Advice for the Newly Diagnosed

BY RALPH BLUM

If you are recently diagnosed, the good news is that promising new drugs and therapies, as well as new thinking about when to treat and when it is not even necessary to treat, have made a diagnosis of prostate cancer far less threatening than in the past.  Having said that, remember the old rule of the desert: "Trust in God, but tie your camel to a tree." Because the same applies with a cancer diagnosis. It's not enough to depend entirely on your medical team. Now is the time to consider what you can do to support your recovery and reduce the risk of recurrence.

First, you need to be involved in each treatment decision, making certain that you are fully informed, and that you understand the risks and side effects involved. It is all too easy to play a passive role and just go along with whatever the urologist or oncologist recommends. But you need to take charge. Research your diagnosis on the Internet. Explore all your treatment options and decide whether you do, in fact, need treatment, or if active surveillance is your best option. Get a second opinion.

Next--and I'm sure you don't want to hear this--you need to examine your lifestyle. Yes, I know you would prefer just to let your treatment get rid of the cancer.  But everyone I have talked with who has done really well in the cancer wars has made good nutrition, moderate exercise, stress management, and positive engagement in their own health and healing--key parts of their recovery program.

So where to start? Anyone overweight? A new study suggests that being overweight or obese lowers the chances of successful treatment. It is also known to increase the risk for prostate cancer, particularly for more aggressive, high-risk disease.  So experts agree that losing weight is an important first step.

A study led by UC San Francisco involving 4,600 men diagnosed with non-metastatic prostate cancer found that by substituting healthy vegetable fats--olive and canola oils, nuts, seeds and avocados--for animal fats and carbohydrates, the men lowered their risk of disease progression. Men who replaced 10 percent of their daily calories from carbohydrates with healthy vegetable fats had a 29 per cent lower risk of increasing aggressive prostate cancer.

There is no doubt that certain foods are helpful in reducing cancer growth and other foods are not. High on the "not" list is sugar, especially high fructose corn syrup, and processed meat--salami, bologna, sausage, hot dogs etc. Your shopping list for "helpful" foods should include all fish and skinless chicken breast, beans, vegetables and fruit, whole grains and breads, and non-fat dairy. It doesn't mean you can never have another slice of pizza in your life, it just means cutting out the steak and fries. Because there has never been a more important time in your life to eat well.

Here are a few other simple things you can do:

 Take Vitamin D³. Credible research links Vitamin D³ deficiency to cancer growth, predominantly breast and prostate cancer. The recommended dose is 2,000 to 4,000 IU daily.

·       Hydrate. Lack of water inhibits immune function.

·       Get eight or more hours of sleep each night.

·       Laugh a lot. Laughter is the ultimate antioxidant.

·       Listen to music.

·       Stay in the moment. Don't let past regrets and future fears contaminate the present. Remember Deepak Chopra's words: "Every cell in your body is eavesdropping on your thoughts."

 

A Xofigo Update

BY MARK SCHOLZ, MD

Since Xofigo was FDA approved two years ago, the doctors at Prostate Oncology—Dr. Richard Lam, Dr. Jeffrey Turner and I—have been avid users.  So this seems to be a good time to provide an informal update of our experience with Xofigo to the present time.

The clinical trial that led to Xofigo’s approval by the FDA was a prospective, placebo-controlled study demonstrating improved survival in Xofigo-treated men compared to men treated with placebo alone.  The trial showed a very low incidence of side effects and good relief for men who were suffering from bone pain.

Xofigo is made out of radium, a radioactive element. After it is injected into the blood stream it concentrates near the cancer and delivers a potent dose of radiation.  So after Xofigo is injected into the patient, it travels through the blood stream and concentrates in the irritated areas of the bone and emits radiation where the cancer is most active.  Since prostate cancer spreads almost exclusively to bone, an injection of Xofigo ends up targeting most if not all of the cancer. Radiation consists of high energy, subatomic particles that blast cellular DNA. Once the DNA of the cancer cell has been hit, the cell is rendered incapable of reproduction.  If you stop cancer reproduction you basically stop the cancer.

