"Screening" tests

Robert A. Fink said:

From the Washington Post:

----------------------------------------------------------
--------------

washingtonpost.com Dangers in Early Detection

By H. Gilbert Welch

Thursday, July 1, 2004; Page A23

You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin,
you learn of recent research that suggests you still might
have prostate cancer. But the only way researchers know
this is because they performed a more aggressive test
--
placing a probe through the rectum of normal men and
inserting a biopsy needle six, maybe 12 times to search
for cancer in various parts of their prostate. Should this
procedure be performed on you? Should it be performed on
all healthy men?

This is American medical care today -- care increasingly
directed toward the well. Ironically, the primary service
we offer them is relentless testing to establish whether
they are, in fact, sick. We screen for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is
that early detection improves health. But this assumption
may be wrong.

Why? Because early disease detection means more people
become patients. Inevitably some will be treated
needlessly and suffer as a result.

To understand this, you need to understand that each of us
harbors early forms of disease. Even in middle age, many
of us who feel well have evidence of diabetes, heart
disease, osteoporosis, hepatitis, vascular disease and
cancer. Just because we harbor these early forms of
disease doesn't mean that they will ever affect our
health. Some diseases progress so slowly that people die
of other causes long before the diseases generate
symptoms. Other diseases may not progress at all. Unless
we were tested, we'd never have known we were sick.

Prostate cancer is the classic example. Among men age 60,
around half have microscopic evidence of prostate cancer
if we look hard enough. Yet only four in 1,000 will die
from prostate cancer in the next 10 years. How can this
be? Because prostate cancer isn't just one disease: It's a
spectrum of disorders. Some forms of prostate cancer grow
very rapidly and kill men. Some grow slowly and men die of
something else before the cancer ever causes symptoms. And
others look like cancer under the microscope but never
grow at all.

A little over a decade ago, doctors started looking hard
for prostate cancer using the PSA and lots of needle
biopsies. And we found a great deal: Roughly 2 million
cases were diagnosed in this period -- almost a million
more than would have been without the test.

Did prostate cancer screening help men? To be honest, we
aren't sure about the net effect. There has been a small
decline in the death rate from prostate cancer, but this
may simply reflect that our treatments are better.

Actually the absolute number of deaths in the US due to
prostate cancer has dropped by about one quarter during the
time of large scale PSA testing. For the arithmetically
challenged, let me explain what "death rate" means. It is
the number of deaths divided by the size of the vulnerable
population, usually expressed in deaths per 100,000. So if
the actual number of deaths has declined by about 25
percent, and the vulnerable population has increased, that
means that the death rate has actually declined by more than
25 percent. That seems to me to be more than a small
decline. Also, note that death rates due to prostate cancer
have not declined in countries like Sweden which don't do
large scale PSA testing. There is no reason to believe that
US doctors are better at treating prostate cancer than
Swedish doctors. The author of this article, who has been
sermonizing about this for years, is being very misleading.
He uses language imprecisely and tries to imply more than
his words actually say. Notice the regular use of the word
"may". He is trying to convince people not to be tested for
prostate cancer. While the situation is not entirely clear,
there is no scientific evidence today for such a
recommendation. It would be better to present the actual
facts that are known, including all the uncertainties, and
then let men decide for themselves what to do.

Quoted message said:

While screening probably has helped a few men live longer,
it has also clearly hurt others.

The author has no scientific evidence which allows him to
estimate just how many men have had their life expectancies
increased because of screening. I could just as well say it
this way. "Screening has clearly helped some men live
longer, but it has also clearly hurt a few others." Both my
statement and his statement are misleading and not based
firmly on what we now know. There are a few studies ongoing
now which are investigating these matters, but the results
won't be in for a while. Also, since prostate cancer is such
a complex disease, any one study has to be confirmed through
other studies.

Quoted message said:

Millions have been biopsied who otherwise wouldn't have
been. Many with nonprogressive disease have been turned
into cancer patients unnecessarily.

Again, he has no idea how often this happens. For example,
one study based on Medicare data estimated that 15 percent
of prostate cancer in men of European descent was treated
unnecessarily and 45 percent of men of African descent were
so treated. I don't have any great confidence in that
particular study. But suppose you learned that you had a 50-
50 chance of living a long disease free life vs suffering a
painful, quite unpleasant disease. Suppose also that the
treatment probably would cure you and you might have some
undesirable side effects which you could live with. What
would you decide?

In article <[email hidden]>,

Robert A. Fink said:

From the Washington Post:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

I admit to not reading the entire above, sorry.

It's my understanding that early detection is key to curing
cancer of almost any kind. Do I have that part right?

Dale J.

