Category Archives: Prostate Cancer

Microscopic view of prostate cancer

New PSA screening guidelines urge weighing harms, benefits

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By Rita Rubin

This KHN story was produced in collaboration with 

Microscopic view of prostate cancer

Prostate Cancer

For nearly a quarter century, doctors have ordered annual PSA tests for men of a certain age to screen for prostate cancer, despite a lack of evidence that the benefits outweighed the risks — especially when tiny, slow-growing tumors were detected.

But the landscape appears to be changing. While questions about PSA screening remain, physicians increasingly recognize the need to discuss both the harms and benefits with patients.

The U.S. Preventive Services Task Force shook up the status quo last July when it advised against using the simple blood test, which measures levels of a protein called prostate specific antigen, with average-risk men of any age who had no prostate cancer symptoms.

That recommendation prompted a backlash from urologists, who argued that screening saves lives, but gave pause to primary care doctors.

In recent weeks, though, urology and internal medicine groups have published surprisingly similar directives.

“I would say it’s a shift toward a more targeted screening approach rather than a one-size-fits-all screening approach,” said Dr. H. Ballentine Carter, a Johns Hopkins urologist, of the American Urological Association guidelines released May 3 and developed by a committee he chaired. The international association has more than 19,000 members worldwide.

Carter’s committee noted that the greatest benefit appears to be for those 55 to 69 but urged that men in that age group discuss the pros and cons with their doctor before deciding whether to proceed.

For those who opt for screening, waiting at least two years between tests could minimize potential harms — namely false-positives and the detection of slow-growing tumors that wouldn’t have caused any symptoms — while preserving most benefits.

Similarly, the American College of Physicians, representing internists, released guidelines April 9 advising members to discuss the test’s “limited benefits and substantial harms” with patients 50 to 69 years old and let them decide.

Both groups agreed that doctors should not screen men younger or older than their guidelines’ age ranges or those expected to live less than 10 to 15 years because of other health conditions.

An elevated PSA level doesn’t necessarily signify prostate cancer, but it can trigger a cascade of tests and treatments that could be riskier than the disease itself, potentially causing impotence, incontinence or even death from prostate cancer surgery.

Even before the latest sets of guidelines were released, Dr. Michael Albert, a Hopkins internist, said he began to change his approach, spurred by the Preventive Services Task Force recommendations and a 2009 U.S. study that concluded PSA screening didn’t save lives.

“It used to be much easier for me to click on the PSA button and order it,” said Albert, medical director of the East Baltimore Medical Center, part of Johns Hopkins Community Physicians.

Dr. Gene Green, a board-certified family practice doctor and internist who is president of the Hopkins-affiliated Suburban Hospital in Bethesda, said he’s been screening a smaller percentage of patients and referring fewer of them with a PSA level of 4 — traditionally the point at which prostate cancer concerns are raised in older men — to urologists.

Carter, head of adult urology at Hopkins, said the AUA guidelines “had absolutely nothing to do with the task force,” and though the two groups’ guidelines were based on similar scientific evidence, they viewed the evidence differently.

“We interpreted the evidence from an individual’s perspective vs. a public health perspective,” he said. Prostate cancer might not represent a threat to the public health the way diabetes or heart disease does, but it’s a “major risk to an individual who’s in your office and who may be very concerned about the possibility,” Carter said.

Dr. Kenny Lin, a family physician, called the informed-consent approach a “cop-out.” Simply by raising the subject of screening, doctors push patients toward it, said Lin, who as a medical officer at the Agency for Healthcare Research and Quality wrote the evidence review on which the Preventive Services Task Force based its recommendation. So, said Lin, now on the faculty at the Georgetown University School of Medicine, “I don’t bring it up necessarily.”

Meanwhile, the American Association of Clinical Urologists, whose website said its membership includes 45 percent of U.S. urologists, warns in a statement that these recent sets of guidelines could leave the impression that early detection of prostate cancer is no longer needed.

The Preventive Services Task Force and the AUA committee agree that one life is saved for every 1,000 men screened.

“There’s really no doubt [it] saves lives,” said Dr. William Nelson, a medical oncologist and urologist who directs Hopkins’ Sidney Kimmel Comprehensive Cancer Center.

The death rate from the disease has been declining since it peaked 20 years ago, although it isn’t clear how much is due to PSA screening and how much to improved treatment.

Still, Nelson acknowledged, “a lot more men die with prostate cancer than will ever die of it. The greatest threat to their health and happiness is attempts to treat them.”

ProstateSince the 1990s, screening has led to a diagnosis of early-stage prostate cancer in more than a million U.S. men who probably never would have developed symptoms. More than nine out of 10 of them chose aggressive treatment.

Mark Humphrey, now 71, a retired General Electric executive, lived in western Massachusetts when a 2006 test showed his PSA had nearly doubled to 3.5. Although still in the normal range below 4, the rapid increase spurred his doctor to refer him to a urologist for a biopsy, which revealed abnormal cells.

But his cancer appeared unlikely to be aggressive. That information, coupled with memories of his late brother-in-law’s experience with incontinence and impotence after surgery, led Humphrey to take a pass on the aggressive approach.

So Humphrey, who now lives in Baltimore, enrolled in the world’s first prostate cancer “active surveillance program,” which Carter directs at Hopkins. Instead of treating Humphrey’s disease, Carter is keeping an eye on it, with PSA testing and a rectal exam every six months.

Approximately 1,000 men have opted for active surveillance since the program launched more than 16 years ago. By following the participants, Carter said, he and his colleagues hope to learn more about what distinguishes slow-growing from aggressive cancers. Their goal: to build a better screening test.

“And then we want to learn more about the personal preferences of patients,” Carter said. For example, are they comfortable living with cancer?

Albert remembers seeing one patient, an otherwise healthy man in his early 60s with a PSA-detected tumor. After six months in the program, the man chose surgery. “He couldn’t fathom the idea that you’d sit on a cancer that could metastasize.”

Carter, Nelson and Green are among a group of Hopkins urologists and primary care doctors working on an app to help doctors discuss the risks and benefits of PSA screening with patients.

The app, to be tested later this year, takes into account such factors as life expectancy and prior PSA levels. It will be integrated into patients’ electronic medical records.

Notes Green: “Very few times in our lives can we say ‘always’ or ‘never.'”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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U.S. cancer deaths continue long-term decline

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By Bill Robinson
NCI Cancer Bulletin

According to the latest national data, overall death rates from cancer declined from 2000 through 2009 in the United States, maintaining a trend seen since the early 1990s.

SR-inside

Mortality fell for most cancer types, including the four most common types of cancer in the United States (lungcolon and rectumbreast, and prostate), although the trend varied by cancer type and across racial and ethnic groups.

The complete “Annual Report to the Nation on the Status of Cancer, 1975–2009″ appeared January 7 in the Journal of the National Cancer Institute.

The report also includes a special section on cancers associated with the human papillomavirus (HPV) that shows that, from 2008 through 2010, incidence rates rose for HPV-associated oropharyngealanal, and vulvar cancers.

HPV vaccination rates in 2010 remained low among the target population of adolescent girls in the United States.

As in past years, NCI, the American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), and the North American Association of Central Cancer Registries (NAACCR) collaborated on the annual report.

Cancer incidence data came from NCI’s Surveillance, Epidemiology, and End Results (SEER) database and the CDC, with analyses of pooled data by NAACCR. Mortality data came from the CDC’s National Center for Health Statistics.

Incidence Rates Vary, Death Rates Continue to Drop

Among men, the overall rate of cancer incidence fell by an average of 0.6 percent annually from 2000 through 2009. Cancer incidence rates were stable among women during the same time period and rose by 0.6 percent per year among children. (See the table.)

“The continuing drop in cancer mortality over the past two decades is reason to cheer . . . The challenge we now face is how to continue those gains in the face of new obstacles, like obesity and HPV infections.”

The declines in cancer mortality averaged 1.8 percent per year for men, 1.4 percent per year for women, and 1.8 percent for children (ages 0 to 14 years) from 2000 through 2009.

During the same period, death rates among men fell for 10 of the 17 most common cancers and rose for three types of cancer. Death rates among women fell for 15 of the 18 most common cancers and also rose for three types of cancer.

“The continuing drop in cancer mortality over the past two decades is reason to cheer,” said ACS Chief Executive Officer Dr. John R. Seffrin in a statement. “The challenge we now face is how to continue those gains in the face of new obstacles, like obesity and HPV infections. We must face these hurdles head on, without distraction, and without delay, by expanding access to proven strategies to prevent and control cancer.”

HPV Vaccination Rates Low

The special section on HPV-related cancers showed that from 2000 through 2009, incidence rates for HPV-associated oropharyngeal cancer increased among white men and women, as did rates for anal cancer among white and black men and women. Incidence rates for cancer of the vulva also increased among white and black women.

However, cervical cancer rates declined among all women except American Indian/Alaska Natives. In addition, cervical cancer incidence rates were higher among women living in lower-income areas.

The annual report also showed that, in 2010, fewer than half (48.7 percent) of girls ages 13 through 17 had received at least one dose of the HPV vaccine, and only 32 percent had received all three recommended doses, a rate that fell well short of the Department of Health and Human Services’ Healthy People 2020 target of 80 percent.

The rate is also much lower than vaccination rates reported in Canada (50 to 85 percent) and the United Kingdom and Australia (both higher than 70 percent).

Vaccination series completion rates were generally lower among certain populations, including girls living in the South, those living below the poverty level, and Hispanics.

“The influence that certain viral infections can have on cancer rates is significant and continued attention to the effect[s] of HPV infection, in particular, on cervical cancer rates is critical,” said NCI Director Dr. Harold Varmus in a statement. “It is important, however, to note that the investments we have made in HPV research can only have the tremendous payoff of which they are capable if vaccination rates … increase.”

