BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, September 16, 2014

PCRI Conference Recap

MARK SCHOLZ, MD

Early feedback about last week’s PCRI conference would seem to indicate that it was a resounding success. Close to 800 attended.  More importantly, the overall spirit of the conference was energized by hope as people learned about the many new treatment options. Also, we were blessed by one of the finest speaker lineups ever.  PCRI invited the world’s most eminent prostate cancer doctors to share information in their specific area of expertise.  

We also encountered real enthusiasm about the SHADES campaign.  I loved one comment from a conference sponsor, “It is truly imperative that we eliminate the shades of gray and replace it with SHADES of Blue.” It seems our message about prostate cancer not being a single disease is finally being heard.

For those of you unfamiliar with SHADES, PCRI has changed the technical names: Low-Risk, Intermediate-Risk, High-Risk, Relapsed, and Advanced disease each into a different SHADE of Blue: SKY, TEAL, AZURE, INDIGO AND ROYAL.  “Prostate cancer” is merely a broad umbrella term encompassing an immense spectrum varying from harmless to potentially life threatening. In this vast and confusing marketplace, SHADES help men distinguish between the different types of prostate cancer so they can be wise shoppers. Optimal treatment depends on correctly matching individual characteristics to appropriate therapy.

“Patient Empowerment” was the theme for the conference. The PCRI wanted to provide a place for patients to interact closely with experts and connect with other patients. Cancer care is advancing so rapidly that it takes a team effort with physicians and other patients to achieve the best care. For the average patient it’s too overwhelming to try and analyze the latest clinical studies, journal articles, and protocols.

The conference program opened with an update on active surveillance from Dr. David Krasne, a pathologist from St. Johns Hospital in Santa Monica. Dr. Krasne discussed how imaging may be superior to using random needle biopsies for ongoing monitoring. Dr. Anthony Zietman, Associate Director of Radiation Oncology at Harvard Medical School presented the latest information about radiation therapy for intermediate and high-risk disease.  Dr. John Mulhall from Memorial Sloan Kettering discussed state-of-the-art science on preserving sexual function. My presentation was on relapsed prostate cancer. Dr. Mark Moyad moderated all the talks and gave a typically entertaining presentation on diet and supplements. During the Sunday breakout sessions patients and experts interacted with each other on a full spectrum of prostate cancer related topics.

No one can learn all about prostate cancer in a weekend; it’s too vast and confusing. Our job was to get patients started in the right direction.  Awareness is critical.  Now that treatments are becoming more effective, the stakes are much higher. No one wants to miss out on getting the best treatment.

PCRI strives to be an excellent resource by empowering patients, family, friends and support groups. PCRI also wants to foster a spirit of teamwork and cooperation that can make Shared Decision Making between patients and doctors a reality. We believe that the conference was able to successfully exemplify this spirit. DVD’s from the conference will be available soon and can be preordered at www.PCRI.org

Tuesday, September 9, 2014

The Lowdown On Testosterone Supplement and Low T

BY RALPH BLUM

Low testosterone or “low T,” also called hypogonadism, affects millions of aging men. Testosterone levels normally peak in a man’s 20s, then fall by 1% to 2% per year. Indisputably, low T is responsible for reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, and diminished muscle mass and bone density.  As the poet T.S. Eliot reminded us, time the healer is also time the destroyer.

Men through the ages have tried outlandish cures for impotence, including chewing the roasted penis of a wolf! More recently they have plunged the family jewels into cold baths, choked down heaping spoonfuls of wheat germ, swallowed vitamins and most recently stockpiled Viagra.

When, in 1939, two scientists shared the Nobel Prize for Chemistry for their work in isolating and identifying testosterone, the mad rush for injected, implanted, inhaled or absorbed versions of the hormone began, promising, in the words of one product’s pitch, “power, performance, passion.”

