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> Renaming the lowest-risk prostate cancer would cut down on overly aggressive treatment, some doctors say I'm very skeptical. My father died from metasticized

> Renaming the lowest-risk prostate cancer would cut down on overly aggressive treatment, some doctors say I'm very skeptical. My father died from metasticized prostate cancer, and I'm now showing elevated PSA, though needle biopsy and MRI found no cancer. It's true that prostate cancer is slow-growing, and it affects older men. So the theory is most men die of something else and it's not worth aggressive treatments. That may be true--but there's no reason not to call a cancer "cancer." 65% of men are obese or overweight. So it follows that an obese 70 year old--and the majority of men--who are diagnosed with prostate cancer may die of something else first. But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues.

Ma8ee 3y ago
(I didn’t read the article due to paywall). The reason they are reluctant to aggressive treatment is because risk of side effects that affect quality of life, such as impotence and incontinence. Do you want to wear a diaper for the rest of your life or live with a relatively low risk of earlier death from cancer?
- s1artibartfast 3y ago
  FYI, It seems like you are agreeing with the parent post, but your tone comes off pretty hostile. What point are you trying to make?
  - Ma8ee 3y ago
    My point is that it isn't population considerations that make physicians reluctant to treat many cases of prostate cancer, but balancing relatively low risks of the cancer being aggressive against quite severe quality of life degradation for the individual patients. I really don't see how my post would be considered hostile.
    - jrpt 3y ago
      The vast majority of radical prostatectomies don’t have incontinence (like 95%), and impotence isn’t common either. Furthermore, they’re usually in older men who are already impotent. Many years ago incontinence was a side effect but it isn’t common any longer as surgery has gotten better. The story of how they discovered the nerves they were cutting that causes impotence is kind of crazy, because for years it is basically like nobody even looked into it. Then one day someone decided to and they figured it out pretty quickly. That was in 1982.
      - Ma8ee 3y ago
        I don’t have time to dig out some definitive study, but top google results list incontinence as a “common” side effect.
        jrpt 3y ago
        I’m talking about long-term incontinence which is what people are most concerned about. You probably are reading about short-term incontinence. If you are having a radical prostatectomy done, you probably are hoping to live at least ten more years or even longer, so you’re basically saying you want short-term pain (surgery, pain, incontinence, etc) for long-term peace of mind (no metastases).
        Sebb767 3y ago
        1 in 10 is the usual order of magnitude for side effects labelled "common", so this doesn't disagree with the 90% number at all.
    - s1artibartfast 3y ago
      Population considerations are what make it low risk. If prostate cancer was most common in 10 year old boys, the risk tradeoffs for a slow cancer would be quite different. >I really don't see how my post would be considered hostile. To make a point, you are quite literally asking someone with elevated PSA, whos father died of prostate cancer, if they want to wear a diaper.
- fortran77 3y ago
  I would happily wear a diaper in my 70 and 80s if I was in good health otherwise.
  - petesoper 3y ago
    There is a solution for chronic cases like this: a manually operated valve that stands in for the sphincter. Some of the guys in my prostate cancer support group have described this as "life changing".
    - fortran77 3y ago
      Yes! Also, most people will dribble a bit when they get old no matter what--with or without prostate cancer. I'm much more concerned about my mental health than having to wear incontinence pads in my 80s.
s1artibartfast 3y ago
>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues. I agree. Public health professionals should not engage in deceit in the name of the public good. Utilitarian arguments may rationalize net benefit on average, but that comes with winners and losers. The goal should be clarity of communication, even if it is sub-optimal.
- tptacek 3y ago
  Is cervical dysplasia a deceptive term? CIN 3 dysplasia seems pretty close conceptually to grade 1 prostate cancer. There are doctors on HN, maybe one of them will set the record straight. This doesn't seem like one of those things where public health officials are trying to mind control the public with terminology. There are precancerous neoplastic illnesses, and cancer is defined by the threat of metastasis, which is sort of exactly what you don't have with grade 1 prostate "cancer".
sebtron 3y ago
Sorry for the nitpick, but that 65% number looked very high, so I checked and it is more like 40% according to what I found [1]. [1] https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and...
- atdrummond 3y ago
  Likely difference between international and U.S. numbers.
- greenhexagon 3y ago
  OP said "65% of men are obese or overweight" but your source is only obese. CDC says 73.6% of adults are overweight or obese (https://www.cdc.gov/nchs/fastats/obesity-overweight.htm https://www.cdc.gov/nchs/fastats/obesity-overweight.htm)
  - sebtron 3y ago
    No, my source says overweight (which includes obese). Your source is for the US only.
sroussey 3y ago
For when it metastasizes, aggressive treatment is to get rid of every trace of testosterone in your system. Prostate cells are regulated by it, so removing it is pretty effective… for a while…
- Auracle 3y ago
  As someone who suffered awfully low testosterone for years due to a brain injury (but still not 0), that sounds awful.
  - imtringued 3y ago
    15 years of suffering chemotherapy to get a statistically insignificant extension of your life span? It's a steal according to HN.
i_cannot_hack 3y ago
Your analysis is contradicted by the evidence presented in the article. > One study took 1,600 men with low-risk prostate cancer in the U.K. and randomly assigned them to get surgery, radiation or active surveillance. Fifteen years later, the researchers found that mortality rates for all the men were low, and similar for each group no matter which approach they took, according to the study which was published last year in the New England Journal of Medicine. If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups. Maybe it would be possible to find flaws in the study, or an interpretation of the results that would align with your analysis, but it seems like you haven't engaged with the evidence at all.
- Someone 3y ago
  > If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups. It isn’t different from no treatment according to that statistic, but it does save lives. Unfortunately, it also kills about the same number of men. It also, for thousands, decreases quality of life. Unnecessary operations can have side effects and there are scares on early false positives. Even the visits for checkups decrease quality of life a bit, and you’ve to do millions of those to save a life. The problem is that, once the word ‘cancer’ has fallen, people categorize dying and side effects such as erectile dysfunction as the cancer’s fault and surviving as being thanks to medicine. So, on parties, they’ll say “doctors saved my life” and “cancer killed my brother”
jdietrich 3y ago
>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues. Everyone should be discouraged from choosing treatment that does more harm than good, which (unfortunately) is practically the norm for cancer treatment in the US. If a treatment is described as "aggressive", it is usually inappropriate - aggression is rarely motivated by a thoughtful and careful consideration of the facts. The fear of cancer is wholly understandable, but it often leads to avoidable harm. We're very good at identifying tumours and suspicious cells, but we're very bad at predicting which of those will actually develop into serious disease. As a result, far too many patients are being subjected to painful and risky treatments with life-altering side-effects for no clear clinical benefit. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322920/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322920/
refurb 3y ago
But that’s how public healthcare works. You create a system based on population level evidence. If regular mammograms don’t reduce cancer deaths, then you don’t pay for them. That might be some people get diagnosed later, have to undergo more aggressive treatment, but that added cost is more than offset by not paying for mammograms for the entire population. Works great at the population level, but at the individual level it may mean some people “slip through the cracks”.
- fortran77 3y ago
  I don't disagree! But perhaps they should have two sets of "actuarial tables" -- one for the overweight/obese majority, and one for the right-sized miniority. When ever I see a study that doesn't talk about the "elephant in the room" I don't trust it. There's a prostate cancer treatment algorithm that the Mayo Clinic uses that separates obese people from healthy-weight people. I trust that.

