are not experts in restoring you to your original state or perfect health. A doctor has not been in your shoes. A doctor seldom does to themselves what they are doing to you. A doctor goes home at the end of the day without the repercussions of your listening to and doing what they have done to you. A doctor is looked upon as an expert and therefore is trusted even when they admit that they cannot guarantee anything. A doctor will never be able to prove that they saved your life if the are treating you for a disease that is not immediately killing you. A doctor has responsibilities outside of their profession that affect their decision making objectives. Your doctor might not like you. A doctor might not like themself, their life, or the choices that they have made.
This is more good news for men dealing with the balancing act between acknowledging the seriousness of having an ‘untreated’ cancer in the core of our body and risking side effects of treatment than may seriously diminish quality of day-to-day life. I’ve decided 7 years ago to forgo treatments that my then Urologist strongly recommended and am content with my decision to stay on AS. Yes at times there’s some anxiety(several deaths among relatively young family and friends from other cancers) but overall that’s worth well worth it. And the sense of agency from paying attention to diet, exercise, reducing stress is another positive.
My first contact with a urologist was a couple of years ago when my PSA went up. He wanted to do a full biopsy. I countered that I’d like to try an MRI. It showed no cancer. Another a year later showed a mark which led to a fusion biopsy. The results were Gleason 3+3. I asked about AS. He told me it’d be too hard to manage. Next, he had my wife and I meet a radiologist who explained radiation. As I was leaving the office I saw the urologist and he asked if I’d like hormone shots today? I left this practice and found another who told me I was a good candidate for AS. My recent work history was in spiritual care in nursing homes and a hospital. You learn the importance of advocating for yourself. Like many things in healthcare, this news is important to those with lo grade prostate cancer.
Interesting and encouraging piece Howard. However AS still appears not to be a slam dunk....it may also depend on who the patient is (compliance) and who is doing the monitoring or what protocols are being followed with the monitoring.
Well stated, Howard, "risk of treatment v. lower risk of metastasis with surgery or radiation." How is it we die in this nation judged low risk? Peter Albell, EAU's Scientific Congress Office and German urologist, states, to paraphrase, "Still don't know enough about biology of this disease." What is unequivocal, is, the power of this newsletter not only to spread the word but equally, to elicit response, worldwide. Thanks, Igor! And to each respondent here, thank you also.
I asked my urologist Dr. Brian Helfand, an AS guru from NorthShore University Health system outside Chicago, to comment: "This is a study that was designed many years ago. Therefore, this trial represents 15-year data .which is important to obtain for prostate cancer trials since the tumor growth rate is slow.
"It is important to understand that subjects in this trial were randomly assigned to one of three groups: active surveillance, surgery and radiation. The active surveillance arm is different from many protocols today. Nonetheless this study shows that for many men with low-risk and favorable intermediate-risk prostate cancer, you can achieve similar cancer outcomes whether you watch patients or provide definitive treatment. However, while it did not reach statistical significance, there is about a twofold lower risk of metastasis and dying from prostate cancer with surgery or radiation. These differences were more prevalent in men with intermediate-risk disease. However, this potential benefit should be weighed against the risks of treatment."
Not sure I'm doing the math correctly but if there is 2x risk of failure (LTADT) in the AS group vs. the PT/RT groups then failure in AS group at 15 years would be about 15%, or 2x the 7.5% in the PT/RT groups. In that case, 85% of AS group would have needed no treatment at 15 years. Yet, 75% of the men in the AS group were treated when only 15% should have needed it. What am I getting wrong?
From NEJM article:
"Long-term androgen-deprivation therapy was initiated in 69 men (AS: 12.7%), 40 (PT: 7.2%), and 42 (RT: 7.7%), respectively"
I saw that 75% of AS were treated eventually. That's consistent with other studies. Whether they needed to drop out I am not sure. How did you determine that? This is from the NEJM article. There is a high dropout rate from AS of 33-50% by five years after diagnosis and 2/3 by 10 years in other studies. Some dropout because their cancer advances and others for other reasons. Where do you get the 15% needed to be treated?
