8 ms·

This makes me think of an article I read about prostate cancer detection. Apparently, it is possible to detect the possibility of prostate cancer many, many yea

This makes me think of an article I read about prostate cancer detection. Apparently, it is possible to detect the possibility of prostate cancer many, many years before it is going to develop with a more sensitive, modern test. Once the detection is made both patient and doctor are not in a position to ignore it. At the same time treatment may well be premature or not recommended. But the doctor is left with a dilemma because it may appear they did not take action on something they knew. That at least was the general topic of the article. The question it raises is interesting: is it sometimes too early to know.

hannob 6y ago
This is widely discussed in medical circles, but the real problem is a different one: It's sometimes hard to know what helps and what doesn't. You may see something that may lead to a cancer. But you really don't know. It may be a) harmless, b) lead to a cancer, c) a mistake in your test. If it's b) then treating it early is good. If it's a) or c) then treating it early will ultimately harm the patient. If your test finds mainly a) and c) then your test may ultimately do more harm than good.
- sterlind 6y ago
  Isn't this the idea behind watchful waiting? You have an early signal so you follow up with periodic tests to see if it goes away or shows signs of malignancy. Eventually we'll have studies that show the conditional probability of different cancer outcomes based on these early signals, and from there we'll have a protocol to get the best outcomes, reducing the chance of malignant cancer while minimizing cost and medical intervention.
- forgotmypwbctbi 6y ago
  it is at minimum an early warning for lifestyle change
- jfk13 6y ago
  Even if you could predict with certainty that the patient is going to develop cancer in 10 years, and you know of a course of treatment you could undertake that will ultimately prevent that cancer developing, you still may not be able to say whether this is the best use of the patient's time and resources today. (And the patient can't be sure either.)
  - shard 6y ago
    So the best course to take seems to be a combination of the probabilities of each case along with the risk tolerance of the patient, thus it is not a question the medical community can answer, but needs to be an individual discussion with each patient.
DanBC 6y ago
Early detection of prostate cancer with PSA testing and digital rectal exam: https://www.hardingcenter.de/en/early-detection-prostate-cancer-psa-testing-and-digital-rectal-exam https://www.hardingcenter.de/en/early-detection-prostate-can... > With or without screening, 7 out of every 1,000 men died from prostate cancer over a time period 11 years. But in the screening group additional men were harmed by side effects of surgery.
- shard 6y ago
  I am not sure what percentage of patients still require surgery as opposed to the more modern radiation treatments. My father's radiation treatment was painless except for the placement of the 3 tracking markers in his prostate, and although his side effects were more severe than most, they have disappeared after 3 months. So if prostate cancer treatment does not affect eventual death from the cancer over 11 years, then the questions are whether the treatment improve QOL during the 11 years, and whether the onset is delayed within that 11 years.
pintxo 6y ago
Prostate cancer is somewhat unique by having a very sensitive blood marker (PSA) being available which can be monitored easily over time. And yes, there is an (I would say) ongoing debate about the value of using PSA to detect early cancers. Obviously detecting cancer early is a win. But the downside of this early detection is over-treatment of low-risk cancers. Standard therapy for prostate cancer is the removal of the prostate, but this surgery has a somewhat high (up to ~10-15%) risk of impotence and incontinence (depending on the quality of the surgeon), which can obviously impact life quality quite massively. Current strategy (in the US) seems to basically stop broad usage of PSA testing, which gets rid of the problem of detecting low risk cancers, but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US. This feels like not solving the actual problem (distinguishing low risk from high risk tumors) but glossing over the problem by not actively working on detecting it anymore.
- DanBC 6y ago
  > but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US. Importantly, it doesn't seem to affect mortality rate of prostate cancer, nor all cause mortality. People focus a lot on 5 year survival rate, but sometimes they don't really understand what this means. If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73?
  - pintxo 6y ago
    I tend to agree that this is not such a relevant topic for the average prostate cancer age group which is 70+. Here most might die with prostate cancer but not from prostate cancer. But in the lower age groups 40-60 early detection should IMHO be the aim.
  - thaumasiotes 6y ago
    > If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73? Yes, it matters in both directions. One way is that the cancer might cause you to suffer in other ways, e.g. by metabolizing all of your food, causing you to lose large amounts of weight. If this is addressable (not at all a sure thing!), then knowing earlier is probably better. The other way is that you might not be suffering. In that case, given that your death is fixed, knowing earlier is obviously worse. I've never seen someone die of cancer without being treated beforehand. I understand it's a horrible, painful death. That said, the treatments we apply to someone dying of cancer also make for a horrible, painful death; there definitely is a point at which the treatment is worse than the cancer. Another wrinkle is that treatment may give you a few horrible months, then a few not-so-bad-years before your cancer comes back, and then the horribleness resumes. Those years in the middle are worth something, even if the time at which you die is fixed. If we ignore brief-to-medium remissions, and the hypothetical patient's time of death is fixed, then the obvious recommendation is to avoid all treatment and commit suicide when your quality of life drops too low. But the uncertainty we have in reality makes that difficult.
sradman 6y ago
Stomach cancer, for one, is easy to remove surgically if detected early but it does not exhibit symptoms until it is often too late. I suspect that early warnings would trigger targeted endoscopy procedures. The pathogenesis of prostate cancer may not be representative of other cancers.
- elric 6y ago
  Same with bowel cancer. Easily treated if found early. There are at home test kits which can detect small amounts of blood in stool -- often an early warning sign. And while unpleasant sounding, colo(no)scopy is pretty uninvasive.
henearkr 6y ago