Cancer Incidence and Mortality Rates, 2000–2009

Men Women
Incidence Increase

  • kidney
  • pancreas
  • liver
  • thyroid
  • melanoma
  • myeloma

Decrease

  • prostate
  • lung
  • colorectal
  • stomach
  • larynx
Increase

  • thyroid
  • melanoma
  • kidney
  • pancreas
  • leukemia
  • liver
  • corpus and uterus

Decrease

  • lung
  • colorectal
  • bladder
  • cervix
  • oral cavity and pharynx
  • ovary
  • stomach
Mortality Increase

  • melanoma
  • liver
  • pancreas

Decrease

  • lung
  • prostate
  • colon and rectum
  • non-Hodgkin lymphoma
  • kidney
  • stomach
  • myeloma
  • oral cavity and pharynx
  • larynx
  • leukemia
Increase

  • pancreas
  • liver
  • corpus and uterus

Decrease

  • lung
  • breast
  • colon and rectum
  • leukemia
  • non-Hodgkin lymphoma
  • brain and other nervous system
  • myeloma
  • kidney
  • stomach
  • cervix
  • bladder
  • esophagus
  • oral cavity and pharynx
  • ovary
  • gallbladder

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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Lung Cancer

A glimpse into future of cancer screening

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Lung Cancer

X-ray showing lung cancer – Photo/NCI

By Elia Ben-Ari
NCI Cancer Bulletin

Ask experts to predict the future of cancer screening, and you’ll get a range of answers.

But all would agree that we need better ways to detect cancers early in the course of disease, and these new tools should improve on the benefits of screening while limiting the harms.

“There have been some improvements in triaging patients with new molecular approaches, but with the possible exception of spiral CT screening for lung cancer, we haven’t had any major breakthroughs in early detection” for more than two decades, noted Dr. David Sidransky, director of head and neck cancer research at the Johns Hopkins University School of Medicine.

The dearth of such advances is not for lack of trying. Developing new screening approaches and rigorously establishing their validity is challenging, however, and there are many potential stumbling blocks along the way.

“The bar for ‘proof’ that a particular screening strategy is clinically effective is very high,” noted Dr. Mark Greene, chief of the Clinical Genetics Branch in NCI’s Division of Cancer Epidemiology and Genetics (DCEG). “A screening test must be shown to reduce the death rate from the disease for which screening is being done.”

Much of the search for new screening tests focuses on biomarkers—proteins, DNA, RNA, or other molecules that can signal the presence of cancer and be detected noninvasively in blood, urine, or other readily obtained patient samples or tissues.

Researchers are also developing new imaging methods that could be used for early detection, either alone or in concert with biomarkers.

Whatever the approach, “screening is moving away from detecting an advanced consequence of cancer, which is the formation of a mass [or tumor], toward detecting the very earliest changes in the cancer process,” said Dr. Larry Norton, deputy physician-in-chief for breast cancer programs at Memorial Sloan-Kettering Cancer Center.

Dr. Norton chairs the external consulting team for the Early Detection Research Network (EDRN), an initiative of NCI’s Division of Cancer Prevention that supports efforts to discover and validate new cancer biomarkers and technologies.

“Molecular detection of cancer is possible only through evidence-based strategies and implementation,” commented Dr. Sudhir Srivastava, who directs the EDRN. “It takes a village to meet the challenges of early-detection research.”

The Post-PSA Era

Microscopic view of prostate cancer

Prostate Cancer

In the case of some cancers, researchers are developing new screening tests because the value of existing tests for those cancers has been called into question, perhaps most notably in the case of prostate specific antigen (PSA) testing for prostate cancer.

“The idea that one biomarker such as PSA is going to be useful for all settings has evolved. We now believe that we’ll need panels of biomarkers,” said Dr. Mark Rubin, a professor of pathology at Weill Cornell Medical College.

To identify those biomarkers, researchers are using methods such as microarrays and whole-genome sequencing, which rapidly yield a wealth of information, to profile changes that occur in cancer.

Using such an approach, Dr. Rubin, Dr. Arul Chinnaiyan of the University of Michigan, and their colleagues discovered the fusion gene TMPRSS2-ERG, which is found in about half of all prostate cancers.

“That fusion gene is seen only in cancer, and, in particular, only in prostate cancer,” said Dr. Rubin, whose team has developed a test to assess the levels of this fusion gene in urine samples. “Our approach now is to try to explain the other 50 percent of prostate cancers with other cancer-specific molecular events” that could eventually form a screening test based on a panel of genetic markers.

For example, Dr. Rubin co-led a recent study that identified a gene called SPOP that is mutated in about 10 percent of prostate cancers.

“We can add that gene mutation to the gene fusion to improve on the test,” he explained. “This is the sort of approach we think will be useful for prostate cancer, as well as other cancers in the future.”

Applying Lessons Learned

To avoid unnecessary biopsies or treatment of prostate and other screen-detected cancers, researchers are trying to find biomarkers that better identify which cancers are likely to progress, noted Dr. Joshua LaBaer, director of the Center for Personalized Diagnostics at the Biodesign Institute at Arizona State University and co-chair of EDRN’s steering committee.

“What we’ve learned from PSA is that if we’re going to come up with new screening tools, we also have to develop tools that give us a better idea of disease prognosis.”

Whereas some cancers detected by screening will progress and metastasize, others may never cause illness during a person’s lifetime.

“What we’ve learned from PSA is that if we’re going to come up with new screening tools, we also have to develop tools that give us a better idea of disease prognosis,” said Dr. James Brooks, a professor of urology at Stanford University.

Dr. Brooks and Dr. Sanjiv Gambhir, chair of the department of radiology at Stanford, lead a project to deploy new technologies that could form the basis for the next generation of prostate cancer screening tests.

To pave the way for tests that rely on panels of blood-based diagnostic or prognostic protein biomarkers, they are starting to test the performance of a magneto-nanosensor chip technology developed at Stanford.

The sensor, which detects proteins tagged with magnetic particles, can measure the levels of up to 64 different proteins simultaneously, in very small sample volumes.

The Stanford team also hopes to adapt an imaging technology being studied in Dr. Gambhir’s lab to improve the accuracy of prostate cancer detection by transrectal ultrasound.

The method uses gas “microbubbles” that are encased in a lipid shell to which specific antibodies are attached as a contrast material for ultrasound imaging.

The antibodies target a receptor for vascular endothelial growth factor, which is a protein found in newly formed tumor blood vessels. The patented antibody-labeled microbubbles are awaiting Food and Drug Administration approval for human testing.

The Stanford team’s long-term goal is to combine their blood-based biomarker and imaging methods to improve early detection and prognostic assessment of prostate cancer and eventually other cancers.

Combining molecular biomarkers and imaging for cancer screening “is a very powerful approach,” commented Dr. Sidransky. “We used to believe in the power of a marker to do everything,” he added. “We now know that’s not true.”

A Sense of Urgency

Researchers have long sought an effective screening strategy for ovarian cancer, and numerous candidate biomarkers for the disease have fallen short of expectations.

“Ovarian cancer is the paradigm for why we need early detection,” said Dr. Michael Birrer, a professor of medicine at Harvard Medical School. The disease can be cured by surgery if discovered early. But “75 percent of tumors are detected at the advanced stage, and those patients are hard to cure,” said Dr. Birrer.

Dr. Birrer and Dr. Steven Skates, an associate professor of medicine at Harvard, are leading a two-pronged effort to discover new biomarker candidates that may ultimately lead to a blood test for the early detection of ovarian cancer.

We used to believe in the power of a marker to do everything. We now know that’s not true.—Dr. David Sidransky

The first strategy will use extensive proteomic profiling of fluids from benign and malignant tissues, such as ovarian cysts, “to find candidate biomarkers that are systematically different between the two,” Dr. Skates explained.

The second strategy involves genomic analyses to identify genes that are expressed differently in ovarian cancer tissue samples than they are in normal tissues that may give rise to ovarian cancer, and then bioinformatic analyses to look for genes whose protein products are also likely to be secreted into the bloodstream.

Using either the proteomic or genomic approach, or a combination of both, the researchers hope to come up with a short list of candidate biomarkers for further testing and refinement.

“We may be lucky to find that some of those candidates are actually early-detection biomarkers that can be measured in blood,” Dr. Skates said.

Those biomarkers could form the basis of a blood test to screen postmenopausal women, and other women at increased risk of ovarian cancer, at regular intervals.

For women who test positive on the blood test, a follow-up test, such as transvaginal ultrasound or newer imaging methods, might be used as part of an overall screening approach in the future, Drs. Birrer and Skates suggested.

Gazing into the Crystal Ball

3d Chromosome with DNA visible insideNo one can predict with certainty which types of tests will be most effective for screening for particular cancers. However, “if you want to prognosticate the future of cancer screening, my guess is that nucleotide [RNA or DNA]-based tests are going to be the most promising, at least in the short term,” Dr. Brooks said. “The power of nucleic acids is that you can amplify them to an extraordinary degree, which you can’t do with proteins,” Dr. LaBaer added.

Future DNA-based screening tests might detect methylation or other epigenetic modifications of DNA that occur specifically in cancer. “For example, we published a paper last year showing widespread and reproducible changes in DNA methylation in prostate cancer,” Dr. Brooks said.

And future screening tests may detect biomarkers in patient samples other than blood or urine. “One area where I think you’re going to see a change is in…tumors that affect the gastrointestinal tract” or other parts of the digestive system, Dr. LaBaer predicted. “You can look in stool for aberrant nucleic acids [from cells shed by tumors].” Researchers are also investigating sputum-based tests to detect lung cancer early.

“A possibility for the future is that we may stop thinking about cancers in terms of organ sites and may think more in terms of disrupted pathways or molecular variants of cancer,” Dr. LaBaer continued. In that case, “the biomarker people are going to have to work closely with the imaging people to very quickly turn a biomarker discovery into identifying where the tumor is.”

“We’re rapidly changing our concept of what cancer is,” noted Dr. Norton. “You can’t separate screening from understanding biology, from therapy, from prevention. The biggest challenge is weaving it all together [into] the big picture.”

Furthermore, he added, “we may find out that early detection is not helpful in certain situations, and that’s also important. We may not want to screen for certain cancers if we find out that prevention may be a better place to put our resources.”

“Mortality rates for some cancers have remained constant for the past 40 years, and in some of these cancers, new therapies have extended life for a few years but are not increasing the cure rates,” Dr. Skates noted. “Improved early detection for these cancers could shift that number so that more people are cured…. The payoff could be so big.”