I was looking at NEJM too and corrected the source in my comments. "How did you determine that?" I took this from the Helfand quote, "there is about a twofold lower risk of metastasis and dying from prostate cancer with surgery or radiation." Then I inferred metastasis to the treated men in the study on LTADT (7.2% of men treated with PT and 7.7% of RT) and doubled an average of those two for the percentage of hypothetical metastasis in untreated AS group. That would be 15% of AS group. 100 -15 = 85%
So, of the men on AS, who switched, 25% were untreated, But 85% should have been untreated? So 60% had unnecessary aggressive treatment? I think that holds up with other studies. I wonder why more isn't done to help these men cope with anxiety and related issues to keep them on AS.
25% of the original AS group remain untreated at 15 years. It's not clear to me what happens to the other 75%. Among the possibilities: death from other causes than PCa, treatment for PCa, or dropping out of study. I'd like to know how many men drop out and quit being tested and don't die of PCa. I think about it a lot. If the difference between metastasis in the treatment groups vs. the AS group is as low as it appears to be I'll continue to give it serious thought.
My doubt is also fueled by Dr. Ablin's (one of the discoverer's of PSA) talk at the Max Planck Institute a few years ago. In it he offers a hypothetical case of two 65 year old men diagnosed with PCa. One treats and the other doesn't. Both of them die at 75. The one who treats destroys the quality of his life from side effects of treatment right away while the other sees blood in his semen at 70 and is dead by 75 of PCa.
Is Dr. Ablin a kook or very sane? By the way I was inspired to find out about Dr. Ablin by reading your blog. I'd never heard of him before. I'd be interested in hearing some treatment experts in PCa debunk him and his evidence.
What this study lacks unfortunately, is a random comparison of men who NEVER treated compared with treated men and how many untreated men would have ended up on Hormone Therapy at 15 years. Suppose that number would be less than 20% (compared with 7.2% for surgery and 7.7% for radiation) I think some men, including myself, might give up further Prostate Cancer Testing entirely and the anxiety that comes with it.
This quote is from the NEJM article regarding the 3 control groups (AS, PT, RT) at 15 years:
"Long-term androgen-deprivation therapy was initiated in 69 men (12.7%), 40 (7.2%), and 42 (7.7%), respectively"
Howard, Thank you so much for this info, great news!
It's a pity that most of Moscow's urologists can't read this because at time being, they don't accept AS protocol for men even with low and favorable intermediate PC risk (Gleason 3+3 and 3+4)... Regards from Moscow, Russia.
Steve, I don't the studies by heart. But I know of similar studies in Canada. My urologist in 2010--my second opinion--cited a study by Dr. Klotz as I recall showing a 5-year survival rate for men on AS, surgery or radiation. Howard
The WSJ headline is worthy of the Daily Mail ... sensational and confusing!
I've already had men contact me asking why they got treated .... simple answer - you had more aggressive disease.
Protec-T is very helpful in supporting wider spread implemementation of AS for suitable candidates. Take note AUA!
What I am not sure Protec-T asked - and I plan to spend more time looking at the study this morning - is whether men who elected interventional treatment had lower levels of anxiety than those on AS.
Thanks, Rick. Only one mention of anxiety in the study: "Decisions to change the management approach in the early years were often made without evidence of progression, which probably reflected anxiety on the part of either the patients or their physicians. At 15 years, 39% of the men in the active-monitoring group had not undergone radical treatment, and 24% were alive without either radical treatment or androgen-deprivation therapy."
Thanks to an eagle-eyed reader, I had to update some figures. When I was diagnosed after a rising PSA with a single tiny core of low-risk Gleason 6 cancer in 2010, I faced a dilemma--one urologist was urging me to undergo aggressive treatment--which 94% of us with low-risk disease did then--or roll the dice on AS, a then little used protocol of close monitoring with PSAs, MRIs and biopsies on a regular basis. (Today, the proportion who choose to be treated is 40%—better but still high compared to the 6% in Sweden and 9% in Michigan.) I shouldn't be writing at 4 a.m.