This is an incredible confusion, and I'm angry to see so many medical authorities and administrations taking the same stance: no, it's never too early to know. The more the information the better everything. What could be too early is to act, supposing that by "act" is meant any predefined medical action. However why would it be any "too soon" for an awareness awakening by the sick individual that would bring a healthier lifestyle? Last thing I'd like to add, you just have to tell the individual about the trade-off and risks of the early act too, and this additional information will be enough to cancel any supposed danger of the early diagnostics information. When you think that giving some information is dangerous, then actually it's because you need to provide the targeted individual even more of what info you have.
- foldr 6y ago
  > it's never too early to know I don't see this. Suppose, hypothetically, that we could detect right now every illness or condition that you're ever likely to develop in the course of your life. Do you really want to read through that list? You're better off not worrying about it and enjoying your life.
  - echelon 6y ago
    > You're better off not worrying about it and enjoying your life. I would rather have all of the information upfront so that I can make better informed decisions. We're all going to die. I'm not going to shy away from that by pretending it won't come.
    - foldr 6y ago
      There's no 'pretence' involved in not reading the list. I'm perfectly aware of my mortality. I just don't see any value in placing bets on what's going to kill me.
      - shard 6y ago
        Everyone is living with an invisible list made up by them in their minds. This is what drives people to exercise, eat healthy foods, get vaccinated, and wash their hands. This just clarifies the list, perhaps adding some items, perhaps changing the priorities.
thaumasiotes 6y ago
> Apparently, it is possible to detect the possibility of prostate cancer many, many years before it is going to develop with a more sensitive, modern test. Once the detection is made both patient and doctor are not in a position to ignore it. I'll tell you a story from when my mother was in medical school. There was a class one day in which the students were given a pile of slides of prostate samples and told to identify the cancerous one. Many, many questions ensued, of the form "This looks kind of cancerous. Is this the slide?" Eventually the professor announced to the class "look, there's a bit of cancer in everyone's prostate. The goal here is to find the slide with OBVIOUS cancer." And this is, to the best of my knowledge, still the state of things in prostate cancer today. All prostates are cancerous. A man who lived long enough would eventually be killed by prostate cancer -- a cancer detectable long, long before he actually died. But most men die of other things, because prostate cancer develops so slowly. Ignoring prostate cancer is in fact a common way to handle it, if the patient is old enough or the cancer is small enough when detected. The technical term for this is "watchful waiting".
- pintxo 6y ago
  A pathologist once told me the likelihood of having prostate cancer is basically you age: 50 -> 50%, 70 -> 70%, ...
  - demadog 6y ago
    103% for my grandfather then
    - pintxo 6y ago
      You might want to apply a min(calcProp(), 1)
      - thaumasiotes 6y ago
        Maybe he has one advanced tumor and one polyp that's about 3% more cancerous than expected.
    - deleted 6y ago
raducu 6y ago
I have a SNP (according to ancestry) that gives me ~5X the chance to get prostate cancer. What treatment is available for prostate cancer, besides debilitating surgery?
- HeadsUpHigh 6y ago
  Chemo and radiotherapy, the whole trifecta. Some new ways of implanting small radioactive disks straight into the prostate with a minimally invasive procedure are being developed as well.
- scandox 6y ago
  Someone I know had robotic keyhole surgery and they were up and walking about in a week. That was a man in his 60s with mediocre health. He went to the Henry Ford Medical Centre.
  - pintxo 6y ago
    Keyhole is the key here to walk out asap. The "roboter" is not delivering that much in terms of quality of outcome or speed of recovery.
- pintxo 6y ago
  Surgery, done by good surgeons, has low (single digit) complication rates. Tip: Ask your surgeon how often he does this specific surgery. Removing the prostate requires foremost experience to not severe any nerves surrounding the organ, which are important for potency and continence. As you would not want your cars brake firmware to be written by someone who usually writes marketing apps, you do not want to get this surgery from anyone who has not specialized on it. There are specialists who do this surgery >200 times a year.
  - raducu 6y ago
    I'm in my mid thirties, I'll look into PSA, and my father has prostatitis, but no family history of prostate cancer(my grandfather died 86 years old, but lived a much healthier life than me or my father). So I'll definitely keep it under observation, I just hope those percentages will improve in the next decades.
Zenst 6y ago
>That at least was the general topic of the article. The question it raises is interesting: is it sometimes too early to know. reply Bit like near earth objects, we can detect one far far away and whilst could be 95% sure it will hit, either way, unable to do anything to it until it gets closer. But always good to know ahead of time so can prepare and eventually able to deal with it further out.
abalone 6y ago
I’ve studied this topic a lot and consulted with top prostate cancer centers of excellence. Key points: - Disregard what you may read about PSA testing / screening being “more harm than good”. This was a relatively recent recommendation in the US by a non specialist task force that is looking to be bad advice. Studies now show it has led to an increase in metastatic cancer.[1] You don’t want that. - Every man should get their PSA checked by 45, or earlier if it runs in your family. It is a simple blood test. We are lucky to have a tool like that at our disposal; not always the case for other cancers. - Prostate cancer treatment can have major impacts on quality of life including sexual function. You are much better off getting treated before it reaches stage 3. Quality of life is better. This is not reflected in mortality stats. - People do die from it and it is a slow and painful death like most cancers. About 2.4% of men die from prostate cancer.[2] With early detection it is very treatable, however, even curable. - There are advances in screening techniques. PSA is an imperfect but easy and cheap initial screening tool. Doing it early can also establish a baseline. If it’s abnormal it just opens up a conversation and more screening options. Biopsies are also more accurate these days. Men, go ahead and get your PSA test. [1] https://jamanetwork.com/journals/jamaoncology/fullarticle/2594540 https://jamanetwork.com/journals/jamaoncology/fullarticle/25... [2] https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html https://www.cancer.org/cancer/prostate-cancer/about/key-stat...