--
Email: [email hidden]

"Robert A. Fink, M. D." <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

From the Washington Post:

----------------------------------------------------------
--------------

washingtonpost.com Dangers in Early Detection

By H. Gilbert Welch

Thursday, July 1, 2004; Page A23

You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin,
you learn of recent research that suggests you still might
have prostate cancer. But the only way researchers know
this is because they performed a more aggressive test
--
placing a probe through the rectum of normal men and
inserting a biopsy needle six, maybe 12 times to search
for cancer in various parts of their prostate. Should this
procedure be performed on you? Should it be performed on
all healthy men?

This is American medical care today -- care increasingly
directed toward the well. Ironically, the primary service
we offer them is relentless testing to establish whether
they are, in fact, sick. We screen for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is
that early detection improves health. But this assumption
may be wrong.

Why? Because early disease detection means more people
become patients. Inevitably some will be treated
needlessly and suffer as a result.

To understand this, you need to understand that each of us
harbors early forms of disease. Even in middle age, many
of us who feel well have evidence of diabetes, heart
disease, osteoporosis, hepatitis, vascular disease and
cancer. Just because we harbor these early forms of
disease doesn't mean that they will ever affect our
health. Some diseases progress so slowly that people die
of other causes long before the diseases generate
symptoms. Other diseases may not progress at all. Unless
we were tested, we'd never have known we were sick.

Prostate cancer is the classic example. Among men age 60,
around half have microscopic evidence of prostate cancer
if we look hard enough. Yet only four in 1,000 will die
from prostate cancer in the next 10 years. How can this
be? Because prostate cancer isn't just one disease: It's a
spectrum of disorders. Some forms of prostate cancer grow
very rapidly and kill men. Some grow slowly and men die of
something else before the cancer ever causes symptoms. And
others look like cancer under the microscope but never
grow at all.

A little over a decade ago, doctors started looking hard
for prostate cancer using the PSA and lots of needle
biopsies. And we found a great deal: Roughly 2 million
cases were diagnosed in this period -- almost a million
more than would have been without the test.

Did prostate cancer screening help men? To be honest, we
aren't sure about the net effect. There has been a small
decline in the death rate from prostate cancer, but this
may simply reflect that our treatments are better. While
screening probably has helped a few men live longer, it
has also clearly hurt others. Millions have been biopsied
who otherwise wouldn't have been. Many with nonprogressive
disease have been turned into cancer patients
unnecessarily. Most have been treated, and many have
suffered ill effects. A few have even had their lives
shortened by treatment.

This is the reality of early detection. A few may be
helped, because their disease is destined to cause
problems and because early treatment is able to solve
those problems in a way that later treatment cannot. But
many simply are told earlier that they have a disease and
gain nothing, because their disease could have been
treated just as well later, when symptoms appeared. And
others are hurt by treatment for a disease that would have
otherwise never affected their health.

What's next? Consider CAT scans of the chest to look for
lung cancer. During mass screenings in one region of
Japan, CAT scans found 10 times as many patients with
lung cancer as had been found a few years earlier using
chest X-rays. Incredibly, nonsmokers were almost as
likely to have lung cancer as smokers. Is smoking getting
safer? Of course not. Everyone agrees that smoking is far
and away the most important cause of lung cancer. The CAT
scans were simply labeling some people as lung cancer
patients who otherwise would never be affected by a few
abnormal cells.

Why not treat these patients -- just to be safe? Because
some people die from treatment. In the Mayo Clinic study
comparing lung cancer screening (using chest X-rays) to
standard care, more people in the screening group were
told that they had lung cancer. It didn't help them live
longer; in fact, slightly more people in that group died.

And some think we should scan the whole body. But the
harder we look, the more we find. CAT scans of the chest
lead more people to be told they have lung cancer, and
there are even more abnormalities to find in the abdomen.
As one radiologist who has read thousands of these scans
put it, "With this level of information, I have yet to see
a normal patient."

Millions of healthy Americans are being told that they are
sick (or "at risk"😉. More are undergoing invasive
evaluations with needles, flexible scopes and catheters.
And more are taking drugs for early forms of diabetes,
heart disease, osteoporosis, hepatitis, vascular disease
and cancer.

We need to start asking hard questions about whose
interests are served by the relentless pursuit of disease
in people who are well. Clearly it's good business -- for
test manufacturers, hospitals, pharmaceutical companies.
And it's good for some doctors.

But is it in society's interest? Many suggest that it
saves money by lowering the cost per patient. But the
savings per patient (if they exist) are overwhelmed by
the increased expense of having so many more to treat.
Is it in the interest of sick patients? Absolutely not,
as caring for the well increasingly distracts doctors
from caring for the truly sick. And what about the well?
Is it in their interest? Only they can decide -- after
they have been informed that early detection is a double-
edged sword.

The writer is a professor of medicine in the Department of
Veterans Affairs and Dartmouth Medical School. He is the
author of "Should I Be Tested for Cancer? Maybe Not and
Here's Why."