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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Prostate Cancer: Facts and fiction

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Six Myths about prostate cancer

When it comes to prostate cancer, there’s a lot of confusion about how to prevent it, find it early and the best way – or even whether – to treat it. Below are six common prostate cancer myths along with research-based information from scientists at Fred Hutchinson Cancer Research Center to help men separate fact from fiction.

Myth 1 – Eating tomato-based products such as ketchup and red pasta sauce prevents prostate cancer. 

“The vastmajority of studies show no association,” said Alan Kristal, Dr.P.H., associate director of the Hutchinson Center’s Cancer Prevention Program and a national expert in prostate cancer prevention.

Kristal and colleagues last year published results of the largest study to date that aimed to determine whether foods that contain lycopene – the nutrient that puts the red in tomatoes – actually protect against prostate cancer.

After examining blood levels of lycopene in nearly 3,500 men nationwide they found no association. “Scientists and the public should understand that early studies supporting an association of dietary lycopene with reduced prostate cancer risk have not been replicated in studies using serum biomarkers of lycopene intake,” the authors reported in Cancer Epidemiology, Biomarkers & Prevention.  “Recommendations of professional societies to the public should be modified to reflect the likelihood that increasing lycopene intake will not affect prostate cancer risk.”

Myth 2 – High testosterone levels increase the risk of prostate cancer.

“This is a hypothesis based on a very simplistic understanding of testosterone metabolism and its effect on prostate cancer. It is simply wrong,” Kristal said.

Unlike estrogen and breast cancer, where there is a very strong relationship, testosterone levels have no association with prostate cancer risk, he said.

A study published in 2008 in the Journal of the National Cancer Institute, which combined data from 18 large studies, found no association between blood testosterone concentration and prostate cancer risk, and more recent studies have confirmed this conclusion.

Myth 3 – Fish oil (omega-3 fatty acids) decreases prostate cancer risk. 

“This sounds reasonable, based on an association of inflammation with prostate cancer and the anti-inflammatory effects of omega-3 fatty acids,” Kristal said.

However, two large, well-designed studies – including one led by Kristal that was published last year in the American Journal of Epidemiology – have shown that high blood levels of omega-3 fatty acids increase the odds of developing high-risk prostate cancer.

Analyzing data from a nationwide study of nearly 3,500 men, they found that those with the highest blood percentages of docosahexaenoic acid, or DHA, an inflammation-lowering omega-3 fatty acid commonly found in fatty fish, have two-and-a-half times the risk of developing aggressive, high-grade prostate cancer compared to men with the lowest DHA levels.

“This very sobering finding suggests that our understanding of the effects of omega-3 fatty acids is incomplete,” Kristal said.

Myth 4 – Vitamins and dietary supplements can prevent prostate cancer. 

Several large, randomized trials that have looked at the impact of dietary supplements on the risk of various cancers, including prostate, have shown either no effect or, much more troubling, they have shown significantly increased risk.

“The more we look at the effects of taking supplements, the more hazardous they appear when it comes to cancer risk,” Kristal said. For example, the Selenium and Vitamin E Cancer Prevention Trial (SELECT), the largest prostate cancer prevention study to date, was stopped early because it found neither selenium nor vitamin E supplements alone or combined reduced the risk of prostate cancer.

A SELECT follow-up study published last year in JAMA found that vitamin E actually increased the risk of prostate cancer among healthy men.

The Hutchinson Center oversaw statistical analysis for the study, which involved nearly 35,000 men in the U.S., Canada and Puerto Rico.

Myth 5 – We don’t know which prostate cancers detected by PSA (prostate-specific antigen) screening need to be treated and which ones can be left alone.

 “Actually, we have a very good sense of which cancers have a very low risk of progression and which ones are highly likely to spread if left untreated,” said biostatistician Ruth Etzioni, Ph.D., a member of the Hutchinson Center’s Public Health Sciences Division.

“For the majority of newly diagnosed cases of prostate cancer, by taking into account initial clinical and biopsy information we can get a very good idea of who should be treated and who is likely to benefit from deferring treatment.”

In addition to blood levels of PSA, indicators of aggressive disease include tumor volume (the number of biopsy samples that contain cancer) and Gleason score (predicting the aggressiveness of cancer by how the biopsy samples look under a microscope). Gleason scores range from 2-5 (low risk) and 6-7 (medium risk) to 8-10 (high risk).

“Men with a low PSA level, a biopsy Gleason score of 6 or lower and very few biopsy samples with cancer are generally considered to be very low risk,” Etzioni said.

Such newly diagnosed men increasingly are being offered active surveillance – a watchful waiting approach – rather than therapy for their disease, particularly if they are older or have a short life expectancy.

“The chance that these men will die of their disease if they are not treated is very low, around 3 percent,” she said. Similarly, such men who opt for treatment have a mortality rate of about 2 percent. “For the majority of newly diagnosed cases of prostate cancer, by taking into account initial clinical and biopsy information we can get a very good idea of who should be treated and who is likely to benefit from deferring treatment.”

Myth 6 – Only one in 50 men diagnosed with PSA screening benefits from treatment.

“This number, which was released as a preliminary result from the European Randomized Study of Prostate Cancer Screening, is simply incorrect,” Etzioni said. “It suggests a very unfavorable harm-benefit ratio for PSA screening. It implies that for every man whose life is saved by PSA screening, almost 50 are overdiagnosed and overtreated.”

“The correct ratio of men diagnosed with PSA testing who are overdiagnosed and overtreated versus men whose lives are saved by treatment long term is more likely to be 10 to one.”

“Overdiagnosis” is diagnosing a disease that will never cause symptoms or death in the patient’s lifetime. “Overtreatment” is treating a disease that will never progress to become symptomatic or life-threatening.

The 50-to-one ratio, which is based on short-term follow-up data, “grossly underestimates” the lives likely to be saved by screening over the long term and overestimates the number of men who are overdiagnosed, Etzioni said.  “The correct ratio of men diagnosed with PSA testing who are overdiagnosed and overtreated versus men whose lives are saved by treatment long term is more likely to be 10 to one.”

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Gilda's Club Seattle Logo

You’ve been treated for cancer — now what?

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Treatment Summaries and Surviorship Care Planning

What do you do when you’ve finished treatment?

How do you coordinate your ongoing care with your Primary Care doc?

How do you keep track of your medical records and get the right information to the right people about what you’ve been through?

Now we have some answers.

  • Debra Loacker, RN, will provide an overview of the valuable information provided in cancer treatment summary and the survivorship care plan. You will learn where to obtain a copy of your own treatment summary, and how your doctor can use it.
  • Patricia Read-Williams, MD, will share her perspective as a Primary Care Provider on the importance of these documents in the care provided to cancer survivors.

When:

6/21/12 , 6:45-8:30 p.m.

Where:

Gilda’s Club Seattle • 1400 Broadway, Seattle, WA 98122

Phone: 206.709.1400 • info@gildasclubseattle.org • www.gildasclubseattle.org


Gilda’s Club Seattle

Gilda’s Club is a non-profit group that provides meeting places where men, women and children living with cancer and their families and friends join with others to build emotional, social and educational support as a supplement to medical care.

The club’s services are free and include support and networking groups, lectures, workshops and social events in a nonresidential, homelike setting.

The club is named in honor of Gilda Susan Radner was an American comedienne and actress, best known for her years as a cast member of Saturday Night Live.

Radner, who died at 42 of ovarian cancer, helped raise the public’s awareness of the disease and the need for improved detection and treatment.

Lectures are held on Thursday evenings at Gilda’s Club, 1400 Broadway, Seattle.

Please RSVP to attend.

Refreshments served 6:45-7:00 pm

Lecture begins 7:00-8:30 pm

All lectures are open to the public. There is no cost to attend our lectures.

Please RSVP 24+ hours in advance to attend and pre-register for Noogieland childcare a minimum of 72 hours in advance.

When:

6/21/12 , 6:45-8:30 p.m.

Where:

Gilda’s Club Seattle • 1400 Broadway, Seattle, WA 98122

Phone: 206.709.1400 • info@gildasclubseattle.org • www.gildasclubseattle.org

 

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death-rates-graph-thumb

U.S. cancer deaths continue steady decline

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By Sharon Reynolds
NCI Cancer Bulletin Staff Writer 

According to the latest data on nationwide death rates from cancer, overall mortality from cancer declined from 1999 to 2008, maintaining a trend seen since the early 1990s.

Mortality fell for most cancer types, including the four most common types of cancer in the United States (lungcolorectalbreast, and prostate), although the rate of decline varied by cancer type and across racial and ethnic groups.

The complete Annual Report to the Nation on the Status of Cancer, 1975–2008 appeared March 28 in Cancer.

The declines in cancer death rates (mortality) averaged 1.7 percent per year for men and 1.3 percent per year for women from 1999 through 2008.

Among men, the overall rate of new cancer cases (incidence) fell by an average of 0.6 percent annually from 1999 to 2008.

Among women, incidence dropped by an average of 0.5 percent annually from 1999 to 2006 but held steady from 2006 to 2008.

Cancer incidence in children ages 0 to 14 rose from 1999 to 2008 (by 0.5 percent a year), continuing a trend seen in previous Annual Reports to the Nation.

However, advances in treatment contributed to a steady decline in mortality rates for children with cancer in the last 5 years (an average of 2.8 percent per year).

“Steady progress, as measured by declines in cancer death rates for many cancers, is good because we have an aging, growing population,” said Dr. Brenda K. Edwards, NCI’s senior advisor for surveillance.

“While the number of people diagnosed with cancer or who die of the disease may be increasing, the decline in cancer death rates for more than a decade is the best indicator of progress due to prevention, screening, diagnosis, and treatment,” she added.

NCI, the American Cancer Society, the Centers for Disease Control and Prevention (CDC), and the North American Association of Central Cancer Registries (NAACCR) collaborated on the report. Cancer incidence data came from NCI’s Surveillance, Epidemiology, and End Results (SEER) database and from the CDC, with analyses of pooled data by NAACCR. Mortality data came from the CDC’s National Center for Health Statistics.

Not All Good News

There were some notable exceptions to the overall decreases in incidence and mortality. From 1999 to 2008, death rates rose for pancreatic cancer in men and women, for liver cancer and melanoma in men, and for endometrial cancer in women.

