Dr. Scholz is the prostate cancer expert on veryWELL.com (an ABOUT.COM brand) Check out his articles at www.verywell.com 

https://www.verywell.com/what-about-sex-after-prostate-surgery-2782250

https://www.verywell.com/prostate-size-matters-2781991

A BETTER PROSTATE CANCER TEST?

FEATURED TODAY IN THE WALL STREET JOURNAL - HEALTH

by @melindabeckWSJ   READ FULL ARTICLE HERE

A BETTER PROSTATE CANCER TEST?
Distinguishing aggressive disease from slow-growing tumors means more patients can forgo treatment.  
Several new prostate-cancer tests aim to reduce needless biopsies and unnecessary treatments by sorting out harmless from aggressive tumors. 30 MILLION U.S. men will have a PSA test. 6 MILLION of them will be found to have elevated PSA levels.  1 MILLION of them will undergo a prostate biopsy.  180,000 men who have biopsies will be diagnosed with prostate cancer. Another 180,000 men will have prostate cancer the biopsy missed.100,000 men with prostate cancer will have low-risk tumors that are unlikely to spread or cause symptoms.  60,000 men with low-risk cancers will undergo surgery or radiation anyway, probably unnecessarily.


mpMRI vs BIOPSY
Mark Scholz, a prostate oncology specialist in Marina del Rey, Calif., maintains that an mpMRI can yield much of the same information as a biopsy and far less invasively. Low-risk prostate cancers barely register, he says, adding, “When patients find out they have a choice between 12 harpoon sticks to the prostate through the rectum or an MRI, they are on board big time.” 

Joel Copeland, 62 years old, has been monitoring his PSA closely for a decade; his two brothers were diagnosed with prostate cancer. He opted for an MRI instead of a biopsy when his PSA bounced up in 2013. “I don’t like needles, but that’s not the point,” Mr. Copeland says. “The point is, biopsies can cause infection and miss cancers.”

SEE Prostate Vanguard Mailing List about Active Surveillance + Prostate Imaging

Testosterone Replacement Therapy (TRT)

BY JEFFREY TURNER, MD


Testosterone (T) preparations have been available for more than 70 years.  In 2013, over 2.2 million Americans were prescribed testosterone.  Interestingly enough, about 1 in 4 men prescribed testosterone do not have a baseline testosterone level drawn as primary care physicians may write the prescription without ordering a blood test first.  In a study of 63,000 men from the Truven Health Marketscan Commercial and Medicare Supplemental Insurance database between 2010 and 2012, 71% of men had their testosterone level checked once, 40% twice, and 29% had no measurement at baseline.  Physicians need to do a better job following men on testosterone replacement. Is testosterone replacement therapy really all that good for anything aside from rejuvenation and virility? 

Let’s break this down to risks and benefits below:

Risks of Prostate Cancer

The most universal risk which has been the controversy of much discussion is the association with prostate cancer.  Clinicians remain concerned that Testosterone Replacement Therapy (TRT) can cause or stimulate prostate carcinogenesis and therefore they are reluctant to prescribe it for the aging male who has a higher risk of prostate cancer.  In the 1940s, Huggins and Hodges discovered the association of testosterone with prostate cancer by demonstrating that castration causes the disease to regress. The reality is that TRT may stimulate the growth of existing prostate cancer cells, but it will not cause cancer to form.  As the general male population grows, so does the risk for prostate cancer--patients should be closely evaluated with digital rectal examinations, PSA checks and prostate imaging such as color Doppler ultrasound.

Risk of Prostate Enlargement

Another controversial topic is the assumption that supplemental testosterone leads to a prostate growth, benign prostate hypertrophy, which leads to worse quality of life due to worsening urinary symptoms.  It has long been assumed that high T levels induce prostate overgrowth, but most studies failed to find the correlation between circulating T levels and BPH.  It has been hypothesized that dihydrotestosterone (DHT) could be more responsible for prostate growth than T.  There have been a number of studies evaluating TRT in hypo-gonadal men with BPH.  The results have suggested that there is actually a trend toward an improvement in urinary symptoms.

