Prostate Cancer Roundtable endorses statement on early detection in men at high risk


The Prostate Cancer Roundtable has endorsed a statement developed by the Prostate Health Education Network (PHEN) on the role of PSA testing in the early detection of prostate cancer among men acknowledged to be at elevated risk.

The full text of the media release issued by the Roundtable last Saturday is given below, and the full text of the statement developed by PHEN is also

Washington, DC, December 20, 2013 – Following group discussion at its meeting in Washington, DC, on December 9, the Prostate Cancer Roundtable has agreed to endorse a statement developed by the Prostate Health Education Network (PHEN), a founding member of the Prostate Cancer Roundtable, on the role of PSA testing in the early detection of prostate cancer among men acknowledged to be at elevated risk (as compared to the average 50- to 65-year-old Caucasian American). Such men are known to include African Americans, men with a significant family history of prostate cancer, men exposed to the defoliating agent known as Agent Orange, and men with an above-average baseline PSA level taken in their 40s.

The “PHEN consensus statement on PSA testing for African American men for the early detection of prostate cancer” was developed with the assistance and approval of more than 20 specialists in the detection and management of prostate cancer and includes three core directives:

Consensus Statement 1: Baseline PSA testing for African Americans and other men deemed to be at high risk for prostate cancer is suggested beginning at age 40 for predicting their future risk of prostate cancer.

Consensus Statement 2: PSA testing should not be considered on its own, but rather as a part of a multivarable approach to early prostate cancer detection.

Consensus Statement 3: A prostate cancer diagnosis must be uncoupled from prostate cancer intervention.

“As noted in the full text of this consensus statement, we currently have no specific scientific evidence for or against the value of PSA testing as a method to ensure the early detection of prostate cancer in high-risk men,” stated Wendy Poage, President of the Prostate Conditions Education Council. “The PHEN document is therefore based on expert opinion. However, it is clear that African Americans and others — and the physicians responsible for their care — need some strong guidance about early detection if they are to limit risk for serious, clinically significant forms of prostate cancer among men already known to be at high risk.”

“Recent guidelines and recommendations regarding regular screening for risk of prostate cancer have become increasingly divisive and confusing for many men,” said Mike Scott, a co-founder of Prostate Cancer International. “This PHEN-developed document helps us to distinguish with care between the critical role of early detection of potentially clinically significant prostate cancer in men known to be at high risk and the role of mass, population-based ‘screening’ of all men in selected age groups. It also addresses the important issue of a conservative approach to the management of low-risk prostate cancer in appropriately identified individuals — thus limiting risk for inappropriate over-treatment of low-risk disease.”

“The Prostate Cancer Foundation gives this statement our full and complete support,” said Jonathon Simons, MD, PCF’s president and chief executive officer. “Both I and Stuart Holden, MD, the foundation’s medical director, have asked to be added to the list of prostate cancer specialists who have given their personal backing to this document. We want patients to be informed and educated on this issue.”

Tom Farrington, founder and president of the Prostate Health Education Network, acknowledged his personal gratification that the Prostate Cancer Roundtable was willing to endorse this consensus statement: “We are delighted that the other members of the Roundtable are willing to stand behind this set of principles. This is an important issue for all men at high risk for prostate cancer and for the African American community in particular. We all recognize that the PSA test is far from ideal as a method for identifying risk for prostate cancer, but it is an easy, cost-effective test that is widely available now and that can help men to recognize and manage their personal risk in concert with their doctors.”

About the Prostate Cancer Roundtable:

The Prostate Cancer Roundtable, representing America’s prostate cancer community, is a group of independent, patient-centric, not-for-profit organizations that cooperate to foster the development of policies supporting high quality prostate cancer research, the prevention and early detection of clinically significant prostate cancer, the appropriate care and effective treatment of men with prostate cancer, and the appropriate education of all men at risk for this disease.