hannob 6y ago

This is widely discussed in medical circles, but the real problem is a different one: It's sometimes hard to know what helps and what doesn't. You may see something that may lead to a cancer. But you really don't know. It may be a) harmless, b) lead to a cancer, c) a mistake in your test. If it's b) then treating it early is good. If it's a) or c) then treating it early will ultimately harm the patient. If your test finds mainly a) and c) then your test may ultimately do more harm than good.

sterlind 6y ago
Isn't this the idea behind watchful waiting? You have an early signal so you follow up with periodic tests to see if it goes away or shows signs of malignancy. Eventually we'll have studies that show the conditional probability of different cancer outcomes based on these early signals, and from there we'll have a protocol to get the best outcomes, reducing the chance of malignant cancer while minimizing cost and medical intervention.
forgotmypwbctbi 6y ago
it is at minimum an early warning for lifestyle change
jfk13 6y ago
Even if you could predict with certainty that the patient is going to develop cancer in 10 years, and you know of a course of treatment you could undertake that will ultimately prevent that cancer developing, you still may not be able to say whether this is the best use of the patient's time and resources today. (And the patient can't be sure either.)
- shard 6y ago
  So the best course to take seems to be a combination of the probabilities of each case along with the risk tolerance of the patient, thus it is not a question the medical community can answer, but needs to be an individual discussion with each patient.

DanBC 6y ago

Early detection of prostate cancer with PSA testing and digital rectal exam: https://www.hardingcenter.de/en/early-detection-prostate-cancer-psa-testing-and-digital-rectal-exam https://www.hardingcenter.de/en/early-detection-prostate-can... > With or without screening, 7 out of every 1,000 men died from prostate cancer over a time period 11 years. But in the screening group additional men were harmed by side effects of surgery.

shard 6y ago
I am not sure what percentage of patients still require surgery as opposed to the more modern radiation treatments. My father's radiation treatment was painless except for the placement of the 3 tracking markers in his prostate, and although his side effects were more severe than most, they have disappeared after 3 months. So if prostate cancer treatment does not affect eventual death from the cancer over 11 years, then the questions are whether the treatment improve QOL during the 11 years, and whether the onset is delayed within that 11 years.

