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Old 09-17-2009, 03:14 PM   #1
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Smile The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

What an awesome experience we had last weekend - 600 of us prostate cancer survivors at the LAX Marriott for sessions all day Saturday and all Sunday morning!

This was my fifth national conference, and I'm still surprised at how much I learn at each one. Of course, the conference that made the biggest difference for me was in my first year as a survivor when I was still learning the ropes back in 1999 at Long Beach, CA - soaked up information like a sponge at that one! I also attended the next conference in the series, at Burbank, CA in 2003, and in Washington, DC in 2005 and Reston, Virginia (near Dulles International Airport, just outside DC) in 2006. I missed the next two, but I picked up DVDs for them this weekend. These conferences are first and foremost directed toward patients, but I believe I heard that physicians who were attending were eligible for Continuing Medical Education credit. That has been true for at least a couple of the earlier conferences.

All the speakers know their stuff, and several are clearly geniuses in this field - physicians with unique and rare talent and experience. The "faculty" included speakers as well as other doctors who participated on panels. The major speakers included were as follows, with the notes based on my knowledge of their work or the bios provided in the program (alphabetical order):

- Dr. Duke Bahn, MD, practicing in Ventura, CA, internationally known for his pioneering work and outstanding expertise in color Doppler ultrasound and cryosurgery; his talk was entitled "Transrectal Ultrasound for Cancer Detection, Staging, Biopsy and Future Development. I missed his presentation as I wanted to hear the followup Meet the Speaker session with Dr. Heber, and I had heard Dr. Bahn present several times before. I'm looking forward to seeing his presentation on DVD.

- Dr. John Blasko, MD, practicing in Seattle, also with an international reputation, performed the first transperineal template and ultrasound guided prostate radiation seed implant in the US, in Seattle. Since then he has performed more than 6,000 implants, and he is at the forefront in teaching and researching that technology, which continues to evolve and has an excellent track record.

- Mr. William Cavanagh, now Director of Research and Education for the Prostate Cancer Research Institute and editor of PCRI Insights, has been active in prostate cancer research since 1991. He spoke to us on immunotherapy and related developments.

- Dr. David Heber, MD, PhD, internationally known for his work on nutrition, is the Director of the UCLA Center for Human Nutrition, among other posts. A prolific author of research papers, he is probably best known to most of us for his book "What Color Is Your Diet?", which highlights the benefits of a colorful fruit and vegetable-based diet. One of his contributions to prostate cancer patients was his work on the UCLA study that demonstrated a striking impact on PSA doubling time from consumption of one glass of pomegranate juice per day , the subject of a thread I launched yesterday.

- Dr. Mark Moyad, MD, MPH, very well known among the Us Too community for his regular contributions to the monthly newsletter, as well as to others of us for his books, especially related to nutrition and prostate cancer. He is also an exceptionally fine speaker, and delivered a packed-with-humor-as-well-as-substance keynote speech following our Saturday evening banquet. He also did a superb job as moderator for all the speeches, both introducing the speakers and following up with excellent questions of his own. He is "a bit" (meaning hopelessly fanatic) biased toward the U. of Michigan Football Team, and could not help expressing his glee over Big Blue's exciting victory over Notre Dame.

- Dr. John Mulhall, MD, Director of the Male Sexual & Reproductive Medicine Program, and Director of the Sexual Medicine Research Laboratory at prestigious Memorial Sloan Kettering Cancer Center in New York City, gave us a fine talk on sexual rehabilitation following various treatments, and we also got a free copy of one of his books in our program goody bag.

- Dr. Charles "Snuffy" Myers, MD, former NIH researcher, former Director of the University of Virginia Cancer Center, author of two great books and a highly informative newsletter - Prostate Forum - for patients, a ten year survivor of a challenging case of metastatic prostate cancer himself (going the extra mile to learn what we are experiencing , a speaker in high demand, a medical oncologist with a large, international practice specializing in prostate cancer near Charlottesville, VA, and a wonderful human being, spoke to us on "Second Line Hormone Blockade" this year, one of the topics for which he has an international reputation.

- Mark Scholz, MD, a co-founder of the Prostate Cancer Research Institute with Dr. Stephen Strum, a lead researcher in triple hormonal and intermittent blockade with prestigious journal papers to his credit, a contributor to free communication with patients for years, and a medical oncologist with a highly regarded practice in Marina del Rey (LA area) specializing in prostate cancer with his partner Dr. Richard Lam - two of the top experts in hormonal therapy as well as in other oncology approaches, was the driving force behind this year's conference and delivered opening remarks and the "Review of Conference Highlights" on Sunday morning.

