What does the community think of this article, which says that older men with a limited life expectancy are getting overtreated for PCA? I wonder what the reaction would be if it was written about older women with BC?
PCA Overtreatment of older men (WTF) - Advanced Prostate...
PCA Overtreatment of older men (WTF)
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Derf4223
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This article and the problem it describes is hard to understand. Because it conflates different situations. Teasing apart the different groups that are involved here, I think the scandal is radiation treatments for men with metastatic prostate cancer where the life expectancy is very short and much less than 5 years. Interestingly this is under the VA, which is non-profit. But there may be other incentives for trying new generation fancy radiation treatments. We learn about increasingly sophisticated radiation treatments. But you need to practice to get it right. Hello guinea pigs. Tell me I'm wrong.
I believe the following quote from the article is the crux of their argument, "Life expectancy should be considered during screening decision-making to reduce the number of men with limited life expectancy being diagnosed with asymptomatic localized prostate cancer in the first place."
So to rephrase it, "Why bother screening for (prostate) cancer if you're going to die within 10 years".
If that's actually what the article states, I find it abhorrent; even if a patient's life is deemed to be time limited (but how do they know?) learning on top of this they have prostate cancer that can be treated may afford a better quality of life for their time left.
This nihilistic "don't spend money on a lost cause" in medicine really irks me. The patient should be given all access to information to decide their own fate, not left to bureaucracy.
Your response is a little over stated. The quote stays “life expectancy should be considered” - it does not say don’t screen. Someone with a life expectancy of less than a year eg 95 year old with cardiac failure, is not going to benefit from screening for an symptomatic condition for which treatment is neither indicated nor beneficial.
I agree in part; does this 95 yr old have urinary issues, pain from metastasis, other symptoms that could be attributed to prostate cancer that can be relieved with treatment? The tests and treatments and side effects should be presented to the patient, along with the dr.’s expert opinions, for him to decide.
Yes. You may have noticed a typo in my reply . It should have read “an asymptomatic condition “.
Ok, if we’re being accurate, the study indicates the median age of the men was 66. Given that the average life span of men is 72-76 ish, would you agree to stop all screening of men with no symptoms after age 60? The study's authors conclusions seem a bit out of touch. (edited for clarity)
No of course not. You appear to be making a pejorative personal remark. It is not clear to whom out of touch refers. If so please refrain.
Screening for an asymptomatic condition requires the informed consent of the individual and a careful consideration of the pros and cons in that individual. That must also include prior consideration of what to do with the result if it is positive, negative or uncertain AND the specificity and reliability of the test. Each has consequences for the subject regardless of age.
If we are talking about population screening on public health grounds, all those considerations apply PLUS cost benefit and cost effectiveness analysis.
Every single clinical test has both potential disbenefits and benefits for the subject. So screening over 60’s might or might not be beneficial. I have no idea. The data gives the answers
If an individual wants a test the questions to ask are what benefit do I get from knowing the result and if positive will intervention cause more harm than good.
I believe we are in violent agreement; present to the patient, let him decide.
Yes
My prostate cancer was asymptomatic. At age 66 my GP refused to order a PSA test. I insisted on a DRE, which he dragged his feet on but eventually performed the next visit. I subsequently was sent for a biopsy and a Gleason 8 diagnosis. I chose HIFU as my treatment option and I am doing just fine 8 years later. How would I be doing now had my cancer been left untreated for 8 years because, at age 66, I was too near my expiration date to waste resources on? BTW, I went out of pocket for my HIFU operation and I don't regret it one bit. Was I over-treated? I sure as hell don't think so.
Yes it surely does say don't screen or screen a heck of a lot less for men with five or ten years life expectancy. Life expectancy is a statistical number that can only be applied to a large group. How the hell do they know the life expectancy of any one individual? This whole article sounds like they are trying to resurrect the "prevent over-treatment by avoiding screening" nonsense recommendations that the Preventive services task force came up with years ago. Those recommendations did indeed result in less screening. It also resulted in more men turning up already metastatic and incurable, which is a travesty. Are they really pushing to go back to that?
You got it dead right.
I know a man whose doctor stopped testing PSA because of his age. He died from prostate cancer in 2022. Buyer beware.
Without knowing the full clinical details my suspicion is that local RT is offered to avoid some pretty unpleasant local pelvic problems due to local tumour invasion eg of rectum. So not a scandal unless I am missing something.
"... older men with a limited life expectancy are getting overtreated for PCA."
I am more concerned that this attitude can result in under treatment. At age 78, in the interest of QOL for my age-based life expectancy, I was allowed/encouraged to skip ADT after radiation, and to avoid ADT until after a second radiation for a node met failed to stop further mets.
At 82 after a year of ADT, I feel great and am in good condition. I have no reason to die of anything except prostate cancer that was allowed to reach Stage IV for lack of ADT in the interest of QOL.
