PCRI: Prostate Oncology for the Masses

BY MARK SCHOLZ, MD

Dr. Steven Strum and I, medical oncologists who specialize in prostate cancer, founded the Prostate Cancer Research Institute (PCRI) in 1996. I still support the PCRI by donating my services as Executive Director. Through its conferences, helpline, newsletter and website, PCRI helps patients learn about optimal prostate cancer therapy.

Why is the PCRI important? “Modern” prostate cancer treatment, which is inherently biased toward surgery, is actually a throwback to the past. Prostate cancer is the last remaining type of cancer to have surgeons (urologists) directing care. Thirty years ago, because surgery was the only type of treatment available, cancers­ such as breast, colon, lung, pancreas and bone, for example, were supervised by surgeons. Now, every cancer (except for prostate cancer) is handled by medical oncologists—cancer specialists trained in a multimodality approach.  “Multimodality” means that all treatments (or treatment combinations) get equal consideration. Medical oncologists are trained to tailor therapy to the individual characteristics of each patient’s disease.

The problem is there are less than 100 prostate oncologists in the United States to serve more than three million prostate cancer survivors. That works out to a ridiculous ratio of 30,000 patients per prostate oncologist. To give you an idea of what a manageable patient-to-doctor ratio would be, at Prostate Oncology Specialists where I work with two other full time prostate oncologists, we have 1,600 active patients, a little more than 500 patients per oncologist.

Is prostate cancer an unusually simple cancer to manage?  No. It’s actually quite complex. What we term “prostate cancer” varies between extremes. There are low-grade forms that can be safely monitored; more serious types that require combinations of radiation and hormones; and “in-between” types that defy easy answers.  For men with the advanced, metastatic type of prostate cancer, the FDA has approved four new treatments in the last two years, more than I have seen in my last 20 years as a prostate oncologist.  Sequencing, timing, and combining these new treatments require skills few surgeons have time to master.

Sadly, simply providing up to date and accurate information to patients is not enough. Prostate cancer is not only complex, it is emotional. Patients and their families are all too often so frightened they need to be “talked down” from their emotionally charged state with professional support and encouragement. They can’t even begin to analyze their situation clearly until they calm down.

Also, when suddenly diagnosed with prostate cancer, many men have serious misconceptions that even professionals struggle to counteract. Three fallacies make men easy prey to a “just cut it out” mentality. First, men logically assume prostate cancer is just as dangerous as other cancers (see my October2012 blog, “The Un-Cancer”).  Second, men think the doctor who did their biopsy, their urologist, is a cancer expert. Third, they believe they need to make a quick decision before the cancer spreads. These mistaken beliefs mean men are at a severe disadvantage when seeking the truth.

PCRI tries to counter these problems by providing expert “one on one” support thorough its helpline and the online Blue Community. The PCRI has also recently initiated a new Mentor Program providing in-depth education for leaders of support groups.  We want everyone to understand their situation from the perspective of a prostate oncologist.  However, the magnitude of the task is daunting.  Every year almost a quarter of a million men— 650 men daily—get the shocking news that they have prostate cancer.

Even though this is my 17^th year serving the PCRI and the prostate cancer community, I am more energized, more focused and more determined than ever to make sure men with prostate cancer have the opportunity to get the best possible treatment.

However, the PCRI mission always needs financial support. PCRI heavily utilizes graphics, editing, internet and video to fulfill its mission. We also have expenses for bookkeeping, fundraising and grant writing. Every year PCRI undergoes a stringent “GAP” audit, documenting that more than 90% of dollars donated go to fund programs while less than 10% go to administrative or fundraising expenses.

If you are in a position to support the PCRI mission, your help would be greatly appreciated. Every donation increases our ability to get out much needed information to the prostate cancer community.

 

 

 

Stress: Romancing the Immune System (Part 2)

BY RALPH BLUM

Thanks to having to find a way to co-exist with prostate cancer for nearly a quarter of a century, I found myself enrolled in “Stress 101.”  And as I don’t have Mark’s scientific background, my take on how to alleviate the inevitable stress of dealing with this disease revolves mainly around mind-body interaction; in particular, the ways in which our chronic fears and concerns inhibit immune function and thus jeopardize our recovery.

Around three thousand years ago, King Solomon declared that, “A joyful heart is good medicine, but a broken spirit dries up the bones.” And I learned from Mark that the “wet” part of the bones—otherwise known as the bone marrow—is where the immune system is located.

