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October 29, 2007

More on Prostate Cancer Mortality

And the hits keep coming. Here's a newer chart, from the non-political Cancer Research UK, showing data from 2002 (rather than 1996):

Prostate Mortality

The numbers are a bit hard to eyeball, but it's reporting 15.8 (per 100,000) mortality in the US, and 17.8 in the UK. Moreover, you see the same story as the other graph: Very high incidence rate in America, but a mortality rate clustered around that of every other developed nation. Once again, the most likely conclusion is that bulk of the difference comes from America's aggressive screening procedures. Indeed, the organization explains:

Recent incidence rates are heavily influenced by the availability of PSA testing in the population and incidence varies far more than mortality. The highest incidence rates are in the United States and Sweden and the lowest rates are in China and India (Figure 1.2).7 The extremely high rate in the USA (125 per 100,000) is more than twice the reported rate in the UK (52 per 100,000). This is likely to be due to the high rates of PSA testing in the USA.

That's not a strike against the US. We have quite good prostate cancer treatment, and our mortality is better than most. But we don't have some sort of magical cure that the rest of the developed world missed. Which makes sense. After all, they read the exact same medical journal articles, do business with the exact same medical device companies, and purchase from the exact same pharmaceutical researchers.

October 29, 2007 in Health of Nations | Permalink

Comments

Moreover, you see the same story as the other graph: Very high incidence rate in America, but a mortality rate clustered around that of every other developed nation. Once again, the most likely conclusion is that bulk of the difference comes from America's aggressive screening procedures.

You have no idea how much of the difference is due to differences in screening procedures and how much is due to differences in the rate at which the disease occurs in the population. According to the American Cancer Society, risk factors for prostate cancer include age, race, diet, and obesity. These factors obviously differ significantly across nations. The ACS also says:

More testing in some developed countries likely accounts for at least part of this difference [in incidence of prostate cancer], but other factors are likely to be important as well.

But we don't have some sort of magical cure that the rest of the developed world missed.

I haven't see anyone suggest we have a magic cure. But our higher rate of PSA testing obviously contributes to our higher health care costs, and it may also contribute to a lower mortality rate than we would have if we weren't so aggressive at testing.

Posted by: JasonR | Oct 29, 2007 11:06:36 PM

I'd also like to point out that the technique used on Giuliani, prostate brachytherapy--using radioactive seeds--was pioneered in the modern era by a physician in Denmark, and brought to the US by one of his students.

http://caonline.amcancersoc.org/cgi/reprint/50/6/380.pdf

You'd think a guy whose life was saved by bradytherapy would admit, however grudgingly, that European socialized medicine ain't all bad.

Ah, but when you can make up statistics to justify spending twice as much as anybody else to get the same outcomes--provided you're wealthy or getting it free through your government job like Giuliani was--well, why would you let pesky facts get in the way?

Posted by: anonymiss | Oct 29, 2007 11:09:04 PM

Given that the average age of patients diagnosed with prostate cancer is 70 (src), clearly a large number of patients are being treated by Medicare, America's very own form of socialized medicine.

Posted by: Tyro | Oct 29, 2007 11:19:19 PM

By the way, everyone should look at Figure 1.3 in the document Ezra links to above. That figure provides prostate cancer incidence and mortality data for 27 European nations. The variation in both incidence and mortality is enormous, and there is no correlation between them at all.

Posted by: JasonR | Oct 29, 2007 11:28:27 PM

I hear that orgasms reduce the risk of prostate cancer. That's nice. (Much nicer than the fact that, say, sweets increase the risk of tooth decay, I'd say.)

It would be interesting to see how that chart would look if it were controlled for overall life expectency (or is it already?). It's tempting to attribute Chinese' or Indians' very low incidence to lower life expectency -- dying before prostate cancer becomes a risk -- but Zimbabwe's life expectency is pretty much rock-bottom and it has a quite high prostate cancer mortality rate, so that can't be the whole story (tragically, Zimbabweans can only expect to live half as long as Japanese). I wonder if Zimbabwe's high prostate cancer rate is due to prostate cancer as an AIDS complication. AIDS increases the risk of some cancers, surely, such as cervical cancer and Kaposi's sarcoma, but I haven't heard anything about it increasing prostate cancer.

