The Big Shift: “Eating to Live”

BY RALPH BLUM

For many men, a diagnosis of prostate cancer is a wake-up call to make lifestyle and dietary changes. If you have been diagnosed with the Low-Risk and even Intermediate-Risk form of the disease, and you have decided to delay radical treatment, it is particularly important to follow a diet known to inhibit cancer growth.

While it is not clear exactly what role diet plays in a man’s getting prostate cancer, once diagnosed, there is increasing evidence to support the effectiveness of diet in counteracting the disease.

Body-weight is a major factor. A number of studies conclude that over- eating and being overweight lead to an increase in the incidence of prostate cancer, as well as the aggressiveness of the disease. But until recently, I had done little to change my diet. What did it take to get this mule’s attention?

Over 50 million people in the United States are obese. I am 5’9” and, as of this writing, I weigh 205, which registers as “obese” on any grading system. My wake-up call was watching a 60 Minutes segment about children in Florida living within sight of Disney World, who were going to bed hungry night after night. It hit me like a sucker punch: Being obese in such a world is more than unhealthy and shameful; it is obscene. That same day I not only changed the way I eat but my attitude where eating was concerned, replacing eating for pleasure with eating to live.

To borrow a phrase from Bette Davis, making serious dietary changes “ain’t for sissies.” The approaches we men take to “the food thing,” as one doc I know calls it, range from rigorous, restricted diets on the one hand, to intelligent and moderate monitoring of their intake on the other. I am not talking here about going on a strict macrobiotic or vegan diet, just cutting out foods that have been shown to accelerate the pace of cancer cell growth. What makes a diet most effective is not what you eat, it’s what you abstain from eating.

According to all nutritionists the worst offender is sugar. Cancer cells are especially greedy for sugar—a fact dramatically illustrated in a PET scan. The PET scan uses radioactive sugar injected into the blood stream to locate tumors. Well, the uptake of glucose into the cancer cells occurs so swiftly that they light up like fireworks within ten minutes of the injection.

Sorry guys, but next on the “foods to avoid” list is red meat. Red meat contains more than 50% fat, and high fat diets increase the level of insulin-like growth factor which in turn increases the risk of prostate cancer. I have gone “cold turkey” on red meat, chicken, and almost all fish.

The National Cancer Institute has spent millions of dollars researching diet in China, where the consumption of animal protein—meat, milk, cheese and eggs—is very low. The most significant finding in these extensive studies was: the more animal protein you eat, the higher your risk of dying of cancer.  In the entire Far East, mortality rates from prostate cancer are eighteen times lower than in the U.S. 

So what to do? Start by throwing out the sugar cookies and Krispy Cremes, and cut way down on the booze (Did I forget to mention booze? Sorry). Next, take that steak off the barbie, and chow down on a plate of delicious and creatively seasoned steamed veggies, with a side order of adzuki beans for a shot of pure protein. It took my sense of shame to move me to act. But I’ve stuck with it. And, yes, it’s a little bit boring. But nothing to compare with being dead.

Two “Positive Side Effects” of Prostate Cancer

BY RALPH BLUM

There is an aspect of being diagnosed with prostate cancer that has proved to be, for many men, quite literally, a life-saver, and that is being compelled to undergo a physical. For example, men who had always avoided getting regular physical exams learned that they had dangerously clogged arteries, making that checkup, literally, a life saving event. So that although prostate cancer is no day at the beach, and every treatment comes with a stiff price, there can be unexpected benefits. What I think of as “positive side effects.” Getting a check-up is one such.

The second positive side effect concerns the loss of sexual drive. Aka the loss of libdo. So is there life without libido? Wrong question. Better ask, “After a life lived entirely with sex as your objective, what happens when your libido is gone?”

I spent 24 months with no libido. When I was diagnosed with prostate cancer, given my aversion to being sliced open, fried by radiation, or poisoned by chemotherapy, my choice of treatment was hormone blockade. At the same time, I was far from enthusiastic about becoming a chemical eunuch. So instead of the suggested three drug protocol—Proscar, Casodex, and Lupron—with the approval of my oncologist, Mark Scholz, I decided on “monotherapy,” a single drug treatment with Lupron. In less than four weeks my PSA had dropped from 18 o 5.3, so I knew that the Lupron was working. With no testosterone, however, my libido was zip. Nada.

A fate worse than death, right? Wrong. To my surprise, I didn’t feel defeated or “less of a man.” I realized it was not the end of the world. In fact, if not getting my libido back is my fate, well and good. Been there, done that. And then I got another big surprise: Being in this unfamiliar, hormonally uncharged space, permits a freedom I had not experienced during over half a century of full-blown libido. And a much richer emotional life with my partner. A new kind of intimacy.