OK I am 78 with stage 4 PCa - secondaries on PET no symptoms . I was persuaded to have adt plus enzalutamide. Big mistake as I had made it quite clear I wanted good QOL over duration. The side effects were horrendous the worst being PRES. Now off all for some months and will only accept intermittent ADT, if anything, at present if PSA gets over 5.
Sorry to hear that you are stage 4 with troublesome side effects. My question is, were you under-screened, over-treated, or both?
Fell over log on bum and got haematuria - led to diagnosis in 2009.
Population screening with PSA still really problematic in my view - we need better markers. If I had been asymptomatic and asked for screening and found a moderately raised PSA, I would be offered MRI in UK.
Yeah my PSA was only 2.7, which wouldn't have raised an alarm, when I was diagnosed. It was the suspicious DRE that led to my diagnosis. Some patients and doctors avoid the DRE due to the embarrassment factor.
fast_eddie wrote -- : .... Some patients and doctors avoid the DRE due to the embarrassment factor. "
My PCP used HER gloved finger to probe my prostate and since she was up my butt with her Sigmoidoscopy numerous times it mattered not.
BTW - the lump she felt was GL10 hard
The VA is socialized medicine, with cost control for the masses. You can bet any ex-brass is not going to be pushed off the subway platform.
So many variables to juggle. At 81 I had been told that my "expiration date" was 6 to 8 years. Was on waitful watching and sure enough, ended up with a Gleason 8. Knew a lot of guys who had radiation which worked for some. I wanted to stay alive as long as I could to help my wife, so jumped at that straw. Surgery was off the board from the beginning. The was no indepth discussion with UR regarding SEs. Later, discovered that he was part of Clinic which did the radiation.
Unfortunately, my wife passed 3 years ago because all the hospital beds were full of anti-vaxers and a nessary operation was delayed 10 days leading to her death from in hospital infections. A year later I was diagnosed with myelodysplastic syndromes ( MDS-RS), a bone marrow blood cancer cause by my radiation. Expiration date now 1 to 3 years, so back to the original estimate.
Because of SEs-mostly fatigue, had my MO take me off ADT. It has helped a bit. I ride my MDS horse here and other sites to let folks know about it when they have to make these decisions.
That is an awful story - I am so sorry.
Testosterone can help MDS symptoms so worth considering - but first take a look at my post to tunybgur below - you might find my comments of interest.
Best of luck.
At the age of 76 I was diagnosed with Stage 3b prostate cancer with no visible mets.
My oncologist said he was aiming for a cure with radiotherapy, HD Brachytherapy plus 2 years of ADT.
My PSA is now 0.01 after 12 months of treatment but I have suffered radiation damage to my bowel and bladder which doesn't seem to be getting better and affects my day to day life.
I have very low energy levels even though I take a lot of exercise, and haven't had a full undisturbed nights sleep since RT.
My question is, why at the age of 77 do I need to complete 24 months of ADT?
Surely 18 months is plenty and I might get a tiny bit of testosterone back?
Very sorry to hear about RT side effects. That is a bu***r. It can takes months for T to recover fully.
Options you might like to discuss with your oncologist:
You could go on intermittent ADT which has minor differences in outcome. For example, stop ADT and just monitor and start again if and when PSA hits somewhere between 1 and 5ng/ml. Over treatment can be a problem and careful balancing between quantity of life and quality is vital. I am 78 and trying to minimise therapy and tailor it to my disease - I was over treated with ADT/ARI at time of recurrence and regretted it. Now off the lot, back to my normal QOL, and just monitoring.
There is also the so-called BAT trial which uses testosterone between courses of ADT to re-sensitise PCa to the effects of ADT. Not a fully controlled study but showed better QOL and metabolic profile than traditional ADT. Not a "standard of treatment" though. Some are using it as salvage late stage therapy to re-sensitise PCa to therapy. Seems a bit late in the day to me.
Food for thought. You might like to ask your oncologist why there is a negative correlation between T levels and risk of PCa as we age; ie lower levels of T are associated with increased risk of PCa. This directly contradicts the current therapy paradigm which says T is the bad guy!! Current therapy based on ADT/ARI is in a Darwinian race with cell mutation and never catches up....
These you might find of interest:
Open access article on a very interesting lab study - Nature Communications volume 15, Article number: 7675 (2024). Data shows T at low dose stimulates proliferation, but inhibits proliferation and increases differentiation at high dose. PSA shows linear response to T dose - so increasing PSA synthesis in these experiements do not reflect reduction in PCa cell growth. It is tough reading if you are not a scientist, if so just stick to the summary intro and conclusions, and try the graphs.
Also BAT: The Prostate 76: 1218-1226, 2016. Unfortunately Wiley paywall $15 for 48hours reading.
Possibly at the VA. But ageism is a problem at community cancer centers.
prostatecancer.news/2016/08...
Too many doctors treat according to chronological age instead of physiological age. I have seen on this site, doctors have refused chemo and other life-saving treatments to men with WHO or Karnofsky Performane Status of 0 or 1 based on age alone. It is tragic.
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