Monday, June 16, 2008

Should You Shrink Your Prostate?



Okay, bear with me here while I have a brief fantasy about being a urologist.

New York Times
reporter, Gina Kolata writes in "New Take on a Prostate Drug, and A New Debate" about the pros and cons of asymptomatic men taking a medication to decrease their chances of getting prostate cancer. She notes that screening tests reveal cancers (and therefore have surgery and other treatments) that might not prove to be lethal--- some prostate cancers are slow growing and might be better left undiscovered.

With finasteride, as many as 100,000 cases of prostate cancer a year could be prevented, said Dr. Eric Klein, director of the Center for Urologic Oncology at the Cleveland Clinic.

Dr. Howard Parnes, chief of the prostate cancer group at the National Cancer Institute’s division of cancer prevention, also is convinced. “There is a tremendous public health benefit for the use of this agent,” he said.

While it might seem convoluted to offer a drug to prevent the consequences of overtreatment, that is the situation in the country today, others say. Preventing the cancer can prevent treatments that can be debilitating, even if the cancers were never lethal to start with.

“That’s the bind we’re in right now,” said Dr. Christopher Logothetis, professor and chairman of genitourinary medical oncology at M.D. Anderson Cancer Center. “Most of the time, treatment wouldn’t help and may not be necessary. But the reality is that people are being operated on.”


Kolata goes on to talk about whether all men should take the medication as prostate cancer prophylaxis. She says an early study showed that while it shrunk prostates and decreased the rate of cancer diagnosis overall, among study participants there was a slight increase in the percentage of aggressive tumors found, and initially there was concern that the drug was causing aggressive tumors, rather than just unmasking them.


So why does this Shrink Rapper want to blog about prostates? As I read Gina
Kolata's article, I thought about ClinkShrink's post, An Ounce of Prevention where we talked about the theoretical option of treating people at risk for a psychiatric disorder who may never develop one. It seems we do this all the time-- how many people take Lipitor or other statins who might never develop coronary artery disease? How many people with osteoporosis are given medications who might never break a bone without it, who might break bones even with them? Oh, and if you're male, and therefore at risk for Prostate Cancer, now there's something else to think about. There is, after all, iodine in our salt and fluoride in our water. Maybe it's not all bad?

13 comments:

Still Dreaming said...

interesting, very, very interesting.

I wonder what would have happened if i'd been given low dose ssri's as a teenager...would i have reached the super low point which pushed me to therapy and then the doctor? Depression runs in my family; on both sides. On the other hand, it's my anxiety that's the problem, not the depression thing. Either way, I wonder if things would have been different. Very hard to know.

I wonder if the psych med thing would be sort of like taking painkillers in case you hurt yourself...

Zoe Brain said...

Oh gosh, something I know a bit about.

Finasteride is a 5 Alpha Reductase inhibitor. Finasteride specifically blocks type-II 5-alpha reductase. Dutasteride blocks both Type-I and Type-II 5-alpha reductase.

5ARD inhibitors stop the conversion of testosterone to DHT (dihydrotestosterone).

DHT is the primary androgen in the prostate. It is a primary factor in the development and progression of benign prostatic hyperplasia (BPH) and other prostate diseases. It's also used in a lot of metabolic processes, so reduce it too much, and you get problems.

In this context, see Dutasteride: A Review of its Use in the Management of Prostate Disorders

IMHO I would be very wary of using anything that screws up one's endocrinology. There's too many risks of side-effects on the male reproductive system. But my conservatism in this area may just be a product of my own unusual endocrinology and experiences.

Straying off-topic, though it *is* related...

Parenthetically, my system went haywire the week after I started taking Lipitor. Causation is not proved, but that drug has side-effects on the male reproductive system too for a very few people. Anything that interferes with the LDL cholesterol -> testosterone -> DHT chain should be monitored very carefully. 99%+ will have no problems, but for a few, the effects can be spectacular.

46xy individuals born with 5 alpha reductase deficiency syndrome (5ARDS) look partly, somewhat, or completely female at birth. They masculinise partly, somewhat, or completely at puberty. Which means they face interesting psychological challenges. Many have female gender identities, and for them, Sex reassignment is required emergency treatment. Many have male gender identities, and the natural change cures their gender dysphoria. But a lot seem to just take it in their stride.

