The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, June 30, 2015

The Importance of Diet in Beating Prostate Cancer


If you are one of the nearly three million men currently living with prostate cancer, you need to know that what you eat really can make a difference. Not only does a healthy diet improve your quality of life and enhance the functioning of your immune system, recent studies suggest that as well as reducing the risk of prostate cancer, good nutrition can help slow the progression of existing cancer.

More often than not, prostate cancer is slow-growing and non-aggressive and, therefore, has one of the highest survival rates of any type of cancer. But why not improve your odds? Some of you may know that I have been living with this disease for over two decades, and that I have not always been conscientious about my diet. However, when my PSA spiked again in 2015, I could no longer ignore the mounting evidence that giving up high-fat and processed foods and eating more fruits, vegetables, whole grains, and fish had real benefits for fighting prostate cancer.

Speaking of fish, I read recently that a New Zealand study found that men who ate no fish had a two to three times higher frequency of prostate cancer than those whose diets included moderate to high amounts of fish. So sorry, guys, take those steaks off the Barbie and get out your fishing rods! Red meat contains more than 50% fat, and high-fat diets increase the level of insulin-like growth factor which in turn increases the risk of prostate cancer.

The National Cancer Institute has spent millions of dollars researching diet in China where the consumption of animal protein--meat, milk, cheese and eggs--is very low. The most significant finding in these extensive studies was this: the more animal protein you eat, the higher your risk of dying of cancer. In the entire Far East, the mortality rates from prostate cancer are eighteen times lower than in the U.S.

Another major offender is sugar. Cancer cells are especially greedy for sugar--a fact dramatically illustrated in a PET scan. The PET scan uses radioactive sugar injected into the blood stream to locate tumors, and the uptake of glucose into the cancer cells occurs so swiftly that they light up like fireworks within ten minutes of the injection. According to nutritionists you can slow cancer growth by lowering the amount of fuel available to the tumor cells.

So what to do? I'm not talking here about going on a strict macrobiotic or vegan diet, just cutting out foods that have been shown to accelerate the pace of cancer cell growth. You can start by throwing out the sugar cookies and Krispy Cremes. Next, substitute that juicy steak with wild salmon, and chow down on a plate of creatively seasoned steamed veggies.

This advice is especially relevant for men who meet the criteria for Active Surveillance and are able to postpone the undesirable side effects of radical treatment. And yes, it's a little boring. But it sure beats being dead.

Tuesday, June 23, 2015

Xtandi and Zytiga, The Future is Now


There are two new kids on the block, Xtandi and Zytiga. Both medications are real game changers. They are special because they can induce cancer remissions in men whose prostate cancer has become resistant to Lupron.  These pills are so effective that protocols for managing hormone resistant prostate cancer have been completely revamped.  Previously, men with hormone resistance were first treated with Taxotere chemotherapy, typically with undesirable side effects and frequent doctor’s visits.  When men on Xtandi and Zytiga are responding well, since they no longer need an intravenous infusion of Taxotere every three weeks, they only have to come in for a doctor’s visit every three months.

While Xtandi and Zytiga are now FDA approved for hormone resistant prostate cancer, there is no reason to believe they won’t also show enhanced effectiveness against earlier-stage, hormone-sensitive disease as well.  This rationale is based on a long established fact about anticancer treatments in general: “Any treatment that is effective against advanced cancer generally proves to be more effective against earlier-stage cancer.”  This assumption is so logical one might wonder why the academic medical world insists on doing studies to prove it.  Honestly, the biggest barrier is probably cost.  Insurance companies that pay for these expensive medications demand ironclad proof of a beneficial effect before being willing to cover their expanded use.

Physicians, particularly urologists, who are unfamiliar with these potent new agents, are another barrier to the expanded use of Xtandi and Zytiga in earlier-stage prostate cancer.  Urologists, the surgeons who over the last 20 years have only slowly become familiar with how the standard medications Lupron and Casodex function, are often uncomfortable using new agents that can be associated with rare side effects such as high blood pressure, seizures, liver problems and potassium depletion.  To urologists, the doctors who are managing the men with early-stage prostate cancer, Xtandi and Zytiga are relative unknowns.

In spite of all these barriers, the logical place to consider using Xtandi and Zytiga is in earlier-stage, “high-risk” situations which have suboptimal cure rates with Lupron alone.  The situations where this might apply are listed below:

·         Newly-diagnosed men with a PSA over 20 and a Gleason score over 8

·         Newly-diagnosed men with seminal vesicle invasion or pelvic lymph node metastases

·         Relapsed men after surgery with a PSA doubling < 3 months having salvage radiation

·         Newly-diagnosed oligometastatic disease undergoing radiation to all sites of disease

In all these situations, Lupron is known to be beneficial.  In some cases, the addition of Casodex to Lupron further increases the anticancer effect over Lupron alone. This is an important observation because compared to Xtandi or Zytiga, Casodex is a very weak anticancer agent.  Substituting these far more potent agents for Casodex is very likely to result in substantial improvement of the anticancer benefit and is a logical consideration for men who want to optimize their cure rates.        