The cervical cancer death rate, which had been falling for decades, showed no further decrease over the last 5 years.

And, although incidence rates fell overall for men and women from 1999 to 2008, the decline was not distributed evenly across racial and ethnic groups.

Cancer incidence rates did not decrease significantly among American Indian/Alaska Native men and women combined or among black, Asian and Pacific Islander, and American Indian/Alaska Native women.

Although incidence rates in black men did decline, this group still had the highest cancer incidence rate of any racial and ethnic group, 15 percent higher than that of white men and nearly double that of Asian and Pacific Islander men.

Major Modifiable Risk Factors

Each Annual Report to the Nation includes a special feature that focuses on a topic of importance to the cancer research community and the public.

This year’s report featured an analysis on the contribution of excess weight (overweight and obesity) and insufficient physical activity to the nation’s cancer burden.

More than 60 percent of the U.S. adult population is estimated to be overweight or obese, and a similar percentage of adults do not get the recommended amount of physical activity.

The rates of insufficient physical activity are even worse for children; for example, up to 90 percent of high school girls do not engage in recommended levels of physical activity.

Excess weight “is a major modifiable risk factor for cancer and other diseases—probably second only to tobacco use in terms of its impact on cancer incidence and mortality,” said Dr. Edwards. “The risk may be modest but it’s so pervasive that we felt this was the time to look at [cancer] incidence in this context.” Physical inactivity not only contributes to excess weight but is itself a risk factor for several cancer types.

The report was not designed to quantitatively link the trends in excess weight and lack of physical activity to the national trends for cancer, explained Dr. Rachel Ballard-Barbash, associate director of the Applied Research Program in NCI’s Division of Cancer Control and Population Sciences.

Many other studies have shown convincing links between excess weight and several cancer types, including endometrial, postmenopausal breast, colorectal, kidneyesophageal, and pancreatic cancer.

The point of the special feature, she noted, “is to highlight specific types of cancer that are related to [excess weight and lack of sufficient physical activity], show how these behaviors relate to these cancers in terms of their relative risks, and briefly describe some of the mechanisms by which they relate.”

The special feature also highlights national- and state-level prevention strategies in policy and environmental change that are intended to help people achieve recommended changes in their diets and physical activity levels.

As the nation’s weight has risen, so has the incidence of some, although not all, types of cancer related to excess weight and lack of sufficient physical activity. From 1999 to 2008, incidence rates of kidney cancer and of adenocarcinoma of the esophagus each rose about 3 percent per year for men and women, while incidence of pancreatic cancer rose 1.2 percent per year among men and women.

In addition, incidence rates of endometrial cancer rose significantly among black, Asian and Pacific Islander, and Hispanic women. Incidence of postmenopausal breast cancer stabilized from 2005 to 2008, after a period of decline.

“Although all of these cancers are influenced by multiple factors, the high prevalence of excess weight and insufficient physical activity likely contributed to these observed increases and to the lack of decline in breast cancer,” the authors wrote. “Continued progress in reducing cancer incidence and mortality rates will be difficult without success in promoting healthy weight and physical activity, particularly among youth.”

Excess weight and lack of physical activity also influence cancer survivorship, explained Dr. Ballard-Barbash, as both can negatively affect outcomes after a cancer diagnosis, further increasing the need for these risk factors to be addressed on a personal and societal level.

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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Microscopic view of prostate cancer

Annual prostate screening does not reduce risk of death – study

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Long-Term Trial Results Show No Mortality Benefit from Annual Prostate Cancer Screening

By Sharon Reynolds
NCI Cancer Bulletin Staff Writer 

Microscopic view of prostate cancer

Prostate Cancer

New data from the Prostate, Lung, Colorectal and Ovarian (PLCO) randomized screening trial show that, after 13 years of follow up, men who underwent annual prostate cancer screening with prostate-specific antigen (PSA) testing and digital rectal examination (DRE) had a 12 percent higher incidence of prostate cancer than men in the control group but the same rate of death from the disease.

No evidence of a mortality benefit was seen in subgroups defined by age, the presence of other illnesses, or pre-trial PSA testing. The results were published January 6 in the Journal of the National Cancer Institute.

When the PLCO researchers published their initial prostate screening results in 2009, which also revealed no prostate cancer mortality or overall mortality benefit from annual screening, critics countered that participants had not been followed long enough to detect a difference in prostate cancer mortality, if one existed.

“The natural history of prostate cancer is so long that 10 to 15 years of follow up is usually the window we look for” when determining the effectiveness of a screening intervention, explained first author Dr. Gerald Andriole, who is chief urologic surgeon at the Siteman Cancer Center at Barnes-Jewish Hospital in St. Louis and the Washington University School of Medicine.

Overdiagnosis?

Illustration showing the location of the prostateThe persistent increase in incidence of prostate cancer in the screening arm of the study may indicate that regular screening can lead to overdiagnosis—finding tumors that never would have caused symptoms or death.

“Even if there was just a tiny mortality benefit [from prostate cancer screening], overdiagnosis wouldn’t be so bad if we didn’t hurt people. But we do hurt people by finding a lot of trivial cancers that are most often overtreated,” explained Dr. Andriole.

The PLCO began in 1993 and enrolled men through mid-2001. More than 38,000 men were randomly assigned to annual screening for 6 years (including DRE for the first 4 years and PSA testing for all 6), and the same number of men were assigned to usual care.

Because prostate cancer screening is so common, more than half of the participants in the control arm underwent at least one prostate cancer screening test outside the trial.

This contamination made it more difficult to determine whether annual testing affected mortality. However, “the level of screening in the intervention arm was substantially greater than that in the control arm throughout the trial screening period,” wrote the authors.

“Every time we screened [in the intervention arm] we got a bump of excess cases,” said Dr. Philip Prorok, a lead NCI investigator on the study. “What we can’t say for sure is whether we would have seen more of an effect on mortality had there been absolutely no screening in the control arm.”

Studies differ

Another recent large trial, called the European Randomized Study of Screening for Prostate Cancer, did report a mortality benefit for prostate cancer screening.

Although that trial had less contamination in the control arm, it had other limitations that could bias the results, such as differences in the treatments given to men in the screening and control arms.

To help reconcile the differing results from these two trials—the largest trials to date of organized prostate cancer screening—an effort is under way by the NCI-funded Cancer Intervention and Surveillance Modeling Network (CISNET) to use mathematical modeling to tease out how differences in the trial designs and populations may have contributed to the disparate trial results, explained Dr. Paul Pinsky, an NCI investigator on the PLCO trial and consultant to the CISNET project.

“Even though the results seem to be disparate, because one [trial] found a [statistically] significant protective effect [on prostate cancer mortality] and one didn’t, it could be because of the ways the trials were designed and carried out,” he said. The CISNET study began last year and is examining data from the two trials.

Men and their health providers agree that a more definitive answer is needed as doctors and policy makers seek to understand which, if any, men may benefit from routine prostate cancer screening.

In October 2011, the United States Preventive Services Task Force released new draft guidelines for prostate cancer screening for public comment.

The new draft guidelines, which are based in part on PLCO findings, recommend against routine PSA testing in men who do not have prostate cancer symptoms.

Some doctors think the new recommendations go too far in not accounting for the informed decisions of individual men.

“If prostate cancer constitutes a continuum of disease and its overdiagnosis and overtreatment are mainly limited to low-grade disease, then instead of completely eliminating the potential benefits of screening along with the risks, why not consider managing low-risk patients differently?” asked Drs. Robert Volk from the University of Texas M. D. Anderson Cancer Center and Andrew Wolf from the University of Virginia School of Medicine in a commentary published last month in JAMA.

Practice appears to be moving in this direction, with a greater emphasis on active surveillance instead of immediate treatment for some men who have prostate cancer that is thought to be at low risk of progressing.

A big advance, explained Dr. Andriole, would be the ability to predict, even before a biopsy, whether a man with an elevated PSA level is likely to have an aggressive versus a nonaggressive cancer.

“There’s a lot of effort now being put into this, and not just for prostate cancer, but for a lot of other cancer types as well,” added Dr. Prorok. “If we diagnose someone with symptoms, or you find something on a screening test, can we eventually find a way to determine for which individuals the cancers are in fact aggressive and need more aggressive treatment, versus some that need less aggressive treatment or don’t need any treatment at all?”

Researchers are looking for biomarkers, including genes and proteins, that may give clues to a cancer’s aggressiveness. “If we could selectively change our criteria for biopsy such that only men who are at high risk for aggressive cancer get biopsied, we might be able to substantially shift the overall risk/benefit [ratio] of screening,” said Dr. Andriole.

To learn more:

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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Microscopic view of prostate cancer

Prostate cancer screening test should not be routine — panel

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By Scott Hensley, NPR News
This story comes from KHN partner NPR‘s Shots blog.

Microscopic view of prostate cancer

Prostate Cancer

The same group that caused a ruckus by recommending against mammograms for women in their 40s is about to tell men that a routine blood test for prostate cancer does most of them more harm than good.

The problem is that the test doesn’t do enough to save lives and subjects many men to additional tests and surgery. The side effects, including impotence and incontinence, outweigh the benefits for men in good heath, according to reports about the findings of the U.S. Preventive Services Task Force.

An independent group of medical experts, the USPSTF is in the business of grading the evidence for common tests and procedures. Under the auspices of the Agency for Healthcare Research and Quality, the group’s decisions increasingly serve as guidelines for what doctors do and what insurers and the government will pay for.

The USPSTF has been working on the PSA test for a while. In fact, the group had pretty much reached a decision in 2009 that the evidence for routine PSA testing should be graded “D” (which constitutes a recommendation against the service), according to an article coming inThe New York Times Magazine this Sunday and already posted online.

But the controversy such a recommendation is sure to cause led to a postponement of votes on it, Shannon Brownlee and Jeanne Lenzer report in the story.

Now it’s finally coming out, perhaps as early as today. “The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms,” pediatrician Virginia Moyer, chairwoman of the task force, told the Washington Post.

