The Vital Intangibles

BY RALPH BLUM

After living with prostate cancer for over two decades, there are some things that really stick in my mind as a “need to know” for anyone newly diagnosed with the disease. The most relevant of these is the major impact you can have on your own healing.

Greg Anderson who, after surviving “terminal” lung cancer, founded the Cancer Recovery Foundation, once said, “Retaining a medical team without doing everything you can to help yourself is like attempting to walk with one stilt.”

Your doctors will primarily be focused on attacking the tumor.  It is your responsibility to support your mind, body, spirit—and your immune system.  When I was first diagnosed, my ignorance about the immune system was monumental. Since then I’ve learned that my brain is constantly sending my immune system chemical messages which, for better or worse, influence its ability to function effectively.

A diagnosis of cancer tends to be overwhelming, and can generate feelings of disempowering fear and of loss of control. These responses have a negative physiological impact on the immune system. So reclaiming a sense of being in charge of your own life and health is an important foundation of the healing process.

There is growing evidence that creating high levels of well-being with proper nutrition, adequate exercise, stress management and emotional support is as necessary to your recovery as whichever cancer treatment you choose.

After understanding your diagnosis you will have several treatment options. Depending on the results of your pathology report, your doctor will recommend what he considers to be the best treatment program for you. But you need to play the central role in this decision. A passive, “Whatever you say, doc,” attitude will not serve you.

Before you commit to any treatment it is essential that you thoroughly research it, and are convinced that it is the right treatment for you. It is equally essential that you follow it with conviction, with the belief that it will be successful.  Hope, optimism, and excited belief are the great intangibles. The correlation between belief in treatment and effectiveness of treatment is extremely high.

Remember: Your medical team will be addressing just one part of your cancer journey. It is up to you to focus on your general health, and to examine your attitudes and your beliefs. According to a relatively new field of health psychology called “illness representation,” your beliefs and expectations really do impact the outcome of the disease.

 

The Power of a Word

BY MARK SCHOLZ, MD

At an Active Surveillance Consensus Conference in 2007, it was openly bemoaned that the word “cancer” profoundly overstates the significance of low risk prostate cancer.  The pathology experts who were present, however, shot down the idea of a name change saying, “Under the microscope it looks like a cancer, so it’s cancer.” At that time no one had a rebuttal, so the subject was dropped. Now studies confirm that Gleason grade six prostate cancer never metastasizes.

In retrospect, I wish the conference attendees had been able to rise up to the name-change challenge. Back when the makers of 7-Up wanted to emphasize the distinctness of their product compared to other soft drinks, they came up with the name “Un-Cola,” a stroke of marketing genius. Since the pathology experts insist that low-risk disease is a cancer—we should undo the negativity of this word by renaming it: “The Un-Cancer.” Alternatively, the SHADES of Blue classification system calls this harmless type of prostate cancer SKY BLUE.

Misinterpreting the significance of the word cancer leads everyone to think, “I had better be safe and remove the gland.”  The biggest challenge of educating people about prostate cancer is overcoming their preconceived notions, what they already think they know about cancer.  Random biopsies are detecting cancers that are so small that even if they grow while under observation, they will still be curable.  And for the minority of men on active surveillance who develop progressive disease, at least they have real proof that their cancer truly needs intervention, for this minority, it’s not a paper tiger and undergoing treatment is justified.

Defining the Un-Cancer—The Basic Components of SKY

	Favorable	Ambiguous Zone	Unfavorable
Color Doppler or Multiparametric-MRI	< 10 mm  in maximum tumor dimension	11-17 mm  maximum tumor dimension	> 18 mm max tumor dimension
Highest Gleason Grade	Grade 3 + 3 = 6	3 + 4 = 7	4 + 3 = 7 or higher
PSA Density	Under 0.13	0.14 to 0.17	Over 0.18

Further In-depth Testing for SKY
New technology is also providing new insight into how favorable cancer can be distinguished from unfavorable cancer. The biggest advance is better imaging of the prostate. Other new blood and genetic tests such as Prolaris, Oncotype, MDx, OPKO 4K and Mitomics, can also ferret out the cancers that are prone to behave more aggressively or have been missed on the initial random biopsy.

The Drawbacks for Active Surveillance
The main concern is that the initial random biopsy missed a higher grade tumor somewhere else in the prostate. Most centers address this problem by doing random biopsies over and over. Repeated random biopsies are unpleasant and they can cause serious infections.  Multiple biopsies have also been associated with higher impotence rates and worse urinary symptoms. A better way is to rely on modern imaging with color Doppler ultrasound or multiparametric MRI (MP-MRI). Also, because with active surveillance prostate gland is left intact, there is the possibility of a new, higher grade cancer developing. The privilege of keeping the prostate intact entails the responsibility of close monitoring. Then, if a new higher grade cancer subsequently develops, it can be detected and treated at an early stage.

