The "Big T"

BY RALPH BLUM

In case you haven’t noticed, testosterone has become the hormone du jour as we older men seek to maintain the bizarre illusion that we are still really in our late 30s. The “Big T” is the principal male sex hormone--all about virility, what “makes a man a man.” It is largely responsible for the traits and characteristics that are considered “masculine”—muscle strength and mass, abundance of body hair, power and dominance, libido and—the big enchilada--erection strength and frequency.

The search for increased virility has been ongoing since ancient Greek Olympians feasted on goat and lamb testicles to boost their performance. Traditional Chinese herbalists apparently prescribed dried tiger’s penis for impotence. In 1889, a Harvard professor by the name of Charles-Édouard Brown-Séquard injected himself with a “rejuvenating elixir” containing the extract of dog and guinea pig testicle, reporting increased vigor and well-being. It wasn’t until Big Pharma got into the act in the 1930s that the hormone was isolated and named testosterone.

Fortunately, today, men don’t have to consume animal genitalia to increase their testosterone levels. Testosterone is readily available as injections, pellets, patches or gels for those men who need it. Less fortunately, smart advertising campaigns have made it sound like a panacea, promising increased energy, better concentration, increased muscle tone, less body fat, and, of course, higher sex drive. And who doesn’t want all that!

When the maker of Androgel launched its “Low T” campaign in 2008 showing dumpy, depressed men and their unhappy spouses, 1.4 million prescriptions for the drug were written in the U.S. in its first year alone. Today, men are spending billions of dollars on testosterone replacement therapies. Websites peddle testosterone without requiring a prescription, advertisements for “Low T” are splayed across billboards in Florida, and so many CEOs and Wall Street executives are taking it that the Media has dubbed it “Viagra for the Boardroom.” 

This extreme enthusiasm among men for the “Big T” may or may not turn out to be a good thing. What we do know is that for those men with prostate cancer, testosterone supplementation may be risky. Studies have shown that elevated testosterone levels are associated with increased risk for diagnosis of prostate cancer. The concern of course is that to prostate cancer cells, testosterone is like food.

I’ll let Dr. Brad Anawalt have the last word. In the Journal of Clinical Endocrinology & Metabolism he wrote: “We are threatened with a mad ‘T’ party.”

So if you have prostate cancer (or even if you fear a diagnosis of prostate cancer) and have been tempted by the advertising blitz promising that testosterone supplementation is the ultimate anti-aging formula, as the old Romans used to say, Caveat emptor: “Let the buyer beware!”

Men’s Health, The Big Picture

BY MARK SCHOLZ, MD

As a specialist in prostate cancer, I am in constant contact with men who are exerting prodigious efforts to get appropriate treatment for their disease. However, as many people are learning, low-risk forms of prostate cancer rarely lead to death.  Therefore, I am concerned that many men are missing the big picture regarding their overall health.  They have a greater risk of dying from other causes than from prostate cancer (Table 1).  Many of these common diseases are preventable by early detection.
The obvious place to start is with an annual physical with standard blood tests. Testing should include evaluation of liver and kidney function, mineral levels in the blood, evaluation of vitamin and hormone levels and testing for anemia and serum glucose. The specific blood tests are explained in more detail at http://prostateoncology.com/files/pdf/Standard_Laboratory_Tests.pdf
 
Heart Disease, the #1 Killer
The root cause of heart disease is cholesterol plaque, otherwise known as “hardening of the arteries” or atherosclerosis. Cholesterol infiltrating the arterial wall causes inflammation and scarring. Over time, scar tissue becomes calcified.  When plaque progresses to arterial blockage, a heart attack occurs. Similarly, a stroke occurs if an artery supplying blood to the brain is blocked.
 
Only Scans Can Measure Plaque
Cholesterol blood tests answer the question, “How much cholesterol is floating in the blood?" The real question that needs to be answered is, “How much cholesterol is sticking to the wall of the artery?”  Modern CT scans accurately measure coronary plaque with a dose of radiation similar to a set of dental X-rays. Color Doppler ultrasound measures plaque in the carotid arteries leading to the brain without any radiation exposure at all.
 
