> Look at the Bolla article this week in the NEJM.
I have. Its an important article with an excellent editorial following. It
shows that hormonal therapy appears to markedly enhance the effect of
radiotheraphy on folks with nonlocalized disease. 91% of both control and
experimental groups had T3 or T4 disease. The mean age was 71. 19% of the
men taking LHRH agonists has adverse reactions. Granted these reactions
might have been worth it for the results obtained in these men of high
risk, but I find it difficult to apply the results of this study to
Genevra's Dad.
Also remember that high
> gleason score disease tends to make much less PSA than low gleason
disease.
You are correct when you look at PSA produced per unit volume of tumor. But
men with high grade tumor routinely have higher PSA values than those with
better differentiated tumor because they generally have more volume of
tumor. The most reliable variable for prognosis, efficacy of treatment, and
survival is PSA level at diagnosis.
> Therefore low psa is not a guarantee of early, benign disease. My
question
> to you is why do you want to "play the odds" with a man who has prostate
> cancer.
Yes, an unfortunate minority has bad PCa without elevated PSA. As to your
second point, I don't how one can confront PCa without "playing the odds."
I see the odds of intervention to cause harm, you see the odds of
intervention to produce benefit. Its gonna be awfully difficult to arrive
at a numerical figure for any particular situation. In this particular
case, I give Genevra's Dad's 78 years of age and his active lifestyle
primary importance.
Even if the chance that he has high gleason disease is only 10% for
> example, what is the big deal about doing a biopsy?
I prefer to have an "old" man go ignorant of a cancer that will in all
likelihood not bother him than to tell him that he has cancer, but that he
shouldn't worry about it. This is easier for me to do if by avoiding a
biopsy, I don't even know that he has the cancer in the first place. This
may seem regressively paternalistic, but in a situation where I see the
chances of beneficial therapeutic intervention as very slim (and/or just
not worth it), that's the way I'd play it. I do not advocate hiding ANY
information from a patient, but neither do I think that force-feeding info
is desirable.
I am no doubt influenced by my own outlook which values quality over
quantity of life, but that's the head I'm working with. I don't know that
it is possible to educate every patient to the extent necessary so that
they can make this decision for themselves, especially when we docs lack
the hard data on which to base these decisions. (Putting my thoughts into
words while I write this makes me uncomfortable and somewhat vulnerable,
but what the hay. I should be able to survive the flames that will
inevitably result).
But, hey, if a pro-active "old" patient wants the biopsy and understands
the implications of its possible findings, let him have it. I don't see
that as the case here.
Regards,
JR Oppenheimer
**********************************
Janet Hubbard kindly objects:
>
> Without PSA testing (which some advocate), who would know to request a
> biopsy? Geneva's dad now has had the PSA and obviously Geneva suspects
> something is amiss even though the doctor either doesn't know the
possible
> significance or doesn't care. Now Geneva has the moral dilemma.
Yes she does. Its a very tricky situation with no obvious right answer. In
my initial response, I gave my gut response. You have witnessed first-hand
where that has led me.
>
> We now enter the area of knowing about your own case. It's not just being
> pro-active. It's being informed. I guess I am incredibly sensitive about
> the patient's knowledge of the deck he has been dealt because of my
> grandfather's experience. Having experienced incontinence, he was
operated
> on but sewn up because the PCa was so widespread. They evidently gave him
> some "special medicine" (actually chemo) but he was never told what it
> really was. He had all sorts of side effects and spent months/years
> wondering why he felt as he did. Eventually he became so bad that he was
> forced to go to a nursing home, where he languished in a side building.
> With cataracts and poor hearing, he couldn't read or hear. The days
passed
> slowly for several years. The last time I saw him he cried and cried and
> hung on to my hand with the true grip he always had. I cannot think of
this
> without crying again.
This is a sad story. Docs have come very far when it comes to informing the
patient. And patients have learned to ask the important questions. Both
partners have to do the same dnce, or toes will be squooshed.
