Too Many Pills

BY MARK SCHOLZ, MD

It’s a painful reminder of failing health to be taking handfuls of pills every morning. Frustration mounts and the question often arises, “Are these pills really necessary?” Have I become the victim of a multibillion dollar medical establishment?

It’s logical to have questions. After all, what happens when your pills are stopped for a couple days—usually nothing! One can’t help but wonder, maybe some of these pills are necessary but all of them?  There must be some “extras” in there someplace. And what about interactions? Some patients intuitively suspect the human body has a maximum pill quota—they believe exceeding that maximum must be dangerous.

As a practicing physician, I have conversations about “too many pills” all the time. It makes me think of the movie Amadeus when the Emperor Joseph complained that Mozart’s music had, “Too many notes,” he said,” just cut a few and it will be fine.”

Patients often don’t understand the reason for their medications. Everyone agrees that the game of selecting medications is played by balancing benefits with risks. But this type of analysis requires homework beyond most people’s capability.

Yet when people unquestioningly defer to their doctor they feel powerless. They often have second thoughts.  Sometimes they feel resentment. Managing one’s health is a really high-stakes game. How can one attain greater peace of mind?

Bill Clinton famously stated, “Character doesn’t matter.”  But character is all we have to go on when we appoint a leader to make important decisions on our behalf. So actually, the opposite is true.  Character is very important.

While no human is perfect, physicians (and politicians) need to be held to a higher standard because in their position of power mistakes are much more damaging.  It may seem obvious to state, but the best way to find peace of mind is to look for a physician with exemplary character.

Making accurate character judgments is challenging, but for most of us, the alternative of running our own medical care is practically unattainable. I don’t mean to impugn doing some background medical research to take your conversation with the doctor to a higher level. But God forbid you discover in the course of your conversation that you know more about the subject than your doctor. Is there any revelation of character deficiency more devastating than that?

You can’t place all your trust in an Ivy-league degree or a Beverly Hills address. It’s the overall picture of the physician’s character that matters most. What type of people does the doctor hire for his office? What kind of doctors does he refer to?  Does his billing department behave in an ethical manner? Does he respect your time?   Does he listen to your questions? Realize that people can justify just about any kind of behavior if they consider themselves more important than you.

All of us practice character analysis in our daily life. Some of us are better judges than others. Ask friends or family members to come with you to the doctor visit and get their opinions as well. My co-author Ralph Blum who successfully dodged the prostate snatchers for twenty years has stated many times, “Patients must trust their instincts about their doctor and be willing to act on them.”

The Billion Dollar Question: Aggressive or Not?

BY RALPH BLUM

The billion-dollar question facing the approximately 240,000 men in the U.S. diagnosed each year with prostate cancer is: Do I get treated? Or not?

Overtreatment of prostate cancer is both a major problem and extremely costly both financially and physically.

Financially, because of the high cost of radical treatments and physically because most treatments can cause unpleasant and long-lasting side effects. Overtreatment was also the most important driver of the 2012 decision by the United States Preventive Services Task Force to recommend against routine screening for prostate cancer. Approximately 30-40% of men who have previously undergone surgery or other radical invasive treatment likely had indolent, slow-growing tumors that would never have become a threat to the man’s lifespan or health.  However, there is hope.

At the AACR-PCF conference in January 2014, Dr. Matthew Cooperberg, a urologic oncologist at the University of California, San Francisco (UCSF) warned, “If we don’t fix the problem of prostate cancer overtreatment, we will lose screening.” And losing screening would almost certainly mean more prostate cancer deaths—reversing a nearly 45% decline in mortality rates since screening started.

The crux of the problem is the supposed uncertainty about the accuracy of current predictors of tumor aggressiveness, leading physicians and patients alike to opt for a better-safe-than sorry approach that in turn results in extensive overtreatment. However, the vast majority of prostate cancers do not change their stripes. Cancers that appear to be slow growing when diagnosed are unlikely to cause serious problems during a man's lifetime. On the other hand, cancers that appear high-risk at diagnosis are indeed more likely to behave aggressively. So identifying them remains vital in deciding whether to treat or not to treat.

Some physicians and researchers are currently combining this clinical information with genetic information. Adding biomarker tests to clinical predictors further improves the identification of which prostate cancer patients could undergo Active Surveillance versus immediate treatment.