In Invasion of the Prostate Snatchers I reported that, due to my refusal to redo a botched biopsy, there was no “proof positive” that I had prostate cancer. So, despite a urologist’s report evaluating the lump in my prostate as “suspicious for well-differentiated adenocarcinoma,” I returned to my home on Maui where I spent nine peaceful years enjoying my life. I had no idea at the time that those worry-free years in upcountry Maui supported and even strengthened my immune system. I am now convinced that they helped to keep the cancer dormant, on hold.

But then a series of life circumstances left me chronically stressed and depressed. I began to worry that perhaps I had been a fool not committing to treatment. And sure enough, that was when my PSA began to climb and the tumor began to grow.

My ignorance about the immune system at that time was monumental, but when I started to find out what makes it tick, I realized that my brain was constantly sending my immune system chemical messages which, for better or worse, influenced its ability to function. There is no doubt that good nutrition and staying physically active play a role in supporting a healthy immune system. My problem was I have never been big on raw foods, low carbs or a high intake of leafy greens. And I have an aversion to most forms of exercise. So I decided to focus on “romancing” my immune system by sending it benign signals.

In my next blog I will go further into what I have termed positive emotional-chemical text messages.

A Prostate Biopsy Can be Dangerous

BY MARK SCHOLZ, MD

Last August, I railed against too many biopsies. However, my experience at a recent prostate cancer meeting prompted me to revisit the topic for today’s blog.  There is now general agreement among experts that prostate cancer is over-diagnosed.  I believe this results from the excessive use of random prostate biopsy and, all too often, leads to radical over-treatment.

More than a million men in the United States have prostate tissue extracted by transrectal needle biopsy every year. Of all those biopsied, one-fourth, about 240,000 men, are diagnosed with prostate cancer. Of these 240,000, between one-third and one-half—that is, from 80,000 to 120,000—are diagnosed with a harmless condition destined to remain dormant for life. And yet, despite the innocuous nature of low-grade prostate cancer, the great majority of these unfortunate men still undergo radical treatment with decidedly negative impact on their quality of life.

The unwillingness of surgeons and radiation therapists to withhold treatment for low-grade prostate cancer is not entirely surprising given that doctors are specifically trained to treat cancer.  Understandably, patient enthusiasm for treatment is also a major contributing factor, considering how dangerous it would be to withhold treatment of most any other type of cancer.

The overtreatment of prostate cancer is giving experts sufficient concern that editorials are appearing in prestigious scientific journals, such at the Journal of Clinical Oncology and Lancet Oncology, discussing the possibility of renaming low-grade prostate cancer something besides “cancer.” Everyone seems to agree that it’s unreasonable to name a condition cancer when we know this low-grade form doesn’t usually metastasize.

Given these daunting issues, I was interested to survey a group of twenty male experts at a prostate cancer meeting last month about their attitudes toward biopsy.  Because the average age of the group was around sixty, everyone in the group readily agreed that if all of us underwent a standard random biopsy at least five would be diagnosed with prostate cancer. With such a high statistical risk of finding cancer, I then asked by a show of hands if anyone was interested in having a biopsy.

While an unnecessary cancer diagnosis is one risk of biopsy, there is one other significant risk: the possibility of toxic effects of biopsy itself.  The Journal of Urology this month reports that with prostate biopsy the rate of infections serious enough to require hospitalization has quadrupled to approximately one in fifty. One out every twenty of these infected men admitted to the hospital actually dies—making the risk of death from biopsy is one in a thousand.

Not a single doctor raised his hand.

Fortunately there is an excellent alternative to random biopsy.  Modern prostate imaging with 3-Tesla MRI or color Doppler ultrasound, is just as accurate for detecting high-grade disease. When an abnormality is detected through imaging, it can be targeted with just one or two biopsy cores instead of randomly shooting a dozen cores throughout the gland. And yet, despite the obvious advantages of imaging and targeted biopsy, practically all biopsies done in the United States are being performed randomly. 

Sadly, the general public—including most primary care physicians and even perhaps the majority of urologists and radiation oncologists—remains uninformed about the advantages of modern imaging technology. For more information about biopsy and Imaging Technology see my March 27, 2012 blog, Biopsy, Biopsy Everywhere: http://prostatesnatchers.blogspot.com/2012/03/biopsy-biopsy-everywhere.html

Stress: The Battlefield of Recovery

BY RALPH BLUM

When you are dealing with any kind of cancer, one of the really big questions is, “What can I do to help myself?” Well, one of the most important things you can do is look at the role stress plays in your life. Especially chronic stress.