What if Plaque is Detected?
1. Obtain an exercise stress treadmill
2. Lower cholesterol and blood pressure
3. Inhibit blood coagulation with aspirin and fish oil
4. Follow a sensible diet and exercise regularly
 
Osteoporosis
With age, bones weaken from calcium loss. Osteoporosis is mistakenly thought to occur only in women.  However, one-third of hip fractures occur in men of advanced age.  Bone fractures have dire consequences associated with shortened survival, chronic pain and loss of height. Causes of osteoporosis include over-activity of the thyroid or parathyroid glands, excessive alcohol, caffeine or tobacco. Cortisone use, excess vitamin A, lack of exercise and vitamin D deficiency are additional potential causes. Hormone therapy used to treat prostate cancer can also cause osteoporosis.
 
Only Scans Can Detect Osteoporosis
Osteoporosis needs to be identified and treated before a fracture occurs. There are two types of scanning technology used to detect osteoporosis, DEXA and QCT.  While both types of scan are accurate in women, only QCT is accurate in men.  In men, DEXA seriously underestimates the degree of osteoporosis. 

Osteoporosis Treatment Protocol
1. Calcium 500 mg with dinner or at bedtime
2. Vitamin D 1,000 units daily.  Adjust dosage according to measured blood levels
3. Weight bearing exercise
4. Consider prescription medication with Fosamax, Boniva or Prolia
 
Colon Cancer
Colon cancer is easily curable when detected early. Screening can be accomplished with colonoscopy (a scope performed by a physician called a gastroenterologist), or with a CT scan, which is termed a virtual colonoscopy. 

Beware of Sarcopenia Muscle mass and strength automatically decline with age. Studies in otherwise healthy individuals indicate that poor fitness is more dangerous than smoking! Table 2 shows the dramatic difference in predicted 10-year survival of men age 65 depending on their fitness level. Muscle loss can be prevented with regular exercise consisting of weight training for an hour twice a week.

Lung Cancer Smokers who forgo lung scans are taking a huge risk. Lung cancer is almost universally fatal if diagnosed after symptoms such as cough, chest pain, or weight loss appear. CT scans can detect small lung cancers at an early stage when it can still be surgically removed and cured.  Smokers (and any ex-smokers who quit in the last 10-15 years) are crazy not to spring for $300 each year to have a lung scan done.

Flu and Pneumonia Flu is easily recognized by the sudden onset of fever, sore throat and body aches. Most people know about vaccines but forget that Tamiflu, an antibiotic, is effective if started within 24 hours of initial symptoms. The risk of pneumonia can be reduced by Pneumovax given every ten years. It is recommended for men who are over age 65 or who have a chronic illness. 

Conclusion The screening and early prevention program outlined in this article relies more heavily on scans, vaccines and prescription pharmaceuticals than many men would prefer. However, the serious health conditions listed above have a propensity to incubate silently until the day they suddenly explode on the scene as a full-blown disaster. The old aphorism, “An ounce of prevention is better than a pound of cure” certainly applies when there is an opportunity to detect and prevent life-threatening illness at the earliest possible stage. 

Why Is There So Much Resistance to Active Surveillance?

BY RALPH BLUM

Multiple studies have shown that the survival rate of men with early stage low-risk prostate cancer who choose Active Surveillance, matches that of men who choose immediate surgery, and without all of the attendant risks. Men who choose Active Surveillance are enthusiastic about having dodged the double bullets of erectile dysfunction and loss of urinary control. So if the virtues of active surveillance are so obvious, and major medical centers like Johns Hopkins are reporting excellent results with their active surveillance program, why are prostates still being removed at a record pace?

One reason is the pressure on for-profit private hospitals to boost the volume of procedures in a bid to hold onto huge annual profit margins. And the 2,900 non-profit hospitals across the country, which are exempt from income taxes, actually end up averaging higher profit margins than the 1,000 for-profit hospitals—in one case more than $500 million in the fiscal year 2010.

I’m not suggesting that these jaw-dropping profit margins are solely the result of the drastic over-treatment of men with prostate cancer. However, there is also no doubt that prostate cancer is a multi-billion dollar industry.