- Dr. Evan Yu, MD, a noted oncologist from Seattle and Assistant Professor of Medicine at the U. of Washington and Assistant Member of the Fred Hutchinson Cancer Research Center, with a research focus on bone health for men with prostae cancer. He gave a fine talk on "Reducing Side Effects of Testosterone Deprivation," a topic of great interest to me.

Here are just a few highlights from the talks; I'm hoping to provide more detail and a more specific focus in future threads, as well as hoping to cover more topics from the conference:

- From Dr. Heber (nutrition): Next year we can expect results from a multi-institution, randomized, double-blind, placebo controlled clinical trial on pomegranate juice (extract too?), following up the breakthrough 2006 research published by his expert UCLA team on greatly extending PSA doubling times of recurring patients due to consumption of pomegranate juice. This trial is vitally important as it will bolster the credibility of the earlier study with with awesome results. Although the earlier study was performed by a team with a stellar reputation, and although the design and execution of the trial have won plaudits, the study was funded by the POM Wonderful company, and such sponsorship by a commercial company with an interest in the results always introduces a grain of doubt about the objectivity of the results. I need to add this to the thread launched yesterday on pomegranate juice.

He also emphasized that an extension of that earlier study had demonstrated even greater benefits for men who had stuck with the program, as described in yesterday's new thread on pomegranate.

Dr. Bahn: He uses ten criteria for judging whether Active Surveillance (AS) would be a good approach for low-risk prostate cancer patients. Several of these indicators depend on talented use of color Doppler ultrasound (CDU). As far as I know, none of the major AS programs use CDU, and they still achieve impressive results. Nonetheless, I've thought for some time that their results would be even better if they screened AS candidates with CDU performed by a talented doctor, and, if I were seriously considering AS, I would sure want such a CDU exam for myself.

Dr. Mulhall (sexual dysfunction and rehabilitation for prostate cancer patients): A couple of his main points were that only a small proportion of doctors communicate with their patients about this - WE need to be proactive with our doctors, and that patients need to attend to sexual rehabilitation early!!! That's because success falls off sharply if treatment is delayed, especially beyond six months, as I recall it. Another key point was that a high proportion of patients experience these problems, often minimized by doctors who do not realize that; while we will willingly record such problems on anonymous research questionairres, many of us shy away from telling our doctors that they have left us with sexual and urinary problems. He also emphasized something that surprised me: that no study yet shows that robotic surger is better than open surgery for such side effects. (It is clear that hospital time and general recovery from the surgery are more rapid.)

Dr. Blasko (seeds): Wow! While other treatments, including other radiation treatments have generated a lot of hype lately, the track-record leader for both cancer effectiveness and minimizing side effects is seeds, or seeds combined with external beam of some kind. This deserves its own thread, but in essence he used research from a panel of 18 expert doctors who treat prostate cancer who reviewed published studies, for various risk levels. I was particularly surprised that seeds did better, in general, for low-risk prostate cancer patients; seeds held their own for effectiveness, and the were clearly superior for urinary, rectal and incontinence side effects, except for men with a pre-existing tendency toward urinary blockage and irritability, cases where surgery held a clear advantage compared just to seeds. In sum, regarding the head-to-head comparison with surgery, modern radiation, particularly at centers of excellence, does better than surgery at centers of excellence, for both effectiveness and side effects (except as noted just above). It is not surprising that radiation, including seeds, does better for intermediate and high-risk cases; that has been well-established for some time. (This doesn't mean that you are preordained to inferior results with surgery or other therapies, especially if delivered by experts, it just means that the odds are not quite as strong and the track record is not as convincing. For low risk men, at least for the effectiveness side of the coin, modern therapies that are well delivered have an extremely high likelihood of success in eliminating the cancer.)

Dr. Yu (countermeasures for side effects of hormonal blockade) A "new" bone density drug, Toremifene, which has been available in Europe for some years, is now under FDA review, maby be available soon. Among other things, it blocks breast enlargement and hot flashes, as I heard it.

