Post by Tony Crispino on Mar 20, 2014 21:17:33 GMT -8
I am well pleased seeing online discussions about the Klotz interview on the Cure Panel Talk show. I don't agree with all that I see but I see rational discussion and some from people I wouldn't expect it from. As a former "that's not for me" kinda guy, I have come to understand Active Surveillance to be a vital tool for addressing Over Diagnosis and Over Treatment (ODOT).
Here are the major challenges:
ODOT ~ The patient community is starting to grasp the extent of over treatment in the prostate cancer arena. Even over diagnosis a little but I have learned to never walk to a survivor group and mention the OD part of ODOT without careful wording. We need more time for patients to grasp the true meaning of what OD really is. I've defined it according to the professionals as a diagnosis of an ailment that would never cause harm to a patient in his lifetime. Thus if you find a cancer that will never harm the patient you already have delivered some harms by finding it much less treating it. The psychosocial affects are almost if not completely irreversible.
US Preventive Services Task Force (USPSTF) ~ ODOT was cited as their primary reason for issuing the Grade D recommendation to call for an end to all PSA based screening for prostate cancer. The USPSTF has left the door open to review new data but none has been presented. The advocacies and some advocates have summoned congress members, namely Jeff Sessions, to draft a bill, SR251, calling for the USPSTF to be forced to reevaluate their previous recommendation and change the panel to have doctors that will change it. And reading between the lines it is a threat to the USPSTF to change it or worse will happen. This legislation is given favor over science for setting standard of care through SR251. This is a serious negative blow to all in the medical community should the USPSTF be forced to delete the recommendation by anything other than science.
Screening at age 40 years old or getting a "baseline" at 40 ~ Advocacies and others are suggesting that the best way to impact PCa mortality is by earlier and more frequent screening which unfortunately exacerbates the previous two challenges. To the point that the USPSTF will be far more justified. And 40yo men do not want to hear this.
Active Surveillance (AS) ~ Rather than define AS, because there are many versions, I will comment that the extended use of AS just may be the only way to solve all three previous challenges without a breakthrough in screening methods. It won't solve over diagnosis but it provides a pathway if taken seriously enough to solve over treatment, allow for younger screening, and provide new data to the USPSTF that they can consider changing the Grade D recommendation with. Today 250,000 men are diagnosed each year and nearly 90% will be treated in the US. With 28,000 per year dying that means there is a lot of room for improvement. Developing an agreed upon set of rules for AS can in fact be the key to screening younger men. It is said that for a 40yo man he has a 40% probability of having trace prostate cancer that can be picked up on a biopsy. 50% for a 50yo and so on. So if the same rate of screening for a 40yo man happens as does current guideline for 50 and above it is likely that we can diagnose 400,000 men per year. With an estimate that 80,000 probably needed therapy that leaves a huge number of men diagnosed with little impact on 28,000 per year mortalities because very few 40yo men die of PCa. It is estimated that if 50% of men are left untreated in an active monitoring program today, and perhaps 75% of low risk patients it is possible to have ammunition for the USPSTF to reconsider the recommendation while still addressing the need to screen younger higher risk men.
There is no easy equation for this problem and much has to be done to get the advocacies and physicians on board with this. But I personally think it's a move in the right direction. Clearly using congress to solve scientific issues is not the answer and a very dangerous precedent. I personally will not support such a measure. I believe that the near future will bring upon the PCa community more AS cases, and less over treatment. And that's a good thing. We have already seen an increase in online posters from younger men and we have seen an increase in AS cases. But very few younger men on AS indicates that physicians are still afraid to indicate AS to a younger man. In addition, there is still an issue with diagnosing a man that cannot process this in a reasonable way. But by weighing all of the options versus the current pathways we need to change the industry drastically and the industry knows it. And change is coming.
A couple clarifications on the Klotz webcast. I asked him about the Scardino interview at ASCO GU2014 not in support of Scardino's plan but to ask how we can get the US medical community on board with what is clearly working in Canada in a physician community that has little regard for such a protocol. I used the Scardino interview because he, like Klotz, is a surgeon. Both still do radical prostatectomies but have changed the game in a good way. But many doctors reject these ideas and want to stay with their current game plans. It's time to make drastic changes and in the next couple years I can easily predict that change will be the direction of the industry in the US.