>
> This wonderful person had better things to do than to try to figure out
> what was wrong with him. He should have been allowed to make peace with
> death in his own way, not according to everyone else's and wondering what
> was wrong. Don't we all do better when we aren't facing an unknown
> diagnosis but a known enemy?
Of course. But in the great majority of cases the undetected cancer that
MAY be growing in their prostates of ELDERLY men will never have the chance
to be their "enemy." The very word "Cancer" is capable of terrible harm
when introduced into our lives. Most prostate cancer is so different from
other types that it really deserves a different name. The PSA test has
introduced an awfully powerful tool to detect cancers that would have gone
unnoticed if not detected. This is especially true when applied to older
men.Our ability to stage and treat PCa must catch up to our ability to
detect it. I am not against the use of PSA testing in the informed patient
when it has a decent chance of providing benefit.
>
> The crux of the matter is knowledge. Do the doctors and family have the
> right to withhold knowledge from the person who is most involved? How
would
> Russ Ingram feel if his family and doctors withheld information?
No one is advocating withholding information. I just don't see the need to
DO something to someone (a biopsy in this case) when I don't see it as
medically indicated. The PSA is a tad high. Most probably means nothing. If
I do a biopsy that shows cancer, I would in all probability advise to
watchfully wait. The man is happily enjoying his golden years, why muck it
up for him? ON THE OTHER HAND I could sit down with him, talk to him about
what he values, etc. , and then open up a discussion concerning the risks
and benefits of a biopsy. You know, Janet, I think this is actually better.
Now if we docs could just have the knowledge and find the time to do this .
. . .
> believe that Geneva's father is less capable of making decisions than
Russ
> is? Surely not age, since we know Geneva's father still works actively
> every day.
Personally, I'd rather be found slumped over my microscope at 81 than
hooked up to chemo at 84. Maybe I'll feel different about this at 80.
Anyway, I look at the patient's active life as a reason NOT to intervene.
But you are correct in that he should be making this decision.
>
> I grant each patient the right to stop learning and controlling his own
> destiny. But I don't often grant anyone *else* that right (It would have
to
> be in cases where the patient is himself totally incapable of making
> decisions). I believe that with education even the general public is
often
> capable of learning about and understanding much about the tests and
> treatments and even the research. Many of us on the PPML are prime
> examples. I'll bet when the PPML was started in 1995 no one thought that
it
> would have such an impact on the medical and patient community. Granted
we
> are a bit of spray (not even a drop in the bucket) of the whole world of
> PCa patients (survivors). But we are making some headway. There are now
at
> least a *few* doctors who have learned from us, the patients/families! A
> few who have started questioning the traditional treatments and gotten
> newer equipment and training.
I've learned more from the PPML than I have contributed, Janet. No
question. If Geneva's Dad was subscribed, he could tell us himself what he
would like to do!
>
> I must admit, however, that I am often as discouraged as you are about
our
> successes. Primarily I am depressed when I talk with a newbie and try to
> explain the possible negative side effects of some treatments and suggest
a
> course of tests to determine whether it has any chance and/or suggest
other
> treatment alternatives. Then I hear that he has rushed into the first
> treatment suggested to him, no matter how completely illogical and
> inappropriate it seems to me. After spending hours with this person, I
> think What is the USE?! But then one out of a dozen gets the message and
> has major success and suddenly I'm read to go again.
Way to go Janet. I read you loud and clear.
>
> I guess my motto is and will continue to be, "Ignorance is not bliss."
But can't selective igorance may help us to live happier, more joyful
lives. Problem is we can't know what we don't want to know before we know
it!
>
> I can't wait to see you again in San Diego in September, Jonathan.
Can't wait to see you, too, Janet. It's been a while since Buena Park.
It'll be good to get the whole prostatic gang together.
Warm regards,
Jonathan