© 2004 The Washington Post Company

===================================

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

Well, this is going against the cultural bias of more,
more and more health care. Patients seem to demand it, and
think that if some test somehow discovers even one cancer
cell, or something which might be one, they need immediate
aggrressive therapy or they are doomed. Culture, not
science, is the issue here.

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical exam
including PSA... After this, I found out that my PSA was 5.2
( at 49 years old)....subsequent test indicated that I also
had PCa !!! 5 years ago, I had RRP....my last PSA test was
still undetectable....In the meantime, One of my brothers
died of PCa, another is on his last days and the other is
still fighting the cancer strong....

I have SOLID evidence and experience that screening is very,
very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

"Robert A. Fink, M. D." <[email hidden]> wrote in
message "]news:[email hidden]...

Quoted message said:

From the Washington Post:

----------------------------------------------------------
--------------

washingtonpost.com Dangers in Early Detection

By H. Gilbert Welch

Thursday, July 1, 2004; Page A23

You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin,
you learn of recent research that suggests you still might
have prostate cancer. But the only way researchers know
this is because they performed a more aggressive test
--
placing a probe through the rectum of normal men and
inserting a biopsy needle six, maybe 12 times to search
for cancer in various parts of their prostate. Should this
procedure be performed on you? Should it be performed on
all healthy men?

This is American medical care today -- care increasingly
directed toward the well. Ironically, the primary service
we offer them is relentless testing to establish whether
they are, in fact, sick. We screen for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is
that early detection improves health. But this assumption
may be wrong.

Why? Because early disease detection means more people
become patients. Inevitably some will be treated
needlessly and suffer as a result.

To understand this, you need to understand that each of us
harbors early forms of disease. Even in middle age, many
of us who feel well have evidence of diabetes, heart
disease, osteoporosis, hepatitis, vascular disease and
cancer. Just because we harbor these early forms of
disease doesn't mean that they will ever affect our
health. Some diseases progress so slowly that people die
of other causes long before the diseases generate
symptoms. Other diseases may not progress at all. Unless
we were tested, we'd never have known we were sick.

Prostate cancer is the classic example. Among men age 60,
around half have microscopic evidence of prostate cancer
if we look hard enough. Yet only four in 1,000 will die
from prostate cancer in the next 10 years. How can this
be? Because prostate cancer isn't just one disease: It's a
spectrum of disorders. Some forms of prostate cancer grow
very rapidly and kill men. Some grow slowly and men die of
something else before the cancer ever causes symptoms. And
others look like cancer under the microscope but never
grow at all.

A little over a decade ago, doctors started looking hard
for prostate cancer using the PSA and lots of needle
biopsies. And we found a great deal: Roughly 2 million
cases were diagnosed in this period -- almost a million
more than would have been without the test.

Did prostate cancer screening help men? To be honest, we
aren't sure about the net effect. There has been a small
decline in the death rate from prostate cancer, but this
may simply reflect that our treatments are better. While
screening probably has helped a few men live longer, it
has also clearly hurt others. Millions have been biopsied
who otherwise wouldn't have been. Many with nonprogressive
disease have been turned into cancer patients
unnecessarily. Most have been treated, and many have
suffered ill effects. A few have even had their lives
shortened by treatment.

This is the reality of early detection. A few may be
helped, because their disease is destined to cause
problems and because early treatment is able to solve
those problems in a way that later treatment cannot. But
many simply are told earlier that they have a disease and
gain nothing, because their disease could have been
treated just as well later, when symptoms appeared. And
others are hurt by treatment for a disease that would have
otherwise never affected their health.

What's next? Consider CAT scans of the chest to look for
lung cancer. During mass screenings in one region of
Japan, CAT scans found 10 times as many patients with
lung cancer as had been found a few years earlier using
chest X-rays. Incredibly, nonsmokers were almost as
likely to have lung cancer as smokers. Is smoking getting
safer? Of course not. Everyone agrees that smoking is far
and away the most important cause of lung cancer. The CAT
scans were simply labeling some people as lung cancer
patients who otherwise would never be affected by a few
abnormal cells.

Why not treat these patients -- just to be safe? Because
some people die from treatment. In the Mayo Clinic study
comparing lung cancer screening (using chest X-rays) to
standard care, more people in the screening group were
told that they had lung cancer. It didn't help them live
longer; in fact, slightly more people in that group died.

And some think we should scan the whole body. But the
harder we look, the more we find. CAT scans of the chest
lead more people to be told they have lung cancer, and
there are even more abnormalities to find in the abdomen.
As one radiologist who has read thousands of these scans
put it, "With this level of information, I have yet to see
a normal patient."

Millions of healthy Americans are being told that they are
sick (or "at risk"😉. More are undergoing invasive
evaluations with needles, flexible scopes and catheters.
And more are taking drugs for early forms of diabetes,
heart disease, osteoporosis, hepatitis, vascular disease
and cancer.