Risk of High Red Counts—Polycythemia or Erythrocytosis

Erythrocytosis is the increase in red blood cell mass production which can be the result of testosterone replacement therapy.  This is the most frequent adverse effect associated with TRT.  Recent trials have demonstrated that men on TRT have a 4 times higher chance of having high red blood cell counts.  Some reports have implicated excessively high red blood cell levels with an increased risk for heart attack or stroke. We commonly recommend patients remain on a baby aspirin daily and monitor their blood counts. Some patients may benefit by donating a unit of blood if the levels are too high.

Risk of Obstructive Sleep Apnea

Frequently reported in various literature is the association of worsening sleep apnea symptoms for men on testosterone replacement.  There has been only one randomized control trial to date that addresses this association and it showed that obese men with severe sleep apnea may worsen their oxygenation with TRT at relatively high doses.  This study evaluated injection formulations of testosterone. So far transdermal formulations have not been similarly implicated.

Risk of Infertility

Testosterone replacement leads to inhibition of the pituitary gland located at the base of the brain which can potentially suppress the production of sperm.  Hence, cases of TRT-induced male infertility have been reported. This impact appears to be transient and disappears once TRT is stopped.

Improved Sexual Function

A decreased libido and/or potency remains one of the most common reasons that men desire testosterone replacement.  TRT can certainly improve sexual function in those who have erectile dysfunction primarily due to a low level of testosterone.  Patients need to recognize that there are a series of other reasons for being impotent that are unrelated to low levels of testosterone which must also be investigated as well before concluding that TRT will be the optimal corrective measure.

Improved Cardiovascular Effects

The association of TRT with heart attacks has been very controversial. We must not forget that men with low T levels are at higher risk for poor health due to being more frail and susceptible to other medical issues including obesity and diabetes. As a result, they become more prone to adverse cardiovascular outcomes.  Four out of five of the most recent meta-analyses demonstrated neither a protective or harmful effect of TRT on cardiovascular events. In men with heart failure, it has been demonstrated that low T levels are an independent risk factor for worse outcomes.  Studies also demonstrated that men with heart failure who supplemented with testosterone had a better exercise capacity, oxygen levels, and less fatigue.

Improved Metabolic Effects

Large scale data exists to document the association of low T and worsening blood sugar levels along with a higher chance of developing diabetes. TRT can improve body composition and help to reduce fat which can lead to better control of diabetes.

Reversal of Osteoporosis

Lower testosterone levels are associated with a higher risk of bone fractures and worsening bone health.  TRT has been demonstrated to have a positive effect on bone mineral density.

Improvement in Chronic Kidney Disease

Low T is very common (approximately 50%) in men undergoing dialysis for end stage renal disease. Reduced T levels have in men on hemodialysis have been tied to higher rates of all-cause cardiovascular mortality.   Studies suggest that TRT may improve the levels of a hormone called erythropoeitin (EPO). This hormone stimulates improved production of red blood cells which in turn increases levels of red blood cell mass, energy, stamina, and overall well-being.

Conclusion

It is clear to see that testosterone replacement offers a multitude of benefits which span past merely increasing one’s libido or potency.  The bottom line remains that patients on testosterone supplementation must have close follow-up including both clinical and laboratory evaluation to ensure they are gaining benefit and not placing themselves at increased risk from potential adverse effects.  Physicians must clearly discuss the risks and benefits of supplementation along with employing routine monitoring of PSA, testosterone levels, blood counts, digital rectal examination, and color Doppler ultrasound. 

Modern Taxotere Chemotherapy for Prostate Cancer

BY MARK SCHOLZ, MD


In prostate cancer, the word “chemotherapy” is essentially synonymous with Taxotere (docetaxel). Taxotere is by far the most common chemotherapy medicine for prostate cancer. Taxotere is an active agent that is also employed for the treatment of breast cancer and lung cancer.  Jevtana, which has many similarities to Taxotere, more than any differences, is the second most commonly used type of chemotherapy. Taxotere (and Jevtana) are administered intravenously every three weeks in a cyclical fashion.

