Medications for Prostate Cancer that Might Help and Probably Won’t Hurt

BY MARK SCHOLZ, MD

Do we have confidence in our prescription pills?  How can we really know that they are helping?   It partly depends on whether or not there is a benefit.  Fever disappears soon after starting an antibiotic.   PSA declines in men with prostate cancer who undergo hormone blockade.  Blood pressure is better after starting a new blood pressure medication.

We have confidence in these medications because there is a measurable benefit.  Seeing a benefit offsets our suspicions about potential side effects. Medication choices really boil down to a simple equation: balancing the benefit against the risk of side effects.

But sometimes it’s difficult to see the benefit, especially if the medication is being used because of the benefits were only reported in a population study showing and advantage of one group of people over another.  Baby aspirin is a good example. How do you really know that the pill you took today helped you dodge a heart attack?

Science and the Media
Interpreting scientific studies requires skill and training. But these days, the challenge is even greater because scientific studies are primarily reported in the media.  Unfortunately, media experts face tremendous temptations to make their stories more interesting. So they tend to overstate their importance.  As a result the general public is becoming very wary of supposed scientific finding.   

Considering Risk, What about Low Risk Medications that “Might” Work?
Few people have the time or skills to do their own research. But deciding “yea” or “nay” on a new medication can also be based on its perceived risk. If a medication is considered relatively safe, people with a chronic illness like prostate cancer may start thinking along the following lines: “I can’t be sure it will help, but at least it won’t hurt.”  This is a common mindset with vitamins and supplements because they are generally perceived to be harmless.*

Modifying the Down-Side Risks
This “why not” mindset comes into play when considering certain common generic medications that have been on the market so long their potential side effects are well known.  Specifically I am referring to four medications—aspirin, metformin (a diabetes medication), 5-alpha-reductase inhibitors like Avodart and Proscar, and Lipitor (a cholesterol drug).

In previous blogs I have presented arguments in favor of aspirin, Avodart and Proscar. In my next blog I’ll review some of the arguments for using metformin and Lipitor in patients with prostate cancer.

However, in the remainder of this blog I would like to outline an approach for reducing the risk of experiencing serious side effects:

1)     The greatest vigilance is necessary in the first few weeks after a new medicine is started.  When a medication causes side effects they usually appear fairly quickly.

2)     Generally, there is no rush. So why not begin at half dose? If after a few weeks or a month there are no negative side effects, the dosage can be gradually increased.

3)     Medication side effects follow specific patterns. Aspirin, for example, can cause intestinal bleeding.  So patients need to be carefully informed about the significance of any new symptoms of heartburn and the meaning of having black stools should they appear.

4)     Some side effects are only detected with blood tests.  Everyone who starts a cholesterol drug—Lipitor for example—needs to have liver function tested within a month or so.  Liver problems heal quickly if the side effects are detected and the medication is stopped in a timely fashion. It can be dangerous if negative effects persist undetected.       

*Ironically, in the absence of overt deficiency, when vitamin supplementation is subject to careful testing it sometimes has been shown to be deleterious.   Vitamin E is one good example. In a large randomized, double-blind placebo-controlled trial, prostate cancer mortality was higher in the men who took vitamin E compared to those who took a placebo. 

Risk

BY RALPH BLUM

Prostate cancer is the most common non-skin cancer in the U.S. affecting one in seven men. It is estimated that there are nearly 3 million American men currently living with prostate cancer and it is still not known what causes the disease. However, here are the main factors that might affect your risk level of risk.

Age
Age is the most significant risk factor. Your risk increases exponentially as you get older. In old age, up to 8 out of 10 men harbor microscopic amounts of the disease in their prostate, live with it, and die of something else. In the opinion of one well-known urologist, “If you are over seventy and you don’t have prostate cancer, chances are you’re a woman.”

A Family History of Cancer
Generally speaking if you have a father or brother who was diagnosed with prostate cancer you are twice as likely to develop the disease compared to the average man, while men with two or more relatives with the disease are nearly four times as likely to be diagnosed. If your relatives were diagnosed before the age of 60, this increases the risk slightly. And the younger the age at diagnosis, the more likely it is you have a faulty gene called BRCA2 in the family. Cutting edge research is ongoing to read and interpret the genetic code of prostate cancer.

Race & Ethnicity
Prostate cancer is more common in black Caribbean and black African men than in white or Asian men. The difference seems to be a mixture of inherited genes and environmental factors. African American men are 56% more likely to develop prostate cancer than Caucasian men, and nearly 2.5 times more likely to die from the disease.

Height & Body Weight
Research has shown that taller men have a higher risk of getting aggressive prostate cancer, or prostate cancer that has spread. And there are a number of studies confirming that men who overeat and who are overweight display increased incidence and aggressiveness of the disease.

IGF-1
Insulin growth factor is involved in the regulation of normal cell growth and death. Some studies have shown that men with a higher level of IGF-1 in the blood have a higher risk of developing prostate cancer. So it is not high blood sugar, but rather the high level of insulin triggered by high blood sugar that stimulates rapid cancer growth.

