MEDICAL NOTICE FOR MEN......

Discussion in 'VMBB Fire For Effect' started by rooter, Mar 19, 2009.

  1. rooter

    rooter *VMBB Senior Chief Of Staff*

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    March 19, 2009
    Prostate Test Found to Save Few Lives
    By GINA KOLATA
    The PSA blood test, used to screen for prostate cancer, saves few lives and leads to risky and unnecessary treatments for large numbers of men, two large studies have found.

    The findings, the first based on rigorous, randomized studies, confirm some longstanding concerns about the wisdom of widespread prostate cancer screening. Although the studies are continuing, results so far are considered significant and the most definitive to date.

    The PSA test, which measures a protein released by prostate cells, does what it is supposed to do — indicates a cancer might be present, leading to biopsies to determine if there is a tumor. But it has been difficult to know whether finding prostate cancer early saves lives. Most of the cancers tend to grow very slowly and are never a threat and, with the faster-growing ones, even early diagnosis might be too late.

    The studies — one in Europe and the other in the United States — are “some of the most important studies in the history of men’s health,” said Dr. Otis Brawley, the chief medical officer of the American Cancer Society.

    In the European study, 48 men were told they had prostate cancer and needlessly treated for it for every man whose death was prevented within a decade after having had a PSA test.

    Dr. Peter B. Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center, says one way to think of the data is to suppose he has a PSA test today. It leads to a biopsy that reveals he has prostate cancer, and he is treated for it. There is a one in 50 chance that, in 2019 or later, he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.

    Prostate cancer treatment can result in impotence and incontinence when surgery is used to destroy the prostate, and, at times, painful defecation or chronic diarrhea when the treatment is radiation.

    As soon as the PSA test was introduced in 1987, it became a routine part of preventive health care for many men age 40 and older. Experts debated its value, but their views were largely based on less compelling data that often involved statistical modeling and inferences. Now, with the new data, cancer experts said men should carefully consider the possible risks and benefits of treatment before deciding to be screened. Some may decide not to be screened at all.

    For years, the cancer society has urged men to be informed before deciding to have a PSA test. “Now we actually have something to inform them with,” Dr. Brawley said. “We’ve got numbers.”

    The publication of data from the two new studies should change the discussion, said Dr. David F. Ransohoff, an internist and cancer epidemiologist at the University of North Carolina. “This is not relying on modeling anymore,” he said. “This is not some abstract, pointy-headed exercise. This is the real world, and this is real data.”

    Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who studies cancer screening, also welcomed the new data. “We’ve been waiting years for this,” he said. “It’s a shame we didn’t have it 20 years ago.”

    Both reports were published online Wednesday by The New England Journal of Medicine. One involved 182,000 men in seven European countries; the other, by the National Cancer Institute, involved nearly 77,000 men at 10 medical centers in the United States.

    In both, participants were randomly assigned to be screened — or not — with the PSA test, whose initials stand for prostate-specific antigen. In each study, the two groups were followed for more than a decade while researchers counted deaths from prostate cancer, asking whether screening made a difference.

    The European data involved a consortium of studies with different designs. Taken together, the studies found that screening was associated with a 20 percent relative reduction in the prostate cancer death rate. But the number of lives saved was small — seven fewer prostate cancer deaths for every 10,000 men screened and followed for nine years.

    The American study, led by Dr. Gerald L. Andriole of Washington University, had a single design. It found no reduction in deaths from prostate cancer after most of the men had been followed for 10 years. Every man has been followed for at least seven years, said Dr. Barnett Kramer, a study co-author at the National Institutes of Health. By seven years, the death rate was 13 percent lower for the unscreened group.

    The European study saw no benefit of screening in the first seven years of follow-up.

    Screening is not only an issue in prostate cancer. If the European study is correct, mammography has about the same benefit as the PSA test, said Dr. Michael B. Barry, a prostate cancer researcher at Massachusetts General Hospital who wrote an editorial accompanying the papers. But prostate cancers often are less dangerous than breast cancers, so screening and subsequent therapy can result in more harm. With mammography, about 10 women receive a diagnosis and needless treatment for breast cancer to prevent one death. With both cancers, researchers say they badly need a way to distinguish tumors that would be deadly without treatment from those that would not.

    When the American and European studies began, in the early 1990s, PSA testing was well under way in the United States, and many expected that the screening test would make the prostate cancer death rate plummet by 50 percent or more. Dr. Brawley was at the cancer institute then, though not directly involved with its prostate cancer screening study. But he saw the reactions.