Tony
Here are the major challenges:
ODOT ~ The patient community is starting to grasp the extent of over treatment in the prostate cancer arena. Even over diagnosis a little but I have learned to never walk to a survivor group and mention the OD part of ODOT without careful wording. We need more time for patients to grasp the true meaning of what OD really is. I've defined it according to the professionals as a diagnosis of an ailment that would never cause harm to a patient in his lifetime. Thus if you find a cancer that will never harm the patient you already have delivered some harms by finding it much less treating it. The psychosocial affects are almost if not completely irreversible.
US Preventive Services Task Force (USPSTF) ~ ODOT was cited as their primary reason for issuing the Grade D recommendation to call for an end to all PSA based screening for prostate cancer. The USPSTF has left the door open to review new data but none has been presented. The advocacies and some advocates have summoned congress members, namely Jeff Sessions, to draft a bill, SR251, calling for the USPSTF to be forced to reevaluate their previous recommendation and change the panel to have doctors that will change it. And reading between the lines it is a threat to the USPSTF to change it or worse will happen. This legislation is given favor over science for setting standard of care through SR251. This is a serious negative blow to all in the medical community should the USPSTF be forced to delete the recommendation by anything other than science.
Screening at age 40 years old or getting a "baseline" at 40 ~ Advocacies and others are suggesting that the best way to impact PCa mortality is by earlier and more frequent screening which unfortunately exacerbates the previous two challenges. To the point that the USPSTF will be far more justified. And 40yo men do not want to hear this.
Active Surveillance (AS) ~ Rather than define AS, because there are many versions, I will comment that the extended use of AS just may be the only way to solve all three previous challenges without a breakthrough in screening methods. It won't solve over diagnosis but it provides a pathway if taken seriously enough to solve over treatment, allow for younger screening, and provide new data to the USPSTF that they can consider changing the Grade D recommendation with. Today 250,000 men are diagnosed each year and nearly 90% will be treated in the US. With 28,000 per year dying that means there is a lot of room for improvement. Developing an agreed upon set of rules for AS can in fact be the key to screening younger men. It is said that for a 40yo man he has a 40% probability of having trace prostate cancer that can be picked up on a biopsy. 50% for a 50yo and so on. So if the same rate of screening for a 40yo man happens as does current guideline for 50 and above it is likely that we can diagnose 400,000 men per year. With an estimate that 80,000 probably needed therapy that leaves a huge number of men diagnosed with little impact on 28,000 per year mortalities because very few 40yo men die of PCa. It is estimated that if 50% of men are left untreated in an active monitoring program today, and perhaps 75% of low risk patients it is possible to have ammunition for the USPSTF to reconsider the recommendation while still addressing the need to screen younger higher risk men.
There is no easy equation for this problem and much has to be done to get the advocacies and physicians on board with this. But I personally think it's a move in the right direction. Clearly using congress to solve scientific issues is not the answer and a very dangerous precedent. I personally will not support such a measure. I believe that the near future will bring upon the PCa community more AS cases, and less over treatment. And that's a good thing. We have already seen an increase in online posters from younger men and we have seen an increase in AS cases. But very few younger men on AS indicates that physicians are still afraid to indicate AS to a younger man. In addition, there is still an issue with diagnosing a man that cannot process this in a reasonable way. But by weighing all of the options versus the current pathways we need to change the industry drastically and the industry knows it. And change is coming.
A couple clarifications on the Klotz webcast. I asked him about the Scardino interview at ASCO GU2014 not in support of Scardino's plan but to ask how we can get the US medical community on board with what is clearly working in Canada in a physician community that has little regard for such a protocol. I used the Scardino interview because he, like Klotz, is a surgeon. Both still do radical prostatectomies but have changed the game in a good way. But many doctors reject these ideas and want to stay with their current game plans. It's time to make drastic changes and in the next couple years I can easily predict that change will be the direction of the industry in the US.
Tony
