Active Surveillance: Follow-Up Essential

BY RALPH BLUM

 

A recent UCLA study found that a significant percentage of men diagnosed with low-risk prostate cancer who chose "active surveillance," rather than aggressive treatment in order to avoid the debilitating side effects of surgery or radiation, don't follow up with the required tests and office visits.

 

This is an alarming finding, because not being monitored appropriately puts them in danger of the cancer progressing or metastasizing without their knowledge. Before patients decide on active surveillance as a management option for prostate cancer they should agree with their physician on a strict follow-up schedule to closely monitor the cancer.

 

There is no doubt in my mind that active surveillance is the smart treatment option for low-risk prostate cancer.  With other cancers, or if the prostate cancer is aggressive, the main issue is survival. But with low-risk prostate cancer, since long survival is the norm, the most important consideration is quality of life. Having said that, with active surveillance regular check-ups are essential, because when men are watched closely, treatment can be started at the first sign of cancer progression.

 

So what does active surveillance require? How exactly is it carried out?

 

Different centers have different requirements. At a 2007 Active Surveillance Conference, attended by over 200 of the world's leading prostate cancer experts, the attendees recommended a biopsy after one year, subsequently repeating it every two to three years. But as I have often said, I am not a fan of biopsies. So I prefer to recommend doing a repeat targeted biopsy only on the basis of a PSA and prostate imaging with either color Doppler ultrasound or 3T multi-parametric MRI.

 

Here is an Active Surveillance Protocol that Dr. Mark Scholz recommends:

 

• PSA every three months
• Rectal examination every 12 months
• Color Doppler ultrasound annually
• Multi-parametric MRI annually

Whatever protocol your urologist recommends you need to be committed to following it. It may be inconvenient or uncomfortable but the alternative is aggressive treatment that has the potential to leave you with erectile and urinary dysfunction.

 

There is always the consideration to just treat the cancer and be rid of it. But having lived with this disease for over two decades, with my prostate intact, I am a firm believer in avoiding radical treatment and preserving quality of life as long as possible. And if you have low-risk prostate cancer, bear in mind that the longer you can wait before you submit to radical treatment, the better the odds are that research in the field will have advanced, and treatment will have become more effective and less toxic.                                                                

Taking Charge of Your Prostate Cancer Recovery:Fast Forward From the Old Model

RALPH BLUM

In the old model of prostate cancer care, you were rushed into radical treatment--usually surgery or radiation--often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.  

The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving "terminal" lung cancer founded the Cancer Recovery Foundation, has said that "Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt."

So what do you need to know in order to take charge of your recovery?

 There are three common misperceptions about prostate cancer:

*The assumption that the disease is as dangerous as other cancers.
*The assumption that the urologist who did your biopsy is a prostate cancer expert.
*The assumption that a quick treatment decision is necessary before the cancer spreads.

First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 3% will eventually die from it, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.

 
Your local urologist has a busy medical practice that involves treating problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist performs fewer than five prostate removals (prostatectomies) a year--far too few to be considered proficient. He may be a talented doctor, but he is unlikely to be a prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.

As for the third misperception, it is essential, before committing to any form of treatment, that you do your own research, and are convinced the treatment you choose is the right one for you.  Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option--including no treatment whatsoever--for your type of disease.  If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.

Your role in your recovery, however, doesn't end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels.  And according to a relatively new field of health psychology called "illness representation," your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment.

For the Sake of Our Partners

BY RALPH BLUM

I'm not usually a fan of statistics, but I was pleased to discover that although the American Cancer Society estimates in 2015, there will be approximately 220,800 new cases of prostate cancer in the U.S., more than 2.9 million men who have been diagnosed with the disease at some point are still alive today. So if your partner is one of the 220,800, take heart: In most cases, prostate cancer is not nearly as scary as it sounds.