The following members of the Prostate Cancer Roundtable support this statement:

• Ed Randall’s Fans for the Cure (www.fans4thecure.org)
• Malecare Prostate Cancer Support (www.malecare.org)
• Men’s Health Network (www.menshealthnetwork.org)
• National Alliance of State Prostate Cancer Coalitions (www.naspcc.org)
• Prostate Cancer International (www.pcainternational.org)
• Prostate Conditions Education Council (www.prostateconditions.org)
• Prostate Health Education Network (www.prostatehealthed.org)
• The Prostate Net (www.prostatenet.org)
• Us TOO International Prostate Cancer Education and Support Network (www.ustoo.org)
• Women Against Prostate Cancer (www.womenagainstprostatecancer.org)
• ZERO – The End of Prostate Cancer (www.zerocancer.org)

36 Responses

  1. The crucial thing is to convince docs to intelligently, and thoughtfully, consider these recommendations, and then work accordingly with their patients.

  2. Of course if they were really consistent about reducing prostate cancer deaths then they would be recommending that all men get their prostates removed before their 50th birthday. In Australia this would save close to one life per 23 treatments which is comparable to existing strategies.

    I know people then argue “but what about the side-effects?” but they invariably go silent when asked why side-effects of existing strategies matter less.

  3. While I endorse the Round Table/ PHEN’s consensus statements, I do have one question: how does a Caucasian male at average risk know he has a high baseline PSA in his 40s if he is not tested until he is 50?

    This statement needs to recommend a baseline test at 40-45 for all men for that part of the recommendation to make sense — otherwise an “average risk” man gets a first test at 50 and finds he has a problem that may possible have initiated some type of treatment (including active surveillance) at an earlier age.

    Mike, was this discussed? It seems strange to leave a hole in the recommendation large enough for a London bus to drive through!

    Personally, I tested “high” (> 4.0) two or three times in my 40s, but sadly in the ’90’s that association was not made.

  4. Regardless of race, having a brother, father or both with prostate cancer increases risk several-fold and the son can get the cancer much earlier (late 30s, early 40s) especially if father or brother was 63 or younger at diagnosis.

    High-risk occupations include those exposed to metal particles (including moly grease) and cutting fluid; such as mechanics or machinists. I was exposed to TCE solvent and Arsine gas in semiconductor manufacturing and cutting fluid vapors when passing our CAD machine shop. Dad was stage II, Gleason 3 + 3 at age 63. By age 43, mine was stage III, Gleason 3+3.

  5. Dear Chris:

    On that basis, all women should have a double mastectomy at age 35 or so. How do you feel about that?

    And the side effects of existing strategies don’t “matter less” at all, but existing strategies limit those side effects to the men who actually get treated. Anyone who “goes silent” when you ask them that question apparently is missing a brain, not a prostate.

  6. Dear Rick:

    The problem here is not whether one should or shouldn’t get a baseline PSA test done. The statement doesn’t discuss this because it is only focused on men at high risk. However, you are correct, one won’t know if one has an elevated PSA level in one’s 40s if one doesn’t get a PSA test until one is 50.

    Conversely, however, there are men at low risk as well as men at high risk and men at average risk (otherwise there wouldn’t be any men at “average” risk). Arguably, there should indeed be guidance suggesting that all men should have a PSA test in their 40s to assess their risk for prostate cancer to establish a baseline. But that is complicated by the fact that a single elevated PSA result is not actually definitive in a specific individual at a specific point in time. The guidance only works “on average”. While some members of the Roundtable might support the type of guideline you are suggesting, I am certain that others would not … although the Roundtable is starting to discuss a broader set of guidance on early detection, and we may well get to a resolution on this issue some time in the next 12 months.

    And if you were being shown to have a PSA level > 4 ng/ml in your 40s back in even the early 1990s, there were actually strong recommendations that a biopsy was appropriate even then, so I have no idea why this wasn’t recommended to you.

  7. “all women should have a double mastectomy at age 35 or so”

    If the statistics are the same with prostate and breast cancers then of course the same recommendation should apply to breast cancer.

    “existing strategies limit those side effects to the men who actually get treated”

    Unfortunately, existing strategies don’t limit the side effects to the men who actually benefit from treatment, which is only a small minority of the men who are treated, 1 in 48 in the case of the Randomized European Study.