Anxiety and uncertainty about living with untreated cancer is also a problem, one that is often magnified by the treating physicians, surgeons or radiation doctors who often send an ambivalent and lukewarm message about active surveillance to their patients.  This half-hearted attitude is probably rooted in the doctor’s own uncertainties about untreated cancer. Despite all these very real issues, however, studies show that men on an active surveillance program are no more anxious than men who have had surgery or radiation and are being monitored after therapy to make sure their cancer stays in remission.

It’s Hard to Teach an Old Dog New Tricks
It’s easier to teach a proper golf swing to a true beginner than to someone who has previously developed bad habits.  The mind of a child learns a new language much more easily than the cluttered mind of the adult.  Good first impressions are valued so highly because we all know how hard it is to undo a bad first impression.  Changing the mindset of doctors and patients about how to treat something called CANCER is going to be a slow process.

Men need to realize that survival rates with low-risk prostate cancer managed with observation are extremely favorable.  Studies show that survival with active surveillance matches the survival of men getting immediate surgery. Men need to guard themselves from being rushed into unnecessary treatments that have irreversible side effects.

Concerning Nutrition

BY RALPH BLUM

My last blog but one was about caloric restriction, because there is ever increasing evidence that overeating and being overweight leads to an increase in the incidence of prostate cancer, as well as the aggressiveness of the disease.

If you have been diagnosed with prostate cancer and want to delay radical treatment for as long as possible, I firmly believe that the best thing you can do for yourself is take a good, hard look at your eating habits, and probably make some serious dietary changes.

Despite conflicting medical recommendations concerning the role of diet in the treatment of cancer, men who have gone on strict macrobiotic or vegan diets have shown impressive results. However, most of us are not sufficiently disciplined to go to such an extreme. So I'm just talking here about cutting out foods that have been shown to accelerate the pace of cancer cell growth. And sorry, guys, but the two chief offenders are sugar, and red meat.

Glucose functions like gasoline, fueling all the cells in the body, and nutritionists all agree that cancer cells are especially greedy for sugar because growing cells have even greater energy needs. Dr. Patrick Quillin PhD, RD, CNS, internationally respected expert in the area of nutrition and cancer, claims he has yet to see a cancer patient beat the disease while eating a diet that constantly raises blood glucose levels. However, controlling blood sugar levels is no easy task when sugar is everywhere in our food supply.

While healthy, "essential" fats make the immune cells more likely to recognize and destroy cancer cells, the wrong kind of fat--the kind found in red meat-- increases the risk of disease progression. After extensive studies in China, where the consumption of animal protein is very low, the National Cancer Institute found that 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.

It amazes me how often the critically important topic of how diet affects cancer growth is underemphasized in most doctors’ offices. Part of the problem is the overwhelming flood of conflicting and constantly changing information about what does and what doesn’t help control cancer growth.  But the truth is there has never been a more important time in your life to eat well than when fighting cancer. And all the evidence points to a diet low in sugar and animal protein for cancer prevention and control.

I have recently become aware of the buzz about Vitamin D and prostate cancer. Greg Anderson, who in 1984 was diagnosed with stage 4 lung cancer and given 30 days to live, is founder of the Cancer Recovery Foundation International group of charities whose mission is to help people prevent and survive cancer. In the recently updated version of his book, CANCER: 50 Essential Things to Do, Anderson claims that excellent science shows that an adequate level of Vitamin D hinders inappropriate cell division and metastasis, decreases blood vessel formation around tumors, and regulates proteins that influence tumor growth. Additional research, he claims, shows that Vitamin D also enhances the immune system’s ability to fight cancer, and is an effective cancer preventative, particularly for breast cancer and prostate cancer.

Most of us, it appears, do not get adequate vitamin D in our typical diets—especially if we are elderly, dark-skinned, obese, or avoid the sun. Anderson stands firmly behind his recommendation for those dealing with a cancer diagnosis to supplement with vitamin D3 (not D2) at the rate of 5,000 IU daily. He believes that over 50% of all prostate cancers can be prevented with vitamin D supplementation, and that it helps make cancer treatments more effective.