However, when you first heard the diagnosis, "prostate cancer,"  you no doubt experienced a tidal wave of emotions. And at the same time you were trying to get a handle on your own fears, you wanted to support and try to reassure your partner. It's a tough act to balance, and it's only too easy to contain or ignore your own feelings and needs.

Often it seems that men are more intimidated than women about health problems, and when you are first given the bad news, you may find it is up to you to ask the pointed questions in the doctor's office, while your partner sits there in apparent--usually temporary-- shock. Also men are conditioned not to talk about their fears and anxieties, and you may fall into the trap of struggling to remain upbeat while hiding your own fears from him.

It's natural for both of you to fear how the cancer could change your lives, how it might affect your relationship, especially your intimate relationship. Your partner is likely to be fearful that a treatment that might be his best chance of eradicating the cancer would also have the highest chance of leaving him impotent.  Although most men don't subscribe to the idea that they are exclusively the products of their hormones, the degree to which sexual function returns--or fails to return--after prostate cancer treatment, is a matter of serious concern to them all.

So while it's helpful to be as positive as you can, it's equally important to talk openly about intimacy issues. Perhaps point out that sex isn't just about erections. And let him know that your main concern is his survival, and that what both of you need now is emotional closeness.

Let your partner know that you need to help him in any way you can--that helping him will make you feel better. One way you can do this is by learning everything you can about prostate cancer and the various treatments, so that you can discuss them knowledgably with him as he decides his best treatment option.  Hopefully, his best option will be Active Surveillance. If not, you can help by driving him to treatments, picking up his medications at the pharmacy, and by keeping track of all his test results, X-rays and medical records--so that if he wants to get a second opinion (and he should!), he will have a folder with everything he needs to take with him.

 

Having said all that, it is vital that you don't neglect your own health or give up your own life and center everything around your partner and the cancer. Take time out from thinking and talking about the disease and enjoy activities you have always liked doing together. Remember: the statistics are on your side, so don't let your lives be held hostage to prostate cancer!

CHECK OUT PCRI 2015 PROSTATE CANCER CONFERENCE - PATIENTS & PARTNERS WELCOME! http://pcri.org/2015conference/
 

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."

 

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.

The Importance of Diet in Beating Prostate Cancer

BY RALPH BLUM

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.

When “No Action” Can Be “Right Action”

BY RALPH BLUM

Back in 1990, when a suspicious lump was discovered on my prostate, my ignorance of the prostate gland and the possibility of prostate cancer was monumental. No one in my family or even among my close friends had ever had prostate cancer, and it never occurred to me that I might one day have the disease.

Now, 25years later I am still alive, the average man over 50 is more aware of prostate cancer, and also many less toxic and more effective treatment options are available. And yet one thing has not changed: just hearing the doctor say, “I’m afraid it’s cancer,” can leave even the most pragmatic man planning the music for his funeral.

Truth is there is still a lot of misinformation and misunderstanding out there about this disease. So here are some facts that I hope will alleviate some of your fears, and also clarify why I still contend that if you have to have cancer, prostate cancer is the best deal in town.

Prostate cancer is unique among cancers because the mortality rate is so low. According to the American Cancer Society, more than 2 million men who have been diagnosed at some point are living with the disease in the U.S. It’s difficult to determine actual prostate cancer survival rates because most men are around 70 years old when diagnosed, and many of them will die from medical problems unrelated to the disease. But if you check out the “relative” 5-year survival rate of all stages of prostate cancer, you will find it is almost 100%. And that almost 100% of men with low-risk or  intermediate-risk disease live more than 10 years after diagnosis.

Why is it that the statistics for prostate cancer are so much less frightening than for other cancers?
 
1)    The PSA test is an early warning system that other cancers don’t have.
2)    It can easily be diagnosed at an early stage.
3)    In most cases it has an exceptionally slow growth rate.
4)    Extremely effective monitoring and treatment is now available.
5)    It has a pattern of spread that spares critical organs like the brain, lungs and liver.
6)    There is a safety net like no other called “hormone blockade” that induces remissions lasting more than 10 years in men with relapsed disease after surgery or radiation.