These agents are typically used to treat advanced metastatic prostate cancer. Men with preexisting bone pain usually notice significant improvement within a week or two of starting therapy.  Another sign that the Taxotere is working is PSA levels decline.  If the PSA does not decline immediately, Taxotere should still be continued for at least two or three cycles before concluding the treatment is not working. An initial increase in PSA for 30-60 days is not an indication to stop Taxotere because on occasion men have a bump upward in the PSA, a “flare” from the dying cancer cells.  However, if the PSA continues to rise after three cycles, it indicates that the Taxotere is not working.

Cancer response rates can be further improved by using Taxotere in combination with Carboplatin.  Carboplatin is also administered intravenously and can be conveniently administered at the same time as the Taxotere. In patients who have normally functioning bone marrow and normal kidney function, a small dose of Carboplatin, say 200 mg, can be safely administered along with full-dose Taxotere.  Carboplatin is well-tolerated though occasional side effects include low-grade nausea, numbness in the hands or feet and tiredness.

Taxotere administered in combination is with Avastin and Revlimid is another very active combination that will induce a cancer response in most men. Avastin, which is FDA-approved for colon cancer but not prostate cancer, is an angiogenesis inhibitor given intravenously every two weeks.  It is generally well-tolerated but requires concomitant blood thinners due to a higher risk of blood clots.  Avastin can also cause slow wound healing and can't be used before or after surgery. Revlimid oral agent that is FDA-approved for a type of bone cancer called myeloma.  Like Avastin, it also functions by blocking new blood vessel growth. When using Revlimid in combination with Taxotere and Avastin we typically limit the Revlimid dosage to 5 mg daily.  Side effects at this dose range are rare though occasionally platelet counts can be suppressed.

A study using these three agents in combination that showed very high response rates was published by Dr. Figg from the National Cancer Institute.  This same study also reported a high frequency of fairly notable side effects including numbness of the hands and feet as well occasional cases of jaw damage, a condition called osteonecrosis.  Despite these significant problem, Dr. Figg reported that the vast majority of the men achieved significant remissions and that the remissions tended to be quite long lasting.  

Aggressive combination protocols like these require various supportive measures to be successful.  Defending against low white blood cell counts with an immune stimulator such as Neulasta should be considered routine. Neulasta is a powerful medicine that stimulates the bone marrow to manufacture white blood cells more quickly and in greater numbers. Side effects are rare but occasionally, serious but transient episodes of lower back pain can occur.

Another bone marrow stimulator, Aranesp, can defend against the development of progressive anemia. Anemia is a common in men with prostate cancer and can be due to hormone therapy, chemotherapy, or even from the prostate cancer invading the bone marrow. Symptoms of anemia are shortness of breath and fatigue. Timely and appropriate use of Aranesp helps to maintain normal red blood cell counts and can reduce the need for blood transfusions.

Taxotere usage has been greatly postponed in men with metastatic prostate cancer ever since the FDA approval of Xtandi and Zytiga. These agents induce meaningful remissions with far fewer side effect than Taxotere.  However, patient tend to have a rapid and virulent progression of the cancer after Zytiga and Xtandi stop working.  Taxotere, possibly in combination with Carboplatin should probably be implemented quickly in most cases. 

Memorials: Peter Grimm, MD and Jay Cohen, MD

BY MARK SCHOLZ, MD

I am sad to report the passing of two giant contributors in the prostate cancer realm, Dr. Peter Grimm and Dr. Jay Cohen. 

Dr. Grimm was the Director of the Prostate Cancer Center of Seattle which pioneered seed implantation for prostate cancer. He was instrumental in establishing the Seattle Prostate Institute in 1997. Along with his colleagues, Dr. John Blasko and Dr. Haken Ragde, he trained over 6000 physicians worldwide in how to administer seed implants. Their team has treated over 10,000 patients since 1985. Over one thousand centers now perform seed implantation, which is now a treatment of choice for many men with prostate cancer.   Dr. Grimm completed his graduate training in radiation oncology at UCLA. 

