A prostate cancer bumper edition

ICYMI here’s a suite of studies – principally the ProtecT and linked study.

I’m told this is the most expensive trial ever. Which concluded that no difference in prostate specific cancer survival between three arms – active surveillance, radiotherapy, surgery.

(Remember we know that robotic surgery is no better than standard surgery – study earlier this year)

but………..lets buy lots of proton beam therapy and da Vinci robots

Oh and with all the spare capacity we can let the robots and protons free in other specialties and other surgical indications (with equally zero evidence of gain and mega cost)

I despair

Is it any wonder we are broke. Is it any wonder why the budget for specialised is continually overspent (ref HSC report, NAO, I could go on). It’s not just a prostate issue, it’s generalised.

We spend a lot in this area of medicine. For some it does good, for many it does harm…….stop and think about that…..the balance of good and harm in healthcare is rather a delicate thing. We often underplay the harm issue…..

And then we play in cost, and opportunity cost. Opportunity also counts as harm, in terms of what others are denied.

here’s why we should not screen for prostate cancer and be fairly circumspect about invasive treatments.

1)

Screening

the screening front end study is here (march 18). Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer Mortality The CAP Randomized Clinical Trial. This study matters because Prostate cancer screening remains controversial because potential mortality or quality-of-life benefits may be outweighed by harms from overdetection and overtreatment.

In this RCT, across nearly 600 UK practices 415k men aged 50 to 69 years undergoing a single PSA screening (n = 189 386) vs controls not undergoing a PSA screening (n = 219 439), the proportion of men diagnosed with prostate cancer was higher in the intervention group (4.3%) than in the control group (3.6%); however, there was no significant difference in prostate cancer mortality (0.30 per 1000 person-years for the intervention group vs 0.31 for the control group) after a median follow-up of 10 years.

Vinay Prasad did a good thread on Twitter unpacking the paper and background

See this icon array explaining risks and benefits of screening 1000 people.

2)

Treating localised cancer

10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer — NEJM

No survival differences between arms.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer — NEJM

Patient report outcomes deteriorate in all three groups in a way that you’d expect

Invasive treatment leads to more complications and worse outcomes.

EditorialTo be fair there are some nuances here that do warrant attention – esp age and risk stratified and re metastatic disease. Helpful in shared decision making,

Treatment or Monitoring for Early Prostate Cancer — NEJM

NIHR write up also worth a read

Science media centreexpert reaction to two studies reporting results on monitoring prostate cancer versus surgery or radiotherapy, and survival and cancer progression | Science Media Centre

3)

Gizmos – here robotic surgery but equally one could say the same about proton beam therapy, ask @pash22 on that.

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