So instead of thinking about your funeral, what you really want to be focusing on is not rushing into some form of radical treatment that will virtually guarantee  some degree of impotence or incontinence.

It appears that patients and doctors alike struggle with the idea of “watching” anything called cancer. But unless you have the less common high-risk form of the disease, my advice to you is to consider “Active Surveillance” really carefully, especially if you are over 70. Because bottom line—and it bears repeating—out of over 200,000 men in the U.S. diagnosed annually with prostate cancer, the overwhelming majority will die with the disease, and not from it.

Who Asked You for Your Opinion Anyway?

BY RALPH BLUM

Unsolicited Advice from Survivors for the Newly Diagnosed

In 2014, approximately 233,000 men in the U.S. were told they had prostate cancer and to many of them it sounded at best, like the end of their sex life, and at worst like a death threat. In reality, the majority of them turned out to have an indolent form of the disease that was not life threatening and could safely be monitored without any immediate treatment.

 

Having said that, a diagnosis of prostate cancer is not a walk in the park. Just when you are most vulnerable you are obliged to confront so much complex and conflicting information that to say it leaves you reeling would be an understatement. So your first and most important decision is not to make a pressured decision, not to rush the treatment selection process or allow anyone else—including any doctors you consult—to rush you into undergoing an irreversible treatment until the shock has worn off and you have had time to carefully analyze all the data that applies to your particular case.

 

The first step after being diagnosed is to understand the concepts of staging and grading. The grade of your cancer will tell you how aggressive the cancer cells are. The stage tells you how extensive or advanced the cancer is. This information, together with your PSA level, will help determine your prostate cancer’s risk factor—whether you are in the low-risk, intermediate-risk, or high-risk category.

 

If your cancer is low-risk it can be safely monitored with “active surveillance” and does not require any immediate treatment.  If you are in the intermediate-risk category, you have many treatment choices, and in order to make the best decision you will need to get opinions from specialists with state-of-the-art knowledge.

 

You will already have seen a urologist who, if you are a candidate for surgery, is likely to have recommended a prostatectomy. If this is the case, it is essential to ask him the tough questions: What are the risks? How many prostatectomies has he performed overall and how many has he done in the past twelve months? Does he perform nerve-sparing surgery, and if so what is his success rate with preservation of potency and continence? And if you are over seventy, please consider prioritizing  almost any other treatment option ahead of  going through a major surgical procedure.

 

Before making a treatment decision you should consult a radiation oncologist about brachytherapy (radioactive seed implantation), and IMRT (Intensity Modulated Radiation Therapy), a precisely targeted type of radiation that delivers high doses to the prostate without damaging surrounding organs. In my opinion both these options are at least as effective as surgery at curing the disease and both are associated with significantly lower risk of long-term toxicity.

 

You should also consult a medical oncologist about hormone therapy, a treatment that blocks the male hormone testosterone and significantly slows the spread of the cancer, often for years. Hormone therapy does not promise a cure, but it is a viable, non-invasive alternative to surgery, an effective delaying action. A medical oncologist is a good doctor to consult with as they have no vested interest in either surgery or radiation and can often be helpful in sorting out the conflicting opinions you likely have heard.

 

If your cancer is in the high-risk category you will usually need two or more different kinds of treatment—probably hormone therapy plus radiation. Some centers even may mention chemotherapy such as commonly done for patients with colon cancer or for women with breast cancer.  And there are many new treatment methods in the pipeline, so even if your cancer is aggressive, you are not looking at an imminent death threat.

 

So do your research and take your choice. And always remember: Prostate cancer is about the best possible cancer to deal with.

Finding a Skilled Specialist

BY RALPH BLUM

Your number one priority when you have an elevated PSA and prostate cancer is suspected, is to take the time to find the very best urologist in your area. What you need now is an experienced urologist who specializes in treating prostate cancer, a urologist who is up on all the latest medical knowledge and surgical techniques, and who will thoroughly discuss all viable treatment options with you in an even-handed manner.