We need to start asking hard questions about whose
interests are served by the relentless pursuit of disease
in people who are well. Clearly it's good business -- for
test manufacturers, hospitals, pharmaceutical companies.
And it's good for some doctors.

But is it in society's interest? Many suggest that it
saves money by lowering the cost per patient. But the
savings per patient (if they exist) are overwhelmed by
the increased expense of having so many more to treat.
Is it in the interest of sick patients? Absolutely not,
as caring for the well increasingly distracts doctors
from caring for the truly sick. And what about the well?
Is it in their interest? Only they can decide -- after
they have been informed that early detection is a double-
edged sword.

The writer is a professor of medicine in the Department of
Veterans Affairs and Dartmouth Medical School. He is the
author of "Should I Be Tested for Cancer? Maybe Not and
Here's Why."

© 2004 The Washington Post Company

===================================

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

"Leonard Evens" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Robert A. Fink said:

From the Washington Post:

--------------------------------------------------------
----------------

washingtonpost.com Dangers in Early Detection

By H. Gilbert Welch

Thursday, July 1, 2004; Page A23

You feel well. You're only 60. Your PSA -- the blood
test for prostate cancer -- is normal. Much to your
chagrin, you learn of recent research that suggests you
still might have prostate cancer. But the only way
researchers know this is because they performed a more
aggressive test
--
placing a probe through the rectum of normal men and
inserting a biopsy needle six, maybe 12 times to search
for cancer in various parts of their prostate. Should
this procedure be performed on you? Should it be
performed on all healthy men?

This is American medical care today -- care increasingly
directed toward the well. Ironically, the primary
service we offer them is relentless testing to establish
whether they are, in fact, sick. We screen for early
forms of diabetes, heart disease, osteoporosis,
hepatitis, vascular disease and, of course, cancer. The
conventional wisdom is that early detection improves
health. But this assumption may be wrong.

Why? Because early disease detection means more people
become patients. Inevitably some will be treated
needlessly and suffer as a result.

To understand this, you need to understand that each of
us harbors early forms of disease. Even in middle age,
many of us who feel well have evidence of diabetes,
heart disease, osteoporosis, hepatitis, vascular disease
and cancer. Just because we harbor these early forms of
disease doesn't mean that they will ever affect our
health. Some diseases progress so slowly that people die
of other causes long before the diseases generate
symptoms. Other diseases may not progress at all. Unless
we were tested, we'd never have known we were sick.

Prostate cancer is the classic example. Among men age
60, around half have microscopic evidence of prostate
cancer if we look hard enough. Yet only four in 1,000
will die from prostate cancer in the next 10 years. How
can this be? Because prostate cancer isn't just one
disease: It's a spectrum of disorders. Some forms of
prostate cancer grow very rapidly and kill men. Some
grow slowly and men die of something else before the
cancer ever causes symptoms. And others look like cancer
under the microscope but never grow at all.

A little over a decade ago, doctors started looking hard
for prostate cancer using the PSA and lots of needle
biopsies. And we found a great deal: Roughly 2 million
cases were diagnosed in this period -- almost a million
more than would have been without the test.

Did prostate cancer screening help men? To be honest, we
aren't sure about the net effect. There has been a small
decline in the death rate from prostate cancer, but this
may simply reflect that our treatments are better.

Actually the absolute number of deaths in the US due to
prostate cancer has dropped by about one quarter during
the time of large scale PSA testing. For the
arithmetically challenged, let me explain what "death
rate" means.

I knew you would respond immediately. Demographers have
long known that even if cancer were 100% cured, the
nation's life expetancy would increase by only 2 years. 2
years. Why? Because if one cause of death declines,
others take over. Since the life expectancy of the nation
has been going UP anyway, all diseases show declines,
including prostate cancers. Heart attacks showed a real
decline long before modern aggressive treatments came
along. In Canada, you don't have the aggressive
treatments for heart ailments, yet you live just as long
after an attack. What about prostate cancer? Yes, Len,
there is a connection.

"dale.j. " <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

In article <[email hidden]>,

Robert A. Fink said:

From the Washington Post:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500
Milvia Street Suite 222 Berkeley, CA 94704-2636 USA
510-849-2555

**********************************
NOTE: The material above is not "medical advice".
Medical advice can only be given after an in-
person contact between doctor and patient.
**********************************

I admit to not reading the entire above, sorry.

It's my understanding that early detection is key to
curing cancer of almost any kind. Do I have that
part right?

Dale J.

Not according to the article. Early detection simply means
you know about it earlier.

dale.j. said:

In article <[email hidden]>,

Robert A. Fink said:

From the Washington Post:

Quoted message said:

Quoted message said:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

I admit to not reading the entire above, sorry.