To almost everyone, radiation conjures up horrible visions of toxicity. Fortunately, bone marrow toxicity is rare in men because Xofigo emits a different type of radiation, “alpha particles,” rather than the standard “photon type” of external beam radiation. Alpha particles dissipate their energy over a very short distance, only a couple of millimeters. External beam radiation therapy, the type of radiation that has traditionally been relied on to kill cancer cells in the bone, needs to be used very judiciously because the radiation is “beamed” through the body to hit the target in the bone. Typically it causes irreversible damage to the surrounding bone marrow.

Over the last two years at Prostate Oncology, we have treated over 50 patients with Xofigo.  The treatment has been very well tolerated.  Occasionally, we have seen a few patients with mild diarrhea or nausea that has been easily managed with common medications. Men experiencing pain from cancer usually see either partial improvement or total resolution of their pain after one to three of the monthly treatments.

As reported from the original study that led to FDA approval, even though pain relief occurs and alkaline phosphatase (ALP) levels in the blood decline, PSA may continue to rise.  This “disconnect” between PSA and other clinical parameters such as pain and ALP can be disconcerting to doctors and patients alike.  The reason that it occurs is unclear. A similar phenomenon has been observed with another FDA-approved cancer therapy called Provenge.

Experts hypothesize that the survival advantage from Xofigo and Provenge is due to a slowing of cancer progression rather than an actual regression of the cancer. This “slowing” is powerful enough to extend patients’ lives but insufficiently powerful to consistently induce a decline in PSA.  However, in our practice at Prostate Oncology notable declines in PSA have been observed in a few patients treated with Xofigo.  One patient dropped his PSA from 50 down to zero and his PSA still remains at undetectable levels.  Another recent patient has dropped his PSA from 150 down to 8.

For the patients on Xofigo who have rising PSA levels, it is logical to consider adding another effective anticancer agent such as Xtandi, Zytiga or Taxotere.  It is encouraging to know that several studies now show that Xofigo can be safely combined with these other effective therapies.

Xofigo has been a very welcome addition to our anticancer armamentarium.  The standard FDA approved protocol consists of a course of monthly treatments continued for a total of six months.  Further trials are in progress to study the potential advantages of continuing Xofigo for longer than six months.  Our experience to date suggests that longer therapy would indeed be advantageous in some instances.

Finally the Word is Out

BY RALPH BLUM

In the five years since writing our book, Invasion of the Prostate Snatchers, with the subtitle “No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency,”  Mark and I have continued advocating for changes in the management of low-risk prostate cancer. It has been an uphill battle, mainly because most men find it hard to believe that anything called “cancer” can be safely monitored, probably for years, even—in my case, for example—for decades.

Now, at long last, it appears the word is out: Finally more men are opting for regular, close monitoring, while holding off on aggressive treatment unless the disease progresses.  Instead of yielding to an overwhelming desire to "cut the damn cancer out and be done with it," men are increasingly choosing "active surveillance" and by so doing, dodging the two bullets of erectile dysfunction and loss of urinary control.

In a study published in JAMA this month, Dr. Matthew Cooperberg and Dr. Peter Carroll of the University of California, San Francisco, drew on data from 10,472 men with localized prostate cancer, who were treated at 45 urology practices in 28 states, between 1990 and 2013. The use of active surveillance among men with low-risk cancer ranged from 7 to 14 percent from 1990 through 2009, then increased to 40 percent between 2010 and 2013. Among men age 75 or older, 76 percent opted for active surveillance.

Rates of active surveillance in the U.S. have historically been lower than in other countries. In Sweden, for instance, 2013 figures indicate that active surveillance was used to manage 78% of men with very low-risk disease, and 59% of men with low-risk disease. Unfortunately, men in this country have been motivated to submit to radical treatment for what is typically a non-life-threatening condition.