Now that Active Surveillance is a valid and safe way to treat low-risk prostate cancer men should not shy away from PSA screening.  We can’t return to the era prior to PSA screening.  Back then half the men diagnosed had cancer that was already outside the prostate.

PCRI Conference Recap

MARK SCHOLZ, MD

Early feedback about last week’s PCRI conference would seem to indicate that it was a resounding success. Close to 800 attended.  More importantly, the overall spirit of the conference was energized by hope as people learned about the many new treatment options. Also, we were blessed by one of the finest speaker lineups ever.  PCRI invited the world’s most eminent prostate cancer doctors to share information in their specific area of expertise.  

We also encountered real enthusiasm about the SHADES campaign.  I loved one comment from a conference sponsor, “It is truly imperative that we eliminate the shades of gray and replace it with SHADES of Blue.” It seems our message about prostate cancer not being a single disease is finally being heard.

For those of you unfamiliar with SHADES, PCRI has changed the technical names: Low-Risk, Intermediate-Risk, High-Risk, Relapsed, and Advanced disease each into a different SHADE of Blue: SKY, TEAL, AZURE, INDIGO AND ROYAL.  “Prostate cancer” is merely a broad umbrella term encompassing an immense spectrum varying from harmless to potentially life threatening. In this vast and confusing marketplace, SHADES help men distinguish between the different types of prostate cancer so they can be wise shoppers. Optimal treatment depends on correctly matching individual characteristics to appropriate therapy.

“Patient Empowerment” was the theme for the conference. The PCRI wanted to provide a place for patients to interact closely with experts and connect with other patients. Cancer care is advancing so rapidly that it takes a team effort with physicians and other patients to achieve the best care. For the average patient it’s too overwhelming to try and analyze the latest clinical studies, journal articles, and protocols.

The conference program opened with an update on active surveillance from Dr. David Krasne, a pathologist from St. John's Hospital in Santa Monica. Dr. Krasne discussed how imaging may be superior to using random needle biopsies for ongoing monitoring. Dr. Anthony Zietman, Associate Director of Radiation Oncology at Harvard Medical School presented the latest information about radiation therapy for intermediate and high-risk disease.  Dr. John Mulhall from Memorial Sloan Kettering discussed state-of-the-art science on preserving sexual function. My presentation was on relapsed prostate cancer. Dr. Mark Moyad moderated all the talks and gave a typically entertaining presentation on diet and supplements. During the Sunday breakout sessions patients and experts interacted with each other on a full spectrum of prostate cancer related topics.

No one can learn all about prostate cancer in a weekend; it’s too vast and confusing. Our job was to get patients started in the right direction.  Awareness is critical.  Now that treatments are becoming more effective, the stakes are much higher. No one wants to miss out on getting the best treatment.

PCRI strives to be an excellent resource by empowering patients, family, friends and support groups. PCRI also wants to foster a spirit of teamwork and cooperation that can make Shared Decision Making between patients and doctors a reality. We believe that the conference was able to successfully exemplify this spirit. DVD’s from the conference will be available soon and can be preordered at www.PCRI.org

The Lowdown On Testosterone Supplement and Low T

BY RALPH BLUM

Low testosterone or “low T,” also called hypogonadism, affects millions of aging men. Testosterone levels normally peak in a man’s 20s, then fall by 1% to 2% per year. Indisputably, low T is responsible for reduced sex drive and sense of vitality, erectile dysfunction, decreased energy, and diminished muscle mass and bone density.  As the poet T.S. Eliot reminded us, time the healer is also time the destroyer.

Men through the ages have tried outlandish cures for impotence, including chewing the roasted penis of a wolf! More recently they have plunged the family jewels into cold baths, choked down heaping spoonfuls of wheat germ, swallowed vitamins and most recently stockpiled Viagra.

When, in 1939, two scientists shared the Nobel Prize for Chemistry for their work in isolating and identifying testosterone, the mad rush for injected, implanted, inhaled or absorbed versions of the hormone began, promising, in the words of one product’s pitch, “power, performance, passion.”

In 2013, U.S. sales of testosterone reached $2.4 billion. According to Global Industry Analysts, the market is projected to swell to $3.8 billion by 2018. Moreover, in 2013, 7.5 million prescriptions for testosterone were written. And all this is happening without explicit FDA approval. There have been few, if any, large, randomized studies on the long-term risks or benefits of testosterone supplementation. Some maintain that we are undergoing a massive science experiment with unknown risks. But foggy science has not deterred Big Pharma from spending untold millions to encourage those of us who are wan, limp and flabby to climb onto the low T bandwagon.