It's my understanding that early detection is key to
curing cancer of almost any kind. Do I have that
part right?

No. It depends on the cancer. There is considerable
uncertainty about how effective early detection is for some
common cancers. Certainly some will tell you that there is
no proof that early detection makes any difference. What
that means is that there has been no double blind randomized
study demonstrating it. In such a study a carefully chosen
group is randomly assigned to two different groups, one is
subjected to the method being proposed and one is not, and
then the results are compared. There is one such study in
progress in the US now, but the results are not in yet.

But double blind studies are not the only kind of valid
evidence. They are the best kind because they try to avoid
what are called confounders, which are other factors which
might explain the results other than the feature being
studied. But they are not foolproof themselves. Actually a
study will only tell you about what you might expect to find
in a population which matches that of the study population.
For example, if you study PSA testing and follow you
population for 12 years, you can't necessarily translate the
results to another population which would be followed for
15-20 years. Also, results in one country might not be
helpful for men in another country.

But note that just because we haven't proved by a certain
method that something is beneficial doesn't mean that we
have proved that it isn't beneficial. Some people think you
shouldn't do anything not supported by a double blind
study. By that argument, it has never been proved that
smoking causes lung cancer, heart disease, etc., so it
would be perfectly safe to continue smoking. You would of
course be ignoring all the other evidence about the dangers
of smoking.

Quoted message said:

Dale J.

"Fernando" <[email hidden]> wrote in message
news:6sCFc.19141$IQ4.2196@attbi_s02...

Quoted message said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical
exam including PSA... After this, I found out that my PSA
was 5.2 ( at 49 years

old)....subsequent

Quoted message said:

test indicated that I also had PCa !!! 5 years ago, I had
RRP....my last PSA test was still undetectable....In the
meantime, One of my brothers

died

Quoted message said:

of PCa, another is on his last days and the other is still
fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

But you would not accept the results in any case.

On Sat, 03 Jul 2004 06:27:01 -0500, "dale.j. " <[email hidden]>

Quoted message said:

It's my understanding that early detection is key to curing
cancer of almost any kind. Do I have that part right?

This is not always true. Some cancers which are easily
detectable are associate with a poor survival even if
treated early (certain malignant brain tumors, for
example); and other malignancies (like prostate cancer) may
take a very long time to kill (or never will) even if
picked up late.

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

On Sat, 03 Jul 2004 17:57:22 GMT, "Fernando" <[email hidden]>

Quoted message said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical exam
including PSA... After this, I found out that my PSA was
5.2 ( at 49 years old)....subsequent test indicated that I
also had PCa !!! 5 years ago, I had RRP....my last PSA test
was still undetectable....In the meantime, One of my
brothers died of PCa, another is on his last days and the
other is still fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

Fernando,

Your "statistics" are what is called "anecdotal". You need
thousands of cases in order to prove a statistical
correlation, and those studies which *are* truly statistical
are quite equivocal as to whether widespread screening with
the PSA followed by aggressive treatment/biopsy really makes
a difference in survival.

Your comments suggest that you have an emotional attachment
to your beliefs (they are beliefs, not scientific evidence),
and while I can understand that (in view of your family
history), it doesn't make them "scientific".

Why, BTW, do you need to disparage my title, Fernando? You
know, I am a "real doctor".

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

On Sat, 03 Jul 2004 06:27:01 -0500, "dale.j. " <[email hidden]>

Quoted message said:

It's my understanding that early detection is key to curing
cancer of almost any kind. Do I have that part right?

This is not always true. Some cancers which are easily
detectable are associate with a poor survival even if
treated early (certain malignant brain tumors, for
example); and other malignancies (like prostate cancer) may
take a very long time to kill (or never will) even if
picked up late.

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

Fernando said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical
exam including PSA... After this, I found out that my PSA
was 5.2 ( at 49 years old)....subsequent test indicated
that I also had PCa !!! 5 years ago, I had RRP....my last
PSA test was still undetectable....In the meantime, One of
my brothers died of PCa, another is on his last days and
the other is still fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

To be fair to the critics of PSA testing, many of them would
recommend testing for men with a family history or other
special characteristics. There are a few extremists among
the critics who will claim that even men like you should not
be tested. What most of the critics claim is that it is not
clear that men in the general population benefit enough to
justify the cost, economic and in unnecessary treatment. I
don't agree with that, but it is an arguable position. One
thing should be made clear. No one really knows how to do
the cost-benefit analysis at this stage. Also, this is
basically an unsettled scientific debate and should probably
not be taken to the public.

Quoted message said:

"Robert A. Fink, M. D." <[email hidden]> wrote in
message "]news:[email hidden]...