In 2013, U.S. sales of testosterone reached $2.4 billion. According to Global Industry Analysts, the market is projected to swell to $3.8 billion by 2018. Moreover, in 2013, 7.5 million prescriptions for testosterone were written. And all this is happening without explicit FDA approval. There have been few, if any, large, randomized studies on the long-term risks or benefits of testosterone supplementation. Some maintain that we are undergoing a massive science experiment with unknown risks. But foggy science has not deterred Big Pharma from spending untold millions to encourage those of us who are wan, limp and flabby to climb onto the low T bandwagon.

Meanwhile, the most heated debate is centered on whether testosterone fuels prostate cancer. Not long ago, the consensus was that, as far as prostate cancer cells were concerned, testosterone was nature’s perfect food. It was like spinach to Popeye. Suppressing the hormone is still a standard part of treating the disease. But attitudes are changing.

The debate goes something like this:  If it’s true that testosterone fuels prostate cancer, why do most men develop the disease when they are older and their testosterone levels are dropping?  Others, however, point out that when men take hormone therapy that virtually stops the production of testosterone, tumors regress. So wouldn’t the opposite be true--adding testosterone should be expected to accelerate tumor growth? I personally believe that my episode of hormone treatment—monthly Lupron injections over a 15 months’ period—helped to delay the growth of my non-aggressive cancer for many years.

So far a few small studies of using testosterone in men with prostate cancer have shown fairly positive results. For example, men who had been treated for prostate cancer and who then received testosterone therapy did not appear to have an increased risk of recurrent disease. But it’s impossible to make broad, generalized statements based on these studies. Chances are the result will depend on a number of variables, not the least of which is the seriousness of the cancer. It seems likely that a man with low-risk of disease recurrence would also have low-risk of testosterone creating a problem. Therefore, it would seem ridiculous to deny that man testosterone when it would improve his quality of life.

There has been a major push for reconsidering testosterone therapy from the large population of men who have been treated for prostate cancer over the last 10-25 years. No surprise there. Which of us wouldn’t prefer to be firm and sharp rather than soft and dull? But remember, marketers are spending millions to raise our expectations, and testosterone is not a silver bullet.

In September, the FDA is gathering a group of experts for a T summit. But it’s doubtful if they will clarify a topic that has more guesses and theories than real answers based on reliable information. Bottom line it is our decision when the conditions are right to use testosterone, and when to refrain. As the old saying goes, “You pays your money and you takes your choice.”

Tuesday, September 2, 2014

Balance, Strength and Longevity

BY MARK SCHOLZ, MD

This morning I reached a milestone.  Standing up on one leg at a time without leaning on anything, I pulled on my shoes and socks without falling over.  Ever since I hired a trainer more than a year ago my balance has been steadily improving.  But it has taken me this long to gain enough strength and balance to pull of this feat.

My goal wasn’t performing successful balancing acts when I finally threw in the towel and hired a trainer.  For years I have known about the scientific studies equating fitness with longevity.  This connection is much more significant than most people realize.  The risks of a sedentary lifestyle equate to a pack-a-day smoking habit.

Knowledge is power but only if you act on that knowledge.  For three years I bought gym memberships, purchased a spectacular exercise machine (which I am trying to sell) and treated myself to a beautiful set of matched weights (which I am also trying to sell).  I even used my equipment a few times. I made a couple of visits to the gym, but with no consistency.

What was wrong?  Most of you already know the answer.  Bottom line for me—exercise causes pain. I am a busy person. I already have enough pain in my day-to-day life.  Last thing I wanted was to spend my limited free time experiencing more pain.

But my scientifically oriented brain just can’t ignore those pesky studies showing that a sedentary life style is as dangerous as smoking.  And after all, longevity is really my life’s work. People visit me from all over the country for advice on how to reduce their risk of dying from prostate cancer. When taken in its entirety, poor fitness is probably even more dangerous than prostate cancer itself.