This year, about 241,000 cases of prostate cancer are expected to be diagnosed, according to estimates from the American Cancer Society. About 34,000 men will die from it. More than 20 million U.S. men have their PSA’s tested each year.

A federally funded study presented at a meeting of urologists this spring found that, overall, early surgical removal of the prostate was no better than waiting to see how the cancer would progress. And there were more side effects among men who had surgery.

In a Times editorial published in March, Dr. Richard Ablin, who discovered prostate specific antigen, lamented the overuse of the test. Yes, the test has its place, he wrote, to monitor men after treatment for prostate cancer and in screening men whose family histories put them at high risk.

“But these uses are limited,” Ablin concluded. “Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”

While the USPSTF’s decisions carry a lot of weight, a separate report out today shows the limits of its ability to change medical practice.

The Center for Public Integrity finds that 40 percent of Medicare spending on cancer screenings, or about $1.9 billion over five years, is wasted on tests, including PSA, for people older than the cutoff recommended by the USPSTF.

Opposition to a change in PSA recommendations is certain. Dr. Benjamin Davies, a urologist and cancer specialist at the University of Pittsburgh Medical Center, tweeted this morning:

the data for screening healthy patients <65 is strong, not debatable, and level 1. Hard to tweet all of the evidence

He called the USPSTF’s determination “soulless” and faulted some of the evidence the group, including this Swedish study, used to make its decision.


This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Doctor inspects mammogram. Photo by Bill Branson/NCI

Do the elderly get too many medical tests?

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By Sandra G. Boodman
This story was produced in collaboration with wapo

Every year like clockwork, Anna Peterson has a mammogram. Peterson, who will turn 80 next year, undergoes screening colonoscopies at three- or five-year intervals as recommended by her doctor, although she has never had cancerous polyps that would warrant such frequent testing. Her 83-year-old husband faithfully gets regular PSA tests to check for prostate cancer.

Doctor inspects mammogram. Photo by Bill Branson/NCI

“I just think it’s a good idea,” says Peterson, who considers the frequent tests essential to maintaining the couple’s mostly good health. The Fairfax County resident brushes aside concerns about the downside of their screenings, which exceed what many experts recommend. “Most older people do what their doctors tell them. People our age tend to be fairly unquestioning.”

But increasingly, questions are being raised about the overtesting of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their 70s, 80s and even 90s.

Critics say there is little evidence of benefit — and considerable risk — from common tests for colon, breast and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.

Too often these tests, some doctors and researchers say, trigger a cascade of expensive, anxiety-producing diagnostic procedures and invasive treatments for slow-growing diseases that may never cause problems, leaving patients worse off than if they had never been tested. In other cases, they say, treatment, rather than extending or improving life, actually reduces its quality in the final months.

“An ounce of prevention can be a ton of trouble,” observed geriatrician Robert Jayes, an associate professor of medicine at George Washington University School of Medicine. “Screening can label someone with a disease they were blissfully unaware of.”

Dartmouth physician Lisa M. Schwartz cites one such case: a healthy 78-year-old man who was left incontinent and impotent by radiation treatments for prostate cancer, a disease that typically grows so slowly that many men die with — but not of — it.

The U.S. Preventive Services Task Force, an independent panel of experts that evaluates the risks and benefits of screening tests, does not endorse PSA testing or routine colon screening after age 75.

The panel, whose recommendations will guidesome coverage decisions under the 2010 federal health law that expands access to screening, says there is no evidence for or against mammography after age 74 and recommends that most women stop getting Pap smears to detect cervical cancer after 65.

So far the task force’s guidelines appear to have had limited impact. Researchers in June reported in the journal Cancer that nearly half of primary-care doctors would advise a woman with terminal lung cancer to get a routine mammogram — even if she was 80 years old.

“More is not always better.”

A 2010 study in the Journal of the American Medical Association of more than 87,000 Medicare patients found that a “sizeable proportion” with advanced cancers continued to be screened for other malignancies.

Last May, Texas researchers reported in the Archives of Internal Medicine that 46 percent of 24,000 Medicare recipients with a previous normal test underwent a repeat colonoscopy in less than seven years and sometimes as few as three — compared with the 10 years recommended by the task force.

In nearly a quarter of cases, the repeat test was performed for no discernible reason. (Medicare is supposed to cover the screening test, which can cost about $2,000, only once a decade if no cancer or polyps have been found, but the program paid for all but 2 percent of the procedures reviewed by the Texas researchers.)

“More is not always better, and that becomes particularly true in older Americans where the dangers of medical care grow,”said Michael LeFevre, a professor of family medicine at the University of Missouri School of Medicine who is co-vice chair of the task force. “The older you get, the more likely it is that something else is going to make you sick or die.”

Colon polyps take 10 to 20 years to become cancerous, while the risks from colonoscopy, including intestinal perforation and heart attack, substantially increase after age 80.

Experts point to several reasons for the persistence of overscreening: habit; incentives that pay doctors and hospitals for individual procedures; quality assessments that rely on how many patients receive such tests; physicians’ fears of missing something important or of upsetting elderly patients — or their children — by suggesting that screening is unnecessary because a patient is too old or too sick to benefit.

In an era where discussions about end-of-life care are branded as “death panels” and curtailing unnecessary and expensive testing is regarded by some as rationing, experts say it is not surprising that overtesting endures. Many doctors say it’s easier to simply order a test than to discuss its risks and benefits with patients.

But some doctors believe it’s time to resist. “I think we need to say we can’t do everything for everybody, and it doesn’t make sense,” said Washington radiologist Mark Klein, who recently performed a virtual colonoscopy on a 99-year-old woman. Klein said he considered not doing the procedure but decided to go ahead because he didn’t learn how old the patient was until she was lying on the table, having undergone the prep.

“The most important thing on any referral is the date of birth,” said Klein, who said he tries to talk some older patients and their doctors out of pursuing tests and treatments he considers overly aggressive. “The game is not finding things, it’s can you improve mortality? And if you do find something, it’s very hard for a doctor to say, ‘Don’t do anything.’ ”

While cancer screenings are most common, other tests are overused among the elderly, Klein and others say. They include cholesterol testing, which can lead to the prescription of statin drugs that require regular blood tests to check liver function; typically, cholesterol plaque takes years to accumulate, and statins confer only a modest benefit in the elderly.

Likewise, CT scans of the heart or whole body can unearth suspicious findings, such as lung nodules, which trigger a painful and risky lung biopsy, but often turn out to be benign.

First Mammogram — At 100

Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and an author of the 2011 book “Overdiagnosed,” said that overtesting may reflect in part the use of screening tests as a barometer of quality. “Unfortunately that’s how we’ve measured quality: Did they get tests? And doctors are being judged and paid accordingly. So all these crazy things get done that don’t help people.”

“I makes absolutely no sense whatsoever to put a 100-year-old woman through a mammogram.”

Patients feel the pressure, too, Schwartz maintains. Screening has become a mantra, she said, trumpeted by advocacy groups. “The message is that you’re a good person if you get screened.”

The American Cancer Society doesn’t support an upper age limit for colonoscopy or mammography, although the group does not endorse PSA testing.

The society’s director of cancer screening, Robert C. Smith, said he thinks underscreening is a bigger problem than overtesting. “As long as a patient is in good health and a candidate for treatment, they are a candidate for screening indefinitely,” he said.

But Smith says there are limits. He recalls the loud cheer at a medical meeting after it was announced that a 100-year-old woman had just undergone her first mammogram.

“Several of us were just shaking our heads in disbelief because it makes absolutely no sense whatsoever to put a 100-year-old woman through a mammogram,” he said.

Telling someone that screening is no longer necessary can be dicey, as California family physician Pamela Davis discovered when she advised her robust 86-year-old mother to stop getting mammograms and routine colon tests.

Why do doctors continue to screen terminally ill patients? 

Her mother was incensed, Davis recounted in a recent Los Angeles Times article, accusing her of wanting to “save money to spend on the young people and just let us old folks die.” Davis was even more taken aback by the wave of hate mail she received after the article was published, some of it from doctors, accusing her of essentially the same thing.

“I have many, many patients who are like my mother,” said Davis, who directs the family medicine residency program at Northridge Hospital Medical Center. “It’s not about shortchanging them” but about putting screening in context. “Part of keeping people healthy and elderly is keeping them away from the hospital. Sometimes I’ll say, ‘Well, if we do this heart test and then find something then you’ll need a procedure.’ And they’ll say, ‘Oh, I don’t want heart surgery.’ And I’ll say, ‘Why do the test?'”

Baltimore internist Mary Newman said she largely hews to the task force recommendations, and she jokes to patients that “after 85, everything’s optional.” She considers Medicare’s new annual wellness exam, part of the health law, a good time to raise the subject of screening. Newman said she focuses on concerns that geriatrics specialists say matter most in old age: maintaining hearing and vision, stabilizing blood pressure and addressing problems related to dementia and mobility.

In some cases doctors counsel against testing — but patients demand it. Alan Pocinki, an internist who practices in the District, said he tried to persuade an 80-year-old patient, a survivor of several heart attacks, to stop PSA testing. The man’s son, a Boston oncologist, agreed with Pocinki, but the patient insisted.

The elevated reading led to a biopsy, which found cancer. Pocinki said the patient contracted a serious infection from the biopsy, his cancer is being monitored through “watchful waiting,” and he has repeatedly said he wishes he’d never had the test. “He always tells me, ‘I know you told me not to do it.’ ”

Screening The Dying

Why do doctors continue to screen terminally ill patients? Smith, of the American Cancer Society, thinks a primary reason is that they avoid difficult conversations that would involve telling patients they won’t live long enough to benefit.

“Just because it’s hard for doctors doesn’t mean it’s not a conversation worth having,” said Camelia Sima, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York and lead author of the 2010 JAMA study. Doctors may regard additional tests as relatively inconsequential, but Sima notes that they can cause additional pain and suffering in the form of biopsies, surgery and chemotherapy.

To Dartmouth’s Schwartz, the message for older patients, regardless of the state of their health, is essentially the same: “It’s not always in your best interest to do more or to keep looking. But we never seem to talk about the downside of testing.”