Quoted message said:

From the Washington Post:

----------------------------------------------------------
--------------

washingtonpost.com Dangers in Early Detection

By H. Gilbert Welch

Thursday, July 1, 2004; Page A23

You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin,
you learn of recent research that suggests you still might
have prostate cancer. But the only way researchers know
this is because they performed a more aggressive test
--
placing a probe through the rectum of normal men and
inserting a biopsy needle six, maybe 12 times to search
for cancer in various parts of their prostate. Should this
procedure be performed on you? Should it be performed on
all healthy men?

This is American medical care today -- care increasingly
directed toward the well. Ironically, the primary service
we offer them is relentless testing to establish whether
they are, in fact, sick. We screen for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is
that early detection improves health. But this assumption
may be wrong.

Why? Because early disease detection means more people
become patients. Inevitably some will be treated
needlessly and suffer as a result.

To understand this, you need to understand that each of us
harbors early forms of disease. Even in middle age, many
of us who feel well have evidence of diabetes, heart
disease, osteoporosis, hepatitis, vascular disease and
cancer. Just because we harbor these early forms of
disease doesn't mean that they will ever affect our
health. Some diseases progress so slowly that people die
of other causes long before the diseases generate
symptoms. Other diseases may not progress at all. Unless
we were tested, we'd never have known we were sick.

Prostate cancer is the classic example. Among men age 60,
around half have microscopic evidence of prostate cancer
if we look hard enough. Yet only four in 1,000 will die
from prostate cancer in the next 10 years. How can this
be? Because prostate cancer isn't just one disease: It's a
spectrum of disorders. Some forms of prostate cancer grow
very rapidly and kill men. Some grow slowly and men die of
something else before the cancer ever causes symptoms. And
others look like cancer under the microscope but never
grow at all.

A little over a decade ago, doctors started looking hard
for prostate cancer using the PSA and lots of needle
biopsies. And we found a great deal: Roughly 2 million
cases were diagnosed in this period -- almost a million
more than would have been without the test.

Did prostate cancer screening help men? To be honest, we
aren't sure about the net effect. There has been a small
decline in the death rate from prostate cancer, but this
may simply reflect that our treatments are better. While
screening probably has helped a few men live longer, it
has also clearly hurt others. Millions have been biopsied
who otherwise wouldn't have been. Many with nonprogressive
disease have been turned into cancer patients
unnecessarily. Most have been treated, and many have
suffered ill effects. A few have even had their lives
shortened by treatment.

This is the reality of early detection. A few may be
helped, because their disease is destined to cause
problems and because early treatment is able to solve
those problems in a way that later treatment cannot. But
many simply are told earlier that they have a disease and
gain nothing, because their disease could have been
treated just as well later, when symptoms appeared. And
others are hurt by treatment for a disease that would have
otherwise never affected their health.

What's next? Consider CAT scans of the chest to look for
lung cancer. During mass screenings in one region of
Japan, CAT scans found 10 times as many patients with
lung cancer as had been found a few years earlier using
chest X-rays. Incredibly, nonsmokers were almost as
likely to have lung cancer as smokers. Is smoking getting
safer? Of course not. Everyone agrees that smoking is far
and away the most important cause of lung cancer. The CAT
scans were simply labeling some people as lung cancer
patients who otherwise would never be affected by a few
abnormal cells.

Why not treat these patients -- just to be safe? Because
some people die from treatment. In the Mayo Clinic study
comparing lung cancer screening (using chest X-rays) to
standard care, more people in the screening group were
told that they had lung cancer. It didn't help them live
longer; in fact, slightly more people in that group died.

And some think we should scan the whole body. But the
harder we look, the more we find. CAT scans of the chest
lead more people to be told they have lung cancer, and
there are even more abnormalities to find in the abdomen.
As one radiologist who has read thousands of these scans
put it, "With this level of information, I have yet to see
a normal patient."

Millions of healthy Americans are being told that they are
sick (or "at risk"😉. More are undergoing invasive
evaluations with needles, flexible scopes and catheters.
And more are taking drugs for early forms of diabetes,
heart disease, osteoporosis, hepatitis, vascular disease
and cancer.

We need to start asking hard questions about whose
interests are served by the relentless pursuit of disease
in people who are well. Clearly it's good business -- for
test manufacturers, hospitals, pharmaceutical companies.
And it's good for some doctors.

But is it in society's interest? Many suggest that it
saves money by lowering the cost per patient. But the
savings per patient (if they exist) are overwhelmed by
the increased expense of having so many more to treat.
Is it in the interest of sick patients? Absolutely not,
as caring for the well increasingly distracts doctors
from caring for the truly sick. And what about the well?
Is it in their interest? Only they can decide -- after
they have been informed that early detection is a double-
edged sword.

The writer is a professor of medicine in the Department of
Veterans Affairs and Dartmouth Medical School. He is the
author of "Should I Be Tested for Cancer? Maybe Not and
Here's Why."