Hiring a trainer is what finally got me over the hump. By making myself accountable to someone, my exercise became more consistent. It turns out that it’s in my nature not to cancel training sessions lightly because it affects someone else’s livelihood and schedule.  Also, I find the presence of someone with me during exercise is a welcome distraction, making the sessions less miserable.

I say, “over the hump” because once you get started exercising, you soon notice a subjective sense of well-being, more energy, smaller waistline,  more dietary freedom and better balance.  These successes all serve to remind me that my expensive exercise habit is really worth the cost.

There is a lot more to be said in favor of fitness.  The intimate connection between balance and strength alone is a huge issue for my mostly elderly clientele.  Acquiring the right kind of fitness trainer—a discerning one—is also important.  The message is clear:  attaining fitness is achievable.  All you need is enough conviction about the benefits of exercise to break out your checkbook and hire a trainer.  
                     
 

Tuesday, August 26, 2014

First, find a Doctor You Like . . .

BY RALPH BLUM

A urologist I consulted in Hawaii, a man with a big reputation, told me to go home and settle my affairs, because I was going to die. That was 16 years ago.

When your are visiting a doctor, his reputation shouldn’t matter.  Even if he’s a great urologist or a world class prostate oncologist, If he makes you uncomfortable, dump him!  Never mind why.  This is your life. Find yourself another doctor.

Nor is this simply a matter of learning to be comfortable with personality differences. There is also a purely practical side to this— studies show that personality influences treatment selection.  “The physician a patient sees can influence their treatment fate,” according Dr. Karen Hoffman, lead author of a recent study from the University of Texas MD Anderson Cancer Center in Houston. “Physicians play an important role in whether or not men with low-risk prostate cancer are managed with observation or treatment.”

According to a new study, whether a man’s low-risk prostate cancer gets treated with surveillance, surgery or another form of radical treatment, may have more to do with his doctor than that man’s health status.   For example, the study found that urologists who have been practicing for more years or had more patients with advanced disease were less likely to use a wait-and-see approach to manage low-risk prostate cancer.

The issue of how physicians steer patients toward one treatment or away from another has become a major national health issue since prostate cancer is so common, occurring in over 200,000 men annually.  Dr. Hoffman and her colleagues write in JAMA Internal Medicine that most common type of prostate cancer, the low-risk variety, is not likely to affect how long men live even without treatment and  radical treatment  can lead to complications like rectal bleeding, impotence and problems with bladder control.

Good medicine dictates that the treatment a patient receives is supposed to be dependent on factors such as their age, health status and the stage of their disease.  Dr. Hoffman’s study euphemistically described as “doctor characteristics” as the main force driving treatment decisions. The study analyzed data from 12,068 men ages 66 years and older who were diagnosed with low-risk prostate cancer by 2,145 urologists between 2006 and 2009.

Only about a fifth of the men had their prostate cancer managed with active surveillance. The rest received up-front treatment, such as surgery or radiation.

The proportion of patients that each doctor put on active surveillance varied from less than five percent to about 64 percent.

The researchers found that doctor characteristics were twice as important as patient characteristics, such as age and other conditions, in predicting whether a patient would receive active surveillance or up-front treatment. “The rate of treatment of older men with low-risk disease is well documented to be extremely high,” said Dr. H. Ballentine Carter, professor of urology and oncology at Johns Hopkins Medicine in Baltimore “I think we need to do a better job of educating older individuals with low-risk disease.”

According to Ballantine, we are asking the wrong questions. The question should not be which treatment men need but whether they need any treatment at all.

One option for reducing potentially unnecessary treatment is to make public the track records of doctors who consistently advise radical treatment so primary care doctors would know that information before they referred their patients.

Dr. Hoffman pointed out that doctors would also want to base their decision on other measures, such as potential complications after treatment, age, and follow-up care, because active surveillance is not always the best treatment option.

Bottom line, patients need to feel good about their physician. And equally important, they must become more proactive regarding the big question: To treat or not to treat?