Posted by: Julian Elson | Oct 30, 2007 12:25:42 AM

Hmm, if this is true, quite a change to the positive side since 1997. In only five years, the deaths by prostrate cancer declined from 26 to about 16/100k? Can we be sure that this isn't simply due to a different way of accounting???
:-/

Posted by: Gray | Oct 30, 2007 4:55:32 AM

It would be interesting, too, to see a statistic on the number of prostrate cancer operations. Regarding the high number of incidents, I guess it'sa almost certain that the US also have much more operations. Regarding the fact that every operation in old age is a considerable risk, it might be that any advantage from the bettewr screening is offset by more deaths because of complications arising form the treatment. The result being of course that the costs skyrocket without providing a significant advantage for the population...
:-/

Posted by: Gray | Oct 30, 2007 5:01:38 AM

"The variation in both incidence and mortality is enormous, and there is no correlation between them at all."

Well, it would be interesting to know if the statistic about incidents really covers the same diagnosis in all those nations. As we all know, there are benign and malignent tumors. Could it be that the US accounts all tumors as cancer, while in Europe, only malignent tumors go into the statistics? And, of course, this leads to another question: Is it possible that in the US many benign tumors are treated with surgery, exposing patients to unnecessary risks?
:-/

Posted by: Gray | Oct 30, 2007 5:22:52 AM

Don't want to spam this thread, but I'm still thinking about the surprisingly high number of incidents in the US. I have the suspicion that this can't really only be the result of better screening. Generally, better screening should help in diagnosing cancer at an ealier state. And the 'more conservative' screening in Europe should find cancer in a later, more urgent state. However, the numbers of incidents should be much closer together, if the only difference was a delay in diagnosis. Of course, some patients may have died in the meantime because of prostrate cancer or other, totally unconnected illnesses, but the 'body count' can't be that high. There have to be some other mechanics at work. Is it possible that prostrate cancer is actually really more common in the US, as a result of a different lifestyle? The high number of obese Americans comes to mind, for instance...

Posted by: Gray | Oct 30, 2007 5:32:51 AM

I am waiting for Ste/ve Sa/iler to turn up and explain that the high US cancer rate is because the US has so many genetically inferior minorities.

Posted by: ajay | Oct 30, 2007 7:03:16 AM

China has a miniscule mortality rate. I wonder if they have socialized medicine? Ya think?

Posted by: Mudge | Oct 30, 2007 7:31:53 AM

I know that genetics is a problematic topic, dangerously close to racism, but it seems there are some differences that should be noted. I mentioned this in a comment from 2006, when the prostrate cancer issue came up the same time:

"Via google, I've checked some german sources about the differences in prostate cancer incidences. It looks like the US uses a method called PSA-screening for diagnosing prostrate cancer. This has led to a huge boost in numbers of possible cancer cases. My guess is that this method produces some false positives, too. Also it has to be taken into account that the average age for patients diagnosed with this is 72 years here in Germany. This is only slightly below the average lifespan for males. The methods of treatment are very advanced in all western countries, resulting in a high chances of containg the tumor even in advanced cases. The chances for surving five years are at 74-80%.

Also it is a fact is that the risk for prostrate cancers depends on genetical, cultural and social factors. In Asia, men are less likely to get it, but the risk for Afro-americans is twice as high as that for caucasian white males. Studies hint that the risk for a male in one country may be seventy times that of the average man living in another part of the world. And scientist at the State University of New York even conclude that stress at the job, with the family or in the surrounding may boost the risk by several hundred percent!

So, this is a very complex issue. And there are huge differencies between different countries. Imho it's impossible to draw any conclusions from a simple graph like the one that cannon is relying on for his dishonest statement."

Posted by: Gray | Oct 30, 2007 7:52:51 AM

The numbers for Japan make me think that there is an ethnic component to the disease. You need the numbers by ethnic group before you can judge. I bet the USA has a higher rate of sickle cell anemia would this be due to more screening in the USA? I think not.