pintxo 6y ago

Prostate cancer is somewhat unique by having a very sensitive blood marker (PSA) being available which can be monitored easily over time. And yes, there is an (I would say) ongoing debate about the value of using PSA to detect early cancers. Obviously detecting cancer early is a win. But the downside of this early detection is over-treatment of low-risk cancers. Standard therapy for prostate cancer is the removal of the prostate, but this surgery has a somewhat high (up to ~10-15%) risk of impotence and incontinence (depending on the quality of the surgeon), which can obviously impact life quality quite massively. Current strategy (in the US) seems to basically stop broad usage of PSA testing, which gets rid of the problem of detecting low risk cancers, but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US. This feels like not solving the actual problem (distinguishing low risk from high risk tumors) but glossing over the problem by not actively working on detecting it anymore.

DanBC 6y ago
> but at the cost of delaying the identification of high risk cancers. This is visible in the falling rate of newly diagnosed prostate cancer patients in the US. Importantly, it doesn't seem to affect mortality rate of prostate cancer, nor all cause mortality. People focus a lot on 5 year survival rate, but sometimes they don't really understand what this means. If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73?
- pintxo 6y ago
  I tend to agree that this is not such a relevant topic for the average prostate cancer age group which is 70+. Here most might die with prostate cancer but not from prostate cancer. But in the lower age groups 40-60 early detection should IMHO be the aim.
- thaumasiotes 6y ago
  > If I die at 75 does it matter if my cancer is detected when I'm 68 vs 73? Yes, it matters in both directions. One way is that the cancer might cause you to suffer in other ways, e.g. by metabolizing all of your food, causing you to lose large amounts of weight. If this is addressable (not at all a sure thing!), then knowing earlier is probably better. The other way is that you might not be suffering. In that case, given that your death is fixed, knowing earlier is obviously worse. I've never seen someone die of cancer without being treated beforehand. I understand it's a horrible, painful death. That said, the treatments we apply to someone dying of cancer also make for a horrible, painful death; there definitely is a point at which the treatment is worse than the cancer. Another wrinkle is that treatment may give you a few horrible months, then a few not-so-bad-years before your cancer comes back, and then the horribleness resumes. Those years in the middle are worth something, even if the time at which you die is fixed. If we ignore brief-to-medium remissions, and the hypothetical patient's time of death is fixed, then the obvious recommendation is to avoid all treatment and commit suicide when your quality of life drops too low. But the uncertainty we have in reality makes that difficult.

sradman 6y ago

Stomach cancer, for one, is easy to remove surgically if detected early but it does not exhibit symptoms until it is often too late. I suspect that early warnings would trigger targeted endoscopy procedures. The pathogenesis of prostate cancer may not be representative of other cancers.

elric 6y ago
Same with bowel cancer. Easily treated if found early. There are at home test kits which can detect small amounts of blood in stool -- often an early warning sign. And while unpleasant sounding, colo(no)scopy is pretty uninvasive.

henearkr 6y ago

This is an incredible confusion, and I'm angry to see so many medical authorities and administrations taking the same stance: no, it's never too early to know. The more the information the better everything. What could be too early is to act, supposing that by "act" is meant any predefined medical action. However why would it be any "too soon" for an awareness awakening by the sick individual that would bring a healthier lifestyle? Last thing I'd like to add, you just have to tell the individual about the trade-off and risks of the early act too, and this additional information will be enough to cancel any supposed danger of the early diagnostics information. When you think that giving some information is dangerous, then actually it's because you need to provide the targeted individual even more of what info you have.

foldr 6y ago
> it's never too early to know I don't see this. Suppose, hypothetically, that we could detect right now every illness or condition that you're ever likely to develop in the course of your life. Do you really want to read through that list? You're better off not worrying about it and enjoying your life.
- echelon 6y ago
  > You're better off not worrying about it and enjoying your life. I would rather have all of the information upfront so that I can make better informed decisions. We're all going to die. I'm not going to shy away from that by pretending it won't come.
  - foldr 6y ago
    There's no 'pretence' involved in not reading the list. I'm perfectly aware of my mortality. I just don't see any value in placing bets on what's going to kill me.
    - shard 6y ago
      Everyone is living with an invisible list made up by them in their minds. This is what drives people to exercise, eat healthy foods, get vaccinated, and wash their hands. This just clarifies the list, perhaps adding some items, perhaps changing the priorities.