Dr. Grimm’s technical endeavors, such as the development of six US patented devices, have led to continuous improvements in the equipment widely used in prostate brachytherapy. He has served as one of fifteen physicians on the Medicare Practicing Physicians Advisory Board in Washington DC and served on the American Society of Therapeutic Radiation Oncology economic committee. He was the CEO of ProQura, and served on advisory boards for many seed implant companies. As lead editor, Dr. Grimm and members of the Prostate Cancer Results Study Group published a collaborative book on prostate cancer, The Prostate Cancer Treatment Book. His curriculum vitae included over 80 scientific articles and book chapters on prostate cancer.  

Dr. Grimm received an Outstanding Achievement awards from the American Brachytherapy Society, Midwestern University, and the Northwest Osteopathic Foundation. Born and raised in Seattle, he had a lifelong passion for preserving wild salmon. He was a board member of Long Live the Kings, a non-profit organization dedicated to preserving wild salmon in the Northwest. In a cooperative effort with the Hood Canal Salmon Enhancement Group and Washington State Department of Wildlife, he has released over 3 million wild salmon.  He also serves as a board member for Pacific Northwest College. He leaves behind his spouse Dawn Winters, PhD and two children, Robyn Vera, DO a radiation oncology physician in Olympia Washington and Justin Grimm, an IT specialist.

I am also saddened to report that Dr. Jay S. Cohen passed away in December 2015. My interactions with Dr. Cohen were related to his excellent book on prostate cancer: Prostate Cancer Breakthroughs. However, outside of the prostate cancer world, his researching and writing skills were eclectic and broad. Among his many and varied interests were his extensive research on the causes of medication side-effects. He published his findings in eight books, leading medical journals, and articles and publications such as Newsweek, Bottom Line Health, The New York Times, The Washington Post, Consumer Reports, Wall Street Journal. Another of his books, Over Dose: The Case Against the Drug Companies was favorably reviewed by the Journal of the American Medical Association.  Dr. Cohen was an Adjunct Associate Professor of Psychiatry and the Chairman of the Medical Advisory Committee of the Erythromelalgia Association, and a Fellow of the American College of Nutrition. He lived in Del Mar, CA for over 40 years. He is survived by his son Rory Cohen and daughter-in-law Alana Cohen, and a nephew, Hal Cohen.

Sometimes Going Fishing with the Doctor Isn’t So Much Fun

BY A PATIENT OF MARK SCHOLZ, MD

When you go fishing, you can bring up all kinds of things besides fish—old rubber boots, pieces of a broken net and discarded trash. Once I caught an eel.  You never know what you will drag in when you drop your line overboard. 

The same analogy holds true for diagnostic testing in the medical world. Investigative studies can have unintended consequences. Of course the studies seem justified at the time. We presume that the doctor is being rightfully conscientious by using all the tools of modern medicine, “fishing” for the right answers.

Dr. Scholz asked me to relate the story of an extended medical fishing trip that started with my dermatologist for my annual, too-much-California-sun screening. While talking to my dermatologist, I mentioned some itching on my arms.  He gave me a few samples of lotion and referred me to my internist for further evaluation and blood testing to “make sure” the itching wasn’t a symptom of something more serious. My internist ordered some lab work (which was normal) but recommended that I have a routine chest x-ray since itching can be associated with lung cancer.  This suggestion may have occurred to him because he knew that lung cancer caused my mother’s death.  Since I hadn’t had a chest x-ray in years, I thought, “why not?”

In retrospect, the chest x-ray may have been a mistake.  Because that’s when the boat left the dock and the fishing really began in earnest.  Two days later, the chest x-ray revealed a “suspicious” spot on my lung. So, to identify what it was, a CT was ordered.  The spot was benign. “Whew!” It was only a bone artifact (the end of a rib visible due to the angle of the x-ray).  But…. the CT scan showed a suspicious spot in the liver, which shouldn’t have been there and was large enough to be of concern.  So, an MRI of the abdomen was ordered.  The MRI revealed that the liver spot was nothing but a harmless hemangioma, a collection of blood vessels that are common and mean nothing.  Another big relief. But…. guess what else the MRI found?  At the top end of the scan in my lower neck, it showed some abnormalities in my thyroid “that could not be ignored.”  So, a thyroid ultrasound was ordered.  It revealed two nodules that looked benign and would have been ignored completely if there had only been one.  But the only way to really know what types of cells the nodules consisted of was by doing a needle biopsy or an exploratory surgery. 

