R U Male? Read this....

[purplefaithful]

I just put my dad in the ground at 91 from end-state prostate cancer...I have a # of (much younger) friends/relatives who have under-gone treatment/surgeries...

It's a serious question regarding how this isn't screened for once you reach your 70's...


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On Sunday came word that former President Joe Biden has stage four prostate cancer that has metastasized to the bone. We don’t know definitively whether he had been tested for the disease regularly, but it seems that if he had been, he — and we — would have known sooner, at an earlier, more easily treatable stage. Bone metastasis is a big problem.

Maybe he was tested and it was kept secret. Alternatively, he followed U.S. Preventive Services Task Force (USPSTF) guidelines not to test men 70 and older, which makes no sense for a sitting president.

Two to three percent of men, mostly older, reportedly die from prostate cancer. However, in one study, autopsies of men never diagnosed revealed that nearly 35%, ages 70 to 80, died with, if not from, prostate cancer. With more time, some of the cancers might have caused those deaths. 

An estimated 12.5% of men will be diagnosed with prostate cancer in their lifetime, yet fewer than 50% are regularly screened, if at all. 

Prostate cancers are mostly found in men 65 and older but can be found in men 40 to 50. Of men diagnosed with prostate cancer, 10-20% will have locally advanced/regional or distant metastasized cancer. Statistics on prevalence and mortality rates in Black men are around twice that of white men. 

Conclusion: Prostate cancer is fairly common, increasingly so in older men, and for a minority of men it can be deadly.

With that confounding statistical backdrop, in 2012 the USPSTF astonishingly recommended with unambiguous clarity that doctors should not screen for prostate cancer. Their rationale was that harms outweighed the benefits of screening. For if you tell a man he has cancer, he’ll want it gone the fastest way possible, usually surgically, even with unpleasant, though normally temporary side effects. (Citing similar statistics on prevalence and mortality rates, the USPSTF has worryingly drawn similar conclusions regarding overdiagnosis and overtreatment of breast cancer.)

Here’s the calculus: With a first prostate-specific antigen (PSA) blood test, a second confirmatory PSA, then an MRI and a biopsy followed by surgery, combined, too much money is spent on treating the majority of diagnosed men who would probably not die from prostate cancer anyway. The USPSTF reasoned thus, with a spreadsheet-like medical perspective.

But avoid screening as a matter of policy and you risk missing men with aggressive or metastasized cancer. Somehow catch it late, and thereafter may come very costly treatment, somewhat extending life, or not — either way, it’s a dubious ethical and financial proposition.

In an overextended medical system, cost savings was a worthy, and maybe the most important, goal of the task force. Though, in a commentary published by the Minnesota Star Tribune on March 24 — “Is the now-standard approach to prostate cancer too lax? 

In my case it was.” — I observed that in fact the cost of treating aggressive or metastasized cancers is orders of magnitude greater than if the cancer is found and treated earlier, thus negating part or all of the projected cost savings from not screening. Did the guidelines meet that goal?

Since diagnosis with a locally advanced/regional cancer, I have received three years of androgen (hormone) deprivation therapy (ADT), two concurrent years of androgen receptor pathway inhibitor drugs, quarterly labs, 45 days of high-dose radiation, genetic testing, two bone density scans, oncology visits every six months and two surgical procedures to correct the toxic effects of radiation, plus miscellaneous office visits to address other side effects.

Because my cancer had regionally metastasized, though it is now dormant, it probably will recur and spread to bones, liver and lungs, if it follows a normal progression. The standard of care would then entail at least one high definition scan and a course of ADT until the cancer becomes treatment resistant. 

Thereafter may follow five courses of injections of a radioactive molecule that kills cancer cells and extends life an average of 15 months. 

Though, alternate treatment approaches may be indicated. The grand total cost of all my treatments could, at current prices, range from $500,000 to $650,000, depending on treatment approach, and assuming no intervening cause of death.

If my cancer had been caught early, while the lesion was still encapsulated, and had been treated by a radical prostatectomy, possibly curatively, those costs would have totaled about $60,000 to $70,000. Thus, the total cost of treating aggressive or metastasized prostate cancer, as may be true in my case, can be up to around seven to 11 times greater.

Managing risk is appropriate, but risk is like a two-sided coin. On one is probability of occurrence; on the other, consequence. On multiple levels, USPSTF guidelines, and their adherents, failed in managing risk well. Others are paying the cost.

However flawed prostate cancer screening guidelines were, newer biomarker screening tools and ablative treatments with fewer quality-of-life effects demand that every man be screened at least every other year no later than age 50, and until he and his doctor agree that it is no longer warranted. Men shouldn’t assume they are without significant cancer risk, however small the probability, especially when the consequence is lethal or very costly.

[badgervike]

Anybody else believe there is any chance in hell that the 82 year old former President hadn't been administered a PSA test while in office? He had access to the best healthcare in the World..and they didn't think that they should give him (and President Trump) PSA tests given their respective ages. When they made the announcement, they said that Biden's Cancer was responding to hormones. How do they know if they just made the diagnosis? Makes me think that Biden and co. knew about this well before his exit and had been getting treatment behind the scenes to avoid it becoming a campaign issue.

I agree with you PF...PSA and Colon screening should be an absolute minimum for all men depending on your age.

[purplefaithful]

Some Americans say they don’t understand how former President Joe Biden could have only recently learned that he had an aggressive form of prostate cancer that had already spread to his bones. How could the former commander in chief, a man with access to high-quality medical care, not have known earlier that he had such a serious condition?