    It may be better to express the success rate as a ratio of lives saved to cases of undesirable side effects. If, say, undesirable side effects occur in 50% of treatments, then treating all men in Australia before the age of 50 would have a lives saved to undesirable side effects ratio close to 1 to 11.5. For the Randomized European study it would be 1 life saved for 24 cases of undesirable side effects. The logical conclusion is the same as above.

  8. Dear Chris:

    Either you don’t really mean “all men in Australia of 50 years of age” or there is something badly wrong with your mathematics. Why would you want to subject (say) half the men in Australia of 50 to the side effects of radical prostatectomy when you don’t even know what their actual survival benefit might be? We know that in fact something like 80% of men who have a radical prostatectomy are going to lose some degree of erectile and sexual function as a consequence.

    What is more, in truth, you aren’t going to “save a life” at all. You will extend some lives — and that life extension would vary from a few months (in many cases) to several years (in a relatively small number of cases), but you will also shorten some others (because people die from some of the side effects of surgery). In a large number of cases you won’t have any meaningful impact on survival at all.

  9. A recipe for over-diagnosis, over-treatment, needlessly destroyed men and relationships, and fat pocketbooks for docs.

  10. The 40+ piece of the recommendation does not correlate logically with the current science. This recommendation will result in significant, unwarranted over-diagnosis, over-treatment, destroyed men, unnecessarily degraded relationships, and a continuously refilled population of lifelong customers for the urology and Rx industries. Deeply cynical stuff.

  11. Dear Tracy:

    With respect, I absolutely disagree with you. This statement is a step towards a much more thoughtful approach toward the identification of clinically significant disease in the men who really do need treatment … but it is only one step. The other one needs to come from the physicians who have (and in some cases still are) over-treating men who don’t need immediate treatment — and may never need treatment at all.

  12. Dear Tracy:

    Again … I am sorry to have to disagree with you. Have you read any of the studies correlating PSA levels in the 40s with later diagnosis? And I would point out the fact that the statement needs to be seen in the context of all of its parts, in particular the need to disconnect diagnosis from immediate treatment.

  13. “men in Australia of 50 to the side effects of radical prostatectomy when you don’t even know what their actual survival benefit might be?”

    Would that not save (or extend if you prefer) the lives of nearly all the men who are currently recorded as dying of prostate cancer? If a man has no prostate and little chance of any metastatic prostate cells in his body (such as one who has had a prostatectomy before the age of 50) then are they not very very unlikely to ever die from prostate cancer?

    Would not the result be hardly any deaths from prostate cancer at all which would be a huge improvement on the outcome of the present strategy?

    I note that you didn’t challenge my success rate figures.

  14. Chris:

    No … it wouldn’t necessarily have that effect at all. You are making a huge assumption about that. As yet we have no way to know with any high degree of probability which men we diagnose in their 40s are actually going to go on to have clinically significant disease, let alone metastatic disease (although that is probably going to be the case for the vast majority of men initially diagnosed with Gleason 8-10 disease). Furthermore, the vast majority of men don’t have any evidence of prostate cancer until they are in their 60s or 70s.

    You are suggesting a strategy that would have massive consequences in terms of morbidity with no necessary evidence of clinical effectiveness.

    Finally, the only reason I’m not challenging your numbers is because I don’t think your premise is meaningful at all, so I’m not concerned about the details.

  15. So you’re saying that if a man under 50 has his prostate removed then it won’t make much difference to his future risk of dying from prostate cancer. In that case, where do the metastatic prostate cancer cells come from? If he’s younger than 50 then there is little chance that he has any anywhere to begin with and if he doesn’t have a prostate then there is no large number of prostate cells available to generate a significant risk of a metastatic mutation some time in the future.

    So basically, if there is no prostate, where would the metastatic prostate cancer cells come from?

  16. it’s a lie that 80% of men who seek treatment will lose some degree of sexual function. That’s not even close to the real numbers and doesn’t take into account important variables such as age, quality of care and health heading into treatment.