There are many definitions of stress. The dictionary simply defines stress as pressure or strain. Hans Selye was the first to use the term “stress” in a biological context, defining it as a “state of prolonged tension from internal or external stressors.” Joan Borysenko, Ph.D. describes stress as the expectancy that bad things are going to happen and the expectation that we may not be able to cope with the fallout.   A diagnosis of cancer is a prime stressor, and causes a whole slew of emotions including fear, anxiety, grief, and resentment, all of which cause dramatic changes in the body’s hormones that suppress immune function. How does this occur? A fearful thought like, “Oh God, I think I’m going to die!” activates a primitive circuit known as “fight-or-flight.” When a threat is recognized, heart rate and blood pressure skyrocket, sugar pours into the blood, muscles tense for quick action, and the entire metabolism goes into survival mode.

This is great if you’re on the African savannah and you hear a lion growling outside your tent. However, Nature never intended the fight-or-flight response to last more than a moment or two. So when the brain sends a threat message for which there is no swift resolution, the fight-or-flight response stays stuck; you begin to put needless wear and tear on your body, and your immune system is no longer capable of performing the remedial function that is your most powerful defense against cancer.

Way back in 1964, Dr. George Solomon published a landmark article entitled “Emotions, Immunity and Disease: A Speculative Theoretical Integration.” Ten years later, Solomon’s findings were no longer regarded as speculative. There is no doubt today that living in chronic emotional stress inhibits immune function. According to Bruce Lipton, Ph.D., stress hormones are so effective at curtailing immune system function that doctors provided them to recipients of transplants so that their immune systems wouldn’t reject the foreign tissues.

So what can you do to counteract the inevitable stress of a cancer diagnosis and take an active part in your recovery process? In Invasion of the Prostate Snatchers I talk about “Emotional-Chemical Text Messaging” to the immune system. Because it possesses no analytical filter, the immune system acts on what it is, in effect, “told” by the brain. Although body cells possess intelligence, their only “knowledge” is the information they receive.  So you can either send messages that evoke a positive biochemical response in the immune system, or you can send messages that suppress immune function.

In my next Blog I will tell you how you can “romance” your immune system. In the meantime, as you make your way through the medical minefield, remember Deepak Chopra’s famous words: “Every cell in your body is eavesdropping on your thoughts.”

Happy New Year Announcement from Prostate Oncology Specialists

Jeffrey Turner, MD, Medical Oncologist, Joins Prostate Oncology Specialists in Marina del Rey, CA.

MARINA DEL REY, Ca., December 31, 2012 - Prostate Oncology Specialists is pleased to announce that Jeffrey Turner, MD has joined the prostate cancer specialist team. Dr. Turner is a board-certified internist and medical oncologist and will be specializing exclusively in prostate cancer with Mark Scholz and Richard Lam. Dr. Turner has been specializing in prostate cancer since 2009. He graduated cum laude from USC. Thereafter, he worked in research at UCLA studying infectious disease and molecular biology.  He earned his medical degree in Canada at Memorial University of Newfoundland and completed his internal medicine residency at the University of British Columbia and fellowship in medical oncology at the Medical University of South Carolina. Dr. Turner has published several articles on urologic cancers with an emphasis on prostate cancer.  He is a sub-investigator of a number of ongoing prostate cancer clinical trials.

Dr. Mark Scholz, Medical Director of Prostate Oncology Specialists commented, “Dr. Turner joins us during a time when the number of new prostate cancer treatments is exploding. He will add his expertise and knowledge to help patients make informed decisions. In 2012, we conducted clinical trials with Zytiga and Xtandi, agents that are now FDA approved.  We are presently evaluating new agents such as Curstersin, XL-184 and Ipilimumab in combination with Provenge.  We are happy to welcome a talented new member to the team who is familiar with all the many new treatment options for patients—this also includes Active Surveillance which is rapidly gaining acceptance as a viable treatment for prostate cancer.”

Active Surveillance remains very popular given the alternative risk of permanent side-effects from surgery, radiation, or cryotherapy. Dr. Turner added, “With the dramatic evolution of today's imaging techniques (including color Doppler ultrasound and MRI), Active Surveillance is best for men with Gleason 6, PSA<10, and clinical stage less than or equal to T2a.  Due to the fact that men with Gleason 6 prostate cancer have an incredibly low risk of mortality, Active Surveillance should remain a strong alternative.”
As skilled leaders in treating prostate cancer, our medical oncologists use PSA monitoring and color Doppler scanning to accurately monitor men on Active Surveillance. These techniques can detect early disease progression in men who may need to pursue treatment intervention.  

For more information about Active Surveillance or Prostate Oncology Specialists - visit: www.keepmyprostate.com or www.prostateoncology.com/activesurveillance