A doctor will always be able to find something wrong with you if you allow them to or complain enough. A doctor was educated to do something, and he/she wants to make you better, as that is why they sought out their profession. A doctor will try to fix that which they are a specialist of, and save the side effects for the next doctor, regardless of the quality of life issues, as they will convince themselves that they are saving your life. A doctor will give you pills, shots and surgeries as long as you have the insurance or money to pay for it. A doctor will say that there is nothing more that they can do for you after all the money is gone. If something goes wrong, the doctor will not take responsibility for it, but instead say, every body is different. A doctor will not guarantee their work, like a mechanic will, but instead blame the victim for their poor health. A doctor’s job is to make money for himself, his staff, his facility, the insurance companies and the pharmaceutical industry. A doctor will try to instill fear in the patient in order to convince the patient that they need the doctor and the medical institutions. A doctor is a person who must believe in their ability regardless of their ability. A doctor is a doctor no matter how they placed in their class. A doctor has emotional baggage. A doctor practices medicine, they are not experts in restoring you to your original state or perfect health. A doctor has not been in your shoes. A doctor seldom does to themselves what they are doing to you. A doctor goes home at the end of the day without the repercussions of your listening to and doing what they have done to you. A doctor is looked upon as an expert and therefore is trusted even when they admit that they cannot guarantee anything. A doctor will never be able to prove that they saved your life if the are treating you for a disease that is not immediately killing you. A doctor has responsibilities outside of their profession that affect their decision making objectives. Your doctor might not like you. A doctor might not like themself, their life, or the choices that they have made.
This is more good news for men dealing with the balancing act between acknowledging the seriousness of having an ‘untreated’ cancer in the core of our body and risking side effects of treatment than may seriously diminish quality of day-to-day life. I’ve decided 7 years ago to forgo treatments that my then Urologist strongly recommended and am content with my decision to stay on AS. Yes at times there’s some anxiety(several deaths among relatively young family and friends from other cancers) but overall that’s worth well worth it. And the sense of agency from paying attention to diet, exercise, reducing stress is another positive.
My first contact with a urologist was a couple of years ago when my PSA went up. He wanted to do a full biopsy. I countered that I’d like to try an MRI. It showed no cancer. Another a year later showed a mark which led to a fusion biopsy. The results were Gleason 3+3. I asked about AS. He told me it’d be too hard to manage. Next, he had my wife and I meet a radiologist who explained radiation. As I was leaving the office I saw the urologist and he asked if I’d like hormone shots today? I left this practice and found another who told me I was a good candidate for AS. My recent work history was in spiritual care in nursing homes and a hospital. You learn the importance of advocating for yourself. Like many things in healthcare, this news is important to those with lo grade prostate cancer.
Good points, Anthony. Race can be an issue. Also, anxiety, family pressures not a slam dunk. Howard
Interesting and encouraging piece Howard. However AS still appears not to be a slam dunk....it may also depend on who the patient is (compliance) and who is doing the monitoring or what protocols are being followed with the monitoring.
Thanks, Steve. Appreciate the support. Howard
Well stated, Howard, "risk of treatment v. lower risk of metastasis with surgery or radiation." How is it we die in this nation judged low risk? Peter Albell, EAU's Scientific Congress Office and German urologist, states, to paraphrase, "Still don't know enough about biology of this disease." What is unequivocal, is, the power of this newsletter not only to spread the word but equally, to elicit response, worldwide. Thanks, Igor! And to each respondent here, thank you also.
I asked my urologist Dr. Brian Helfand, an AS guru from NorthShore University Health system outside Chicago, to comment: "This is a study that was designed many years ago. Therefore, this trial represents 15-year data .which is important to obtain for prostate cancer trials since the tumor growth rate is slow.
"It is important to understand that subjects in this trial were randomly assigned to one of three groups: active surveillance, surgery and radiation. The active surveillance arm is different from many protocols today. Nonetheless this study shows that for many men with low-risk and favorable intermediate-risk prostate cancer, you can achieve similar cancer outcomes whether you watch patients or provide definitive treatment. However, while it did not reach statistical significance, there is about a twofold lower risk of metastasis and dying from prostate cancer with surgery or radiation. These differences were more prevalent in men with intermediate-risk disease. However, this potential benefit should be weighed against the risks of treatment."
Not sure I'm doing the math correctly but if there is 2x risk of failure (LTADT) in the AS group vs. the PT/RT groups then failure in AS group at 15 years would be about 15%, or 2x the 7.5% in the PT/RT groups. In that case, 85% of AS group would have needed no treatment at 15 years. Yet, 75% of the men in the AS group were treated when only 15% should have needed it. What am I getting wrong?
From NEJM article:
"Long-term androgen-deprivation therapy was initiated in 69 men (AS: 12.7%), 40 (PT: 7.2%), and 42 (RT: 7.7%), respectively"
I saw that 75% of AS were treated eventually. That's consistent with other studies. Whether they needed to drop out I am not sure. How did you determine that? This is from the NEJM article. There is a high dropout rate from AS of 33-50% by five years after diagnosis and 2/3 by 10 years in other studies. Some dropout because their cancer advances and others for other reasons. Where do you get the 15% needed to be treated?