In his play, Testosterone: How Prostate Cancer Made a Man out of Me, Hal Ackerman confessed that when he was on hormone blockade he found women’s bodies about as exciting as covered furniture. But through the wonders of Big Pharma, Ackerman discovered that having sex, love-making without libido, was a completely different and very rewarding experience: During their love-making, he focused totally on his partner’s pleasure instead of on his own.

When I was doing research for Invasion of the Prostate Snatchers, I interviewed a number of men who expressed their own surprise as the result of having no libido. As one man put it, “Remove the ‘slam-bam-thank-you, Ma’am’ routine and what’s left? I guess you could call it taking pleasure in giving pleasure.”

Now there’s a positive side effect if there ever was one.

Summertime

BY MARK SCHOLZ

The PCRI Conference is less than month away!   Every summer I scurry around making preparations.  Speakers have to be coordinated, exhibitors lined up, registrations fulfilled, entertainment scheduled. 

For this year we have significantly expanded the agenda:

Friday:  We have added introductory sessions that will be presented by our seasoned helpline facilitators, Jim O’Hara and Nathan Roundy.

Saturday Morning: Features the treatment of localized disease with various forms of radiation including seed implantation as well as covering high intensity focused ultrasound (HIFU).  In addition we will hear from the preeminent expert in the world on Active Surveillance, Dr. Laurence Klotz.  The morning will be rounded out with an update on the latest breakthroughs in imaging.

Saturday Afternoon: Will cover a multitude of recently FDA-Approved treatments for advanced prostate cancer presented by Eugene Kwon from the Mayo Clinic and Charles Drake from Johns Hopkins and yours truly. Amazing improvements have been made into medications that block testosterone, stimulate the immune system and poison cancer cells.

Saturday Evening: PCRI presents AdMeTech Foundation's “Dance for a Cure” with a LIVE performance by Jonathan Roberts and Anna Trebunskaya from the ABC hit series "Dancing with the Stars".

Sunday Morning: Our esteemed conference moderator Mark Moyad presents his latest thoughts on diet and supplements.  Snuffy Myers will talk about PSA Relapse. Stephen Auerbach discusses sexual rehabilitation.  Tim Wilson from the City of Hope updates us on robotic surgery.

Sunday Afternoon:  Breakout sessions with extensive Q & A will address the following topics: Diet, Focal Therapy, PSA Relapse, Active Surveillance, Radiation and Surgery. We will close with a round table of experts answering questions from the audience and discussing a selected clinical case.

I hope the rest of you are getting sand in your bathing suits and a mildly irritating sunburn.  See you in September.

Why Choosing Treatment for Prostate Cancer is so Difficult

BY MARK SCHOLZ, MD

Selecting the right treatment for prostate cancer is unbelievably challenging. With other cancers, where survival is paramount, the choice is simple—do everything that can be done! But with prostate cancer, quality-of-life considerations play a much larger role, since the treatments available at this time can seriously impact the quality of your life. For some men, once their type of prostate cancer is determined, choices are somewhat easier. For example, Low-Risk prostate cancer is relatively harmless and can be safely monitored. Treatment is often deferred because the cure is worse than the disease. Decisions about treating High-Risk prostate cancer are also fairly straightforward. Most experts agree that treatment with combination therapy is appropriate. The men faced with the biggest dilemma, however, are the 60,000 to 80,000 men diagnosed every year with Intermediate-Risk prostate cancer. 

All too often, prostate cancer treatment causes some degree of impotence and incontinence.  Who wants to face sexual dysfunction unless it is absolutely required for survival? Men with Intermediate-Risk disease often feel like they are in limbo because withholding treatment for their cancer is slightly risky, but so is the treatment.  

The situation is even more confusing because if you talk to men who have already been through treatment, some seem to have weathered surgery or radiation just fine. Unfortunately, if you keep inquiring, you will come across men who feel their lives have been ruined. Men reflecting on these issues face a hard reality: choosing one of the existing treatment options can immediately destroy quality of life, while forgoing immediate treatment means having to live with the ongoing possibility that delaying treatment might someday translate into fewer years of life.

Even after careful analysis, lingering questions are inevitable, since the very best that medical science can offer is an estimate of risk. The ambiguity of these circumstances, however, leaves a lot of room for personal preference. Once a man is thoroughly educated about all his options, he, rather than the physician, is in the best position to select treatment.  After all, he is the one who will spend the rest of his life living with the consequences.