So my advice to you is: cut out the steaks and sugared donuts, and check out your local health food store for Vitamin D3

JUNE IS NATIONAL MEN'S HEALTH MONTH -
Join Mark Scholz, MD at Barnes & Noble - Long Beach Marina Pacifica to discuss Men's Health and Invasion of the Prostate Snatchers. June 26, 2014 @ 7pm
https://groups.google.com/forum/#!topic/prostateoncology/EMCeMwSBvZU

Abstracts from the Meeting of the American Urological Association

BY MARK SCHOLZ, MD

Each year in May the American Urology Association meeting provides a treasure-trove of new scientific information.  As noted in my reviews from earlier scientific meetings, the results of new studies are communicated in 350-word Abstracts which concisely summarize the efforts of a team of scientists working on a specific clinical question.  Several thousand abstracts are published in the proceedings of the meeting, amounting to over a million published words.  On the topic of prostate cancer there were merely hundreds. This year I selected 46 for comment. This blog briefly comments on only a few of these abstracts. Each bullet point is for a separate abstract.

Active Surveillance

·        A large registry in Michigan that tracks prostate cancer treatment reports that about 50% of men with low-risk prostate cancer who are eligible for active surveillance actually undergo active surveillance (the other half get radical therapy). As sad as this sounds, 50% is double the reported active surveillance rates from 3-4 years ago, showing progressively increasing acceptance of active surveillance by doctors and patients. 

·        Laurence Klotz, the father of active surveillance and the lead investigator of the longest study of over a thousand men on active surveillance, reports that after more than ten years of monitoring, 3.6% of patients have developed metastatic disease and 1.7% have died of prostate cancer. Dr. Klotz points out that these statistics are similar to the expected mortality in low-risk patients that get treated with initial surgery or radiation.

Can Gleason 3 + 3 = 6 Metastasize?

·        2500 surgical patients were reviewed to determine if Gleason grade 6 can spread outside the prostate into the seminal vesicle.  In this study not a single case of seminal vesicle invasion was documented when the cancer was exclusively grade 6.

·        Out of 173 men with Gleason grade 6 who had their lymph nodes removed, not a single case of lymph node spread was observed. After an average of five years of observation, no patient has developed metastases.

Metformin and Statins

A number of previous reports have suggested that metformin and statins have anticancer effects. The anticancer effects of metformin have been only studies in diabetics but there is no reason to believe that metformin would be ineffective as an anticancer agent in non-diabetic men. Four abstracts at the AUA elaborate further on this active area of interest.

·        In Denmark, men taking metformin (for diabetes) were at one-third lower risk of being diagnosed with prostate cancer compared to men who were not taking metformin.

·        Men undergoing surgery for prostate cancer who were taking both metformin plus a statin had a reduced risk of cancer relapse—from 30% down to 15%.

·       In Finland, prostate cancer survival was evaluated in 6000 men depending on whether they were taking statins. Statin use reduced prostate cancer mortality by two-thirds.

·       In a study from Europe, there was a 60% reduction in overall mortality in men with advanced prostate cancer who were taking statins compared to those who were not. Both cancer mortality and cardiovascular mortality were reduced by a similar increment.

 Benefits of Surgery

·       In Denmark, the estimated length of life gained with surgery compared to the general population was only 0.4 years after 10 years of observation.

·       In France within 60 days following surgery, the mortality rate was one in a thousand surgeries. Mortality after surgery was nearly twice as high in hospitals performing less than 10 prostate operations a year compared to more experienced centers.

Treatment of a PSA Relapse

Here I quote directly from two abstracts on the topic of a rising PSA after surgery or radiation:

·        “We found that salvage radiation was associated with decreased use of salvage hormone therapy, as well as lower risks of local recurrence, systemic progression, and death from prostate cancer.”

·        “Approximately 16% of patients with a detectable PSA after radical prostatectomy may have false biochemical failure. Repeating the serum PSA in all patients with a detectable level is paramount before making treatment recommendations, especially if the patient had Gleason score 6, negative margins, and the cancer was organ−confined.”

Accuracy of Prostate MRI

One of the problems with random biopsy is that it finds too much grade 6 disease, leading to too much unnecessary radical treatment. Previous studies have indicated that multiparametric MRI finds high-grade disease quite well, only missing small tumors.  However, multiparametric MRI “sees” low-grade tumors much less, which is a good thing. Below are two new reports on this important new technology.

·       A multiparametric prostate MRI showing no cancer in the prostate is accurate 82% of the time for grade 6 cancer and 98% of the time for grade 7 or higher using a 12-core biopsy as the reference standard.

·       A multiparametric prostate MRI showing no high-grade cancer is accurate 74% of the time when using surgical removal and pathologic dissection of the prostate as the reference standard. The types of high-grade cancers that were missed by MRI tended to be smaller, secondary tumors that were organ confined.

I was encouraged to see so many abstracts on active surveillance at this year’s meeting. Also gratifying were the numerous reports on imaging, which in my opinion is the technology of the future that will eventually supplant random biopsy. All the 46 abstracts I judged interesting have been posted here: http://goo.gl/ZzwmpB