    Some urologists said the study was unethical, because some people would not be screened, and demanded it be shut down, he said. One group of black urologists encouraged black men not to participate because blacks have a greater risk of prostate cancer and it seemed obvious they should be screened.

    Some thought that they would see fewer cancer deaths among screened men as quickly as five years. But it became clear that screening would not have a large, immediate effect — if it did, the studies would have been stopped and victory declared. Cancer researchers began turning to less rigorous sources of data, with some arguing that screening was preventing cancer deaths and others arguing it was not.

    In the United States, many men and their doctors have made up their minds — most men over age 50 have already been screened, and each year more than 180,000 receive a diagnosis of prostate cancer. In Europe, said Dr. Fritz H. Schröder of Erasmus University, the lead author of the European study, most men are not screened. “The mentality of Europeans is different,” he said, and screening is not so highly promoted.

    Both studies will continue to follow the men. It remains possible that the United States study will eventually find that screening can reduce the prostate cancer death rate, researchers say, or that both studies will conclude that there is no real reduction.

    “I certainly think there’s information here that’s food for thought,” Dr. Brawley said.

    The benefits of prostate cancer screening, he said, are “modest at best and with a greater downside than any other cancer we screen for.”
  2. Marlin

    Marlin *TFF Admin Staff Chief Counselor*

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    Very good article and a MUST READ for all men.

    Thanks for posting it, Chief.
  3. rooter

    rooter *VMBB Senior Chief Of Staff*

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    By TARA PARKER-POPE
    Published: March 23, 2009
    Last week, two major studies from the United States and Europe found that P.S.A. testing — the annual blood test used to screen men for prostate cancer — saves few if any lives, while exposing patients to aggressive and unnecessary treatments that can leave them impotent and incontinent.

    Prostate Test Found to Save Few Lives (March 19, 2009)
    Health Guide: Prostate CancerThe news was unsettling and confusing to many middle-age men, particularly those who already have diagnoses of prostate cancer as a result of P.S.A. testing. Doctors say some men are reconsidering surgery or radiation treatment they have planned. Others, convinced that their lives were saved by P.S.A. screening, wonder how anyone could question the value of early detection of prostate cancer.

    In the face of all this confusion, what’s a man to think? Here are answers to some frequently asked questions.

    WHAT DID THE STUDIES REALLY SHOW?

    The bottom line of both studies is that P.S.A. screening does find more prostate cancers — but finding those cancers early doesn’t do much to reduce the risk of dying from the disease.

    The American study showed no statistical difference in prostate cancer death rates between a group of men who had the screening and a control group who did not. The European researchers found that P.S.A. screening does reduce the risk of dying from prostate cancer by about 20 percent.

    But in terms of individual risk, even that is not a huge benefit. It means that a man who isn’t screened has about a 3 percent average risk of dying from prostate cancer. If that man undergoes annual P.S.A. screenings, his risk drops to about 2.4 percent.

    And there is an important tradeoff. P.S.A. testing increases a man’s risk of being treated for a cancer that would never have harmed him in the first place. The European study found that for every man who was helped by P.S.A. screening, at least 48 received unnecessary treatment that increased risk for impotency and incontinence. Dr. Otis Brawley, chief medical officer of the American Cancer Society, summed up the European data this way: “The test is about 50 times more likely to ruin your life than it is to save your life.”

    SO DO THESE STUDIES SETTLE THE DEBATE ABOUT THE VALUE OF P.S.A. SCREENING?

    Not necessarily. Both have problems that make it difficult to interpret the data. The American study found no benefit in P.S.A. screening over a period of 7 to 10 years. But so far, only about 170 men out of 77,000 studied have died of prostate cancer. Prostate cancer is slow-growing, so it’s possible that in the next few years, meaningful differences in mortality rates between the two groups will emerge.

    A larger concern is what statisticians call “contamination” in the unscreened control group. Because it would have been unethical to tell men in the control group that they could not be screened, many either sought the test or were offered it by their doctors.

    Investigators initially estimated that 20 percent of the control group would fit in this category, but the numbers ended up being far higher —38 to 52 percent. As a result, the study doesn’t really compare the risks and benefits of screening and no screening. It compares aggressive screening and some screening.

    The fact that so many men in the nonscreening group “dropped in” to the screening category “is a serious concern,” said Dr. Eric A. Klein, chairman of the Glickman Urological and Kidney Institute at the Cleveland Clinic, who added:

    “The argument for screening today is no different than before. These studies do not settle the issue definitively one way or another.”