We want to hear from you: Contact Kaiser Health News


This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Robot

Tracking the rise of robotic surgery for prostate cancer

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By Carmen Phillips
NCI Cancer Bulletin Staff Writer 

In the 11 years since the Food and Drug Administration (FDA) approved the first robotic surgical system for conducting abdominal and pelvic surgeries, its use has skyrocketed.

The da Vinci Surgical System is now used to perform as many as 4 out of 5 radical prostatectomies in the United States. The robotic system is also increasingly being used to treat other cancers, including gynecologic and head and neck cancers.

According to da Vinci’s manufacturer, Intuitive Surgical, Inc., more than 1,000 of the robotic systems are in hospitals across the country.

Dr. Peter Pinto sits at the da Vinci robot console to perform minimally invasive prostate surgery. (Photo by Bill Branson, NIH)

Several recent studies suggest that the ascendance of robotic prostatectomy has had numerous consequences, including a mass migration of prostate cancer patients to hospitals with robotic systems and an overall increase in the number of prostatectomies performed each year.

The latter trend has raised some concern because it coincides with a period during which prostate cancer incidence has declined slightly.

How robotic prostatectomy proliferated so quickly, and what it means for patients and the health care system, is still a matter of study and debate. But the shift appears to have altered the surgical treatment of prostate cancer permanently, observed urologic surgeon Dr. Hugh Lavery of the Mount Sinai Medical Center in New York.

“I think that traditional open and laparoscopic prostatectomies have faded,” Dr. Lavery said. The available data indicate that patients and surgeons “are pushing for the robots,” he added, “and they’re getting them.”

A Compelling Technology, an Intrigued Audience

Type “robotic surgery prostate cancer” into an Internet search engine, and the results will typically include glowing testimonials from patients who were treated with robotic surgery and videos of da Vinci’s surgical instruments roaming about the peritoneal cavity suturing, cutting through tissue, removing fat. In these videos, the surgeon is on the other side of the room, head buried in a console, and hands at the robot’s controls, maneuvering the instruments with the aid of a camera that offers a crisp, 3-dimensional image of the surgical field. (Read more about how the robotic system works.)

Da Vini Surgical System. (Photo: Intuitive Surgical, Inc.)

Dr. Peter Pinto sits at the da Vinci robot console to perform minimally invasive prostate surgery. (Photo by Bill Branson, NIH) [Enlarge]

The Internet videos are just one component of the extensive marketing campaign behind da Vinci by individual hospitals and the system’s manufacturer.

A study of 400 hospital websites, published online in May, found that 37 percent of the sites featured robotic surgery on the homepage, 61 percent used stock text provided by the robot’s manufacturer, and nearly one in three sites had claims that robotic procedures led to improved cancer control.

“The tendency is to associate better technology with better care,” explained the study’s lead investigator, Dr. Marty Makary of the Johns Hopkins University School of Medicine.

Dr. Makary said he performs most operations, including complex pancreas surgery, laparoscopically because he believes the robot does not offer sufficient tactile feedback and takes more operative time. Traditional laparoscopy, however, is now rarely used for prostatectomies because the procedure is considered technically demanding, according to several researchers.

Patients often arrive for an office visit knowing that they want a prostatectomy performed with the robot.

One estimate put the number of laparoscopic prostatectomies each year in the United States at less than 1 percent of the total.

Patients often arrive for an office visit knowing that they want a prostatectomy performed with the robot, said Dr. William Lowrance, a urologic oncologist at the Huntsman Cancer Institute at the University of Utah. “It may be based on something they saw on the Internet or because of a friend or relative who had a good experience” with robotic surgery, he explained. Approximately 70 percent of the prostatectomies he performs are done with da Vinci.

Patient-to-patient referrals and the fact that the robotic procedure is minimally invasive have been two key drivers of the robot’s popularity, said Dr. Ash Tewari, director of the Prostate Cancer Institute at New York-Presbyterian Hospital/Weill Cornell Medical Center, who performs nearly 600 robotic prostatectomies a year.

Several studies have documented that there can be a fairly steep learning curve before surgeons achieve proficiency with the robot. But according to Dr. Warner K. Huh, a gynecologic oncologist and surgeon at the University of Alabama Birmingham Comprehensive Cancer Center, the robot makes it easier to perform many minimally invasive procedures.

“For many surgeons, they feel they can do a minimally invasive procedure more effectively and safely robotically, and I think that’s a big reason that it’s taken off,” Dr. Huh said.

The growth of robotic surgery is more than just a marketing phenomenon, agreed Dr. Tewari. “It has been supported with a lot of good science,” he continued. “We want to make this field better and beyond the hype of robotics.”

What the Science Says So Far

Based on studies to date, there seems to be agreement that robotic surgery is comparable to traditional laparoscopic surgery in terms of blood loss and is superior to open surgery in terms of blood loss and length of hospital stay. Recovery time may also be shorter following robotic surgery than open surgery.

Photo: Intuitive Surgical, Inc.

But for the big three outcomes—cancer control, urinary control, and sexual function—there is still no clear answer as to whether one approach is superior to another, Dr. Lowrance noted.

A large, randomized clinical trial comparing any of the approaches seems out of the realm of possibility at this point. At Weill Cornell, Dr. Tewari has approval to conduct a trial comparing robotic prostatectomy with open surgery. But the trial never got off the ground because there are not enough patients willing to be randomly assigned to surgery without the robot, he said.

A randomized trial may not even be that informative. “Many open surgeons have excellent outcomes, which may be hard to improve upon,” said Dr. Lavery. “I think that if you have an expert surgeon doing either procedure, you’re likely to have an excellent outcome.”

The Peak of the “Robotic Era”?

The remarkably swift proliferation of the da Vinci system in surgery suites across the United States appears to have had population-wide effects. In a study Dr. Lavery presented at the American Urological Association annual meeting in March, he showed that, from 1997 to 2004, the number of prostatectomies performed in the United States was fairly stable, around 60,000 per year.

From 2005 to 2008, however—what Dr. Lavery and his colleagues called the first true years of the “robotic era”—the number of prostatectomies and robotic procedures spiked. The number of prostatectomies rose to roughly 88,000 in 2008, and the number of robotic procedures jumped from approximately 9,000 in 2004 to 58,000 in 2008.

The number of prostatectomies rose to roughly 88,000 in 2008, and the number of robotic procedures jumped from approximately 9,000 in 2004 to 58,000 in 2008.

Two other recent analyses that looked at smaller geographic regions—New York, New Jersey, and Pennsylvania in one study and Wisconsin in the other—yielded similar results. But they also showed something else: Hospitals that acquired robots saw a significant increase in the number of radical prostatectomies they performed. At the same time, the number of procedures at hospitals that did not acquire a robot fell.

“The overall result has been a sudden, population-wide, technology-driven centralization of procedures that is without precedent,” wrote Dr. Karyn Stitzenberg of the University of North Carolina Division of Surgical Oncology and her colleagues, who conducted the study in New York, New Jersey, and Pennsylvania.

Whether the rise in the number of procedures has meant that patients who might have been strong candidates for a different treatment, including active surveillance, instead opted for surgery is “speculative,” Dr. Lowrance said.

“My own feeling is that radical prostatectomy rates in general have probably peaked and are on their way down,” he said, in part because of the increased emphasis on active surveillance in men with localized, low-risk prostate cancer.

Cost Implications Unclear

Another uncertain aspect centers on whether there has been any economic fallout from the increased use of this fairly expensive technology. Hospitals are not paid more for procedures using the robot, despite the fact that its use carries significant extra costs.

The robot itself runs anywhere from $1.2 million to $1.7 million (and many hospitals have several), a required annual maintenance contract is approximately $150,000, and about $2,000 in disposable equipment is required each time the robot is used. Studies have suggested that using the robot may add as much as $4,800 to the cost of each surgery.

Not Just for the Prostate: Robotic Surgery Makes Inroads in Gynecologic Cancers 

The meteoric growth of robotic surgery to treat prostate cancer over the past decade has been mirrored by a similar growth in the treatment of gynecologic cancers, such as cervical and endometrial cancer. (Robotic surgery for gynecologic cancers typically involve a hysterectomy, which may be accompanied by lymph node dissection.)

Minimally invasive surgery with traditional laparoscopy has been a common treatment for gynecologic cancers for two decades, said Dr. Warner Huh of the University of Alabama Birmingham Comprehensive Cancer Center. But many surgeons have switched to the robotic procedure.

In particular, the robotic procedure has given surgeons an important new option for treating obese women, Dr. Huh said. Traditional laparoscopy often cannot be performed on obese women, so before robotic surgery these patients typically had to have open surgery.

“An open surgery in these patients is extremely difficult to do,” he said. “Some of these women had horrific complications related to their incision.”

Obesity rates in Alabama are among the highest in the nation, so robotic surgery has provided an important new clinical option for many women in the state.

The average hospital stay following open surgery in obese patients was 4 to 5 days, he said. Now, with the robotic procedure, the average stay is often 24 hours or less. Complication rates have dropped from anywhere between 5 to 10 percent with open surgery to 1 to 2 percent with robotic surgery.

“It’s completely changed how we manage these diseases in morbidly obese women,” Dr. Huh said.

Shorter hospital stays and less need for blood transfusions may offset some of these costs, however. In fact, data from a study that Dr. Lowrance and his colleagues have in press indicate that, after adjusting for various factors and excluding the fixed cost of the robot, the cost of robotic prostatectomy and the medical care needed for the ensuing year is comparable to the cost of open surgery and the ensuing year of care in a group of Medicare patients.

Although no other surgical robots have been approved by the FDA, at least two companies are developing similar robotic systems that could, eventually, compete with da Vinci, Dr. Lavery noted, which could reduce costs further.

The dramatic centralization of robotic prostatectomy procedures could be a double-edged sword, Dr. Stitzenberg and her colleagues concluded. A multitude of studies have demonstrated that higher volume is linked to better outcomes, suggesting that having fewer centers performing prostatectomies could improve the overall quality of care. But centralization also raises the specter that access to care could be impaired, particularly in rural areas where market forces could limit the availability of surgeons who can perform the procedure.

The rapid growth of robotic prostatectomy is a proxy for the larger debate about the role of technology in medicine, Dr. Lowrance believes. For example, intensity-modulated radiation therapy and proton-beam therapy—which cost tens of thousands of dollars more than robotic surgery—are also gaining popularity as treatments for localized prostate cancer, even though neither has been shown to produce better outcomes than standard radiation therapy.