Many prostate cancers are detected using a test called a PSA, and Biden’s last known PSA was in 2014, according to a spokesperson, Chris Meagher. Guidelines from professional organizations that advise doctors and public health officials recommend against screening for men over age 70. Biden is 82.

But many men, in consultation with their doctors, continue screening into their 70s, which is not unreasonable if the man is healthy and has a life expectancy of at least 10 years, said Dr. Scott Eggener, a prostate cancer specialist at the University of Chicago.

Prostate cancer experts also say, though, that even if Biden had been screened regularly, it’s entirely possible the cancer was not detected till recently. They said that some men suddenly find out they have advanced prostate cancer even after being screened regularly year after year and told they have a clean bill of health.

It is unusual, but it does happen.

“I have an entire collection of what I call rocket PSAs,” said Dr. Ian Thompson, a prostate cancer specialist at the University of Texas Health Science Center in San Antonio. These are men, he said, who are screened year after year with the PSA, a blood test that can pick up signs of prostate cancer. Year after year, their PSA is very low. Then, suddenly, it soars.

He also sees men with advanced prostate cancer who have normal results on their PSA screening tests.

Other physicians, too, like Dr. Otis Brawley, have experience with both of these scenarios.

Every Wednesday, Brawley, a prostate cancer and screening specialist at Johns Hopkins University in Baltimore, sees men with cancers similar to Biden’s.

Many of his patients have been diligent about regular prostate screening and yet, he said, they have advanced disease. He said he’s seen a half-dozen men like that in the past year alone.

“How the hell did I get metastatic disease?” he said they ask him. “Whose fault is this?”

The answer, Brawley tells them, is that it is no one’s fault. Fast-growing and aggressive prostate cancers can suddenly spring up between screenings.

And, occasionally, aggressive prostate cancers arise without giving any hint of their presence on the PSA.

One of Brawley’s patients had such a stealth prostate cancer. He had received multiple normal PSA test results. Then, one morning, he woke up and fell to the floor. His hip broke because he had metastatic cancer that had spread from his prostate and eaten away at the bone. Even after that diagnosis, his PSA remained normal.

One reason that can occur, said Dr. Philipp Dahm, a urologist at the University of Minnesota, is because fast-growing prostate cancer cells can become so deranged that they stop releasing the prostate protein sought by the PSA.

Brawley said too many doctors overestimate the PSA’s power as a diagnostic tool. It “is not a perfect test,” he said.

Guidelines from medical experts and professional organizations in the United States, Canada and Europe are cautious about screening.

The U.S. Preventive Services Task Force guideline, set in May 2018 and now being updated, is typical, said Dr. Barnett Kramer, who formerly directed the division of cancer prevention at the National Cancer Institute. It says men ages 55 to 69 can consider being tested after discussing the risks and possible benefits with their physician.

Its guidelines and those from professional organizations also call for ending screening around age 70. One reason is that about half of men have some cancer in their prostate by their 70s or 80s, although most have no symptoms. Nearly all of these cancers will cause no harm if left alone — they are slow-growing and will never leave the man’s prostate. The condition will not imperil his health.

But, the theory goes, if the men are screened, the test is likely to find cancer. And when it does, the men are likely to be treated with surgery or radiation that will not extend their lives. They were not at risk for a deadly cancer and, Thompson noted, treatments can have devastating effects, sometimes arising years afterward.

Radiation damage to the bladder is one of the delayed and horrific side effects, he said. It can cause pain and bleeding, and, he said, it is “very difficult to manage.” He also sees men diagnosed with bladder cancer that resulted from their radiation treatment years earlier.

Immediate and permanent effects from treatment often include impotence and incontinence.

Part of the problem, says Brawley, who is also the senior author of the American Cancer Society’s prostate cancer screening guidelines, is that many men have a mistaken idea about the benefits of screening. Compared with other cancers, prostate cancer screening has the least persuasive evidence.

“There are 12 studies telling me mammograms save lives for women over age 50,” Brawley said. “There are half a dozen studies telling me colorectal screening save lives,” he added. Lung cancer screening also was shown to save lives, he said.

But with prostate cancer? The best evidence is from a European study that showed a small benefit from screening for men in the Netherlands and Sweden, but not in other European countries, Brawley noted.

“That’s the best we’ve got,” he said.

Dr. Peter Albertsen, a prostate cancer specialist at the University of Connecticut, pointed to a rigorous study that randomly assigned men whose cancers were found with screening into three groups: they either had surgery, received radiation therapy or received regular monitoring of early-stage prostate cancer. There was no difference in health outcomes among the three groups.

“In most cases, it doesn’t matter if you watch it or treat it,” he said, reflecting the fact that most of these cancers were not dangerous.
That may be why it is so difficult to show a screening benefit.

What, then, would a prostate specialist tell a U.S. president, in his early 80s and not in unusually good health for his age, to do about prostate testing? Some observers have said a doctor in that situation should of course tell a president of any age to be tested because a president’s health is of national and global concern.

Thompson disagrees, reasoning essentially that presidents are patients, too.

“It presumes the doctor knows more about the patient’s priorities than the patient,” he said.

Instead, Thompson would engage in “a complex conversation that takes some time and would involve back-and-forth with the patient,” he said.

He added that it would include “a discussion that the potential benefit, that is small to begin with, diminishes with time,” meaning that the older the men are, the less likely they are to have any benefit from screening, or treatment. And, he said, the discussion should also note that “the side effects that can affect quality of life increase with age.”

source: Startribune