Yikes!  When would I get off this merry-go round?  Who could imagine that simply mentioning some itching to a dermatologist would lead me face to face with the possibility of thyroid cancer.  However, the doctor was kind enough to offer another alternative.  Because of the known, slow-growth rates of typical thyroid cancers, active surveillance and re-testing at future intervals was also an option, and the one I have selected.

So, six months later, a second thyroid ultrasound—my fifth imaging test—showed no changes from the previous test.  The fishing trip finally seems to be over.  I am back in the waiting pool anticipating next year’s medical expedition, much the same as the next round of prostate screening tests I am scheduled to undergo early in 2017.  Now, routinely surveilling my thyroid is going to be just like my prostate.  If next year’s fishing trip doesn’t run down any new tributaries and is uneventful, I expect it may even be possible to extend by a year or two the time the frequency of testing.

My medical fishing trip was not much fun.  Personally, I’d rather spend my time working, biking or walking, or doing almost anything besides waiting for the next set of results from the last odd thing that showed up unexpectedly. But life goes on and it isn’t possible to know precisely how it will end.  My recommendation—Give careful consideration to your doctor’s invitation to go fishing.  Take control over your medical destiny and ask you doctors if close surveillance is an alternative to further testing. 

Crila, A Solution to Old Men’s Urinary Problems?

BY MARK SCHOLZ, MD

As we get older, we run into all kinds of difficulties.  Poor hearing, sexual dysfunction, memory problems and arthritic joints, just to name a few. Bladder issues in particular can be troublesome, interrupting sleep, making us dread long drives or forcing us to visit the bathroom at an inopportune time.

As a prostate oncologist taking care of many men who are in their 60s and 70s, it’s no surprise that I hear a lot about urinary difficulties. These problems are often thought to result from prostate enlargement, otherwise known as BPH. The swollen gland ends up pinching the urinary passage way (called the urethra).  Slow urination and incomplete emptying of the bladder are the result. 

Prostate gland enlargement with incomplete bladder emptying can frequently be solved with common prescription medications like Flomax, Rapaflo and Uroxatrol which relax the muscles in the wall of the urethra and help to open up the passageway.  Proscar and Avodart can shrink the prostate but they also tend to shrink your libido. The most popular treatment is a nonprescription—Saw Palmetto an herbal product that works by relaxing the muscles in the urethra.

However, after doing thousands of color Doppler ultrasound examinations, which by the way is the most precise way to measure the size of the prostate, I have learned that BPH is a less common cause of men’s urinary problems. So what is the primary reason for men’s urinary frustrations? Prostatitis—low grade inflammation of the gland with secondary irritation. What causes prostatitis?  In a minority of cases it is due to bacterial infection. When this type of prostatitis occurs it may improve with antibiotics. But for the vast majority of cases we simply don’t know the cause.  Virus or autoimmune causes have been theorized but nothing has been proven. Our ignorance, however, has nothing to do with its prevalence. It is not widely realized, but almost all men have some degree of chronic inflammation in their prostate glands.

Though we don’t know the precise etiology, anti-inflammatory medications can be quite effective at alleviating the symptoms of prostatitis. Over the counter products like Aleve and Motrin are effective. Celebrex, is a prescription anti-inflammatory agent that is billed as having less stomach irritation. However, unless the pills are used continuously, the inflammation comes back.

Recently, I have been introduced to a natural anti-inflammatory substance discovered in the flower of the Crila plant. Several of our patients tried Crila with notable improvement to their urinary symptoms. So far we have not observed any side effects.  To investigate Crila’s effectiveness further, I have petitioned the manufacturer to provide a 3-month supply of Crila to 15 of our patients at no cost. Patients who have problems with frequent urination, a strong sense of urinary urgency or have to get up frequently at night to urinate may want to consider contacting Sabrina in our office about their eligibility for participating in this clinical trial. 