  17. Dear Chris:

    No. I am not saying that “if a man under 50 has his prostate removed then it won’t make much difference to his future risk of dying from prostate cancer.”

    To the contrary … I am saying that if a man under 50 has his prostate removed, he is at a high degree of risk for all sorts of side effects and complications of such treatment, that those side effects and complications may severely affect his quality of life, and that unless there is some degree of certainty that he actually has clinically significant prostate cancer (or major risk for clinically significant prostate cancer), undergoing such an operation would be beyond daft!

    Furthermore, I am saying that we know that young men with low PSA levels and limited clinical evidence of prostate cancer can have micrometastatic disease that is not curable at the time of diagnosis, so taking out a young man’s prostate is no guarantee of curative treatment.

    Your hypothesis that implementing early (prophylactic) surgical treatment for all the men in Australia would be a good idea fails to take any account of the fact that you would be leaving behind a legacy of significantly emasculated men, many of whom would also have other complications from their surgery, and some of whom would be dead of those complications. Worse still, there would still be some men (although we have no idea how many) would would go on to have metastatic prostate cancer anyway because their cancer had micrometastasized before they ever had surgery.

    I am aware of just two cases of prophylactic radical prostatectomy being carried out in the past 30-odd years (although I suspect there may be a few more than that). In each case the patient came from a family with a very high risk for aggressive prostate cancer (multiple family members diagnosed and several with metastatic disease). Even then, it is my understanding that these two patients had a very difficult time persuading a surgeon to treat them prophylactically. I do think there are a few patients who could benefit from prophylactic radical prostatectomy. I just don’t think it is a wise idea from the vast majority of men. Of course I also think that the majority of men who do get diagnosed with localized prostate cancer are getting over-treated anyway because they probably don’t have clinically significant disease.

  18. “To the contrary”

    What you said is not contrary, it is dodging the issue. I’m asking is it not true that prostatectomy for all men before 50 would nearly wipe out all future prostate cancer early deaths for such men and you are ignoring that question.

    “he is at a high degree of risk for all sorts of side effects and complications of such treatment, that those side effects and complications may severely affect his quality of life”

    As indeed is the case with the current strategy but those issues are purportedly acceptable with the (rather low) success rate of the current strategy. If the current strategy with its rather low success rate is acceptable then would that not mean that a strategy with a higher success rate (in reducing future prostate cancer deaths) would also be acceptable?

    “I am saying that we know that young men with low PSA levels and limited clinical evidence of prostate cancer can have micrometastatic disease that is not curable at the time of diagnosis, so taking out a young man’s prostate is no guarantee of curative treatment.”

    Does that not also mean that a man with evidence of prostate cancer can have micrometastatic disease that is not curable at the time of diagnosis, so taking out that man’s prostate is no guarantee of curative treatment? You are just dodging the issue with this response. Is it not true that the vast majority of metastatic prostate cancers that cause early death do not come into existence until after the man turns 50?

    “fails to take any account of the fact that you would be leaving behind a legacy of significantly emasculated men, many of whom would also have other complications from their surgery, and some of whom would be dead of those complications. Worse still, there would still be some men (although we have no idea how many) would would go on to have metastatic prostate cancer anyway because their cancer had micrometastasized before they ever had surgery.”

    That’s actually a very accurate description of the current strategy.

    I’m not denying that there is very small minority of men below the age of 50 who have metastatic prostate cancer that will kill them regardless. But the vast majority of death-causing metastatic prostate cancers are generated by the prostate at some time after the man turns 50. Does that not mean that if the prostate is removed before the age of 50 then the vast majority of prostate cancer deaths would not occur? This outcome would be a huge improvement on the death rate reduction of the current strategy.

    The current strategy produces perhaps 47 cases of unnecessary side-effects of varying degrees for every life extended. Removing every man’s prostate before the age of 50 in Australia could reduce this to 22 cases of unnecessary side-effects of varying degrees for every life extended. If you’re saying the latter strategy is no good then to be consistent you must also say the current strategy is no good (or daft).

    Anyway, thanks for not going silent.

