Adjuvant Hormone Blockade (HB) after Surgery for Men with Aggressive Disease

BY MARK SCHOLZ

The term "adjuvant" means treatment “added to” the primary or initial treatment. When the primary treatment is surgery, even when all detectable disease is removed, there remains a statistical risk that the cancer will return due to microscopic cancer cells left behind. Men with high-risk features such as extra-prostatic extension or high Gleason score face a higher risk of recurrence.

We need to understand the rationale for considering hormone blockade (HB) in treating aggressive prostate cancer. However, the scientific studies supporting this approach are still preliminary. Patients who have aggressive prostate cancer now are forced to make the best treatment decision possible with the data currently available.

In May 2011 the Journal of Clinical Oncology, Dr. Tanya Dorff and others reported on 351 men, average age 60, who were treated with two years of Casodex & Zoladex initiated immediately following surgery. The average PSA prior to surgery for men in the study was 7.8. PSA had to be less than 0.2 after surgery to be eligible for participating in the study. After completing two-years of hormone blockade half the men recovered normal testosterone within a year. By 18 months, 89% had recovered. After five years, relapse free survival rates of over 90% are impressive for these high risk patients where “high risk” is determined by historical relapse rates that approach 50%.

Almost all previous studies evaluating the benefit of adding HB to surgery showed no benefit. The resultant lack of benefit was probably due to the very short duration of HB—usually for only three months. There is one study by Dr. Martin Gleave at Vancouver General Hospital, comparing three months with eight months of HB after surgery, and showing a slightly better outcome for men with aggressive disease when HB was continued eight months.

The most compelling previously published study of adjuvant HB, authored by Edward Messing was performed in 98 men with proven node metastasis, half of whom received immediate HB.  In the case of men who did not get adjuvant HB, the relapse rate was quadrupled.

Adding HB to radiation for men with bad prognostic factors is standard because several large randomized prospective trials show that HB reduces relapse rates and prolongs survival. Given these indisputable benefits, it is surprising that a similar study to evaluate the benefit of longer duration HB after surgery has never been undertaken.

Long-term HB after surgery results in a much lower incidence of PSA progression compared to historical PSA relapse rates that have been reported in multiple studies. However, actual proof that long-term hormone blockade after surgery will enable men to live longer will require a randomized prospective trial.  The table below lists the projected five year outcome in the study by Dorff et al. depending on the different stages of the men participating in the study.

CLICK TABLE FOR LARGER VIEW

Medical Hexing

BY RALPH BLUM

This report is about a disgrace in the practice of American medicine. It is not an objective report. Because I have been subjected to it, I cannot hope to be dispassionate in my approach to the subject of medical hexing.

The stress of a diagnosis of cancer can throw patients into an “altered state” in which they are particularly vulnerable to suggestion—good or bad.  And because most of us, as children, are taught to believe in the infallibility of doctors, the manner in which a doctor delivers a life-threatening diagnosis has a profound effect, and actually has the power to influence the course of the disease.

If the doctor’s words are positive, they can plant within you, at a very deep level, positive expectations that you will beat the cancer, that you can be cured. Unfortunately, the reverse is equally true. The doctor can literally sentence you to death by using the dreaded word “terminal,” and telling you to go home and “set your affairs in order.”

This reprehensible behavior is a form of “hexing,” the medical equivalent of a voodoo curse. If a witch doctor leaped out of the jungle, pointed a bone at you and told you that you were going to die within six months, you’d probably laugh, albeit a trifle nervously. But when a modern-day witch doctor, wearing a white coat, carrying a stethoscope, licensed by the all-powerful American Medical Association, and supported by state-of-the-art scans and test results, tells you that you have only six months to live, his “curse” can significantly raise the chances that you actually will die. And often, right on schedule.

Everyone has heard of the placebo effect, the beneficial results that a sugar pill or some sham medical procedure can produce if the patient is told by his doctor that it will bring relief or healing. However, the placebo (Latin for “I will please”) has a less known evil twin, the nocebo (Latin for “I will harm”), which can produce equally powerful adverse effects. Medical hexing is a prime example of a nocebo at work.

In his breakthrough book, The Biology of Belief, cell biologist Bruce Lipton examines the mechanisms by which both our positive and negative beliefs control our biology. According to Lipton, our biology adapts to our beliefs—something all of us should keep in mind every time we step into a doctor’s office.

A significant part of any doctor’s job is to create a relationship with his patients based on trust, confidence and hope. Fact: regardless of his or her experience, no physician can predict the future for a specific individual, or the outcome of their disease. So if you are unfortunate enough to receive a “death threat” from your doctor, just remember: That’s his belief, not mine. And head for the door.

Andrew Weil, M.D, was among the first doctors to bring medical hexing to our attention, pointing out that it was a daily occurrence practiced by the entire medical profession—in hospitals, clinics and doctors’ offices. Weil called this behavior “unconscionable,” a term defined in The Concise Oxford Dictionary as “Not guided or restrained by conscience.”

At its most reprehensible, medical hexing becomes a form of  “iatrogenics,” from the Greek iatros meaning “physician” and genic, meaning “caused by,” the term used to identify physician- or drug-induced illness; illness attributable, at least in part, to negative suggestions by doctors, drug companies or other health care professionals.

To some extent, physicians and pharmaceutical companies are in a bind. Out-of-control malpractice suits have obliged them to protect themselves legally. Before surgery, for instance, patients are required by law to sign a consent form that describes everything that could conceivably go wrong as a result of the procedure.  And the form you receive from your pharmacist, along with your drug prescription usually contains a depressing list of warnings about the drug’s possible appalling side effects (“Tell your doctor immediately if any of these rare but very serious side effects occur” . . . “increases the risk of death” and on and on). The problem is that once these warnings have taken root in a patient’s mind, they can bear toxic fruit and become the stuff of self-fulfilling prophecy, the modern equivalent of a voodoo curse. 