Your options might include nerve-sparing prostatectomy, radiation (IMRT and seed implants), cryosurgery, proton beam therapy, hormone therapy, and Active Surveillance. All prostate cancer treatments have their risks and benefits, and sometimes your best decision is no immediate treatment. I strongly suggest that you take the time to do some Internet research so that when you see the urologist you have some knowledge of the various treatments and their side effects, and know what questions to ask.

Before making any treatment decision you should also talk with a medical oncologist.  Urologists are surgeons, so if the cancer is contained within the gland, it’s not surprising that their treatment of choice would be surgery. But if you have done your homework, you will know that a prostatectomy is a complex procedure that can leave you with considerable collateral damage. Similarly, radiation therapists will likely recommend one of the targeted radiation options. However, a medical oncologist has no vested interest in either approach and is familiar with all the treatment options, so he is uniquely qualified to help you decide which treatment to select.

Your primary care doctor usually knows the names of the best local urologists and oncologists in your area. But you may want to go beyond your local area to find a specialist, in which case you can network--ask your friends if they know of any good doctors for treating prostate cancer. Search prostate cancer Web sites. Ask any doctors you have ever consulted who they would see if they had the disease. And most states have prostate cancer support groups that provide excellent advice.

Before making a final treatment decision, it is critically important to get a second opinion, preferably from a highly trained urologist, medical oncologist or radiation oncologist at one of the major cancer centers. Second opinion consultations are standard procedure; your doctor makes such referrals all the time, and a second opinion is reimbursed by most insurance programs. One other thing, be sure to take a complete transcript of your medical records with you.

Above all, don’t rush to make any pivotal decision that could influence the rest of your life while you are still in shock from the diagnosis. You have plenty of time to make sure you are selecting an experienced doctor, and one with whom you feel comfortable, and who gives you confidence.

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.

First, find a Doctor You Like . . .

BY RALPH BLUM

A urologist I consulted in Hawaii, a man with a big reputation, told me to go home and settle my affairs, because I was going to die. That was 16 years ago.

When your are visiting a doctor, his reputation shouldn’t matter.  Even if he’s a great urologist or a world class prostate oncologist, If he makes you uncomfortable, dump him!  Never mind why.  This is your life. Find yourself another doctor.

Nor is this simply a matter of learning to be comfortable with personality differences. There is also a purely practical side to this— studies show that personality influences treatment selection.  “The physician a patient sees can influence their treatment fate,” according Dr. Karen Hoffman, lead author of a recent study from the University of Texas MD Anderson Cancer Center in Houston. “Physicians play an important role in whether or not men with low-risk prostate cancer are managed with observation or treatment.”

According to a new study, whether a man’s low-risk prostate cancer gets treated with surveillance, surgery or another form of radical treatment, may have more to do with his doctor than that man’s health status.   For example, the study found that urologists who have been practicing for more years or had more patients with advanced disease were less likely to use a wait-and-see approach to manage low-risk prostate cancer.

The issue of how physicians steer patients toward one treatment or away from another has become a major national health issue since prostate cancer is so common, occurring in over 200,000 men annually.  Dr. Hoffman and her colleagues write in JAMA Internal Medicine that most common type of prostate cancer, the low-risk variety, is not likely to affect how long men live even without treatment and  radical treatment  can lead to complications like rectal bleeding, impotence and problems with bladder control.

Good medicine dictates that the treatment a patient receives is supposed to be dependent on factors such as their age, health status and the stage of their disease.  Dr. Hoffman’s study euphemistically described as “doctor characteristics” as the main force driving treatment decisions. The study analyzed data from 12,068 men ages 66 years and older who were diagnosed with low-risk prostate cancer by 2,145 urologists between 2006 and 2009.