Take surgical robots: The so-called Da Vinci Robotic system, broadly acclaimed as “state of the art” for prostate surgery, costs more than $1 million to acquire and install. Roughly $1,500 worth of parts must be replaced after every procedure. The Da Vinci System is now in use in more than 1,000 hospitals and clinics across the country. When a hospital invests that much money in a surgical robot and trains surgeons to use it, the pressure is huge to sell surgery over other treatments.

So the advent of robot-assisted prostatectomies has significantly increased the number of surgeries performed each year. Nationally, 80% of men over age 70 with low-risk disease are either undergoing radiation or having their prostates removed unnecessarily. Yet there is a confluence of new evidence that men with a PSA of less than 10 who had surgery gained no benefit from the procedure; that in many cases, no treatment is the best treatment.

Of course what Ted Turner calls “serious cash money” is not the only reason for the radical over-treatment of prostate cancer.  Even though 91% of men with this disease will have a normal life expectancy, a diagnosis of prostate cancer leaves most men reeling and, in many cases, with an overwhelming desire to “just cut it out”—despite the risks and life disrupting side effects one can expect if the delicate nerve-sparing surgery doesn’t go as planned. Yet according to prostate experts at Johns Hopkins, if urologists separated out men with low-risk disease and entered them in an Active Surveillance program, prostatectomies would dramatically decline and patients would be better off.

Research is currently underway at Johns Hopkins to further refine the protocols for separating out low-risk, slow-growing prostate cancers from the high-risk, aggressive cancers. And it is worth noting that, in the meantime, of the hundreds of men who have been enrolled in Hopkins’ Active Surveillance program, not a single patient has died of prostate cancer.

A New Immune Treatment Combination

BY MARK SCHOLZ, MD

In my last blog I contended that of all the different ways to treat cancer—hormone therapy, chemotherapy, radiation or surgery for example—immune therapy has the greatest potential to save lives: Only the immune system, by its very nature, has the ability to adapt to the many thousands of varieties of cancer.  Also, new breakthroughs in understanding how it works have led to real progress inharnessing the immune system to fight cancer. 

One discovery—that the immune system uses a specific type of immune cell called the “dendritic cell” to detect cancercells—led researchers at a company called Dendreon to develop a five-step process for enhancing dendritic cell function.

First the dendritic cells are filtered out of the blood for processing in the lab. Second, the dendritic cells are exposed to prostatic acid phosphatase (PAP), a protein that can be identified on the surface of almost all prostate cancer cells. Third, the dendritic cells are incubated with granulocyte macrophage cell stimulating factor (GM-CSF) which converts the dendritic cells from their dormant state into an activated form. Fourth, the activated dendritic cells are infused back into the patient’s blood. Fifth, once back in the body, the activated dendritic cells recruit the killer cells of the immune system, the T-cells, to attack the cancer cells, which are identified by having PAP on their surface.

This five-step process, called “Provenge,” is an elegant and clever way to enhance immune function. Two prospective, double-blind, placebo-controlled trials have proved the efficacy of Provenge.  However, one cannot help but wonder why—since Provenge is simply an enhancement of the immune system’s normal function—is all this artificial stimulation in the lab necessary?  Why aren’t the dendritic cells in the cancer patient’s immune system detecting the cancer cells spontaneously and recruiting T-cells to attack it?

Another breakthrough has been the discovery that a normally functioning immune system, like all the systems in our body, is tightly organized by a variety of controlling hormones. Obviously, both underactivity and over activity of any system, be it the heart, the pancreas or the immune system, can be dangerous.  Now, new research reveals that malignant cells actually manufacture and release excess amounts of controlling hormones that trick the immune system into remaining dormant.  Thus the natural process of immune system detection is directly inhibited by the cancer.

Provenge partially circumvents this problem by activating the dendritic cells outside the body in the lab. But the dendritic cells still face a hostile inhibitory environment after they are re-infused. The question arises, “Wouldn’t Provenge work even better if the immune environment in the cancer patient could be rendered more “friendly"?”

In this era of rapid technological advancement it is not surprising that amedicine designed for this specific purpose is already on the market! Yervoy, a monoclonal antibody from Bristol-Myers Squib, was FDA approved to treat malignant melanoma in 2011.   Yervoy enhances immune function by counteracting the excess amounts of suppressive hormones being released by the cancer. I heard one researcher characterize Yervoy as the most powerful method available for “taking the brakes off” the immune system.