So what can you do to inhibit prostate cancer growth?  Unfortunately, the days of eating everything you want are over. There has never been a more important time in your life to eat sensibly.  Your diet can no longer be rich in animal fat, processed and fast food and low in fruit and vegetables. We did not evolve and develop to eat this way.  This doesn’t mean you can never have another piece of pizza.  But it does mean that having less than 10% of calories from animal protein can result in a dramatic reduction in cancer risk.

Bottom line, you are not without power in influencing your level prostate cancer risk.

Low Testosterone = Low Sex Drive

BY MARK SCHOLZ, MD

Call me an adolescent, but I think men’s egos are hugely impacted by their ability to satisfy their spouse’s sexual needs. But what if there is no “need” that needs gratification? What if your postmenopausal wife could care less about sex? While there are various other reasons besides hormonal ones for poor sexual dynamics—two obvious ones are relationship issues and sub-optimal function of the anatomy—this article is about the one quintessential ingredient for sexual interest: normal hormone levels in the blood.  What can be confusing is that hormone levels and anatomic function both decline as we get older. Therefore, ferreting out the reason for a low libido level may be confusing.

Other than to acknowledge their obvious importance, I won’t comment on how healthy relational dynamics are a prerequisite for romance. Obviously you ain’t gonna feel sexy if you’re angry at your partner.  Nor will I spend any more than the following paragraph discussing methods to restore anatomic function.  These themes have been thoroughly expounded by other writers. This blog is about how normal levels of testosterone are essential for normal sexual activity in both men and women.     

Anatomic Sexual Issues
Men with erectile difficulties often successfully resume normal function with help from Viagra and Cialis. When these pills are ineffective, prostaglandin injections will often restore erections.  For women in the postmenopausal state, when the ovaries stop producing estrogen, genital atrophy develops, resulting in uncomfortable sexual relations.  Topical estrogen creams are usually corrective.  

Testosterone, the Essential Hormone of Romance

The unbreakable link between testosterone and libido can be illustrated by recalling the baffling behavior of older teenage males when viewed through the lens of younger prepubescent eyes.  Back when I was 10 or 11, I remember being mystified by the behavior of the older boys who for no explicable reason had suddenly become girl crazy.  Now, however,  as an adult experiencing the effects of my own internal testosterone production, I readily confess, it’s no longer a mystery.

Testosterone, which fires up after puberty, works like a literal “on/off” switch for sexual desire.  High levels increase genital sensitivity and heat up sexual desire for both men and women.  When testosterone is low, sexual apathy sets in.  In fact, to a person without testosterone, sexual activity seems totally nonsensical.  As a prostate oncologist with extensive experience administering testosterone-lowering drugs to treat patients with prostate cancer, I am constantly in contact with men who have libido at zero levels. Amazingly, without testosterone, even men don’t want sex. 

Diagnosing My Wife

Familiarity with how my hormonally-deprived patients were wrestling with the effects of low testosterone must have helped me figure out what was happening when my wife’s libido suddenly changed after menopause. She, conversely, was oblivious.

I presented her with an impassioned argument and cajoled her into visiting a doctor specializing in bioidentical hormone replacement.  My diagnosis of inadequate testosterone was quickly confirmed.  The doctor (who my wife subsequently fired) overdosed her with a hefty 4-month testosterone injection. Honestly, it was almost too much of a good thing. For her, living with a male-level libido was painfully distracting (all of us guys can easily relate).

It was no surprise to me that, after the 4-month shot wore off, she became very mistrustful of bioidentical hormones. Eventually, she mustered the courage to consult a second physician who upon hearing her history wisely initiated the bioidentical hormones at a much lower dose.  Small upward adjustments in dose have led to restoration of her libido without untoward side effects.

Beyond normalization of libido, my wife reports another important benefit: improved energy levels. When asked about this, she says the increased energy is comparable to a cup of coffee, but without the caffeine jitters.  Medical studies evaluating testosterone replacement have also shown that raising testosterone levels is associated with improved blood sugar control in people with diabetes.

The setting of the sun on a previously healthy romantic relationship is assumed to be a part of the normal aging process. And of course there are a variety of potential causes besides low testosterone levels in the blood.  However, when testosterone levels are suppressed, the absence of motivation for sexual activity is almost guaranteed.  People need to be aware that both men and women can potentially reignite sexual interest back to youthful levels with skillful replacement therapy.

The Importance of Finding an Experienced Doctor

BY RALPH BLUM

If you don’t live in a city, finding a urologist who specializes in treating prostate cancer can be a major challenge. Usually your choice will be limited to who your primary care doctor will refer you to, generally a local urologist.  But before you take this step you need to be aware that all urologists are not created equal.

Furthermore, the average community urologist has a medical practice most of which involves treating problems like infections, impotence, incontinence and kidney stones. He may be an excellent doctor, but he does not have time to keep up with what is new in the fast moving prostate cancer field. Also, without the opportunity to treat large numbers of men with this disease, how can he be familiar with the advantages and disadvantages of all the new treatments?

