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Prostate cancer kills
LETTERS TO THE EDITOR
Prostate
Cancer Kills
TO THE EDITOR:
Dr. Walsh (Prostate Cancer Kills: Strategy to Reduce Deaths. Urology 44: 463-466, 1994) has presented a brilliant argument in favor of aggressive case finding and surgical treatment for younger patients with “so-called” localized prostate cancer. The problem with his argument, however, is revealed in a statement from his summary: “I firmly believe that the 70-year-old man with D2 disease today was once a SO-year-old man with curable disease.” One could counter that argument by suggesting that if the 50-year-old man diagnosed with early localized disease was left alone and he lived for 20 years, then watchful waiting cannot be all that bad. The issue is that we have spent a substantial portion of the resources for urology research over the last two decades on treatment strategies even though the natural history of the disease remains enigmatic. As Dr. Walsh alluded to, we need to know more about the etiology of the disease if we are to be successful in prevention strategies. It is important, therefore, that enough resources are directed to long-term, population-based, prospective studies to elucidate the natural history of the disease. This effort will require that more urology residency and fellowship training programs place emphasis on teaching the fundamentals of research methodology, biostatistics, and epidemiology. This will help with the development of a cadre of urologists who are competent and interested enough in this not so glamorous of research endeavors. It will also help the average urologist coming out of training to be a better consumer of research literature and hopefully, a more costeffective provider. In spite of advances in diagnosis and treatment, current technology cannot accurately define all the relevant prognostic factors that are important in selecting patients for aggressive treatment. A recent report from Sweden has suggested that at least among Swedes, prostate cancer proliferation and aggressiveness are independent of a patient’s age.l The comparison between breast cancer and prostate cancer screening has to recognize the fact that the former affects mostly women in the prime of their lives, whereas the latter affects mostly men at the end of their natural lives. Of
550
even more significance is the observation that the mean doubling time of organ-confined prostate cancer is 5.8 years, while that for cancer cells left after radical prostatectomy is only 3 months, the same doubling time as breast cancer.2 The controversies over the conclusions of several reports derive from flaws in research design and data analysis. Several of the mortality data, including those cited by Dr. Walsh, suffer from biases that are inherent in case-control (retrospective) studies. Besides, there are no universally agreed criteria for deciding what constitutes a prostate cancer-specific death. Unless such criteria are established there will always be doubt regarding the validity of comparative mortality data from different institutions and even more so, from different countries. The argument that a randomized prospective study of all the available treatment modalities, including watchful waiting, may be unethical is moot because of the lack of consensus among many respected academic urologists regarding the merits or lack thereof of all these modalities. Finally, we have to be cognizant of the limitations of our health care resources and accept the fact that we cannot continue to dispense expensive treatments without clear evidence of costeffectiveness. K. Steven Among, M.D., M.P.H. 1950
McGraw
Avenue
Bronx, NY 10462 REFERENCES 1. Schmid HP, McNeal JE, and Stamey TA: Observations on the doubling time of prostate cancer. The use of serial prostate-specific antigen in patients with untreated disease as a measure of increasing cancer volume. Cancer 71: 20312040, 1993. 2. Gronberg H, Damber JE, Jonsson H, and Lenner P: Patient age as a prognostic factor in prostate cancer. J Ural 152: 892-895, 1994. REPLY BY THE AUTHOR:
I am pleased that Dr. Ansong appreciated my argument in favor of reducing deaths from prostate cancer. I found his rebuttal less convincing. He seems content to see a 70-year-old man die of metastatic prostate cancer. I am not. Furthermore, he attempts to perpetuate the myth that breast cancer is highly lethal, killing young women and
UROLOGY@ /
MARCH
1995 I VOLUME 45, NWBER
3
Prostate
Cancer Kills
TO THE EDITOR:
Dr. Walsh (Prostate Cancer Kills: Strategy to Reduce Deaths. Urology 44: 463-466, 1994) has presented a brilliant argument in favor of aggressive case finding and surgical treatment for younger patients with “so-called” localized prostate cancer. The problem with his argument, however, is revealed in a statement from his summary: “I firmly believe that the 70-year-old man with D2 disease today was once a SO-year-old man with curable disease.” One could counter that argument by suggesting that if the 50-year-old man diagnosed with early localized disease was left alone and he lived for 20 years, then watchful waiting cannot be all that bad. The issue is that we have spent a substantial portion of the resources for urology research over the last two decades on treatment strategies even though the natural history of the disease remains enigmatic. As Dr. Walsh alluded to, we need to know more about the etiology of the disease if we are to be successful in prevention strategies. It is important, therefore, that enough resources are directed to long-term, population-based, prospective studies to elucidate the natural history of the disease. This effort will require that more urology residency and fellowship training programs place emphasis on teaching the fundamentals of research methodology, biostatistics, and epidemiology. This will help with the development of a cadre of urologists who are competent and interested enough in this not so glamorous of research endeavors. It will also help the average urologist coming out of training to be a better consumer of research literature and hopefully, a more costeffective provider. In spite of advances in diagnosis and treatment, current technology cannot accurately define all the relevant prognostic factors that are important in selecting patients for aggressive treatment. A recent report from Sweden has suggested that at least among Swedes, prostate cancer proliferation and aggressiveness are independent of a patient’s age.l The comparison between breast cancer and prostate cancer screening has to recognize the fact that the former affects mostly women in the prime of their lives, whereas the latter affects mostly men at the end of their natural lives. Of
550
even more significance is the observation that the mean doubling time of organ-confined prostate cancer is 5.8 years, while that for cancer cells left after radical prostatectomy is only 3 months, the same doubling time as breast cancer.2 The controversies over the conclusions of several reports derive from flaws in research design and data analysis. Several of the mortality data, including those cited by Dr. Walsh, suffer from biases that are inherent in case-control (retrospective) studies. Besides, there are no universally agreed criteria for deciding what constitutes a prostate cancer-specific death. Unless such criteria are established there will always be doubt regarding the validity of comparative mortality data from different institutions and even more so, from different countries. The argument that a randomized prospective study of all the available treatment modalities, including watchful waiting, may be unethical is moot because of the lack of consensus among many respected academic urologists regarding the merits or lack thereof of all these modalities. Finally, we have to be cognizant of the limitations of our health care resources and accept the fact that we cannot continue to dispense expensive treatments without clear evidence of costeffectiveness. K. Steven Among, M.D., M.P.H. 1950
McGraw
Avenue
Bronx, NY 10462 REFERENCES 1. Schmid HP, McNeal JE, and Stamey TA: Observations on the doubling time of prostate cancer. The use of serial prostate-specific antigen in patients with untreated disease as a measure of increasing cancer volume. Cancer 71: 20312040, 1993. 2. Gronberg H, Damber JE, Jonsson H, and Lenner P: Patient age as a prognostic factor in prostate cancer. J Ural 152: 892-895, 1994. REPLY BY THE AUTHOR:
I am pleased that Dr. Ansong appreciated my argument in favor of reducing deaths from prostate cancer. I found his rebuttal less convincing. He seems content to see a 70-year-old man die of metastatic prostate cancer. I am not. Furthermore, he attempts to perpetuate the myth that breast cancer is highly lethal, killing young women and
UROLOGY@ /
MARCH
1995 I VOLUME 45, NWBER
3