Is staging necessary in low to intermediate risk prostate cancer? Are we talking about me or are we talking about everybody else?

whether you think you can or think you can''re right

First off all…look at the sentence I highlighted in bold. Are you kidding me? Concerns about a CT scan and radiation all the while finding no complaints regarding treating the prostate cancer with radiation regardless if it’s seeds, Proton, or external beam.

The use of “misuse” is an attention getter is it not.

We have known for years that the likelihood of a positive bone scan for bone metastasis and a positive CT scan showing pelvic lymph note involvement is low in the patient with low Gleason’s and low volume disease on his prostate biopsy report.

In today’s world I as a urologist can tell the patient that biopsy shows cancer and then say, “The chances of finding anything on a CT scan or bone scan is low. It is however a part of the staging work-up for the newly diagnosed prostate cancer patient. Would you rather not do these studies? The patient decides based on the information that I have given him. These test are most commonly negative…but not always. What is the consequence of not doing the tests in the face of unknown metastatic disease? Well you get your prostate out, or get radiation, or HIFU, or cryosurgery for local disease when in reality it is not. Are you Okay with that?

You see what all the studies and reports fail to “get” is that statistics are different from actually sitting down with the patient and family and making decisions.

I guess with a National Healthcare Plan…the doctor will just say, ” Your prostate biopsy shows cancer and there is no need to do a bone scan or CT scan based on statistics of similar patients with a biopsy like yours.” Done.

Which is right or which is wrong? Well…everytime I make the diagnosis of prostate cancer someone somewhere sends me a form to fill out about the stage of Prostate Cancer my patient has. Well…if I don’t do a bone scan and a CT…I am assuming. Maybe the forms…i.e. the National Cancer Registry, or your local hospital’s Tumor Board has a little box to check stating the stage is I but that because of parameters of the biopsy a staging work-up was not done. As of yet and as of today…that box does not exist, but I am continually having to stage my patient’s cancer on some form.

So what to do?

Doctors misuse scans? Is it really that simple? Dear Dr. McHugh quit doing bone scans and CT’s to stage your patients. Also please fill out the attached form informing us of your patient’s prostate cancer stage or risk losing your hospital privileges until your medical records are up to date. What’s a doc to do?

Regarding the title of this post-My patients, after I have explained the likelihood of the results of the scans, most commonly opt to have the studies done. It is more information about their cancer and allows them to make treatment decisions. Right or wrong? What would you do given the choice?

What did I do? I did not have a bone scan or CT.

Doctors misuse scans in prostate cancer: study

Fri, Aug 26 2011

By Genevra Pittman

NEW YORK (Reuters Health) – Too many men with low- or medium-risk prostate cancer get CTs and bone scans that aren’t recommended for them, suggests a new study.

The scans are intended to tell doctors if cancer has spread beyond the prostate in men with high-risk cancer.

Doing them in other cases is a concern because CTs expose patients to small amounts of radiation — which itself is linked to future cancer risks — and the scans cost the healthcare system extra money, but have little potential benefit.

The research also suggests that not enough men with high-risk cancer get the scans, which means some of them may get treatment for local (confined to the prostate) cancer that’s unlikely to help if the cancer has spread.

“In high-risk patients, those are the ones that have a high risk of positive lymph nodes or (cancer that has) spread to the bone,” said Dr. David Samadi, a prostate cancer surgeon at the Mount Sinai Medical Center in New York who was not involved in the new study.

“Otherwise for low-risk disease, the likelihood of finding a positive bone scan or CT scan is low,” he told Reuters Health.

Guidelines from the American Urological Association say that doctors should use other measures such as prostate-specific antigen (PSA) testing to determine a man’s risk of advanced cancer and then only scan those with high-risk disease to determine the best treatment.

Researchers led by Dr. Jim Hu of Brigham and Women’s Hospital in Boston wanted to see how frequently those recommendations were being followed.

They consulted a database of U.S. men covered by Medicare who were diagnosed with prostate cancer in 2004 and 2005 — a total of 30,000 cases.

Both bone scans and CTs were more common in men who were diagnosed with high-risk cancer.

Sixty percent of those men had one of the scans. Still, one-third of men with low-risk cancer and almost half of those with medium-risk cancer had a scan in between diagnosis and treatment.

Hu and colleagues calculated that the cost of unnecessary scans in men with low- and medium-risk cancer billed to Medicare during those two years was about $3.6 million for their study group. (The government-run insurance program paid an average of $226 for each bone scan and $407 for a CT).

Extra scanning not recommended by guidelines “significantly increases Medicare expenditure without improving quality of care rendered for men with newly diagnosed prostate cancer,” the authors wrote in the journal Cancer.

And each extra CT scan exposes men to a small amount of radiation, while also providing an opportunity for doctors to catch something “incidental” that may not pose a threat but still leads to more testing or procedures, Samadi said.

Another recent study found that coaching and feedback from peers about the proper use of the tests helped prostate surgeons reduce the number of unnecessary scans they ordered. Samadi thinks many doctors are just trying to be on the safe side by ordering more tests.

“A lot of it has to do with the fact that most urologists when they think of prostate cancer it’s almost like a knee-jerk reaction — automatically they think bone scan and CT scan,” Samadi said.

The researchers noted that finding four in 10 men with high-risk cancer aren’t getting a scan is also “worrisome.”

If doctors don’t recognize that cancer has spread in some of those men, they said, they won’t benefit from treatment directed just at the prostate.

SOURCE: Cancer, online August 5, 2011.

2 Replies to “Is staging necessary in low to intermediate risk prostate cancer? Are we talking about me or are we talking about everybody else?”

  1. Thank you for such a thought inspiring article.

    It strikes so many chords and adds some crutial pieces into the jigsaw that is my understanding of prostate cancer.

    As a non medical guy with advanced non bony metastatic prostate cancer here in the UK my 4 years of research into the disease is always trying to put each stage and treatment options into simple (jargon free) statements that firstly enable me to understand where any confusion is but more importantly how I can explain prostate cancer as I carry out my awareness campaign trying to reach those men who for one reason or another have little or no knowledge of prostate cancer.

    Firstly men need to be offered at least an annual PSA/DRE tests along with other routine health checks.

    Secondly there needs to be clear guidelines as to which men are most at risk and those men MUST be informed of their risk.

    Thirdly we also need clear guidelines about if or when to treat.

    Fourthly we need to empower men so that they can make an informed decision about their treatment options. Currently it is the Dr who is the one that is informed so how can the patient possibly make a ‘shared informed decision’?

    As this article states too many men are exposed to radiation and other men (usually those most at risk) miss out on timely treatment that would give them the best chance of a ‘cure’ if a cure is ever possible with cancer. Early diagnosis surely must be the best way to save so many of our men.

    I have lost two dear (red sock) friends this year to prostate cancer and now I have just heard from Janice (Dougs wife) that Doug Gray of is very ill and getting weaker even though he was allowed Abiraterone 3 weeks ago.
    Doug has done so much work in raiseing the awareness of prostate cancer in men in the UK. Doug myself and many others may not escape from this disease but we will do our very best to make sure that as many men as possible have the opportunity of realising the health risks of prostate cancer and doing something about it.



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