    The American investigators said that while contamination did complicate the interpretation of the data, they were still confident in the finding that there is little or no benefit to P.S.A. screening. “Our statisticians still felt the power of the study to detect a medically meaningful benefit was retained,” said Dr. Barnett S. Kramer, co-author of the study and associate director for disease prevention at the National Institutes of Health.

    The European research has its own set of problems. Although the finding that P.S.A. screening reduces cancer deaths by 20 percent is statistically significant, experts say it’s on the borderline, and a few more years of data could weaken the result. Finally, parts of the study were not “blinded,” meaning that biases could have crept into the interpretation of the data.

    DOES THIS MEAN MEN SHOULD NOT RECEIVE PROSTATE CANCER SCREENING?

    No. Before the studies were released, most major medical groups said P.S.A. testing was a personal decision that a man should discuss with his doctor. The two new studies are unlikely to change that advice, experts say; instead, they give men and their doctors more information with which to make the decision.

    For older men, the screening decision should be easier. P.S.A. screening is already not advised for those 75 and older. And the American research confirms that P.S.A. testing is not helpful for men with 10 years or less of life expectancy. In the European study, among men 70 or older, there were more deaths in the P.S.A. screening group, although the trend could be caused by chance.

    The advice is murkier for middle-age men. In the European study, 50- to 54-year-olds didn’t benefit from screening. But men ages 55 to 69 were 20 percent less likely to die from prostate cancer than those who weren’t screened. (Still, men in that age group must decide whether the high risks of unnecessary treatment are worth it.)

    A co-author of the American study, Dr. Gerald L. Andriole Jr., a surgeon at Washington University, says that while every man shouldn’t get a P.S.A. test, he also doesn’t recommend “wholesale stoppage.”

    Middle-age men or older men with a life expectancy of 10 years or more “need to be informed about the potential pros and harms of screening,” he said, adding:

    “If they want to embark on it, that’s fine. I’m still open to accepting that we learn a lot about a man’s prostate and about the probability of him getting or having prostate cancer by measuring P.S.A..”

    Dr. Brawley of the American Cancer Society agreed that individual men might come to different decisions after talking with their doctors.

    “There is a guy out there whose personal experience is such that he’s very frightened of prostate cancer, so maybe he should be screened,” Dr. Brawley said. “Then there are the guys out there who see that 48-to-1 ratio and say, ‘I don’t want to be screened.’ It’s an individual personal decision. You can’t criticize guys who want it versus guys who don’t want it.”

    WHAT IF I’M IN A HIGH-RISK GROUP, LIKE AFRICAN-AMERICANS OR MEN WITH A STRONG FAMILY HISTORY OF PROSTATE CANCER?

    The studies don’t include enough data to make definitive recommendations for either group. Dr. Andriole said men at higher risk who receive a diagnosis of prostate cancer as a result of screening should be reassured by the data that they don’t have to rush into aggressive treatment. Bear in mind that prostate cancer is usually not fatal.

    “It’s a terrific tool for helping a man assess his risk for having prostate cancer,” Dr. Andriole said. “Does it necessarily mean it’s a killer cancer? The answer is no. We should be more judicious. We should modify the way we’re reacting to the abnormal screens in light of what we now know.”

    SHOULD MEN STILL UNDERGO A DIGITAL RECTAL EXAM?

    Neither study offers insights into the value of this traditional test, in which a doctor feels the prostate for hardness or bumps that may signal risk for prostate cancer. The American study looked at a combination of P.S.A. and rectal screening and found no benefit. The European study provides no specific evidence about the exam.

    DO THE NEW STUDIES MEAN I SHOULD CANCEL SURGERY OR RADIATION?

    The study data speak only to the risks and benefits of P.S.A. screening in healthy men without symptoms. If your cancer was detected as a result of symptoms, nothing in the study should change the medical advice you have already received. Early signs of prostate cancer may include difficulty urinating or blood in the semen or urine.

    And even if the cancer was detected as a result of P.S.A. screening, the data have limited applicability to one’s personal situation. The two studies look at the average risk and benefits across a large group of men, but they don’t take into account the specific factors that influence a man’s individual risk.

    What is your Gleason score — a measure of the cancer’s aggressiveness? What is your family history? How much cancer was in each biopsy? Did you do a repeat biopsy to confirm your case? The answers to those questions will give a man better information about how to proceed. At the same time, even those answers can’t reliably predict a man’s risk for having a serious cancer.

    “The regrettable truth of the matter is we don’t have really good tools to determine from the sea of cancers we discover, which ones are the bad ones,” Dr. Andriole said. “A man who has surgery scheduled tomorrow who is now not sure what to do, we don’t have a whole lot to tell him right now.”
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