There is, in surgeon Atul Gawande’s words, “an art to being a patient,” and practicing that art must include protecting ourselves against medical hexing. But what about the art of being a doctor, which begins with the oath every doctor takes to “First do no harm?” What puzzles and disturbs me is why more doctors haven’t spoken out against the insidious practice of medical hexing. 

Fifteen-Year Outcome of Very Delayed Hormone Therapy (DHT) vs. Immediate Surgery

BY MARK SCHOLZ

In May 2011 the New England Journal of Medicine reported on 695 men from Sweden, Finland and Iceland, average age 65, who were randomly allocated to either immediate surgery or delayed hormone therapy (DHT) between 1989 and 1999.  The median PSA for the 695 men was 13. Eighty percent of the men had palpable disease on digital rectal exam. In the men treated with DHT, hormone therapy was initiated if and when bone metastasis occurred. Bone scans were performed every other year.

The following Table summarizes the findings of the study:

The results of this study are updated and republished every three years since it is the only randomized prospective trial that reports long-term survival figures for surgery. Surgeons commonly refer to the study to bolster their claim that surgery saves lives. However, the survival difference between the two groups is only 6%. In other words, by undergoing surgery, only one man benefits from delayed death from prostate cancer for every fifteen men who have unnecessary surgery.

The message from this study would seem to be that the survival advantage from surgery is real, just not very big. However, there are two problems with this conclusion. First, the way men in this study were treated would probably be considered malpractice by most doctors in the United States. Few doctors recommend forgoing therapy altogether in otherwise healthy men starting with a PSA of 13, as was the case in this study. And delaying hormone treatment until bone metastases occur is generally frowned upon as well.

This study documents a modest longevity advantage as a result of surgery in men with relatively advanced disease compared to men who undergo no treatment whatever. However, the longevity benefit will probably be much smaller or absent in men with earlier-stage disease who are watched closely and treated at the first sign of disease progression, the option commonly termed “active surveillance.”

One potential benefit of immediate surgery should be noted: The men treated with surgery had a 24% lower incidence of requiring hormone therapy down the line. This advantage should be factored into the quality-of-life decision-making process.

   

Romancing the Immune System

BY RALPH BLUM

Mark Scholz, MD, recently posted a blog reporting that harnessing the immune system to fight cancer is a rapidly advancing area of research and new drug development. As I don’t have Dr. Scholz’s scientific background, my take on how to utilize the immune system revolves more around mind-body-interaction—how our thoughts and beliefs can influence immune function, and how we can contribute in subtle yet significant ways to our own recovery process.

As I understand it, the immune system is the body’s equivalent of the Department of Homeland Security. Its primary task is to provide constant surveillance and, when necessary, seek out “terrorists”—defective and cancerous cells—and destroy them. However, when immune surveillance breaks down or is compromised, it is usually as a result of environment pollutants, poor diet, lack of exercise, and an array of emotional suppressors.

We can’t do too much about environmental pollutants, so apart from finding a medical team you can trust, and improving your diet and exercising regularly, I suggest, somewhat tentatively (I’m aware that mind-body communication is not a hot topic with most guys!), that you at least consider the possibility that what you believe and think and feel might manifest in your body.

There is a significant amount of anecdotal evidence to support the whole mind-body-connection theory. Pioneering research by neuropharmacologist Candace Pert, Ph.D., demonstrated that the mind and body are one interconnected system that carries information—via messenger molecules known as peptides and neuropeptides—from the brain to the body and then back again in a continuous feedback loop. Bernie Siegel, MD, summed up the whole amazing process in three words when he famously said, “Feelings are chemical.” And Deepak Chopra went one step further: “Every cell in your body is eavesdropping on your thoughts.”

Emotional-Chemical Text Messages

Whoa! I thought, what does all this mean? What it seems to mean is that we have a simple choice: through this complex interconnected system we can either send our immune system messages that evoke a positive biochemical response, or we can send messages that downgrade or even suppress immune function.

The most potent immune suppressor is prolonged emotional stress—unrelieved grief, unresolved anger and resentment, persistent feelings of fear, anxiety and hopelessness. All these toxic conditions, in varying degrees, transmit negative Emotional-Chemical Text Messages to the immune system.

On the other hand, we can choose to “romance” the immune system by sending it loving thoughts, messages of hope and peace and, above all, our gratitude for the amazing job it performs, and for all the good things in our lives. And we can further support it by staying, as much as we can, in the present moment—by letting go of past regrets and grievances and refusing to squander energy worrying about the future.

Laughter—the Best Medicine

My favorite immune booster and also God’s favorite music (or so I’ve heard), is laughter. Here’s how the Discovery Channel Web site describes the impact of laughter on the immune system: “When we laugh, natural killer cells which destroy tumors and viruses increase, along with Gamma-interferon (a disease-fighting protein), T-cells (important for our immune system) and B-cells (which make disease-fighting antibodies). Laughter may well be the ultimate antioxidant.”

Everyone I know who has done well in the cancer wars has, to some degree, supported their immune system by sending it positive messages. Three thousand years ago, King Solomon declared: “A joyful heart is good medicine, but a broken spirit dries up the bones.” As Dr. Scholz pointed out, the “wet part of the bones, otherwise known as the marrow, is the place where the immune system originates.” Score one for King Solomon!

So I do my best to avoid stressful situations. I eat sensibly and exercise at least semi-regularly.  Above all, I laugh a lot, indulge in loving thoughts, and keep a editorial eye on the content of the Emotional-Chemical Text Messages I’m sending my immune system.