Ma8ee 3y ago

(I didn’t read the article due to paywall). The reason they are reluctant to aggressive treatment is because risk of side effects that affect quality of life, such as impotence and incontinence. Do you want to wear a diaper for the rest of your life or live with a relatively low risk of earlier death from cancer?

s1artibartfast 3y ago
FYI, It seems like you are agreeing with the parent post, but your tone comes off pretty hostile. What point are you trying to make?
- Ma8ee 3y ago
  My point is that it isn't population considerations that make physicians reluctant to treat many cases of prostate cancer, but balancing relatively low risks of the cancer being aggressive against quite severe quality of life degradation for the individual patients. I really don't see how my post would be considered hostile.
  - jrpt 3y ago
    The vast majority of radical prostatectomies don’t have incontinence (like 95%), and impotence isn’t common either. Furthermore, they’re usually in older men who are already impotent. Many years ago incontinence was a side effect but it isn’t common any longer as surgery has gotten better. The story of how they discovered the nerves they were cutting that causes impotence is kind of crazy, because for years it is basically like nobody even looked into it. Then one day someone decided to and they figured it out pretty quickly. That was in 1982.
    - Ma8ee 3y ago
      I don’t have time to dig out some definitive study, but top google results list incontinence as a “common” side effect.
      - jrpt 3y ago
        I’m talking about long-term incontinence which is what people are most concerned about. You probably are reading about short-term incontinence. If you are having a radical prostatectomy done, you probably are hoping to live at least ten more years or even longer, so you’re basically saying you want short-term pain (surgery, pain, incontinence, etc) for long-term peace of mind (no metastases).
      - Sebb767 3y ago
        1 in 10 is the usual order of magnitude for side effects labelled "common", so this doesn't disagree with the 90% number at all.
  - s1artibartfast 3y ago
    Population considerations are what make it low risk. If prostate cancer was most common in 10 year old boys, the risk tradeoffs for a slow cancer would be quite different. >I really don't see how my post would be considered hostile. To make a point, you are quite literally asking someone with elevated PSA, whos father died of prostate cancer, if they want to wear a diaper.
fortran77 3y ago
I would happily wear a diaper in my 70 and 80s if I was in good health otherwise.
- petesoper 3y ago
  There is a solution for chronic cases like this: a manually operated valve that stands in for the sphincter. Some of the guys in my prostate cancer support group have described this as "life changing".
  - fortran77 3y ago
    Yes! Also, most people will dribble a bit when they get old no matter what--with or without prostate cancer. I'm much more concerned about my mental health than having to wear incontinence pads in my 80s.