Tuesday, June 16, 2015

Making Friends with Your PSA


It’s a simple enough blood test. So who’s afraid of a PSA? The straight answer? Every guy who’s ever been told his PSA was elevated for his age, and that he needs to have a biopsy. Because from that point on, things can happen fast. It’s the prostate cancer version of the old Tinker-to-Evers-to-Chance double play: PSA Test to Biopsy to Surgery.

PSA is an acronym for prostate-specific antigen, a protein produced by normal prostate cells. Cancer cells, however, produce more PSA per unit volume than benign cells. Since 1986, PSA testing, although not perfect, has served as the gold standard for early diagnosis and—the area of most controversy—screening for prostate cancer.

While with the majority of younger men, early diagnosis far too often leads to unnecessary treatment and anxiety, urologists are justifiably concerned that, without PSA testing, they will miss diagnosing the less-common high-grade form. So, when in doubt, test.

So, I’m talking primarily to those of you with low-grade tumors, conditions that qualify as “chronic” and might better not even be called “cancer.” That doesn’t mean that being newly diagnosed with prostate cancer is any less of a shock. But there are things you can do to reduce the anxiety.

Bottom line, after all the millions spent and all the years of research, we still don’t have a foolproof diagnostic test for prostate cancer. So don’t panic if you get a high PSA reading. Here are some factors that can distort PSA test results in ways that don’t necessarily indicate cancer:

BPH: Benign prostatic hyperplasia, prostate enlargement caused by age or infection, can produce elevations in PSA not indicative of cancer. Check it out.

Infection: Consider the possibility of infection. When my PSA spiked unaccountably from 5 to 17, my wife, Jeanne, who practices Traditional Oriental Medicine, put me on a course of Cipro, and my PSA plummeted back to 6.5 within two weeks.

The 48 Hour Rule: Strenuous exercise, heavy lifting, sexual activity, even bicycle riding before a PSA test are all considered to negatively effect the result. So don’t do any of it before your PSA test.

Inconsistent Lab Work: Standardization between assays and labs is still lacking, making comparisons between PSA tests from different labs are unreliable. Make certain your urologist uses the same lab every time.

Then, there are those of you for whom PSA testing is a higher priority:

Family history: If you have a family history of prostate cancer, it’s advisable to begin PSA testing at 40 and repeat the test at six-month intervals.

African Americans: All African-Americans are advised to begin tests by age 40 regardless. The death rate from undiagnosed prostate cancer for African-Americans is currently twice that of Caucasian men. Partly for genetic reasons, partly from refusal to submit to the DRE, the finger-up-the-butt trick the rest of us, so to speak, take in our stride. Trust me, it’s over before you know it. 

Men Over 75: Nowadays, men over 75 are apt to be spared testing entirely. So avoid the anxiety, and have a good time? On the other hand, you might just go for the PSA test, and take the prostate cancer alert as a wake up call to get yourself a checkup.How long since your last physical, dude?

Finally, remember that the big decisions are all yours to make. So never hesitate to go for a second opinion—or a third. And if you don’t like the test results, get another PSA test done by a different lab. Or find a different urologist.

The best clinicians do not mindlessly screen all of their male patients. They decide which men should be tested based on age, symptoms, family history, expected longevity, general medical condition, physical examination findings, and—a significant factor—the patient's own request for the test. The goal of early detection remains to identify patients who have clinically significant cancers at a time when treatment is most likely to be effective.  

And here’s the really good news: 28 out of 30 men reading this blog, who do have prostate cancer, will die with it, not of it.  Regardless of its shortcomings, the PSA is still the most useful test that is widely available.

So if you’ve been avoiding it, have a PSA test done this week. And while you wait for results, instead of fretting, call the golf pro and get yourself a tee time for Saturday.

Tuesday, June 9, 2015

Discussing a Painful Subject: Fear of the Process of Dying


Many men tell me that they fear the process of dying—suffering and experiencing pain—more than they fear death itself.  While I am no fan of pain, as a medical oncologist I have been responsible for the treatment of hundreds of patients with terminal cancer. I have learned that with good communication and proper medical management, pain can almost always be effectively controlled.

However, when reviewing the results of a recent patient survey at a meeting sponsored by Bayer Pharmaceuticals with a number of patient advocates, healthcare experts, and other physicians, it became sadly apparent that many patients are not being managed expertly. The survey indicated that many men with advanced cancer are suffering needlessly, mostly due to a lack of good communication with their doctors.