Not many years ago, a PSA reading of 4.0 was considered "abnormal," and triggered an immediate biopsy regardless of age or prostate size. More recent studies show that microscopic amounts of low-grade prostate cancer are so common, that even when the PSA is totally normal, one-fourth of men will have a positive biopsy.  So if the biopsy was positive, inevitably it led to radical treatment; treatment that, in most cases, was unnecessary. Fortunately this is changing.

Some men, however, are still frightened into unnecessary aggressive treatment. They don't want the stress of regular check-ups. They just want to be rid of the cancer. But fear is an untrustworthy advisor. What they don't take into account is that men who have chosen surgery also have to be monitored regularly to make sure their cancer stays in remission.

So if you are blessed with the low-risk, slow-growing form of this disease—the tortoise of prostate cancers— wait and go slow. Your three most important considerations are quality of life, quality of life, quality of life. With active surveillance you avoid the toxic side-effects of radical treatment, without sacrificing the chance for a cure, even if the disease progresses.

Active Surveillance for Men with Intermediate Risk Prostate Cancer

BY MARK SCHOLZ, MD

People are starting to become familiar with the modern way of conceptualizing prostate cancer.  When men are newly diagnosed, they are split into three broad categories: Low-Risk, Intermediate-Risk and High-Risk. This system, which was invented by Dr. Anthony D’Amico, is helpful for the proper selection of optimal treatment; men with more favorable types of prostate cancer can receive milder therapy and still maintain normal survival rates.

As far as treatment selection is concerned, as a general rule of thumb, men with Low-Risk disease are encouraged to simply monitor the disease, withholding therapy altogether unless tumor growth is detected on subsequent testing.  At the other extreme, men with High-Risk disease typically undergo combination treatment with three forms of therapy: seed radiation, IMRT and hormone therapy, which is continued for a year and a half.

Treatment recommendations for men with Intermediate-Risk range widely from surgery, to the many types of radiation—IMRT, seed implants, SBRT and Proton therapy to focal therapy, as well as the alternative of simply giving hormone therapy by itself. This wide variety of treatment options is not merely a result of physician bias.  It turns out that the types of cancer that occur in the Intermediate-Risk category also vary widely.  At the “good” end of the spectrum, men with the favorable type of Intermediate-Risk disease have a condition that behaves more like Low-Risk while cancers men at the unfavorable end of the Intermediate-Risk spectrum have a condition that behaves more like High-Risk.

The indicators that define an unfavorable type of Intermediate-Risk disease are multiple intermediate characteristics rather than having a single Intermediate-Risk factor.  For example, it is considered unfavorable when the PSA is over ten and the Gleason is 4 + 3 (instead of 3 + 4) and there are more than 50% of the biopsy cores containing cancer.  At the other extreme are men with the favorable type of Intermediate-Risk disease. These men are characterized by having all the Low-Risk factors in combination with only a single Intermediate-Risk factor.

Making a proper distinction between the favorable and unfavorable types of intermediate risk disease can be monumentally important as it relates to treatment selection. Studies show that men with favorable Intermediate-Risk disease are potential candidates for active surveillance.  A recently published report at this year’s Genitourinary ASCO meeting bears directly on this issue:

In Abstract #82 from the meeting, authored by Ann Caroline Raldow from Harvard, 6500 newly-diagnosed men treated with radiation and hormone therapy at the Chicago Prostate Cancer Center between 1997 and 2013 were evaluated.  Dr. Raldow calculated their survival rate after treatment based on their risk category: low, favorable-intermediate, unfavorable-intermediate, and high. Eight years after treatment 820 men had died, 72 of them from prostate cancer. Men in the favorable Intermediate-Risk category had the same survival rates as men in the Low-Risk category.  Men in either the High-Risk category or in the unfavorable Intermediate-Risk category demonstrated an increased mortality rate from prostate cancer.

Bottom line, the cancer of men with the favorable type of Intermediate-Risk prostate cancer behaves the same as Low-Risk.  Dr. Raldow’s analysis provides further clinical evidence that men with the favorable type of Intermediate-Risk prostate cancer can forgo immediate radical therapy and embark on active surveillance.