Posted by: Floccina | Oct 30, 2007 9:44:40 AM

"I bet the USA has a higher rate of sickle cell anemia would this be due to more screening in the USA?"

It's a scientific fact that sickle cell anemia is more widespead among Africans (including Afro Americans) than in other ethnicities. Afaik this has some evolutionary advatage, offsetting the handicap. And we shouldn' forget that gentical diversity actually is a good thing. It prevents mankind from becoming extinct from a single spread of a deadly virus. Even in medieval Europe, enough people survived the pest to keep the societies alive.

Posted by: Gray | Oct 30, 2007 10:00:24 AM

Oh my, JasonR is still at it, denying the obvious. Why don't you agree on this: the Guiliani ad is misleading since the data are not sufficient to determine whether Americans are really more inflicted by prostate cancer than Europeans, or if they are just more likely to be diagnosed with cancer. If it were true that indeed more Americans are suffering from prostate cancer, due to factors like "diet and obesity", then this fact would of course be irrefutable proof of the superiority of the USA vis-a-vis Europe. Guiliani would then be completely justified in taking credit for the good news - that Americans have a higher chance of being diagnosed with prostate cancer. If Guiliani had told the whole story and shown the actual graph, there'd be nothing wrong with it. But he didn't, and his ad was grossly misleading.

As an aside, consider this. If Americans have indeed a dramatically higher prostate cancer incidence for, say, genetic reasons (there is nothing to suggest this is the case but theoretically it could be), then it could as well be that their survival rate is higher due to genetic reasons, and not due to better health care. Again there is no evidence for such a mechanism but theoretically it is possible. If you insist on taking all theoretical pssibilities into account, rather than accept a common sense interpretation that is consistent with the data, then you also have to consider that possibility. As a result, you'd have to conclude that the data don't allow any conclusions about the quality of prostate treatment in different countries.

Posted by: piglet | Oct 30, 2007 1:35:15 PM

piglet,

There are obviously significant differences in the genetic composition of the populations of different nations. There are also significant differences in average age, prevailing dietary habits, and levels of obesity. All of these factors are implicated in the rate of occurrence of prostate cancer. The U.S. may have a substantially higher rate of occurrence of the disease than, say, most European nations, just as those nations may have a substantially higher occurrence than, say, most Asian nations. We just don't know. So we're not in a position to make claims about the appropriate level of testing.

Posted by: JasonR | Oct 30, 2007 1:49:42 PM

But the expense of testing is high, particularly for the uninsured. A friend in LA just got laid off and lost his health insurance, after positive PSA tests. So he now has to pay $361 out of pocket for the biopsy which came back negative, fortunately.

Losing insurance in the middle of treatment also meant if he HAD had cancer, he wouldn't have been covered for treatment for it.

Face it, our health care system SUCKS. ANYONE could find themselves in a similar situation, really.

Posted by: donna | Oct 30, 2007 4:46:03 PM

"Well, it would be interesting to know if the statistic about incidents really covers the same diagnosis in all those nations. As we all know, there are benign and malignent tumors. Could it be that the US accounts all tumors as cancer, while in Europe, only malignent tumors go into the statistics?"


Cancer is BY DEFINITION, malignant. Benign growths/cysts dont get counted in these statistics. They are talking specifically about prostatic carcinoma.

"And, of course, this leads to another question: Is it possible that in the US many benign tumors are treated with surgery, exposing patients to unnecessary risks?"


US is probably more aggressive in surgery, but no surgery is done without a biopsy-proven carcinoma, which is by definition, malignant.

They're not removing benign cysts, but its also not clear if USA has higher rate of radical prostatectomy and whether or not that makes any difference in mortality across nations.


Posted by: joe blow | Oct 30, 2007 9:33:36 PM

Referencing to the previous comment that pointed out that most prostate cancer is treated under medicare....

Might this account for the difference between the US-UK prostate cancer spread and the spread on lung cancer.

An American male has, IIRC, a chance of survival that is approximately 20% higher than the equivalent rate in Britain.

Lung cancer strikes much earlier (statistically) than prostate cancer, therefore is more likely to be covered by private insurance.