“The big question is: How do we balance the uptake of new technology and its cost with the additional [clinical] value it may provide?” he continued. “It’s hard to do those types of studies, but we have to continue to ask whether [a new technology] is always worthwhile.”

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

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Watchful waiting: When treatment can wait

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By Amy Sutton
Contributing Writer, Health Behavior News Service

In today’s fast-paced world, waiting — whether it’s at the doctor’s office, in line at the grocery store or for an Internet connection — is rarely considered a good thing.

But when it comes to certain medical conditions, delaying treatment while regularly monitoring the progress of disease — a strategy doctors refer to as “watchful waiting,” active surveillance or expectant management — may benefit some patients more than a rush to pharmaceutical or surgical options.

Patients want to know what they’re waiting for, says urologic oncologist E. David Crawford, MD, chairman of the Prostate Conditions Education Council and associate director of the University of Colorado Comprehensive Cancer Center.

The purpose is to watch in order to see whether a condition progresses. That way, patients and physicians know what kind of threat a disorder poses and they can make a better decision about how urgently treatment is needed. Some people might never need treatment, for instance with a slow-growing cancer. Other people can delay treatment for months or years.

Precancerous conditions may also be monitored with active surveillance. One example is ductal carcinoma in situ (DCIS), or abnormal changes in the ducts of the breast. DCIS may eventually progress into an invasive form of cancer, but most cases do not, so some physicians promote regular monitoring to avoid or delay the side effects of breast surgery, chemotherapy or radiation.

Syd Ball

Often, active surveillance is associated with cancer treatment, particularly cancers that may progress slowly. There’s evidence that active surveillance offers particular benefit for prostate cancer, follicular lymphoma, myeloma and chronic lymphocytic leukemia. Ovarian, endometrial and uterine cancer might also warrant active surveillance at some point during treatment.

When Syd Ball, a nuclear engineer from Tennessee, was diagnosed with prostate cancer, he chose active surveillance over immediate surgery or radiation therapy.

“When I was diagnosed, it did shake me up,” Ball said. “Once I talked to the doctor, and got the statistics about my chances, then I felt there was no question about what to do. Being an engineer, if you give me the risk statistics on it, I’ll tend to believe that the best course of action is based on what my chances are.”

Watchful waiting allowed Ball and his physician to get a better idea of his risk — whether his cancer was growing and how quickly. If the cancer grew quickly, then he knew he should start treatment. If not, he could wait. Ball was not looking forward to possible treatment side effects that could interfere with his quality of life and wanted to delay or avoid them if possible.

The concept of active surveillance isn’t limited to cancer treatment. It occurs across a variety of medical conditions. Pediatricians or family doctors may recommend watchful waiting for children with ear infections, since many resolve without treatment from antibiotics.

Physicians who treat chronic lower back pain might employ watchful waiting, monitoring patients regularly instead of immediately performing surgery to see if symptoms resolve on their own or whether stress management, strengthening exercises and other strategies effectively manage pain.

The physicians of couples trying to conceive a child sometimes suggest watchful waiting for a period of time before starting infertility tests and treatments, because most healthy partners conceive within a year without added intervention.

Women with endometriosis whose pain isn’t severe, who do not want to have children or who are approaching menopause may choose active surveillance, rather than deal with the side effects of surgery or hormonal treatments. And women with ovarian cysts who have mild or no symptoms might be advised to delay active treatments until symptoms become severe, because surgery carries the risk of infection and bowel and bladder damage.

What Happens While You Wait?

Though it’s a common misconception among patients, watchful waiting isn’t just ignoring the disease or disorder, hoping it will go away. “Active surveillance is a term that defines the fact that it’s not just wishful waiting or delayed treatment,” Crawford says. Physicians actively monitor the situation, and if needed, will jump in and begin active treatment, he says.

If you and your physician agree that active surveillance is a good idea, you’ll need regular checkups, and, depending on your condition, medical testing, such as blood tests, biopsies or imaging scans like MRIs or CAT scans, will be part of your regular monitoring. For conditions like chronic back pain, your doctor may recommend you make changes to your dietary habits, exercise regimen or lifestyle.

“We don’t want to let things fall through the cracks. With active surveillance, frequently we would be following patients as often as you would when they are on treatment, checking tumor markers and monitoring for new problems or symptoms they might have,” says Deborah Armstrong, MD, an associate professor of both oncology and of gynecology and obstetrics at the Johns Hopkins University School of Medicine. “It is different from someone who is at the end of their treatment options. It’s not ‘Should I try this?’ That’s a different concept. The concept of watchful waiting is that you do plan that you will be starting treatment but you’re going to delay it.”

The length of time active surveillance is recommended varies from person to person and is based on a variety of factors, including your age and general health, how severe your symptoms are, how quickly the disease progresses and the risks of delay. Physicians may monitor some patients, such as Syd Ball, for more than a decade without changing course. In other cases, active surveillance may take place for only for a few months ─ or in the case of ear infections, a few days ─ before having to move on to active treatment.

Nikkie Hartmann

Nikkie Hartmann, a public relations professional from Chicago, came to the process of active surveillance after more than a decade of battling papillary thyroid cancer. Hartmann, given a cancer diagnosis during her freshman year of college, underwent total thyroid removal surgery, as well as radioactive iodine treatments.

Though her blood tests still show elevated levels of cancer markers, the side effects of the radioactive iodine treatments and lymph node biopsies have proved uncomfortable and time consuming ─ and the active surveillance offers a break from the treatments while keeping an eye on her disease.

“The doctor didn’t use the phrase watchful waiting or active surveillance, but he said ‘watch and wait,’” Hartmann said. Though she’s still monitored with blood tests and will require additional diagnostic testing and possible treatments if she chooses to have children, within the last year Hartmann and her doctors have adopted an active surveillance stance that delays radioactive iodine treatments and lymph node biopsies for now.

Knowing the side effects that biopsies and radioactive iodine treatments can cause, Hartmann says that she’s at peace with the decision. “I was relieved when they told me that they recommended watching and waiting,” Hartmann said.

Asking About Watchful Waiting

Has your doctor recommended active surveillance? Here are some questions to ask as you consider your options:

  • What is the expected course of the disease?
  • If I wait, will the disease be harder to treat later?
  • What types of monitoring will I receive while under active surveillance? How often?
  • At what point would you recommend I move from active surveillance to treatment?=
  • Are there therapies or activities I can do to slow or halt the course of the disease?

Waiting Isn’t for Everyone

Active surveillance is not without risks, however. For some types of cancer, for example, there’s a risk that the cancer may be harder to control if treatment is delayed. Doctors do not recommend active surveillance for fast-growing, aggressive or late-stage treatable cancers.

For other conditions, such as chronic back pain or endometriosis, there’s the risk that painful symptoms may worsen during active surveillance, eroding quality of life and making it difficult to work.

Though active surveillance offers a delay in the physical symptoms caused by treatment, the emotional issues associated with this choice prove difficult for some patients to handle.

“A lot of difficulty comes from the historical context of how we’ve treated cancer,” said Jamie Studts, Ph.D., a psychologist who treats oncology patients and an associate professor at the University of Kentucky College of Medicine. “The idea is very foreign to people that you have cancer in your body and you’re not doing anything to get it out.”

It takes a significant discussion and a decision-making process shared between doctor and patient to understand the pros and cons and how that can be the best way to manage their care at a particular time, Studts says.

“The other problem is the perception of potential rationing of care,” Studts adds. Particularly if people don’t have resources, they could feel like they’re being mistreated or undertreated or not treated fairly if active surveillance is suggested.

But Dr. Armstrong offers reassurance that active surveillance doesn’t mean less face time with your physician: “I spend as much time with these patients as with patients I’m treating. At every point we say, ‘If we see this, we are going to do this. Let’s see what the disease looks like, then we’ll decide if we need to do treatment.’”

For some people, the anxiety of watchful waiting cannot be overcome, Armstrong said. Regardless of the statistics and the doctor’s recommendation, patients who could benefit from active surveillance sometimes insist on and receive treatment instead.

In addition, the influence of a family member or partner who doesn’t fully support active surveillance may erode a person’s initial decision to use it, Dr. Studts says.

Making the Decision

“Watchful waiting may allow people to have a good quality of life and have the tumor completely arrested. Take diabetes. You don’t cure diabetes, you manage it. With cancer, maybe we don’t have to get it all, maybe we can arrest it or stop it so it doesn’t spread or doesn’t affect major organ systems,” Studts said.

So how do you decide whether active surveillance is for you?

The starting point for making the decision is a trusting relationship with your physician, Armstrong says. “This is a situation where patients have to have trust in the physician, trust that the physician is doing the right thing. It’s easier to treat someone than it is to do watchful waiting. The main issue is that people need to be comfortable with the concept and their doctor is doing the right thing,” Armstrong says.

“Trust your gut if it doesn’t feel right and get a second opinion. You have to be your own advocate, and if you don’t feel comfortable, get more information,” Hartmann says.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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Doctors dispute benefits of early diagnosis

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Some Doctors Dispute Benefits Of Early Diagnosis

In a new book, “Overdiagnosed: Making People Sick in the Pursuit of Health,” Dartmouth researchers and physicians H. Gilbert Welch, Lisa Schwartz and Steven Woloshin argue that the medical establishment’s embrace of early diagnosis and treatment as the key to keeping people healthy actually does the opposite.

When doctors order screenings or tests for people who have no symptoms, then diagnose them with illnesses, that’s often overdiagnosis, these authors maintain.

Since many of the patients will never develop symptoms, much less get sick or die from these ailments, it leads to costly, unnecessary medical interventions and promotes a culture of sickness rather than health.

I spoke with Welch, a professor at Dartmouth’s Institute for Health Policy and Clinical Practice, about what health care might look like if more people adopted their approach.

Q. Prevention is at the heart of the health reform law. New health plans are now required to cover for free all measures recommended by the U.S. Preventive Services Task Force, a group of medical experts that evaluates the effectiveness of preventive services. Their recommendations include screenings for osteoporosis, breast and colon cancer. Is this the right way to prevent disease and save the system money?