s1artibartfast 3y ago

>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues. I agree. Public health professionals should not engage in deceit in the name of the public good. Utilitarian arguments may rationalize net benefit on average, but that comes with winners and losers. The goal should be clarity of communication, even if it is sub-optimal.

tptacek 3y ago
Is cervical dysplasia a deceptive term? CIN 3 dysplasia seems pretty close conceptually to grade 1 prostate cancer. There are doctors on HN, maybe one of them will set the record straight. This doesn't seem like one of those things where public health officials are trying to mind control the public with terminology. There are precancerous neoplastic illnesses, and cancer is defined by the threat of metastasis, which is sort of exactly what you don't have with grade 1 prostate "cancer".

sebtron 3y ago

Sorry for the nitpick, but that 65% number looked very high, so I checked and it is more like 40% according to what I found [1]. [1] https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight https://www.who.int/news-room/fact-sheets/detail/obesity-and...

atdrummond 3y ago
Likely difference between international and U.S. numbers.
greenhexagon 3y ago
OP said "65% of men are obese or overweight" but your source is only obese. CDC says 73.6% of adults are overweight or obese (https://www.cdc.gov/nchs/fastats/obesity-overweight.htm https://www.cdc.gov/nchs/fastats/obesity-overweight.htm)
- sebtron 3y ago
  No, my source says overweight (which includes obese). Your source is for the US only.

sroussey 3y ago

For when it metastasizes, aggressive treatment is to get rid of every trace of testosterone in your system. Prostate cells are regulated by it, so removing it is pretty effective… for a while…

Auracle 3y ago
As someone who suffered awfully low testosterone for years due to a brain injury (but still not 0), that sounds awful.
- imtringued 3y ago
  15 years of suffering chemotherapy to get a statistically insignificant extension of your life span? It's a steal according to HN.

i_cannot_hack 3y ago

Your analysis is contradicted by the evidence presented in the article. > One study took 1,600 men with low-risk prostate cancer in the U.K. and randomly assigned them to get surgery, radiation or active surveillance. Fifteen years later, the researchers found that mortality rates for all the men were low, and similar for each group no matter which approach they took, according to the study which was published last year in the New England Journal of Medicine. If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups. Maybe it would be possible to find flaws in the study, or an interpretation of the results that would align with your analysis, but it seems like you haven't engaged with the evidence at all.

Someone 3y ago
> If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups. It isn’t different from no treatment according to that statistic, but it does save lives. Unfortunately, it also kills about the same number of men. It also, for thousands, decreases quality of life. Unnecessary operations can have side effects and there are scares on early false positives. Even the visits for checkups decrease quality of life a bit, and you’ve to do millions of those to save a life. The problem is that, once the word ‘cancer’ has fallen, people categorize dying and side effects such as erectile dysfunction as the cancer’s fault and surviving as being thanks to medicine. So, on parties, they’ll say “doctors saved my life” and “cancer killed my brother”

jdietrich 3y ago

>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues. Everyone should be discouraged from choosing treatment that does more harm than good, which (unfortunately) is practically the norm for cancer treatment in the US. If a treatment is described as "aggressive", it is usually inappropriate - aggression is rarely motivated by a thoughtful and careful consideration of the facts. The fear of cancer is wholly understandable, but it often leads to avoidable harm. We're very good at identifying tumours and suspicious cells, but we're very bad at predicting which of those will actually develop into serious disease. As a result, far too many patients are being subjected to painful and risky treatments with life-altering side-effects for no clear clinical benefit. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322920/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322920/

refurb 3y ago

But that’s how public healthcare works. You create a system based on population level evidence. If regular mammograms don’t reduce cancer deaths, then you don’t pay for them. That might be some people get diagnosed later, have to undergo more aggressive treatment, but that added cost is more than offset by not paying for mammograms for the entire population. Works great at the population level, but at the individual level it may mean some people “slip through the cracks”.

fortran77 3y ago
I don't disagree! But perhaps they should have two sets of "actuarial tables" -- one for the overweight/obese majority, and one for the right-sized miniority. When ever I see a study that doesn't talk about the "elephant in the room" I don't trust it. There's a prostate cancer treatment algorithm that the Mayo Clinic uses that separates obese people from healthy-weight people. I trust that.