© 2004 The Washington Post Company

===================================

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

In article <[email hidden]>,

George Conklin said:

Not according to the article. Early detection simply
means you know about it earlier.

But wouldent that be a good thing?

Dale J.

--
Email: [email hidden]

"Leonard Evens" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

dale.j. said:

In article <[email hidden]>,

Robert A. Fink said:

From the Washington Post:

Quoted message said:

Quoted message said:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500
Milvia Street Suite 222 Berkeley, CA 94704-2636 USA
510-849-2555

**********************************
NOTE: The material above is not "medical advice".
Medical advice can only be given after an in-
person contact between doctor and patient.
**********************************

I admit to not reading the entire above, sorry.

It's my understanding that early detection is key to
curing cancer of almost any kind. Do I have that part
right?

No. It depends on the cancer. There is considerable
uncertainty about how effective early detection is for
some common cancers. Certainly some will tell you that
there is no proof that early detection makes any
difference. What that means is that there has been no
double blind randomized study demonstrating it. In such a
study a carefully chosen group is randomly assigned to two
different groups, one is subjected to the method being
proposed and one is not, and then the results are
compared. There is one such study in progress in the US
now, but the results are not in yet.

But double blind studies are not the only kind of valid
evidence. They are the best kind because they try to avoid
what are called confounders, which are other factors which
might explain the results other than the feature being
studied. But they are not foolproof themselves. Actually a
study will only tell you about what you might expect to
find in a population which matches that of the study
population. For example, if you study PSA testing and
follow you population for 12 years, you can't necessarily
translate the results to another population which would be
followed for 15-20 years. Also, results in one country
might not be helpful for men in another country.

But note that just because we haven't proved by a certain
method that something is beneficial doesn't mean that we
have proved that it isn't beneficial.

But not for prostate cancer treatments as currently
evaluated. Those is a horrible amount of self-selection
by social class. It was the same with women and HRT,
which was ultimately proven to be harmful in many ways,
as in causing higher cancer rates, not lower as supposed.
But the demographic evidence is in, and it does show that
while there are widespread differences of treatment
patterns in the USA, they do NOT correlate with
longevity. Thus what is known is not when you want to
hear Len. Sorry.

"Robert A. Fink, M. D." <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Fernando said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a
Dr friend of mine suggested I go for a complete phyisical
exam including PSA... After this, I found out that my PSA
was 5.2 ( at 49 years

old)....subsequent

Quoted message said:

Quoted message said:

test indicated that I also had PCa !!! 5 years ago, I had
RRP....my last PSA test was still undetectable....In the
meantime, One of my brothers

died

Quoted message said:

Quoted message said:

of PCa, another is on his last days and the other is
still fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very

valuable

Quoted message said:

Quoted message said:

in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

Fernando,

Your "statistics" are what is called "anecdotal". You need
thousands of cases in order to prove a statistical
correlation, and those studies which *are* truly
statistical are quite equivocal as to whether widespread
screening with the PSA followed by aggressive
treatment/biopsy really makes a difference in survival.

Your comments suggest that you have an emotional
attachment to your beliefs (they are beliefs, not
scientific evidence), and while I can understand that (in
view of your family history), it doesn't make them
"scientific".

Why, BTW, do you need to disparage my title, Fernando? You
know, I am a "real doctor".

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

It is hard to give up the cultural bias for more and more
and more medical procedures, both for the averge patient
and the average physician together.

George Conklin said:

"Fernando" <[email hidden]> wrote in message
news:6sCFc.19141$IQ4.2196@attbi_s02...

Quoted message said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical
exam including PSA... After this, I found out that my PSA
was 5.2 ( at 49 years

old)....subsequent

Quoted message said:

test indicated that I also had PCa !!! 5 years ago, I had
RRP....my last PSA test was still undetectable....In the
meantime, One of my brothers

died

Quoted message said:

of PCa, another is on his last days and the other is still
fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

But you would not accept the results in any case.

See my remarks about extremists. Few medical authorities, if
any, whatever their position on testing for the general
population, would recommend against testing for a man with
Fernando's family history.

Robert A. Fink said:

dale.j. said:

It's my understanding that early detection is key to
curing cancer of almost any kind. Do I have that
part right?

This is not always true. Some cancers which are easily
detectable are associate with a poor survival even if
treated early (certain malignant brain tumors, for
example); and other malignancies (like prostate cancer)
may take a very long time to kill (or never will) even if
picked up late.

The operative word is "may". The details are important here.
For example, I had a Gleason 7 prostate cancer.
Retrospective studies on untreated prostate cancer suggest
that the risk of relatively early metastasis is higher than
many of us would want to chance. Also success rates of
treatment, in the best studies, are fairly high for many
such cancers.