A. I’m a supporter of health care reform. The country needs it. Do I have trouble with the emphasis on screening and annual check-ups? Sure. I don’t think people fully understand the ramifications of early detection and that’s why I’m raising questions about it in this book.

There’s the idea that this kind of prevention — identifying medical problems in healthy people — will save money and improve people’s health. It certainly won’t save money. The reason is that early detection identifies so many new patients. Any savings from avoiding the cost of a few patients with advanced disease quickly evaporate in the face of the new cost of intervening early on millions of additional patients.

Q. But will it improve health?

A. It may improve health for some, but it also harms the health of others. The reason is overdiagnosis: the detection of abnormalities in people who are never destined to develop symptoms — or die — from their condition. We don’t know who these patients are, so we treat everybody. That means we are treating some people who can’t benefit from treatment — because there’s nothing to fix. But they can be harmed. The truth is it’s hard to make a well person better, but it’s not hard to make them worse.

Q. Let’s talk about a specific example. You discuss breast cancer screening in your book.

A. Whether a woman should get a mammogram is a personal decision because it’s an incredibly close call. I believe mammography does help some women avoid a breast cancer death, but it’s rare. Our best guess is that you have to screen 2,500 50-year-old women for 10 years in order to help one avoid a breast cancer death.

To be fair to patients, I believe we need to be clear about what happens to the other 2,499. Nearly half will have an abnormal mammogram over that period and have to worry about cancer needlessly. Half of them will have to go on to have a biopsy. And somewhere between 5 and 15 will be overdiagnosed and receive surgery, radiation and/or chemotherapy for a cancer that was never going to bother them.

No one can say what is the “right” thing to do. It’s a personal choice.

Q. Many health care experts today say it’s important that everyone have a “medical home“: a primary care physician who’s their regular go-to person for routine and preventive care, and who coordinates their care with specialists and other health care providers when necessary. If you’re healthy, do you need a medical home?

More From This Series: Insuring Your Health

A. The patients that most need a medical home are those with multiple chronic conditions and who are on many medications.

For people who are well, the virtue of having a regular primary care physician is to establish a relationship and to establish the set of values that will guide your care. You can talk about where you are on the spectrum between aggressively looking for early signs of disease and waiting until you have symptoms to seek out treatment. The first may have the potential benefit of early diagnosis, but the potential harm of being diagnosed and treated for problems that will never become relevant.

Q. Wellness programs for employees used to be pretty limited, offering discounted gym memberships perhaps, but not much else. Now they’re moving into a new realm, with financial incentives for not smoking, and keeping blood pressure, cholesterol and BMI within recommended levels, for example. Is this a good move?

A. It depends. I have no problem with promoting general principles of good health: Eat right, exercise, don’t smoke. Encouraging someone to watch their weight, without being too rigorous or obsessive about it, is reasonable. And people ought to know their blood pressure and cholesterol levels, and get treated if they’re truly at high risk for problems.

But I do worry about two things. First, I believe the recommended thresholds for treating blood pressure, cholesterol and blood sugar have fallen too low. At those levels, the risk that treatment will cause an adverse event — like fainting, in the case of blood pressure medication — is too high. Wellness programs have to be careful not to become part of the problem.

Second, I get a little nervous about tying financial incentives to wellness goals. I don’t want to punish sick people — particularly since they tend to be the most economically vulnerable.

Q. What’s on your wellness wish list?

A. Let’s help people learn how to ask good questions of their doctors. How to understand risk and health statistics so they can make better decisions. Wellness programs could educate and inform people about how to be a critical consumer of health care. Wouldn’t that be something?

Q. You haven’t had a routine physical since you were a child, and it’s not recommended by the U.S. Preventive Services Task Force. Yet many health plans cover an annual physical and health care providers encourage it. Is it a waste of time?

A. If the annual physical is really what it says it is — a comprehensive physical exam to look for something that’s wrong with you — it’s a total waste of time. If it’s an effort to connect with a physician and talk about the way things are going, without looking for lumps and bumps, then having that annual visit may be a good thing.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Microscopic view of prostate cancer

Men with low-risk prostate cancer usually get treatment, despite side effects

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Microscopic view of prostate cancer

Prostate Cancer

Most men with low-risk prostate cancer get aggressive treatment, even though the therapies carry big risks, a new study finds.

Surgical removal of the prostate and radiation therapy can cause incontinence and impotence.

For men with prostate cancer that grows slowly, the researchers who analyzed data on more than 124,000 men with prostate cancer say the treatments may cause more harm than good.

The problem stems from the widely used PSA blood test, which can trigger a biopsy and cancer diagnosis.

Researchers found that about 1 in 7 men diagnosed with prostate cancer had a low PSA — below 4 and considered the upper limit of normal.

Most of these men turned out to have low-risk, slow-growing cancers, yet the great majority of them got aggressive treatment anyway. The findings appear in the Archives of Internal Medicine.

The researchers say that many American men with prostate cancer aren’t likely to benefit from this aggressive treatment. Instead, their cancers could be monitored and many would never pose a threat.

An accompanying editorial calls the nation’s experience with the PSA test a “cautionary tale.” More bluntly, the authors of the commentary write, “Unfortunately, some 2 decades into the PSA era, the promise of early detection has been tarnished.”

Widespread PSA testing and early identification of prostate cancer have led to an epidemic. Aggressive treatment of the many low-risk cancers found is the bigger problem because men who probably won’t get many benefits can suffer life-changing side effects.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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FDA approves Dendreon’s prostate cancer treatment

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Microscopic view of prostate cancer

Prostate cancer

The U.S. Food and Drug Administration (FDA) today approved Seattle biotech company Dendreon’s immunotherapy treatment for prostate cancer.

The treatment, Provenge (sipuleucel-T), is indicated for the treatment of asymptomatic or minimally symptomatic prostate cancer that has spread to other parts of the body and is resistant to standard hormone treatment, the FDA said.

The treatment is an immune therapy in which a patient’s immune cells are removed and exposed to a prostate cancer protein that is linked to an immune-stimulating compound.

The exposure stimulates the immune cells to attack the cancer cells more aggressively. After the treatment, the cells are infused back into the patient.

Provenge is administered intravenously in a three-dose schedule given at about two-week intervals.

In a study of 512 men with with metastatic disease that was not responding to hormone treatment, patients who underwent Provenge treatment, showed an increase in overall survival of 4.1 months, the FDA said.

The a median survival for patients receiving Provenge treatments of 25.8 months, as compared to 21.7 months for those who did not receive the treatment.

Almost all of the patients who received Provenge had some type of adverse reaction, the FDA noted.

Common adverse reactions reported included chills, fatigue, fever, back pain, nausea, joint ache and headache.The majority of adverse reactions were mild or moderate in severity.

Serious adverse reactions, reported in approximately one quarter of the patients receiving Provenge, included some acute infusion reactions and stroke.

Prostate cancer is the second most common type of cancer among men in the United States, behind skin cancer, and usually occurs in older men.

In 2009, an estimated 192,000 new cases of prostate cancer were diagnosed and about 27,000 men died from the disease, according to the National Cancer Institute.

To learn more:

  • Read Sally James’ coverage of Dendreon’s Provenge in Seattle Business magazine here and here.
  • Watch two lectures on UWTV: “Your Immune System vs. Cancer” by Dr. Oliver Press and “Keeping Tumors at Bay With Vaccines” by Dr. Nora Disis from the University of Washington’s Science for Life series available online here.
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Health stories in the news

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Dendreon’s cancer vaccine

Microscopic view of prostate cancer

Seattle Times science reporter Sandi Doughton profiles Dendreon’s prostate-cancer vaccine.

The U.S. Food and Drug Administration is expected to announce its decision whether to approve the Seattle company’s vaccine, Provenge, this week.

“If the U.S. Food and Drug Administration (FDA) gives the expected green light, it will mark Seattle’s biggest biotech breakthrough in nearly a decade,” Doughton writes.

“Dendreon’s case rests largely on a study of more than 500 men with an advanced form of prostate cancer that spread to other parts of their bodies. Of the men who got Provenge, nearly a third were still alive in three years, compared with less than a quarter of those who got placebos. The vaccine boosted median survival time by 4 months, from 22 months in the placebo group to 26 months in the Provenge group.”

A course of treatment is expected to cost between $50,000 and $75,000, potentially earning the company over $1 billion.

If the company isn’t  “swallowed up by a pharmaceutical firm — a big “if” — its success would boost the region’s stature and draw as a biotech hub,” Doughton writes.

PHOTO: photomicrograph of prostate cancer

To learn more:

  • Watch two lectures on UWTV: “Your Immune System vs. Cancer” by Dr. Oliver Press and “Keeping Tumors at Bay With Vaccines” by Dr. Nora Disis from the University of Washington’s Science for Life series available online here.

Did H1N1 “swine” flu vaccine may have side effects?

H1N1 virus growing in tissueThe Washington Post’s Rob Stein reports that health officials are looking into reports that suggest but do not prove that the H1N1 vaccine may have had some significant complications.

Stein writes:

“The latest analysis of data has detected what could be a somewhat elevated rate of Guillain-Barré syndrome, which can cause paralysis and death; Bell’s palsy, a temporary facial paralysis; and thrombocytopenia, which is a low level of blood platelets, officials reported Friday.”

Stein notes that officials say “the concerns will probably turn out to be a false alarm.”

Officials stressed that it is far too early to know whether the vaccine was increasing the risk of those conditions or whether there is some other explanation, such as doctors identifying more cases because of the intensive effort to pinpoint any safety problems with the vaccine.

To learn more:

Scam artists taking advantage of confusion over new health reform law

State and federal authorities are warning consumers to be wary of scam artists who are taking advantage of the confusion over the provisions of the new health reform law to con people out of their money, writes New York Times reporter Robbie Brown in today’s paper.

“The authorities say the elderly and the poor are especially vulnerable to the bogus plans, which have names like Obamacare and Obama Health Plan and promise affordable compliance with the new law. The fraudsters often impersonate insurance agents and government workers.”

“If something sounds too good to be true, it probably is,” advises one state official.

To learn more:

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