Perhaps if Rudy had smoked more cigarettes and eaten less smoked fish we would be having a more interesting debate.

Posted by: K. Larson | Oct 31, 2007 3:31:46 AM

JasonR, you have now repeated for the zillionth time what may theoretically be the case. You are not offering any evidence in support of your hypothesis, but I am willing (as I clearly stated above) to take your theoretical hypothesis seriously. It could be that the available data is not sufficient to support or refute any hypothesis in particular, that "We just don't know".

However from your position clearly follows that Giuliani was not justified to make his claims about lower prostate cancer mortality in the US and a better quality of health care in the US. If "we just don't know", then this must go both ways. Ezra Klein doesn't know, neither does Giuliani. I ask you now to confirm that you understand this implication of your position. I want you to say it: both Klein and Giuliani's claims are not justified by the data, both are misleading. If you are making a serious scientific point in this debate then you should have no problem to honestly state these implications. If however your intention is to deflect criticism from Giuliani by nitpicking around, then you are not in my view worthy of being taken seriously, and I will not continue this debate.

Posted by: piglet | Oct 31, 2007 6:06:50 PM

"I want you to say it: both Klein and Giuliani's claims are not justified by the data, both are misleading."

Nonsense. Where's the claim that Ezra made that is misleading? Read his stuff again, he was very careful in his statements. Totally unlike Giuliani, who bragged about the US being the #1. Btw, afaik Giuliani's caqmpaign already backpeddled and but the blame on a magacene Rudi read!

Posted by: Gray | Nov 1, 2007 4:59:51 AM

Gray, what I described was the implications of JasonRs position, not necessarily mine. Nor surprisingly, JasonR has not responded to my challenge. I assume he is really just trying to muddy the waters, rather than defending a genuine point.

Posted by: piglet | Nov 2, 2007 2:43:05 PM

"we have quite good prostate cancer treatment . . ."

Ezra-- That's the one point I have to disagree with. There is no evidence that any of the treatments that we have for early-stage prostate cancer save lives or even extends life by one day. And the treatments have serious risks. I've written about this on my blog here http://www.healthbeatblog.org/2007/08/screening-for-p.html#more and on tpm cafe here http://www.tpmcafe.com/blog/coffeehouse/2007/aug/27/what_no_one_tells_you_when_you_re_tested_for_prostate_cancer
I also wrote an update about the American Canncer Society saying docotors should Not recommend PSA testing here http://www.healthbeatblog.org/2007/08/update-aug-29-p.html

I'm writing about it again in this comment because it's so very important that men who are diagnosed understand that, rather than being treated, they might well want to choose "watchful waiting." Because the disease progresses so slowly 17 out of 20 men diagnosed with early-stage prostate cancer will die of something else. They will die with, but not of it and the vast majority will never be bothered by it. I'll get back to that later.

But you are entirely right that we appear to have lower mortality rates because we test more. (You can see this in graphs charting incidence of prostate cancer in the U.S. and survival during the time when the PSA test was introduced and became popular. First the indicdence of prostate cancer went way up--as if there was an epidemic. It was in fact, just overdiagnosis of "pseudo-disease"--tiny cancers that would never progress. Then, with time, mortality rates came way down. As testing became routine for everyone over 50, the pool of people disgnosed grew, but over time they died of something else. So it looked like the PSA testing was reducing mortality.

The problem is that once we diagnose early-stage prostate cancer, we over-treat it. There is no way to tell which cancers will progress and kill the patient. So many docotrs and patients feel that they Must Do Something Now. But we have No Evidence that any of our treatments for prostate cancer save lives or even extends life by one day. (Because the disease usually moves so slowly you have to follow men for decades to see which ones die of prostate cancer. There are a couple of long-term trials going on now, but we won't have results for 6 years. . . Observational evidence of risk vs. benefit of treatment is not encouraging.