Meanwhile, the most heated debate is centered on whether testosterone fuels prostate cancer. Not long ago, the consensus was that, as far as prostate cancer cells were concerned, testosterone was nature’s perfect food. It was like spinach to Popeye. Suppressing the hormone is still a standard part of treating the disease. But attitudes are changing.

The debate goes something like this:  If it’s true that testosterone fuels prostate cancer, why do most men develop the disease when they are older and their testosterone levels are dropping?  Others, however, point out that when men take hormone therapy that virtually stops the production of testosterone, tumors regress. So wouldn’t the opposite be true--adding testosterone should be expected to accelerate tumor growth? I personally believe that my episode of hormone treatment—monthly Lupron injections over a 15 months’ period—helped to delay the growth of my non-aggressive cancer for many years.

So far a few small studies of using testosterone in men with prostate cancer have shown fairly positive results. For example, men who had been treated for prostate cancer and who then received testosterone therapy did not appear to have an increased risk of recurrent disease. But it’s impossible to make broad, generalized statements based on these studies. Chances are the result will depend on a number of variables, not the least of which is the seriousness of the cancer. It seems likely that a man with low-risk of disease recurrence would also have low-risk of testosterone creating a problem. Therefore, it would seem ridiculous to deny that man testosterone when it would improve his quality of life.

There has been a major push for reconsidering testosterone therapy from the large population of men who have been treated for prostate cancer over the last 10-25 years. No surprise there. Which of us wouldn’t prefer to be firm and sharp rather than soft and dull? But remember, marketers are spending millions to raise our expectations, and testosterone is not a silver bullet.

In September, the FDA is gathering a group of experts for a T summit. But it’s doubtful if they will clarify a topic that has more guesses and theories than real answers based on reliable information. Bottom line it is our decision when the conditions are right to use testosterone, and when to refrain. As the old saying goes, “You pays your money and you takes your choice.”

Balance, Strength and Longevity

BY MARK SCHOLZ, MD

This morning I reached a milestone.  Standing up on one leg at a time without leaning on anything, I pulled on my shoes and socks without falling over.  Ever since I hired a trainer more than a year ago my balance has been steadily improving.  But it has taken me this long to gain enough strength and balance to pull of this feat.

My goal wasn’t performing successful balancing acts when I finally threw in the towel and hired a trainer.  For years I have known about the scientific studies equating fitness with longevity.  This connection is much more significant than most people realize.  The risks of a sedentary lifestyle equate to a pack-a-day smoking habit.

Knowledge is power but only if you act on that knowledge.  For three years I bought gym memberships, purchased a spectacular exercise machine (which I am trying to sell) and treated myself to a beautiful set of matched weights (which I am also trying to sell).  I even used my equipment a few times. I made a couple of visits to the gym, but with no consistency.

What was wrong?  Most of you already know the answer.  Bottom line for me—exercise causes pain. I am a busy person. I already have enough pain in my day-to-day life.  Last thing I wanted was to spend my limited free time experiencing more pain.

But my scientifically oriented brain just can’t ignore those pesky studies showing that a sedentary life style is as dangerous as smoking.  And after all, longevity is really my life’s work. People visit me from all over the country for advice on how to reduce their risk of dying from prostate cancer. When taken in its entirety, poor fitness is probably even more dangerous than prostate cancer itself.

Hiring a trainer is what finally got me over the hump. By making myself accountable to someone, my exercise became more consistent. It turns out that it’s in my nature not to cancel training sessions lightly because it affects someone else’s livelihood and schedule.  Also, I find the presence of someone with me during exercise is a welcome distraction, making the sessions less miserable.

I say, “over the hump” because once you get started exercising, you soon notice a subjective sense of well-being, more energy, smaller waistline,  more dietary freedom and better balance.  These successes all serve to remind me that my expensive exercise habit is really worth the cost.

There is a lot more to be said in favor of fitness.  The intimate connection between balance and strength alone is a huge issue for my mostly elderly clientele.  Acquiring the right kind of fitness trainer—a discerning one—is also important.  The message is clear:  attaining fitness is achievable.  All you need is enough conviction about the benefits of exercise to break out your checkbook and hire a trainer.