Dr. Myers (second line hormonal blockade therapy): Many doctors pronounce their patients "hormone refractory" - meaning no longer capable of responding to hormonal therapy, when they actually will respond if the therapy is well-delivered. His wide-ranging talk also featured Leukine, and combinations of Leukine with other drugs including chemo drugs; he said his practice was using it a lot and seeing impressive results, a sentiment echoed by Dr. Scholz for his own practice with Dr. Lam. Dr. Myers also said that Provenge was now undergoing FDA review and that approval was expected soon. (In fact Dr. Celestia Higano, a scheduled speaker, was unable to attend because she was testifying before the FDA in support of Provenge.) Dr. Myers noted that Provenge had virtually no side effects, but that it would most likely be expensive. (Earlier estimates were that the series of three recommended treatments would cost between $40,000 and $60,000.) I also learned at the conference that Dendreon, the developer of Provenge, was already constructing manufacturing/processing facilities at two sites, including one in Georgia.

Mr. Cavanagh (immunotherapy): There's a balance between the immune response and the protective immune response that prevents the body's immune system from attacking its own tissues. Cancer often hijacks the latter system to insulate itself from the immune response. Two impressive drugs, Ipilumimab and another that I think was referred to as Roto Cytoxan are in FDA review and approval is expected within the next few months.

He also stressed a point I have mentioned before, that results from drugs in trials are often not as good as what patients can expect in actual practice; that's because the companies doing trials need to see results (bluntly, deaths versus survival) in reasonably short times, and the best way to do that is to focus the trials on men with very advanced disease whose systems have already been also beat up by previous therapies. Better results should be expected when the drugs are used at an earlier stage of disease in men who have not been heavily pretreated with other drugs and therapies.

This is already long, so I will put off describing the Sunday Morning "Ask the Experts" sessions and the Roundtable of Multidisciplinary [meaning Active Surveillance, Radiation (Seeds, Proton, other External Beam, Combinations), Cryosurgery, Hormonal therapy, Chemo, etc.) Approach to Actual Clinical Cases.

The bottom line: I found this latest conference in the series to be a wonderful, awesome, highly informative and inspiring event.

Did anyone else on this board attend?

Take care all,

Jim

 
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Old 09-17-2009, 05:44 PM   #2
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Thanks, Jim, for the wonderful report-out on the Conference. Looking forward to day-2 summaries. Appreciate you capturing & communicating the info you took in. I was in SoCal last week, and in fact stayed at the LAX Hilton Thursday night, and thought of staying the weekend...but it was Freshman Family Weekend at my son's university so I returned home Friday morning.

rgds
kcon

By the way, I bought my first-ever pomegranate juice today for lunch. It was tasty!

Last edited by kcon; 09-17-2009 at 06:30 PM. Reason: added "By the way..."

 
Old 09-18-2009, 05:15 AM   #3
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Jim- another thanks from me for all this....you continue to be one of the most knowledgeable experts in this field and I'm sure have considerably more and balanced information than the vast majority of doctors. I'm curious if you heard any discussion on proton beam radiation.

 
Old 09-18-2009, 04:09 PM   #4
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Good work , Jim. Thanks for the synopsis. Very informative. Couldn't attend since I was undergoing treatment. Thanks for being there to pass along things we all need to know about.

 
Old 09-18-2009, 07:06 PM   #5
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

SUNDAY AT THE CONFERENCE -
AFTER DR. SCHOLZ' REVIEW OF HIGHLIGHTS


Hi again daff, kcon, Bernie and all,

Here is what the rest of the conference looked like, and I'll get right to daff's question:

Quote:
Originally Posted by daff View Post
... I'm curious if you heard any discussion on proton beam radiation.
I wish I could have- it was available.

The next event Sunday morning was a breakout session of "Ask the Experts" meetings. We all had cards for submitting questions the evening before and up to 8 AM, so each expert was able to look the questions over in advance and prioritize and group them. The tough part was that we had to make choices from the following selection of separate meetings:

- Surgery & Erectile Dysfunction - Stanley Brosman, MD;

- Radiation & Proton Beam (There it is daff!) - Lisa Chaiken, MD, Carl Rossi, MD, Michael Steinberg, MD;

- Medicare & Insurance Issues - Arthur Lurvey, MD;

- Chemotherapy - Richard Lam, MD;

- Active Surveillance, Diets & Dietary Supplements - Duke Bahn, MD, and Mark Scholz, MD;

- Hormone Blockade - Charles "Snuffy" Myers, MD;

- Immunotherapy - William Cavanagh

I chose Hormone Blockade and greatly enjoyed Dr. Myers' informative answers to our questions, including one of mine, but I wish I could have also attended several of the other sessions. I don't believe these breakout sessions were recorded.