This is why both the American Cancer Society, the National Cancer Institute, The U.S. Preventive Services Task Force and two colleges of specialists no longer recommend PSA testing. The NCI says there is no evidence that testing and early treatment changes the course or outcome of the diseases and the American Cancer Institute says that it is "inappropriate" for a doctor to recommend PSA testing to average risk men. Though doctors can "offer it" if they explains all of the risks and limitations of testing and early treatment.(Above average risk men are either African Americans or men who have a relative who died of the disease. But even then the ACS doesn't say PSA
testing or early treatment will help . . .)
The only group that now recommends PSA testing and treatment of early-stage prostate cancer is the College of Urologists. Guess Why? And the urologists who are surgeons are adamant that surgery is the best teatment while those who do radiation insist that it is the best and safest treatment.
Nomrally, the American Cancer Society and the National Cancer Institute are big fans of early detection and treatment. So why would they no longer be recommending PSA testing if they thought early treatment did any good?
The tragedy is that in most cases a man who has prostate cancer will never experience symptoms; he will die of something else long before the cancer bothers him. If he was never tested, he would never know he had it. Meanwhile, the treatments have severe life-changing side effects--mainly incontinence and/or impotence. (See my blog for the odds.)
Understandably, men who have been treated and are now impotent and/or wearing pads for incontinence years later insist that the treatment cured them. Most are convinced that the cancer would have killed them if they hadn't been treated. Regret is such a painful emotion--no one wants to feel that they were treated unncessarily. Certainly not Rudy. On the other hand, I recently read a friend of his talking about how much Rudy fears death. So he probably would have felt that
Someone Must Do Something Now.

A good urologist takes the time to talk the patient down from the ceiling. Early-stage prostate cancer is not a disease that will kill the patient in 6 months. He has plenty of time to think it over, make a decision. But I remember the look on Rudy's face when he came on TV to say he had cancer. . .
Other countries are far less aggressive in treating. The alternative to radiation or surgery is "watchful waiting". You go back every year, your urologist looks for signs that the cancer is growing over time (a higher Gleeson score on the biopsy. A single Gleeson score won't tell you if early-stage prostate cancer will progress, but rising Gleeson scores, over time, are a good indication.)
In the U.S. more and more honest urologists are beginning to recommend watchful waiting, particularly at academic medical centers like Dartmouth.
And some excellent work has been done at the University of Toronto where a surgeon named Dr. Lauerence Klotz has been monitoring 231 patients for more than seven years. If their cancer gets worse, he treats them. A year ago, he told Bloomberg Markets magazine that about 2/3 of his patients have not needed treatment, while just three have died of the disease. Over time, Klotz estimates, about 1.5 percent of men who might have been saved by surgery or radiation (again we just don't know if it's effective) but choose active surveillance instead will succumb.

It’s a small percentage—smaller than the percentage of men who suffer severe complications such as heart attack or stroke after prostate or external beam radiation.

I've read so much about this in part because a number of years ago, my husband was diagnosed with prostate cancer while still quite young. The urologist recommended radiation. My husband opted for watchful waiting. Years later, his PSA level has actually gone down. The doctor acknowledges that there is virtually no chance that the cancer will ever give my husband any trouble.

Posted by: maggie mahar | Nov 12, 2007 1:07:36 PM

"we have quite good prostate cancer treatment . . ."

Ezra-- That's the one point I have to disagree with. There is no evidence that any of the treatments that we have for early-stage prostate cancer save lives or even extends life by one day. And the treatments have serious risks. I've written about this on my blog here http://www.healthbeatblog.org/2007/08/screening-for-p.html#more and on tpm cafe here http://www.tpmcafe.com/blog/coffeehouse/2007/aug/27/what_no_one_tells_you_when_you_re_tested_for_prostate_cancer
I also wrote an update about the American Canncer Society saying docotors should Not recommend PSA testing here http://www.healthbeatblog.org/2007/08/update-aug-29-p.html

I'm writing about it again in this comment because it's so very important that men who are diagnosed understand that, rather than being treated, they might well want to choose "watchful waiting." Because the disease progresses so slowly 17 out of 20 men diagnosed with early-stage prostate cancer will die of something else. They will die with, but not of it and the vast majority will never be bothered by it. I'll get back to that later.