So you need to develop the “I’m from Missouri and you’ve got to show me” mindset and ask the tough questions: How many cases of prostate cancer has he treated successfully? And if he recommends surgery, how many radical prostatectomies has he performed overall, and how many in the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of both potency and normal urinary function?

Unless you have the aggressive, high-risk form of prostate cancer my best advice is to resist your natural desire to rush into treatment that will compromise your quality of life.  Of men diagnosed over 50%have slow-growing, low-risk disease and do not need immediate treatment.  However, if you have the “just get it out” attitude, bear in mind that your community urologist is most likely not doing anywhere near enough radical prostatectomies to qualify as or stay proficient.

Despite the well-documented over-diagnosis and over-treatment of prostate cancer, during the past decade, the number of prostatectomies performed each year has more than doubled. And since all the marketing hype surrounding “the robot that can operate,” increasingly men are traveling to high volume centers that offer robotic surgery.  But remember, it’s the man behind the robot who is actually performing the surgery, and you don’t want to be on his learning curve.  Unless you find an experienced and highly skilled surgeon, a satisfactory outcome is extremely unlikely.

Many men are way too motivated to submit to radical treatment for what is typically a non-life-threatening condition. A combination of the urologist’s preference for surgery and most men’s desire for closure, leads to tens of thousands of unnecessary radical prostatectomies every year. You are about to make a pivotal decision that will affect the rest of your life. So before you make any treatment choice, you owe it to yourself to get a second opinion from a prostate cancer specialist—even if it means traveling to a city where such practitioners are available.

Testosterone for Men and Women

BY MARK SCHOLZ, MD

Testosterone is really cool. It improves concentration, energy, strength, and libido. Both men and women experience enhanced performance with higher testosterone levels.  The problem is that testosterone tends to decline with age.  Also, testosterone-blocking therapy to treat prostate cancer can have lingering effects, even after the treatment is stopped.  For women, testosterone levels often decline sharply after menopause.

Low testosterone causes many undesirable effects including muscle atrophy, weight gain, tiredness, osteoporosis, low libido and impotence.  Absent testosterone in women* is usually a secondary effect of menopause, so it usually occurs in conjunction with low estrogen. In women the loss of estrogen and testosterone causes weight gain, tiredness, osteoporosis vaginal atrophy and low libido.

Judicious administration of testosterone in men and a combination of estrogen and testosterone in women, can dramatically improve quality of life. Bioidentical hormone therapy is the term often used by the doctors who specialize in this area.  The idea is to restore hormone levels back to normal.

Risks of Testosterone Therapy
As might be expected, like any powerful tool, misuse of testosterone can be dangerous. Administering testosterone in men with prostate cancer is controversial (see below).  However, there are also risks even in men without prostate cancer.  One reason is that when testosterone is administered to men estrogen levels also rise.  Higher estrogen in men may increase the risk of heart attacks and strokes. Therefore, estrogen levels should be monitored and compensatory treatment with Femara®, an estrogen blocking pill, may be necessary in some cases.

In men, testosterone may also cause an excessive increase in the red blood cell count (RBC). Overly high RBC levels have also been linked to higher risks of heart attack or stroke. The RBC count, therefore, needs to be monitored by measuring the hematocrit, a component of the complete blood count (CBC). If the hematocrit rises above 50% men should consider lowering their testosterone dosage or undergoing a phlebotomy (donating a unit of blood).  In women, excessive amounts of testosterone can cause masculinization.  Estrogen replacement also slightly increases the risk of breast and uterine cancer.  Obviously a full discussion of all the risks and benefits is essential before starting treatment.

Administering bioidentical hormones is as much an art as a science. The hormones themselves are delivered in the form of creams, pills or shots. Studies show that the measurement of hormone levels in the blood stream or in saliva is moderately helpful for guiding the selection of an appropriate dosage. A better indication of proper dosage, however, is the subjective sense of well-being reported by the person receiving the treatment. Therefore, starting hormone therapy should proceed slowly with an incremental escalation of dose while closely observing for the appearance of side effects.

Giving Testosterone to Men with Prostate Cancer
Denying every man with a history of prostate cancer from receiving testosterone is ridiculous. Studies clearly show that about half the men in their 50s and almost all men in their 80s harbor minor forms of prostate cancer; most is low-grade and harmless.  Almost all of these men have substantial testosterone coursing through their blood (from their testicles).  They seem to do just fine. As long as men are regularly screened to ensure the absence of clinically significant prostate cancer, the risks of restoring low levels of testosterone back to normal should be quite low.

Living Longer and Living Better
Just in our lifetimes we are observing a dramatic enhancement of human longevity.  When I was in oncology training at USC just twenty-five years ago, the attitude toward a patient’s death while in his in early 70s would have been, “He lived a full life.”  That attitude is no longer accepted.  Now men and women are not only living longer, they are retaining substantial youthfulness into their 80s. As part of an overall health program that includes diet, exercise and appropriate healthcare, restoring sex hormone levels back to normal can be transformational.  Since giving small amounts of testosterone to females is a foreign idea to many people, in my next blog I will elaborate on this concept further.

* Premenopausal women normally have testosterone in their blood, albeit at much lower levels than men.