  19. Dear Chris:

    You only think I am “dodging the issue” because you are ignoring the point that I am making, which is that your proposed strategy is medical insanity. (I’ve been trying to be polite about it.)

    On what possible grounds can you state that, “The current strategy produces perhaps 47 cases of unnecessary side-effects of varying degrees for every life extended. Removing every man’s prostate before the age of 50 in Australia could reduce this to 22 cases of unnecessary side-effects of varying degrees for every life extended.”

    If you start treating all the men who don’t need treatment at all because they are at no risk and have no cancer, it is absolutely inevitable that you will massively increase (not decrease) the number of men who have side effects per life extended. I have no idea how you are coming up with the numbers you quote in support of a decrease. They make no sense at all. And there is no way that anyone like me who (based on 200 years of family history) had a near to zero risk for any form of cancer and a very reasonable life expectancy of another 40 years when I was 50, would look seriously at having a radical prostatectomy that I didn’t need. I’d have to have been out of my tiny mind!

    And no, it is not necessarily true that “prostatectomy for all men before 50 would nearly wipe out all future prostate cancer early deaths for such men.” We have no data to support that hypothesis. For all we know, many of the men who actually die of prostate cancer already have at least submicroscopically locally advanced disease by the time they are 50 — even if there is no significant clinical evidence of this. One of the most striking things about prostate cancer is the number of men with high-risk (i.e., clinically significant) localized disease either at diagnosis or discovered pathologically post-surgery (as a consequence of upgrading or upstaging) who have progressive disease after theoretically curative surgery. To date, no one has been able to explain this in a manner that is scientifically satisfactory.

    And not least, I am the last person who you should imply to be supportive of historic approaches to prostate cancer treatment. I have spent most of the past 30 years trying to get men to understand that something like 40 to 60 percent of those who get diagnosed with prostate cancer (depending on their age, PSA level, stage, grade, etc., at time of diagnosis) may well be better off just actively monitoring it than having any treatment at all unless it becomes absolutely necessary. The proportion of men being diagnosed today who are going to actually benefit in any way from immediate treatment at diagnosis is (perhaps) something like half the number actually getting treated, and of those many would be much better of having something other than surgery anyway.

  20. “If you start treating all the men who don’t need treatment at all because they are at no risk and have no cancer”

    It is not true that they are at no risk of dying from prostate cancer simply because they do not presently have detectable prostate cancer. Of the 3,224 Australian men who died of prostate cancer in 2010, very few of them would have had detectable prostate cancer before the age of 50 and yet you claim they were at no risk of death from prostate cancer.

    “it is not necessarily true that “prostatectomy for all men before 50 would nearly wipe out all future prostate cancer early deaths for such men.” We have no data to support that hypothesis.”

    So you don’t know whether this is true or not (and hence that my proposal is not necessarily “daft”). So you’re claiming that it could be that a significant number of death-causing metastatic cancers have already escaped the prostate by the age of 50. I ask you, how likely is this? It hardly seems likely considering the age relationship of prostate cancer in general.

    “For all we know, many of the men who actually die of prostate cancer already have at least submicroscopically locally advanced disease by the time they are 50”

    How many would that be? Most of the men who die from prostate cancer? This hardly seems likely. If it was then why isn’t there extensive testing at even younger ages than there is now?

    “One of the most striking things about prostate cancer is the number of men with high-risk (i.e., clinically significant) localized disease either at diagnosis or discovered pathologically post-surgery (as a consequence of upgrading or upstaging) who have progressive disease after theoretically curative surgery.”

    How many of these were younger than 50?

    “I have spent most of the past 30 years trying to get men to understand that something like 40 to 60 percent of those who get diagnosed with prostate cancer (depending on their age, PSA level, stage, grade, etc., at time of diagnosis) may well be better off just actively monitoring it than having any treatment at all unless it becomes absolutely necessary.”

    That’s all very well but it makes little difference if the vast majority of surgeons have a different attitude from yours. Not much point working on the patients if the surgeons advising them don’t change.