The Amazing Gleason Score

BY MARK SCHOLZ, MD


Everyone is excited about the latest craze in medical technology—genetic analysis of tumor cells, which I’ll call GAT for short. The scientific progress that has been made with GAT in my opinion is the second most exciting area of advancement in medical technology today (see further below for more about the first most exciting area). GAT technology is already being commercialized for use in the medical marketplace in products like Prolaris and Oncotype. This technology is able to predict the aggressiveness of prostate cancers, enabling us to differentiate between the men who need immediate treatment and those who can postpone treatment safely.

The predictive power of GAT is certainly exciting, but there is already an effective form of genetic testing available that has been around for more than 40 years, the Gleason scoring system. The Gleason system relies on the visual appearance of cells under the microscope to draw conclusions about their inner genetic makeup. In the medical world, using the visual appearance of the cancer cells is called phenotypic analysis. GAT is genotypic analysis.  Drawing conclusions about underlying genetic makeup by simple visual assessment is a pervasive in human experience.  In courtship, we rely on phenotypic analysis of the underlying genetic make-up of potential spouses to form an opinion about their suitability as potential mates.  Perusal of the genetic pool of immediate family members provides further insight.

So how can Gleason score draw conclusions about the underlying genetic potential for tumor aggressiveness simply by looking at the appearance of cells under a microscope?  The answer is to do a comparison of the visual appearance of cancer cells with the appearance of normal prostate cells. Normal cells in the prostate perform varied functions but still work together as a team.  Specifically, healthy cells form into definable structures called glands.  In these glands some cells manufacture prostatic fluid, a complex liquid comprising the ejaculate for the sperm to swim in.  Other cells organize to form ducts, a piping system to drain the fluid from the outer periphery of the gland and channel it into the middle of the prostate so that a large quantity of fluid can be expelled through the urethra at just the right moment.  All of these different cells work as a team and coexist in the prostate functioning together in a structured glandular arrangement.   
 
When a trained pathologist looks at tumor cells under the microscope he grades them by the degree of cellular disorder.  He is asking himself the question, “How much do these cells retain the normal glandular characteristics of the prostate gland?”  If a cross section of the tumor looks like an unbroken sheet of uniform cells, the cancer is high-grade; the cells have lost their ability to cooperate with each other and form glands. The cancer cells have been honed down into little race cars with only one mission, to aggressively pursue its own replicative destiny. When tumors have this appearance they are graded as a Gleason 9 or 10.  On the other hand, if the appearance of the tumor shows residual glandular components, it is less aggressive, perhaps a Gleason 7.  Gleason 6 “cancer,” the type the one that never spreads, looks almost like normal prostate gland tissue.  
 
Predicting future tumor behavior is obviously very important. How fast will it grow?  Is it likely to spread? How well can it be expected to respond to treatment?  As a result of decades of experience, doctors have learned to use the Gleason scoring system to accurately predict the long-term outcome in individual patients. The new GAT tests represent an important additional refinement, further enhancing our ability to predict the future behavior of an individual cancer. GAT holds one even bigger promise.  In the future we believe GAT testing will be a powerful aid in the selection of targeted therapy, i.e., picking cancer treatments with anticancer activity tailored to individual tumor types.  This hope, however, will have to be postponed until our limited armamentarium of effective treatments is further expanded.    
 
Now, what is it that I consider to be the most exciting area of medical progress? Since I am an impatient type of guy, someone who is looking for quick results, I find immunotherapy more exciting than GAT. To fully exploit the potential of GAT we will need to invent new pills for each of the myriad of genetically different tumor types. Immunotherapy on the other hand comes with its own “built-in” GAT system that enables it to target the unique genetic signature of individual cancer cells. The immune system is so smart, all we have to do is “flip the switch on” and starts cranking out genetically targeted anticancer therapy. Recent developments in the field of immunology are truly mind-boggling and hold promise for a big revolution in cancer therapy within the next 5-10 years.  I’ll try to address some of these recent advances in an upcoming blog.