thaumasiotes 6y ago

> Apparently, it is possible to detect the possibility of prostate cancer many, many years before it is going to develop with a more sensitive, modern test. Once the detection is made both patient and doctor are not in a position to ignore it. I'll tell you a story from when my mother was in medical school. There was a class one day in which the students were given a pile of slides of prostate samples and told to identify the cancerous one. Many, many questions ensued, of the form "This looks kind of cancerous. Is this the slide?" Eventually the professor announced to the class "look, there's a bit of cancer in everyone's prostate. The goal here is to find the slide with OBVIOUS cancer." And this is, to the best of my knowledge, still the state of things in prostate cancer today. All prostates are cancerous. A man who lived long enough would eventually be killed by prostate cancer -- a cancer detectable long, long before he actually died. But most men die of other things, because prostate cancer develops so slowly. Ignoring prostate cancer is in fact a common way to handle it, if the patient is old enough or the cancer is small enough when detected. The technical term for this is "watchful waiting".

pintxo 6y ago
A pathologist once told me the likelihood of having prostate cancer is basically you age: 50 -> 50%, 70 -> 70%, ...
- demadog 6y ago
  103% for my grandfather then
  - pintxo 6y ago
    You might want to apply a min(calcProp(), 1)
    - thaumasiotes 6y ago
      Maybe he has one advanced tumor and one polyp that's about 3% more cancerous than expected.
  - deleted 6y ago

raducu 6y ago

I have a SNP (according to ancestry) that gives me ~5X the chance to get prostate cancer. What treatment is available for prostate cancer, besides debilitating surgery?

HeadsUpHigh 6y ago
Chemo and radiotherapy, the whole trifecta. Some new ways of implanting small radioactive disks straight into the prostate with a minimally invasive procedure are being developed as well.
scandox 6y ago
Someone I know had robotic keyhole surgery and they were up and walking about in a week. That was a man in his 60s with mediocre health. He went to the Henry Ford Medical Centre.
- pintxo 6y ago
  Keyhole is the key here to walk out asap. The "roboter" is not delivering that much in terms of quality of outcome or speed of recovery.
pintxo 6y ago
Surgery, done by good surgeons, has low (single digit) complication rates. Tip: Ask your surgeon how often he does this specific surgery. Removing the prostate requires foremost experience to not severe any nerves surrounding the organ, which are important for potency and continence. As you would not want your cars brake firmware to be written by someone who usually writes marketing apps, you do not want to get this surgery from anyone who has not specialized on it. There are specialists who do this surgery >200 times a year.
- raducu 6y ago
  I'm in my mid thirties, I'll look into PSA, and my father has prostatitis, but no family history of prostate cancer(my grandfather died 86 years old, but lived a much healthier life than me or my father). So I'll definitely keep it under observation, I just hope those percentages will improve in the next decades.

Zenst 6y ago

>That at least was the general topic of the article. The question it raises is interesting: is it sometimes too early to know. reply Bit like near earth objects, we can detect one far far away and whilst could be 95% sure it will hit, either way, unable to do anything to it until it gets closer. But always good to know ahead of time so can prepare and eventually able to deal with it further out.

abalone 6y ago

I’ve studied this topic a lot and consulted with top prostate cancer centers of excellence. Key points: - Disregard what you may read about PSA testing / screening being “more harm than good”. This was a relatively recent recommendation in the US by a non specialist task force that is looking to be bad advice. Studies now show it has led to an increase in metastatic cancer.[1] You don’t want that. - Every man should get their PSA checked by 45, or earlier if it runs in your family. It is a simple blood test. We are lucky to have a tool like that at our disposal; not always the case for other cancers. - Prostate cancer treatment can have major impacts on quality of life including sexual function. You are much better off getting treated before it reaches stage 3. Quality of life is better. This is not reflected in mortality stats. - People do die from it and it is a slow and painful death like most cancers. About 2.4% of men die from prostate cancer.[2] With early detection it is very treatable, however, even curable. - There are advances in screening techniques. PSA is an imperfect but easy and cheap initial screening tool. Doing it early can also establish a baseline. If it’s abnormal it just opens up a conversation and more screening options. Biopsies are also more accurate these days. Men, go ahead and get your PSA test. [1] https://jamanetwork.com/journals/jamaoncology/fullarticle/2594540 https://jamanetwork.com/journals/jamaoncology/fullarticle/25... [2] https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html https://www.cancer.org/cancer/prostate-cancer/about/key-stat...