Unfortunately many are assigned female surgically as infants, and the resultant gender dysphoria in the males can be severe.

This should tell us a lot about the nature of gender identity.

Psychiatry101 said...

Sorry for being so anal but its not any male, it is for males above the age of 55.

The famous phase 3 trial ( i googled it....nope i am not so knowledgable otherwise)
also needed PSA lelvels of less than 3( i forget the units)

Also what i found interesting was that the trial was conducted between years 1993 to 1997.It was meant for 7 years but the results were so overwhelmingly great that it was closed early.

Also I have a feeling I do not make sense in my comments here hence to be doubly sure... is the grand rounds open for us non-doctors folks too?And is the grand about the regular phone that is coming out or the ishrink phone that you had blogged about earlier?

Also completely digressing from the topic here...but did you see this Tornado photo that a lady took on her digital camera?
http://thelede.blogs.nytimes.com/2008/06/13/a-remarkable-photo-from-tornado-country/
Also now that there are restrictions about quoting contents of Associated Press on blogs, I wonder if we could still put up the photo on our blogs and blog about it?
We are not so hard hit here but we had 4 scouts die here too.Its a mess.

Thanks,
Phoebe

Roy said...

Phoebe- Grand Rounds is open to any bloggers to submit their medical- or health-related post. The Submission Guidelines are HERE.

The iPhone theme is about the real iPhone, not the iShrink parody I posted about (please excuse my sense of humor). Why iPhone? Well, it is very close to the timing of the release of the new iPhone, some new medical apps were highlighted in Steve Jobs' WWDC keynote address, and we usually look for totally irrelevant topics to tie things together. Keeps things interesting.

Psychiatry101 said...

Roy: I had no idea you were joking.
Just yesterday night I read about humor of a therapist here http://graffiti99.blogspirit.com/archive/2008/06/17/humour-in-the-counselling-process.html

i was thinking good you are not my Psychiatrist as I would not even know when you joked.!Everything would kind off bounce off my head!
It suits my name though : Phoebe!!!

Anonymous said...

Dinah,

On a related note, why has medicine in general evolved into a drugs or nothing type of deal? Whatever happened to carefully watch your diet and exercise, especially if you are at higher risk for getting something. I admittedly don't know about about prostrate cancer but I am assuming that just like with other cancers, diet is very important.

If patients want to make the choice to have prophylactic treatment, I don't have a problem with that as long as they are fully informed of the risks. But I fear that isn't going to happen and the cure might end up worse than the disease.

AA

Dinah said...

AA--
Good point and I'm all in favor of healthy lifestyles and anything that helps.

Unfortunately, when it comes to cancer (and other illness), even people who do everything right, who live healthy, control their weight, don't smoke, wear seatbelts, exercise, etc...still get cancer. Sometimes the unlikeliest of peeps drop dead of unexpected heart attacks (Tim Russett wasn't one of them, he had a number of known risk factors).

I believe it's clear that modern medicine has extended at least the average lifespan (more people live to be older and healthier while older, people don't actually live to be any older and no matter what you do, 108 years is probably it). What the "right" diet is, however, seems to change depending on who you speak to. And that whole food pyramid thing is voted on by a committee, not something determined by science. So what one "should" eat to prevent cancer, of assorted kinds, isn't clear. Certain veggies probably keep things moving in your colon, and lots of exercise may decrease the risk of breast cancer (over 4 hours/wk).

Dinahs' suggestions:
--Don't Smoke
--Wear your seatbelt.
--Drugs are bad.
--Have really good luck.

Zoe Brain:
Thanks for the education. You know a lot about enzyme pathways.

Anonymous said...

Dinah,

Thanks for your response. On a related note, I came upon a site that had these statistics regarding "Numbers Needed to Treat"

http://www.wanttoknow.info/healthnewsarticles

1. Cholesterol Lowering Drugs - 1 out of 67 would benefit.

If this is accurate, it seems that drugs aren't worth the risk, especially when there are so many non med ways to lower it.

It would imagine it would also depend on family history. If I have a strong history of family heart and related issues, and my risk factors are strong for also developing there problems, then the NNT might not be as relevant for me. But for another person who has cholesterol slightly outside the acceptable range and doesn't have the other risk factors, it seems that meds should be a last option.