Regarding radiation and in particular proton beam, the strong panel included Dr. Chaiken, an expert in IMRT, IGRT and High Dose Rate seed implants, Dr. Steinberg of UCLA, Chair of Radiation Oncology at UCLA with a special interest in prostate cancer (Dr. Scholz's go-to guy for radiation in the LA area), and Dr. Carl Rossi, Chief, Genito-Urinary and Lymphoma Radiation Oncology Services at Loma Linda, with a special focus in prostate cancer. Dr. Rossi appears to be the top expert on proton beam for prostate cancer at the leading proton institution treating prostate cancer in the US. Is that the way you see it daff? I wish I could have heard his comments and the back and forth with the other radiation doctors.

Following the Q&A at the Ask the Experts sessions, we all reassembled for a fascinating roundtable discussion of perhaps a half dozen actual cases, with key initial details presented by Dr. Scholz and displayed on the large TV sets. Following each case description, Dr. Scholz called on one of the doctors on the panel to kick off the discussion with his recommended course of action, which generally involved either additional staging to get more information or treatment recommendations, or both. After the initial round of comments, Dr. Scholz would update some of the cases and get additional comments from the panel.

It was very interesting to get a feeling for how the different doctors thought and and how they approached the cases. For me the highlight was when Dr. Myers rather clearly departed from the rest of the panel by re-emphasizing that he thought active surveillance could be best for one apparently low risk case, though he said he would want to get a color Doppler ultrasound (CDU) biopsy by Dr. Duke Bahn (one of the few national experts) first. Sure enough, Dr. Scholz's update had results of that CDU, and it turned out the case was more aggressive than it appeared on the surface. The findings altered recommendations from the panelists, but all judged that some treatment would be the sound course.

Following the Roundtable Dr. Scholz delivered closing remarks and received a rousing round of applause.

I did not mention the prayer at the beginning on Saturday morning. It reminded us that we were about serious matters. I also did not mention a prayer by Mark Moyad at the start of his keynote address, but that turned out to be a prayer of thanks that Michigan beat Notre Dame, also no doubt serious business to some conference participants.

The one other noteworthy event was a set of breakout support group meetings during the lunch hour on Saturday. One was a general Us Too meeting; one was an advanced disease group; one was an active surveillance group; and the last was a support group for women.

There was an Exhibit Hall across from the main conference hall that was open throughout the conference. That's also where food was served at breakfast and lunchtime. Exhibitors included POM Wonderful with delicious samples, Abbott Pharmaceuticals with information about Lupron, PAACT (Patient Advocates for Advanced Cancer Treatment) - actually a well known group that focuses on prostate cancer and has a free newsletter, PCRI (Prostate Cancer Research Institute) - the main sponsor of the conference and also the publisher of an excellent free newsletter; Dr. Snuffy and Rose Myers' FCRE (Foundation for Cancer Research and Education) - with a display of Prostate Forum materials, Dr. Myers' books, DVDs, and other materials; ActivaMune broccoli supplement; I believe the Prostate Institute of America (Dr. Duke Bahn's clinic focusing on color-Doppler ultrasound and cryosurgery for prostate cancer); Endocare - a medical device company; Prostate Oncology Specialists (Dr. Scholz and Dr. Lam's clinic); Theragenics Corporation - a leading provider of seed devices; Us Too - the leading prostate cancer education and support group; the Life Extension Foundation - a vitamin, etc. and education group. I hope I have covered everyone. You could learn a lot just by browsing the exhibit tables.

Our program packets also included several free books, including books by Dr. Mark Moyad and Dr. John Mulhall.

If you've read both of my posts on this thread, you can understand why attending these conferences is like taking a drink from a fire hose. It's going to take some time to digest it all. PCRI was filming the main events, and I hope they will make a DVD available in the near future as they have for past conferences.

I hope to go into more detail in the coming days and weeks.