But you are entirely right that we appear to have lower mortality rates because we test more. (You can see this in graphs charting incidence of prostate cancer in the U.S. and survival during the time when the PSA test was introduced and became popular. First the indicdence of prostate cancer went way up--as if there was an epidemic. It was in fact, just overdiagnosis of "pseudo-disease"--tiny cancers that would never progress. Then, with time, mortality rates came way down. As testing became routine for everyone over 50, the pool of people disgnosed grew, but over time they died of something else. So it looked like the PSA testing was reducing mortality.

The problem is that once we diagnose early-stage prostate cancer, we over-treat it. There is no way to tell which cancers will progress and kill the patient. So many docotrs and patients feel that they Must Do Something Now. But we have No Evidence that any of our treatments for prostate cancer save lives or even extends life by one day. (Because the disease usually moves so slowly you have to follow men for decades to see which ones die of prostate cancer. There are a couple of long-term trials going on now, but we won't have results for 6 years. . . Observational evidence of risk vs. benefit of treatment is not encouraging.

This is why both the American Cancer Society, the National Cancer Institute, The U.S. Preventive Services Task Force and two colleges of specialists no longer recommend PSA testing. The NCI says there is no evidence that testing and early treatment changes the course or outcome of the diseases and the American Cancer Institute says that it is "inappropriate" for a doctor to recommend PSA testing to average risk men. Though doctors can "offer it" if they explains all of the risks and limitations of testing and early treatment.(Above average risk men are either African Americans or men who have a relative who died of the disease. But even then the ACS doesn't say PSA
testing or early treatment will help . . .)
The only group that now recommends PSA testing and treatment of early-stage prostate cancer is the College of Urologists. Guess Why? And the urologists who are surgeons are adamant that surgery is the best teatment while those who do radiation insist that it is the best and safest treatment.
Nomrally, the American Cancer Society and the National Cancer Institute are big fans of early detection and treatment. So why would they no longer be recommending PSA testing if they thought early treatment did any good?
The tragedy is that in most cases a man who has prostate cancer will never experience symptoms; he will die of something else long before the cancer bothers him. If he was never tested, he would never know he had it. Meanwhile, the treatments have severe life-changing side effects--mainly incontinence and/or impotence. (See my blog for the odds.)
Understandably, men who have been treated and are now impotent and/or wearing pads for incontinence years later insist that the treatment cured them. Most are convinced that the cancer would have killed them if they hadn't been treated. Regret is such a painful emotion--no one wants to feel that they were treated unncessarily. Certainly not Rudy. On the other hand, I recently read a friend of his talking about how much Rudy fears death. So he probably would have felt that
Someone Must Do Something Now.

A good urologist takes the time to talk the patient down from the ceiling. Early-stage prostate cancer is not a disease that will kill the patient in 6 months. He has plenty of time to think it over, make a decision. But I remember the look on Rudy's face when he came on TV to say he had cancer. . .
Other countries are far less aggressive in treating. The alternative to radiation or surgery is "watchful waiting". You go back every year, your urologist looks for signs that the cancer is growing over time (a higher Gleeson score on the biopsy. A single Gleeson score won't tell you if early-stage prostate cancer will progress, but rising Gleeson scores, over time, are a good indication.)
In the U.S. more and more honest urologists are beginning to recommend watchful waiting, particularly at academic medical centers like Dartmouth.
And some excellent work has been done at the University of Toronto where a surgeon named Dr. Lauerence Klotz has been monitoring 231 patients for more than seven years. If their cancer gets worse, he treats them. A year ago, he told Bloomberg Markets magazine that about 2/3 of his patients have not needed treatment, while just three have died of the disease. Over time, Klotz estimates, about 1.5 percent of men who might have been saved by surgery or radiation (again we just don't know if it's effective) but choose active surveillance instead will succumb.

It’s a small percentage—smaller than the percentage of men who suffer severe complications such as heart attack or stroke after prostate or external beam radiation.

I've read so much about this in part because a number of years ago, my husband was diagnosed with prostate cancer while still quite young. The urologist recommended radiation. My husband opted for watchful waiting. Years later, his PSA level has actually gone down. The doctor acknowledges that there is virtually no chance that the cancer will ever give my husband any trouble.

Posted by: maggie mahar | Nov 12, 2007 1:17:53 PM

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