One thing you should think about a bit as a surgeon is the
difference in the risk analysis from the point of view of
the surgeon and from the point of view of the patient. The
surgeon is concerned with how effective a treatment will be
for a population. The patient is concerned with what his
options are and whether the benefit to him is worth the
cost. These are two entirely different questions, and they
will generally have different answers. In particular,
although often prostate cancer will take a long time to kill
the patient (and in some cases may not do so), it may still
lead to unpleasant effects short of killing the patient.
Some patients when faced with such a risk may feel the odds
of side effects are low enough. Each of us will weight
different scenarios differently. In my case, I thought the
risk of metastasis, requiring the use of hormone therapy
with its side effects, and ultimately hormone resistant
prostate cancer, was high enough to justify my doing what I
could to avoid that risk. I didn't know if that risk was
over 50 percent. But even if it were as low as 10-20
percent, I wanted to avoid it if I could. It is pretty clear
from lots of evidence that treatment of early prostate
cancers in cases like mine generally delays the onset of
metastasis and in a high percentage of cases results in a
cure. I have seen no reliable estimates of my chances of
living a completely normal life without my cancer every
bothering me. Do you have an estimate of how many Gleason 7
prostate cancers never need to be treated? I would be
surprised if it were even as high as 10 percent.

Quoted message said:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

Robert A. Fink said:

Fernando said:

Leonard, George and Dale....

Always enjoy your answers and viepoints on subjects
discussed.....I have learned a lot from all of you.....

To "Dr" Fink, I am POSITIVE he is on the wrong track.....

I have 9 brothers....4 of us have been Dx'd with Prostate
Cancer...after knowing that 3 of my brothers had PCa, a Dr
friend of mine suggested I go for a complete phyisical
exam including PSA... After this, I found out that my PSA
was 5.2 ( at 49 years old)....subsequent test indicated
that I also had PCa !!! 5 years ago, I had RRP....my last
PSA test was still undetectable....In the meantime, One of
my brothers died of PCa, another is on his last days and
the other is still fighting the cancer strong....

I have SOLID evidence and experience that screening is
very, very valuable in treating PCa.

To "Dr" Fink, maybe he should go back and do his own
studies.

Fernando

Fernando,

Your "statistics" are what is called "anecdotal". You need
thousands of cases in order to prove a statistical
correlation, and those studies which *are* truly
statistical are quite equivocal as to whether widespread
screening with the PSA followed by aggressive
treatment/biopsy really makes a difference in survival.

You are lissutrating the difference in perspective I
mentioned in another response. It is true that if you want
to discuss the entire population of prostate cancer
patients, then his particular story is just one item which
may prove nothing about the generaly population.

However, as I noted previously, the evidence does support
PSA testing for men with family histories like Fernando's.
Do you know of any studies which dispute that assertion? I
suspect it would be considered unethical even to suggest a
double blind study in such a population. You would have to
find a population of younger men with several close male
relatives with prostate cancer, randomly assign half to PSA
testing and treatment where indicated and the other half to
no testing, and follow them for 15-20 years. I doubt if such
a study would be funded. So we have to base decision making
on other research studies, and I think such studies do
support testing in such cases.

Quoted message said:

Your comments suggest that you have an emotional
attachment to your beliefs (they are beliefs, not
scientific evidence), and while I can understand that (in
view of your family history), it doesn't make them
"scientific".

You also have an emotional attachment to your beliefs. We
all do. But I don't think you are in the habit of
questioning them.

Quoted message said:

Why, BTW, do you need to disparage my title, Fernando? You
know, I am a "real doctor".

But you are presumably not a prostate cancer researcher, so
your medical degree doesn't give you any more authority than
the rest of us in this discussion.

By the way, an old friend of mine, who also has a Ph. D.
maintains that you "real doctors" are only "doctors" by
curtesty. Originally there were only the teacher kind of
"doctors", and in the Middle Ages the term was extended by
curtesty to physicians. As you probably know, in England,
you would not be a "doctor" but would have another title
entirely. Unfortunately, physicians have so monopolized the
title that "real doctors" like me don't generally insist on
being addressed by that title, which seems ostentatious.

Quoted message said:

Best,

Bob

Robert A. Fink, M. D. Neurological Surgery 2500 Milvia
Street Suite 222 Berkeley, CA 94704-2636 USA 510-849-2555

**********************************
NOTE: The material above is not "medical advice". Medical
advice can only be given after an in-person contact
between doctor and patient.
**********************************

dale.j. said:

In article
<[email hidden]>,

George Conklin said:

Not according to the article. Early detection simply
means you know about it earlier.

But wouldent that be a good thing?

Again it depends. If there is no known effective treatment,
knowing about it early rather than late may not be helpful.

For prostate cancer I think it is generally helpful. You
don't necessarily have to treat prostate cancer just because
you know you have
it. It depends on the details of the diagnosis, the age of
the patient and some other factors.

Quoted message said:

Dale J.