This survey of 410 men with advanced prostate cancer reported that two-thirds of men are trying to handle their pain by ignoring it!  One-third of all the men surveyed felt that acknowledging pain made them more fearful, raising anxiety about the possibility that their cancer is progressing.  A quarter of the men said, “It was difficult to talk about their pain,” relating that such discussions made them feel weak.

In other words, these men are using a common psychological defense mechanism called “denial.” One thing I have learned from years of experience treating patients is that denial can be a wonderful approach, but only if the situation is totally hopeless. I have observed men who appear to be in denial who are quite happy even when everyone knows that they are dying.

On the other hand, denial is a serious problem if what is being denied, in this case pain, can be fixed or remedied.  If men who are in denial fail to discuss pain with their doctors, their access to a solution is blocked.

Using denial can effectively control pain for short periods of time, however, using it on an ongoing basis is psychologically exhausting. Also, while denial might work for the patient, it can’t fool their surrounding loved ones. They see the effects of pain in the patient manifesting as fatigue, depression, inactivity, impatience, insomnia and hopelessness. Ultimately, the caregivers who are not shielded by denial end up suffering even more than the patient.

Cancer patients experience pain from multiple causes, not just their cancer.  Invariably, life itself is painful.  However, most types of cancer pain can be resolved.  The first step is to acknowledge its existence. The second step is to diagnose whether the pain is cancer-related. In the prostate cancer world, cancer-related pain is usually the result of bone metastases. Of course, not all bone pain is from cancer and not all bone metastases cause pain. If a man has pain in one of his bones and a bone scan shows a metastatic lesion in the exact same area as where the pain is occurring, then the probability is high that the pain is cancer-related.

The third step, once it has been confirmed that the pain is cancer-related, is to undertake the appropriate treatment. How to treat cancer-related pain is a topic big enough for another blog all its own. In my next blog I will also elaborate further on the correct medical approach used to distinguish cancer pain from non-cancer pain.

Someone has said, “Not knowing what to do is the worst kind of suffering.”  Helping men find a workable solution for pain not only relieves their pain, but it also releases them and their caregivers from the uncertainty and anxiety that comes from not knowing what to do.   

Tuesday, June 2, 2015

The Premature Biopsy Blues


As I have said many times I am no fan of biopsies, but to most urologists, an elevated PSA calls for an immediate biopsy. A majority of urology practices rush men into biopsy despite the risks and discomfort involved, and despite the fact that there are other, far less invasive indicators to help determine what is going on in the prostate before doing a biopsy. If these indicators point to the presence of an aggressive cancer, submitting to a biopsy to get further information is appropriate. But in most cases, it is not appropriate, and almost inevitably gets you a first class ticket on the Overtreatment Express.

Prostate cancer is different from other cancers and, in a majority of cases, far less malignant. Accumulating studies show that approximately 30% of men in their fifties, and as many as 70% of eighty-year-old men, harbor microscopic amounts of the disease. In fact, 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."

Yet despite the fact that so many men have it, less than 3% of men in the U.S. die from it, and the mortality rate is dropping every year.

So if your PSA is elevated, take a deep breath and don't panic. Rather than triggering an immediate biopsy, an elevated PSA should set a risk assessment process in motion. More than half the biopsies in this country are done for evaluation of an elevated PSA coming from BPH—an enlarged prostate. And there are various other non-cancerous causes of an elevated PSA. So check them out and repeat the test. Still elevated? Insist on having an OPKO-4k blood test. Studies show that the OPKO-4K can not only demonstrate the presence or absence of cancer, it gives a readout on the likelihood of higher-grade cancer, the kind of cancer that should be treated rather than watched.

Some major cancer centers use 3-Tesla, multi-parametric MRI as a diagnostic tool. Also to be considered is another form of imaging—color Doppler ultrasound—that is comparable in quality to MP-MRI, is easier to perform, takes less time, can be done in the doctor's office. Color Doppler provides higher resolution images than the usual gray-scale ultrasound machines, and also shows areas of increased blood flow associated with higher-grade or more aggressive prostate cancers. If a suspicious lesion is detected a targeted rather than a random biopsy can be performed.

PSA is a remarkable tool. However PSA testing alone frequently gives an inconclusive message. So if your PSA is slightly elevated, instead of submitting immediately to a random needle biopsy that would likely lead to un-called-for radical treatment for a non-threatening cancer, ask your urologist to slow down. Now is the time to gather more information by testing with OPKO-4K and color Doppler ultrasound. Never forget that prostate cancer is the tortoise of cancers, so don’t be frightened into making a decision you might regret.  This is one situation where taking the Local may provide a better ride than the Express.