2. Mammograms - 1 out of 2000 would have a breast cancer death prevented - This seems low to me.

3. Osteoporosis Drugs - 1 out of 700 would benefit. I am really concerned about this one because I think these drugs are prescribed too loosely when there are so many non med ways to lower this risk factor.

I4. High Blood Pressure Meds - 1 out of 16 with mild high blood pressure would be prevented from having a stroke or heart attack

The key word is "mild" In this case, meds should be a last resort when just like with high blood pressure, there are ways to lower it without using meds.

5. The number of infections prevented by treating a victim of a dog bite with a week of antibiotics. 1 in 7 - In this case, this seems like a reasonable risk because the damage from a dog bite could be devastating and I can't think off hand of non medical ways to lower the risk of infection.

Please understand I am not against the use of meds as long as patients are given all the necessary information to make an informed choice. But I feel they aren't.

Take the NNT issue. I have not seen a serious discussion of what this really means as far as the odds in providing meds. vs. not proving them.

Even if the the figures this site provided are extreme, I still think this is a good starting point and I think this needs to be incorporated into discussions about meds with patients. Saying that every Dick, Tom and Harry should get prophylactic treatment is simply irresponsible and can cause tremendous damage. I know you get this Dinah but your colleagues in the psych and non psych world generally don't in my opinion.

AA

Anonymous said...

Dinah,

The site that I provided a link to in my previous post may seem extreme as it focuses on news coverups. I don't agree with things like UFO coverups for example

But think of how many times in our history, something seemed unbelievable only to find out it was true.

AA

Roy said...

This is quite thought-provoking. So, another way to look at it is, say, for the hypertension example where you need to treat 16 people to prevent 1 heart attack or stroke, it's like saying you have a room full of 16 people and you announce that 1 person it the room is going to have a heart attack or stroke, and this can be prevented if everyone takes the pill.

So, it comes down to how much of a risk-taker you are. Oh, add a financial risk to it. Saying to the room of 16 people, "The cost of the heart attack or stroke will be $20,000 and if it occurs, AND if you pay $100/mo for insurance, we will charge each of you 1/16th of that cost ($1250). If you don't pay the insurance, you have to pay the whole $20,000 (unless you declare bankruptcy or are indigent; in that case, the remaining 15 of you will pick up his tab at the cost of $1333 each). The pills would cost each of you $10 per month. So it costs $10/mo to prevent the eventual layout of $1200. (Mind you, I'm just picking random numbers here, but probably in the ballpark.) (It's not really costing you $100/mo in insurance to cover the risk of a heart attack or stroke, as the insurance covers many other things too, so maybe the proportion covering heart attack or stroke is $5-10?)

So there is also an element of altruism here (taking my pill and participating in the insurance scheme reduces the financial risk to the other people in the room).

Roy said...

AA said "But think of how many times in our history, something seemed unbelievable only to find out it was true."

This is also an NNT issue. How many unbelievable false things do we have to accept as truth in order to be right when one of the unbelievable things turns out to be true?

This is why so many people don't believe these unbelievable things, because we hear about so many things that turn out not to be true (boy who cried wolf syndrome).

Matt said...
This comment has been removed by the author.
Matt said...

roy your NNT analogy is different from what I understand it to be

Doing some rounding, figures would work more like this- two rooms of 100 people, and 20 in each group are going to have a stroke. With drug therapy (16 patients as NNT), one group will only have 14 people have a stroke while the untreated group will still have 20 strokes. 6 less will have strokes, but 80 will have taken medication for something that wasn't going to happen and 14 people will have taken medication that didn't do anything positive. Granted, it is extremely difficult to hand-pick the 6 that will benefit and only give medication to them.

I felt I needed to clarify since your example makes it seem like if we just treat enough sets of 16 people we won't have strokes (or whatever complications of hypertension) anymore.

For myself as a future physician, the problem is not in risk assessment- I think that a lot of that should be left up to patients based on information of an appropriate level for a patient with physician guidance as necessary. The problem I have is when one might have to go back to a patient 10 years down the line and say "well, according to a new study your seizure disorder might have been brought on by that medication I thought I told you all the risks for. Sorry!"

Had to edit for some grammar....whoops