Still, there is good reason to expect things to change, hopefully in the near future. Effective ongoing research is progressing rapidly in the areas of imaging, genetics, immune therapy, and targeted pharmaceuticals. The fact that prostate cancer, in the majority of cases, is a slow-growing condition, also works to the patient’s advantage.  Every year that goes by we are one step closer to less toxic solutions. As Ralph and I always emphasize, “If waiting makes sense, time is on your side.”

*See the What’s Your Type brochure at PCRI.org for a full explanation of the difference between Low, Intermediate and High-Risk prostate cancer

The Robots Have Landed

BY RALPH BLUM

Nearly every industry on God’s good earth has become mechanized in some form or another over the past 200 years, and the Prostate Cancer Industry—yes, it’s an industry, folks—is no exception. Enter the da Vinci Robot.

In 2009, according to Intuitive Surgical Systems (the company that manufactures the da Vinci robot), 85,000 American men, 86%  of those who underwent prostate cancer surgery that year, had robot-assisted surgery. Furthermore, roughly 75% of today’s urologists are being trained in robotic surgery, and the da Vinci robot is now found in more than 1000 hospitals and clinics across the country, snipping, slicing and dicing the family jewels. These are fairly staggering statistics. So let’s examine this infatuation with the robot.

Undoubtedly robotic surgery is currently the most advanced treatment option for men with localized cancers who still belong to the “just cut it out” school of prostate cancer. In the hands of an experienced robotic surgeon, you will experience less blood loss, less pain, a shorter hospital stay—usually only one or two nights—and faster recovery. Some men claim to be teeing off in a week. All great selling points. But what is the downside?

Obviously recovery varies from man to man depending on age, general health, and cancer stage. However it is not at all clear whether the long-term results or survival rate after robotic surgery are better, worse or the same when compared to the traditional open prostatectomy. And despite the marketing frenzy surrounding robotic surgery, studies to date show that rates of incontinence and impotence are virtually identical to the results obtained with the traditional methods, and ultimately depend on the skill and experience of the surgeon.

According to a recent study, a year after robotic surgery only one out of four men had recovered the ability to have intercourse. Another new survey showed that half of the men who undergo robotic surgery experience a greater incontinence problem and less sexual function than they anticipated.

A radical prostatectomy, whether traditional or robotically assisted, is a complex and intricate surgery. The prostate is located within millimeters of the bladder and the rectum, giving the surgeon very little room in which to work. And blood pooling in the operative field makes it seriously challenging to avoid damaging the nerves—thinner than a human hair—that run along each side of the prostate and control erections. Even in the hands of the most highly skilled surgeon you are fortunate if you achieve what Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering calls a “Trifecta:” negative margins (meaning no cancer left behind after the operation), maintained potency, and preserved urinary control. However, in less skilled hands such  good results are extremely unlikely.

Remember, it’s the surgeon behind the robot who is actually performing the operation. Even the best surgeons report impotence rates of up to 50% and incontinence rates of 10%. And not all surgeons are created equal. Too often, operations are being performed at community hospitals by surgeons without sufficient experience.

Opinions differ widely about how many robot-assisted operations a surgeon needs to perform in order to be considered “proficient.”  Some researchers estimate as few as 150 to 200 procedures. Others claim that as many as 1,600 operations are required in order to gauge with 90% accuracy how much tissue surrounding the prostate needs to be removed to get all the malignant cells.

Bottom line: A good outcome depends on the experience and skill level of your surgeon. So choose carefully. And before you decide, be sure to ask how many robot-assisted prostatectomies he has performed. You do not want to be part of your surgeon’s learning curve.

The lure of the robot is high-tech glamorous. The promise of a less invasive surgery with faster recovery time, plus the expectation of a better long-term outcome (based more on marketing hype than on actual studies), has almost doubled the number of radical prostatectomies performed each year in this country. So before you make what is sure to be a life-changing decision—and especially if your prostate cancer is the low-risk variety or you are 70 or over—don’t let all the publicity, or your urologist’s bias in favor of robotic technology, persuade you that surgery is your best treatment option.

Data from the recent Prostate Cancer Intervention Versus Observation Study (PIVOT) indicates that a vast majority of the 85,000 prostate cancer surgeries performed in 2009 were simply unnecessary. In other words, most of those men would live just as long without any surgery at all, and would be spared the risk of impotence and incontinence. Clearly men are failing to get the full picture of the risks and benefits of all the different options—Surgery, Seeds, IMRT, Testosterone Deprivation, Hormone Blockade, Focal Cryotherapy, Active Surveillance—before they commit to robotic surgery.

So, yes, the robots have landed. And whatever else is still uncertain, one thing is for sure—they employ first-rate Madison Avenue publicists.