I was looking at NEJM too and corrected the source in my comments. "How did you determine that?" I took this from the Helfand quote, "there is about a twofold lower risk of metastasis and dying from prostate cancer with surgery or radiation." Then I inferred metastasis to the treated men in the study on LTADT (7.2% of men treated with PT and 7.7% of RT) and doubled an average of those two for the percentage of hypothetical metastasis in untreated AS group. That would be 15% of AS group. 100 -15 = 85%
So, of the men on AS, who switched, 25% were untreated, But 85% should have been untreated? So 60% had unnecessary aggressive treatment? I think that holds up with other studies. I wonder why more isn't done to help these men cope with anxiety and related issues to keep them on AS.
25% of the original AS group remain untreated at 15 years. It's not clear to me what happens to the other 75%. Among the possibilities: death from other causes than PCa, treatment for PCa, or dropping out of study. I'd like to know how many men drop out and quit being tested and don't die of PCa. I think about it a lot. If the difference between metastasis in the treatment groups vs. the AS group is as low as it appears to be I'll continue to give it serious thought.
My doubt is also fueled by Dr. Ablin's (one of the discoverer's of PSA) talk at the Max Planck Institute a few years ago. In it he offers a hypothetical case of two 65 year old men diagnosed with PCa. One treats and the other doesn't. Both of them die at 75. The one who treats destroys the quality of his life from side effects of treatment right away while the other sees blood in his semen at 70 and is dead by 75 of PCa.
Is Dr. Ablin a kook or very sane? By the way I was inspired to find out about Dr. Ablin by reading your blog. I'd never heard of him before. I'd be interested in hearing some treatment experts in PCa debunk him and his evidence.
https://www.youtube.com/watch?v=lTjs0K-q5Is
Igor, maybe you can find a sympathetic doctor on Moscow? Meanwhile, stick with us. Howard
What this study lacks unfortunately, is a random comparison of men who NEVER treated compared with treated men and how many untreated men would have ended up on Hormone Therapy at 15 years. Suppose that number would be less than 20% (compared with 7.2% for surgery and 7.7% for radiation) I think some men, including myself, might give up further Prostate Cancer Testing entirely and the anxiety that comes with it.
This quote is from the NEJM article regarding the 3 control groups (AS, PT, RT) at 15 years:
"Long-term androgen-deprivation therapy was initiated in 69 men (12.7%), 40 (7.2%), and 42 (7.7%), respectively"
Howard, Thank you so much for this info, great news!
It's a pity that most of Moscow's urologists can't read this because at time being, they don't accept AS protocol for men even with low and favorable intermediate PC risk (Gleason 3+3 and 3+4)... Regards from Moscow, Russia.
Steve, I don't the studies by heart. But I know of similar studies in Canada. My urologist in 2010--my second opinion--cited a study by Dr. Klotz as I recall showing a 5-year survival rate for men on AS, surgery or radiation. Howard
This is good news for those of us on AS.
Are there any other studies that confirm the same? What have studies in the US shown?
The WSJ headline is worthy of the Daily Mail ... sensational and confusing!
I've already had men contact me asking why they got treated .... simple answer - you had more aggressive disease.
Protec-T is very helpful in supporting wider spread implemementation of AS for suitable candidates. Take note AUA!
What I am not sure Protec-T asked - and I plan to spend more time looking at the study this morning - is whether men who elected interventional treatment had lower levels of anxiety than those on AS.
Thanks, Rick. Only one mention of anxiety in the study: "Decisions to change the management approach in the early years were often made without evidence of progression, which probably reflected anxiety on the part of either the patients or their physicians. At 15 years, 39% of the men in the active-monitoring group had not undergone radical treatment, and 24% were alive without either radical treatment or androgen-deprivation therapy."
Thanks to an eagle-eyed reader, I had to update some figures. When I was diagnosed after a rising PSA with a single tiny core of low-risk Gleason 6 cancer in 2010, I faced a dilemma--one urologist was urging me to undergo aggressive treatment--which 94% of us with low-risk disease did then--or roll the dice on AS, a then little used protocol of close monitoring with PSAs, MRIs and biopsies on a regular basis. (Today, the proportion who choose to be treated is 40%—better but still high compared to the 6% in Sweden and 9% in Michigan.) I shouldn't be writing at 4 a.m.