Provenge and Yervoy used together are so attractive conceptually that the only question remaining is about the optimal method of delivery.  Yervoy, unlike Provenge, can have serious side effects.  In excess amounts it can induce the immune system to run wild and start attacking the organs in the body like the liver, thyroid and intestines. Caution dictates beginning with a small initial dosage of Yervoy.

In the study we will be conducting at Prostate Oncology Specialists in Marina del Rey the first three patients we treat will be given one-twelfth of a normal dose of Yervoy one week after the Provenge is completed.  The second group of three patients will receive a one-sixth dose of Yervoy.  The third group of three patients will get three-twelfths of a Yervoy dose. All patients will receive full-dose Provenge and will be closely monitored for disease response, immune function and for possible side effects.

Provenge and Yervoy are just two of the many exciting new methods being studied for harnessing the immune system to fight cancer.  However, to my knowledge, we at Prostate Oncology Specialists are privileged to be the first to test the effectiveness of these two exciting treatments in combination.  Our first patient is scheduled to start on trial this month. 

What Diet Can Do For You

BY RALPH BLUM

Since my latest scare, when my PSA spiked and a color Doppler MRI showed a small but discernable growth in my tumor, my immediate focus has been on whether or not to begin treatment with IMRT. At the same time my wife, Jeanne, has been drawing my attention, once again, to my diet, and to which supplements can slow cancer growth.

It amazes Jeanne how this critically important topic is underemphasized when treating prostate cancer, despite overwhelming evidence that diet affects cancer growth. And even knowing what I know, I have been paying scant attention recently to my diet. Clearly now is the time to change that.

Extensive studies have proved that while certain foods are helpful in reducing PSA levels and cancer growth, other foods are not. First among the “not helpful” foods is animal protein that, particularly in the form of red meat, has been associated with an increasing incidence of prostate cancer. Other animal proteins—milk, cheese and eggs—also fuel the pace of cancer cell growth. As do all sugars, fats, and processed foods. In other words my basic food groups! But I can’t ignore the evidence. Dr. Dean Ornish, of cardiac diet fame, has achieved significant reduction of PSA levels in men with prostate cancer who went on his program consisting of a vegan diet (vegetarian, non-dairy) supplemented with antioxidants such as lycopene and selenium.

So given I intend to up my intake of “cruciferous vegetables”—in other words, broccoli, brussel sprouts and cabbage--that have been associated with a 50% reduction in prostate cancer risk, which supplements should I add to my diet?

Well, eating tomato sauce, which is high in lycopene would be a good start. A compilation of multiple studies measuring the amount of tomatoes in the diet, particularly cooked tomatoes, showed a 20% reduction in prostate cancer risk with increased consumption. (Lycopene can also be taken as a supplement.) And along with lycopene, selenium has strong antioxidant properties. Higher levels of selenium in the blood are associated with a 50% reduction in the incidence of prostate cancer. But as I am not a big consumer of Brazil nuts, clams, turkey or mushrooms, I am pleased to note that selenium can also be bought as a supplement in any good health food store.

There is increasing evidence that vitamin D inhibits prostate cancer growth. In studies using pharmacologic doses of synthetic vitamin D in men with relapsed prostate cancer, PSA levels stabilized and even declined in some men. Mark suggests a supplement of 2000 IU daily. He also advises against taking multivitamin or multimineral supplements as in some cases they may accelerate cancer growth.

It is much easier to swallow a pill than to change the dietary habits of a lifetime, but I intend to cut out red meat and eat more leafy greens and cooked tomatoes. And then there is pomegranate juice. According to Erik P Castle M.D., a urologist at the Mayo Clinic, early research suggests that drinking 8 oz of pomegranate juice daily may slow the progression of prostate cancer. And if you’re concerned about all that sugar, there is, of course, a pomegranate pill!

By the way, from everything I have read, dark chocolate is packed with flavonoids, a group of phytochemicals that act as antioxidants. I will take a closer look at chocolate in my next blog.