  21. Dear Chris:

    Now you are (a) putting words in my mouth that I have never uttered; (b) changing the premise of the discussion to suit your goals; and (c) failing to acknowledge or recognize that in the past 5 years there has actually been a major change in the behaviors of a very significant number of members of the surgical community (although not, as I will certainly acknowledge, as many as I would like).

    You also seem to not understand that many, many men who are actually advised by their urologists that active monitoring of some type would be the most appropriate form of management, refuse that option and insist on having some form of invasive treatment.

    I can’t answer the questions you are raising. No one can. I do, however, know that there is a significant subset of men who get diagnosed with high-risk disease not when they are 50 but when they are in their 40s. Some of those men are curable and some are not. This implies that there is going to be a significant subset of men who wouldn’t benefit from your strategy to begin with.

    You aren’t answering my fundamental question. Based on your suggestion that every man in Australia has his prostate removed at age 50, how are you computing that there would be major decrease in the number of men who would need to be treated to save/extend a life without a simultaneous and massive increase in the number of men who would have to suffer the consequence of significant side effects and complications? It makes no logical or mathematical sense.

    If you won’t answer my fundamental question, I don’t see much future to continuing this discussion. (Although if there is someone else reading this who thinks that Chris’s hypothesis makes any sense, please feel able to contribute!)

  22. What is the definition of a “significant” family history of prostate cancer?

  23. There is no formal definition that I am aware of, but a reasonable set of inclusion criteria is probably any one of the following: (a) a male parent or brother who has or has died from metastatic prostate cancer; (b) a male parent and one brother who have been diagnosed with prostate cancer, of whom at least one has progressive disease; (c) three male relatives who have been diagnosed with prostate cancer.

    Having just one close male relative who has been diagnosed with prostate cancer is probably not necessarily significant since in the recent past so many men have been diagnosed with and treated for what is not really clinically significant disease.

  24. You are simply missing the point that you cannot say that men younger than 50 with no sign of prostate cancer have no risk of dying from prostate cancer. It is a simple fact that of the 72,957 Australian men that died in 2010, 3,224 of them died from prostate cancer. Without a shadow of a doubt, nearly all of those 3,224 would have had no sign of prostate cancer before the age of 50. i.e. there was a risk of dying from prostate cancer, without detectible signs, of around 1 in 23. This is prima facie evidence that removing the prostates of all men before the age of 50 would have a success rate of 1 in 23 (barring the likely small number for whom it is too late), which most people think is a satisfactory success rate.

    “in the past 5 years there has actually been a major change in the behaviors of a very significant number of members of the surgical community”

    There has been a small drop in the number of prostatectomies per year in Australia. I wouldn’t call that a major change.

    “there is a significant subset of men who get diagnosed with high-risk disease not when they are 50 but when they are in their 40s.”

    Is it significant enough to make a substantial difference to a success rate of 1 in 23? I’m not claiming this is going to save everyone. And you’re putting words in my mouth by the way.

    “how are you computing that there would be major decrease in the number of men who would need to be treated to save/extend a life without a simultaneous and massive increase in the number of men who would have to suffer the consequence of significant side effects and complications? It makes no logical or mathematical sense.”

    You’re completely missing the point. There would be more men treated AND more lives saved.

  25. I’ve always understood it to be just one close male relative — father, uncle, or brother — although I take the point about the greater frequency of diagnosis.

    Also, breast cancer in your immediate female family raises the risk of prostate cancer.

  26. “unless there is some degree of certainty that he actually has clinically significant prostate cancer (or major risk for clinically significant prostate cancer), undergoing such an operation would be beyond daft!”

    Silly statement. One must take into account numerous factors when deciding if treatment is best for him and if so, what treatment. At the end of the day it is a very personal decision and to label it “daft” defeats the purpose of sites like this that have the noble mission of helping other men with cancer.

  27. Dear Rick:

    (1) I am not aware of any data that suggest that having a single close male relative who was diagnosed with early stage, low-risk prostate cancer presents any increase in risk for clinically significant prostate cancer (i.e., prostate cancer that really needs earky first-line treatment), although it may increase risk for the same finding in a child or sibling (i.e., potentially insignificant prostate cancer).

