Prostate cancer controversy – should you treat or wait?

This study will challenge all of your beliefs about how medicine treats cancer today. Pay attention to it because it’s critically important.

It’s amazing how rarely medicine is treated as a science.

So most people go off to the doc or the surgeon and get carved up, poison through chemotherapy, or otherwise given potions and pills, and there is rarely clear proof that these treatments make people better.

One of the worst areas of over-treatment is in prostate cancer. Some studies show that 70% of men will show some form of prostate cancer by the time they’re very old.

The controversy has to do with whether to treat prostate cancer at all

This study is interesting. They took over 100 men who were diagnosed with prostate cancer and who decided to do nothing about it, and they just followed those men and determined over a few years whether the prostate cancer was the same or worse as a result of failure to treat.

Prostate cancer controversy - should you treat or wait?“One hundred five (of a total of 168 eligible patients underwent a follow-up prostate biopsy during surveillance.

“Median time to a follow-up biopsy was 22 months.”

On the follow-up, here is how the numbers line up:

31% unchanged (neither better or worse)

35% slightly worse

32% slightly better

10% got considerably worse (Gleason score increased 2 or more points)

8% got a LOT worse but not terrible (they didn’t get a “really bad” Gleason score)

And 27% showed no malignancy on follow-up

I think it’s that 27% that is quite interesting. All these people were diagnosed with cancer, and 27% show no cancer a couple of years later.

The reality is that most of these men, by doing nothing about their cancer, were much better off.

So now with this data, let’s take a look at this very important opinion piece written by very prestigious doctors

Prostate cancer controversy - should you treat or wait?“The observed all-cause mortality was similar to the expected mortality for men without prostate cancer.”

That means that for men diagnosed with prostate cancer if they do nothing, they are going to live about as long as they would have if they hadn’t been diagnosed. Think about that one. Is there a sense in treating prostate cancer, if you’re going to live just as long without treatment?

Treatment has terrible risks. They poisoned men, they give them radioactive seeds that move around in their system and expose them to more cancer, they have cutting procedures that render men unable to have an erection, they are terrible treatments.

And men without the treatments live about as long as men with the treatments, in general. According to this study.

“The majority of men with low or intermediate-risk prostate cancer will not die from their disease, even when curative interventions are withheld.”

In fact, most men will die from other diseases or causes, rather than prostate cancer, even if they get no treatment.

The key to prostate cancer’s aggressiveness is how well differentiated or encapsulated it is

Tumor size doesn’t have much to do with it. What seems to determine the aggressiveness of prostate cancer, is whether it is well encapsulated, well contained, or whether it is spread out and poorly differentiated from surrounding tissue.

Poorly differentiated spread out the prostate cancer has a much more aggressive tone to it and much worse outcome. But even cancers that are fairly large, as long as there well contained, may not be a problem left untreated.

The Swedish study emphasizes that most patients diagnosed with Gleason score 6 should seriously be considered for active surveillance provided there is no evidence of extracapsular growth or a tumor volume>0.5 ml,  even tumors with volumes 1.3 ml for patients with T2 and Gleason score 6.

“Patients with poorly differentiated prostate cancer (Gleason score 8 and 9) showed a poor outcome in the Swedish population.”

“Even after local treatment with curative intent, many of these patients are destined to die because they had micrometastatic disease at the time of diagnosis.”

Many men will go through very painful and difficult therapies such as androgen deprivation (chemical castration) therapy, or removal of the prostate. But in any event, if the cancer is poorly differentiated, these may not do much good.

As the article concludes:

It is time to substantially reduce overtreatment of
patients with Gleason score 6 and small-volume Gleason
score 7 prostate cancer. Instead, we should focus on early detection and treatment of patients with Gleason score 8 and 9 

Citations

How much does Gleason grade of follow-up biopsy differ from that of initial biopsy in untreated, Gleason score 4–7, clinically localized prostate cancer?
http://onlinelibrary.wiley.com/doi/10.1002/pros.20648/abstract

It’s Time to Change the Treatment Paradigm for Prostate Cancer!
http://www.europeanurology.com/article/S0302-2838(12)00999-2/pdf/it-s-time-to-change-the-treatment-paradigm-for-prostate-cancer

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