Take care all,

Jim

 
Old 09-19-2009, 03:34 PM   #6
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Thanks Jim for the review of the Conference. It really is great being able to read what went on there. Thanks again for your time and effort. Rich

 
Old 09-19-2009, 03:51 PM   #7
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Quote:
Originally Posted by IADT3since2000 View Post
SUNDAY AT THE CONFERENCE -
AFTER DR. SCHOLZ' REVIEW OF HIGHLIGHTS

....Dr. Rossi appears to be the top expert on proton beam for prostate cancer at the leading proton institution treating prostate cancer in the US. Is that the way you see it daff? I wish I could have heard his comments and the back and forth with the other radiation doctors.
....
That sure was a lot to absorb in a short time period, but I'm sure you were well-rewarded for the time spent. Thanks for following up on my proton question.

Yes, Dr. Rossi is probably the best known right now, having been through many developments while at Loma Linda for a number of years. It was Dr. Rossi who was going to be my doctor had I gone to Loma Linda instead of Jacksonville. I don't have any regrets.

I think that for a surgeon, one needs to find as great a doctor as possible, with the experience to go with it. For the proton treatments, so much is behind the scenes with the facility, equipment, design of the treatment-- that it's good to have an excellent doctor to answer all the questions, especially for the curious like me. But I think that anyone opting for this treatment now is fine with any of the doctors who oversee the treatment.

Obviously for one who is on a regimen as you have been for all these years, you want the advice and counsel of the best minds and the greatest experience level. Only thing with you is, your knowledge exceeds most of the doctors out there. I know you have a few favorites though, and you must be pleased to be able to communicate with them given your background.

 
Old 10-04-2009, 12:13 AM   #8
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Was there anything on screening and detection of prostate cancer, particularly distinguishing aggressive and dangerous prostate cancers that will kill men soon if not treated from the slow growing ones that men will die with rather than from?

As you probably know, PSA-based screening has been the subject of some recent large studies that have found it not to be very good, resulting in a lot of invasive procedures (biopsies and treatment) for a very small decrease in mortality.

Every so often, there is an article about some experimental new form of screening based on something found in blood that more specific to aggressive prostate cancer, but nothing seems to come of it.

 
Old 10-04-2009, 05:34 AM   #9
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Hi Tjlhb,

I'll insert some comments in green to answer your question.


Quote:
Originally Posted by tjlhb View Post
Was there anything on screening and detection of prostate cancer,

Screening and detection have been featured several times in this series of national conferences in the past, but there was nothing this year. The organizations that produce the series shortened this one from the equivalent of 2 full days spread over 3 (2 1/2 the first year I attended in 2000) to 1 1/2, probably in response to input from attendees, and the part they cut was about screening and early staging - makes sense since the audience has already been there and done that. (Feedback has always been an important feature.)That cuts one night of hotel time for out-of-towners and puts the whole show on the weekend, so you don't have to fight traffic if you are commuting locally. DVDs and tapes of past conference talks are probably still available from the key sponsor of most of the conferences, the Prostate Cancer Research Institute (PCRI - a non-profit organization) and from the Foundation for Cancer Research & Education (FCRE - also a non-profit organization.

particularly distinguishing aggressive and dangerous prostate cancers that will kill men soon if not treated from the slow growing ones that men will die with rather than from?

This has been important in some of the past conferences and is a theme that runs through a number of the talks in all the conferences including the one this year. One key aspect always featured is how to turn the aggressive and dangerous killer cancers into chronic cancers that are not deadly (like my own case). Would you like some leads specifically on that?

As you probably know, PSA-based screening has been the subject of some recent large studies that have found it not to be very good, resulting in a lot of invasive procedures (biopsies and treatment) for a very small decrease in mortality.

It is really very unfortunate that the studies themselves turned out to be not very good, essentially proving nothing. In essence, they were simply too short, something that leaped out at me as I read the initial reports. There were other details of the study that basically washed out meaning. (Did you notice that Dr. Otis Brawley, MD, a doctor with a former large practice in prostate cancer at Emory in Atlanta and now medical director of the American Cancer Society, essentially did a 180 - first endorsing the studies, and later commenting on their serious flaws after he had had time to read and consider them carefully.)

While the media ignorantly hyped the conclusions you mention, the studies themselves noted their own serious limitations, though not going far enough. Until then I had had great respect for the New England Journal of Medicine which published the studies (and an editorial that also emphasized the limitations). I still have great respect for the NEJM, but I'm keeping that grain of salt a lot handier when I read its papers now and then. This episode was a real eye opener for me!