    (2) As far as I am aware, the only forms of breast cancer that have clearly been shown to raise risk for prostate cancer are the presence of certain, specific, familial genes like the BRCA2 gene. Again, I know of no data that clearly suggest that having a mother, sister, or aunt who was diagnosed with breast cancer necessarily presents any increase in risk for clinically significant prostate cancer.

    You need to bear in mind that the single greatest risk for a diagnosis of prostate cancer is simply getting to be older than 50. Once you get to be older than 50, your risk rises massively over time. And if you get to be over 50, there’s a pretty fair chance that your parents and siblings did too, so the age factor starts to bias the risk associations. In other words, in families where everyone lives to be 80+, there is an inevitably higher risk for things like breast and prostate cancer, but that increase in risk has far more to do with people’s ages than it has to do with other factors.

  28. Chris:

    Where are you getting the idea that I ever suggested that “men younger than 50 with no sign of prostate cancer have no risk of dying from prostate cancer”? I never suggested or implied any such thing! Every man is at some risk of dying from prostate cancer from the moment he is born. The issue is the degree of risk for each individual, which may be near to zero for some and near to 100% for others (e.g., those born to families with a high hereidary risk for metastatic prostate cancer). Bear in men that every male (and female) child born is also at 100% risk for death!

    Thank you for the data. These are helpful. I shall get back to you.

    Mike

    Mike

  29. “Bear in men that every male (and female) child born is also at 100% risk for death!”

    Death is inevitable but earlier death from prostate cancer requires you to have a prostate gland for at least some part of your life.

    Another thing I’ll point out is that the vast majority, probably at least 80%, of prostate cancers in Australia that would go on to cause early death are still causing early death with the current treatment strategy. That’s a lot of remaining potential for saving lives.

  30. Chris:

    No one is arguing about the fact that we need far better diagnostic and treatment methods in order to (a) identify the men who need treatment in a timely manner and (b) treat them with far less risk for side effects. That’s a given.

  31. Mike — the original statement just says “significant family history”. For me that would suggest a close male relative (father, brother, uncle) diagnosed with prostate cancer. If “significant” means more than early stage, low risk, then the recommendation should be more specific. You have added the qualifiers in this discussion, although that may have been the intent — was it?

    For me when advocating, I recommend testing even if the relative has only been diagnosed with T1, 3 + 3 and is certain that is the extent of the disease: better to be safe than sorry. Other family males are at higher risk for disease and they may not be as fortunate with their own disease demographics. I think this is particularly important when male offspring are at risk: better to start testing earlier, and to diagnose earlier even if dad only had T1 3 + 3 disease.

    As for breast cancer, I definitely agree with you re BRCA2. I also understood that other types of breast cancer could present greater risk for prostate cancer, but have never researched the issue.

  32. The word “significant” is important in all this. No one really has a well-defined understanding of exactly what degree of family history is “significant”, but, at least in my opinion, I would distinguish between having just one immediate relative (say one’s father) who was diagnosed with early stage, low-risk Gleason 6 disease, which may well not be clinically significant at all, and the same relative who died of metastatic prostate cancer, and which therefore clearly was clinically significant.

  33. “No one is arguing about the fact that we need far better diagnostic and treatment methods”

    By this I take your point to be that the current diagnostic and treatment methods are mediocre at best which agrees with my observation that a naive strategy, such as prostatectomy for all men before the age of 50, could well have a success rate at least as good as, if not better than, the current diagnostic and treatment strategy. That a naive strategy could actually have a higher success rate than the current strategy shows just how mediocre the current strategy is.

  34. Chris: Did you look at the e-mail that I sent you? I still don’t agree with your premise above, because I don’t think it is medically sound or ethical. You are over-interpreting my comment. Just because the current situation isn’t as good as we would like it to be is no justification for mass prophylactic surgery.

  35. My premise is that prostatectomy for men before the age of 50 could nearly eliminate their risk of death from prostate cancer. We might not know that is true but it could be true.

  36. Chris:

    No one disagrees with your premise. It is quite certainly true. The problem is with the ethics and medical practicality of executing on that premise.

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