I posted in detail about the flaws in the studies in a thread titled "Two new screening studies - crucial flaws in interpretation," started on 3/18/2009. Dr. Charles "Snuffy" Myers, MD, an eminent medical oncologist specializing in prostate cancer, wrote a detailed, incisive critique supported with citations of research in a recent edition of his Prostate Forum newsletter, back copies of which are obtainable. I am working on a summary of what he said for the board; his comments are like mine, but are far more detailed, insightful and, of course, authoritative (I've had no enrolled medical education). The issue is Volume 11 Number 3, July 2009, "The Recent Screening Studies for Prostate Cancer."


Every so often, there is an article about some experimental new form of screening based on something found in blood that more specific to aggressive prostate cancer, but nothing seems to come of it.
There are several promising tests in the works, but nothing approved yet. My guess is we well have something in two to five years.

However, for truly low risk men, putting the cancer on probation with an Active Surveillance (AS) program appears to be highly effective. AS was featured at the conference in 2005 in Washington, DC (FCRE main sponsor) with a presentation by Dr. H. Ballantine Carter of Johns Hopkins. AS was featured last year (PCRI main sponsor) in presentations by Dr. Peter Carroll of UCSF and Dr. Babaian of MD Anderson. I started a thread on AS (one of at least two) "Active Surveillance for Prostate Cancer - Age of the Patient" on 6/17/2009, if you are interested.

At the other end of the risk spectrum, the key doctors usually involved closely with the conference strongly advocate getting the PSA to a nadir of <0.05 (and at least one wants it there for a year) on triple hormonal blockade therapy as a diagnostic indicator of the presence and strength of hormone refractory prostate cancer. Dr. Myers likes to see the PSA reach a nadir of <0.01.

There is more on risk assessment in "A Primer on Prostate Cancer - The Empowered Patient's Guide," Strum and Pogliano, and in publications by PCRI. Many clues and techniques like ploidy, PAP, CEA, CGA, NSE, fusion ProstaScint, and Combidex lymph node scanning are discussed as aids to assessing spread and aggressiveness.

Hope this helps, but please ask any followup questions you wish to ask.

Take care,

Jim

 
Old 10-05-2009, 02:17 PM   #10
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

Quote:
Originally Posted by IADT3since2000 View Post
There are several promising tests in the works, but nothing approved yet. My guess is we well have something in two to five years.
Well, let's hope so. A screening test that does not require invasive prostate biopsy and can find aggressive prostate cancer with good sensitivity and specificity would be a huge improvement over the current PSA-based screening, from both a cost and quality of life standpoint.

Currently, the USPSTF give prostate cancer screening an I grade -- insufficient data to recommend for or against it (for men over 75, they give it a D grade -- discourage screening -- presumably because men that age tend to have a lower life expectancy than the length of time a prostate cancer will take to kill them, as well as greater difficulty undergoing treatment).

In the US, there is another problem. If one is diagnosed with a low risk slow growing prostate cancer (the more common kind), one might choose to do watchful waiting. But the problem is that once one has been diagnosed with any cancer, one can never again buy an individual medical insurance policy, due to the pre-existing condition. This may impact one's health in other ways (e.g. staying at a stressful job in a big company in order to stay under a group medical insurance plan, instead of retiring early or going into self-employment).

Last edited by tjlhb; 10-05-2009 at 02:19 PM.

 
Old 10-05-2009, 04:34 PM   #11
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Re: The National Conference on Prostate Cancer 2009 - last weekend in LA - Awesome!

More on screening, detection and assessing aggressiveness from posts #8 - #10

Hi again tjlhb,

I can add a few thoughts and I will put them in green, and I thought it would help to add a subtitle to track this discussion. The excerpts below are from your post #10.


Quote:
Originally Posted by tjlhb View Post
...

Currently, the USPSTF give prostate cancer screening an I grade -- insufficient data to recommend for or against it (for men over 75, they give it a D grade -- discourage screening -- presumably because men that age tend to have a lower life expectancy than the length of time a prostate cancer will take to kill them, as well as greater difficulty undergoing treatment).

I'll spell out USPSTF as some of our readers may not be familiar with the abbreviation; it stands for the US Preventive Services Task Force. I am highly unimpressed with their work with prostate cancer, and if I were to assign the USPSTF a grade, it would be an F for failure, and, to put it politely, insufficient competence! I do not believe in name calling or besmirching reputations, but I'm convinced the facts justify that grade, and here is an overview.

For starters, for a long time the USPSTF actually recommended against prostate cancer screening, period! Their current stance is neutral for screening for all men younger than 76, as you indicate. To me, that is likely causing many men and doctors to omit PSA testing and DRE exams, and that means that the men in that group who develop prostate cancer will probably be diagnosed at a stage when they have advanced disease and are not curable.

Like me! Yes, I was one of those health conscious individuals in the 1990s who were aware that many doctors and presumed experts were basically opposed to screening. I finally decided to be screened in 1999, though the doctor examining me said he did not think I needed a PSA test, and the PSA test done only at my insistence came back 113.6. (The doctor was clearly embarrassed.) I fully recognize that one case, such as mine, or even a small group of such cases, does not prove the value of screening, but it does illustrate what happens without screening, and prostate cancer statistics demonstrate conclusively, in my opinion, that screening sharply reduces the stage of prostate cancer at diagnosis. I'm convinced that the clear downtrend in prostate cancer mortality in the US is also related to aggressive screening. I can provide summaries of some of those statistics and leads to the key documents if you would like to have them.

Another key point is that NONE of the listed members of the USPSTF has significant involvement of prostate cancer patients in his or her practice, if any involvement at all! I was shocked when I first realized that. While I can understand that many diseases and medical conditions are sufficiently straightforward and uncomplicated that a doctor with only general medical school familiarity could make good decisions regarding them on a screening policy board, prostate cancer is very far from a straightforward and uncomplicated disease. It is quite complex. Among other key features, for most men it is remarkably slow growing compared to other cancers.

Therefore, the kinds of studies that show reasonably rapid results of screening programs and treatments for other cancers simply are impractical for prostate cancer - in essence, most of us survive too long. I've become convinced that the USPSTF simply does not grasp this key point. And, based on the ready acceptance by many doctors of those two very premature screening studies earlier this year, the USPSTF is not alone. Until the USPSTF acquires adequate prostate cancer expertise, we should not regard it as a competent organization regarding prostate cancer!

Regarding the cutoff of screening after age 75, to me it is too early for a healthy elderly man. However, there is more of a factual basis for the USPSTF position - something they can reasonably defend. I much prefer the stand of the American Urological Society, an organization that obviously does have competence in prostate cancer, in their "Prostate-Specific Antigen Best Practice Statement," which was published in April this year. (Apparently the AUA aims to do this about every ten years; the previous such statement was published in 2000.) Here's an excerpt of what they said on page 32, and I'll put it in blue:

"Recently, the U.S. Preventative Services Task Force issued guidelines which recommend against screening men over age 75 (USPSTF 2008 [a reference]). While this recommendation estimates the age at which the average American male has ten years or less life expectancy, individualization of this recommendation is warranted, especially in men with excellent health, absence of comorbidities, and family longevity. The incidence of high-risk prostate cancer in fact increases with age, accounting for 43% of cancers diagnosed in men > [meaning "greater than"] 75 vs. 25% among men <75 [meaning "less than 75"] (Konety 2008 [another reference]). Additionally, there must be a distinction made between screening for prostate cancer and treatment of prostate cancer."

There last point is especially important; a great many doctors would favor no aggressive treatment or any treatment for older men diagnosed with low-risk prostate cancer. In fact, some of the major Active Surveillance programs will accept such older men even if they have Gleason 7 cancer. The USPSTF needs to understand that an elderly patient does not necessarily get treatment just because screening results in a diagnosis.

If you know some favorable information about the USPSTF that would enhance their standing as an organiztion competent to make policy regarding prostate cancer, I would be very interested. Truly, I am mystified that they lack expertise in prostate cancer, that that does not seem to bother them, and that their pronouncements have credibility with many in the medical community and medical media reporters.


In the US, there is another problem. If one is diagnosed with a low risk slow growing prostate cancer (the more common kind), one might choose to do watchful waiting. But the problem is that once one has been diagnosed with any cancer, one can never again buy an individual medical insurance policy, due to the pre-existing condition. This may impact one's health in other ways (e.g. staying at a stressful job in a big company in order to stay under a group medical insurance plan, instead of retiring early or going into self-employment).
You raise a very important practical medical point that I'm sure is of interest to many families today. I have very strong feelings on that, but the solution appears to me to be political, and board rules do not permit political discussion, no doubt sparing us a lot of clutter and distraction. I'll bow out and just thank you for making this point!

Take care,

Jim

Last edited by IADT3since2000; 10-05-2009 at 05:28 PM. Reason: Noticed faulty color at end - fixed it.

 
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