Only about a fifth of the men had their prostate cancer managed with active surveillance. The rest received up-front treatment, such as surgery or radiation.

The proportion of patients that each doctor put on active surveillance varied from less than five percent to about 64 percent.

The researchers found that doctor characteristics were twice as important as patient characteristics, such as age and other conditions, in predicting whether a patient would receive active surveillance or up-front treatment. “The rate of treatment of older men with low-risk disease is well documented to be extremely high,” said Dr. H. Ballentine Carter, professor of urology and oncology at Johns Hopkins Medicine in Baltimore “I think we need to do a better job of educating older individuals with low-risk disease.”

According to Ballantine, we are asking the wrong questions. The question should not be which treatment men need but whether they need any treatment at all.

One option for reducing potentially unnecessary treatment is to make public the track records of doctors who consistently advise radical treatment so primary care doctors would know that information before they referred their patients.

Dr. Hoffman pointed out that doctors would also want to base their decision on other measures, such as potential complications after treatment, age, and follow-up care, because active surveillance is not always the best treatment option.

Bottom line, patients need to feel good about their physician. And equally important, they must become more proactive regarding the big question: To treat or not to treat? 

Advances in Diagnosis: Magnetic Resonance Imaging

BY RALPH BLUM

Prostate tumors are often multifocal, which means they tend to occur in more than one place within the gland. The digital rectal exam performed by the urologist will often miss tumors. The PSA test, used to screen for prostate cancer, has a sensitivity of about 70% and will often yield unclear results. And the random prosate biopsy, which seeks to identify tumors, while performed systematically, is also done blindly, resulting in roughly one-third false negative results.



In recent years, Multi-parametric Magnetic Resonance Imaging (MP-MRI) has played an increasing role in prostate cancer detection. MP-MRI scans are now more effective in distinguishing cancer from normal prostate tissue.  And although MP-MRI is not yet considered the standard tool for diagnosis, it can uncover cancer that has been missed during biopsy. Moreover, MP-MRI plays a significant role in helping to determine whether active surveillance is a safe procedure, or whether a patient requires definite treatment.

Advances in MP-MRI technology include specific targeting known as MRI-guided biopsy. Since cancers that occur in the anterior or front part of the prostate are often not being sampled because they are “out of the reach” of standard biopsy techniques, they often contain undetected areas of cancer.  An optimal magnetic resonance imaging study employs a powerful magnet to create detailed images that are then displayed on a computer screen. According to K.J. Macura, MD, at Johns Hopkins:

Based on the scans, radiologists assign scores of 1 to 5 for the presence of prostate tumor on MRI, with 1 being deifinitely benign, 3 either benign or not (i.e. we can't tell), 4 being probably malignant, and 5 definitely malignant.

This greater specificity is valuable since a lower score indicates that a follow up biopsy may not be necessary, while high scores indicate that a confirmatory biopsy may be advisable, and that the disease may require up-grading.

There are various types of MRI equipment available. When my MRI was performed, the MRI unit was operating at “3T”, T standing for Tesla and 3 the current state of the art technology, a unit of magnetic strength that provides hundreds of images and a detailed anatomy of the prostate.  However as of 2014, most of the men I have spoken with have undergone MRI testing with the older, less comprehensive 1.5 Tesla unit.

And while the number  of the MRI centers that use the latest technology is increasing, progress has been slow. So if you are scheduled to undergo an MP-MRI-guided biopsy using transrectal ultrasound and MRI guidance, make sure your MRI guidance is performed with the 3-Tesla machine. The results may make the difference between your being subjected to unnecessary, invasive treatment versus continued on active surveillance.

 
If necessary, make a fuss. It's your prostate cancer and your life.

FIND OUT MORE ABOUT RALPH'S STORY IN THE BOOK Invasion of the Prostate Snatchers


 

The Vital Intangibles

BY RALPH BLUM

After living with prostate cancer for over two decades, there are some things that really stick in my mind as a “need to know” for anyone newly diagnosed with the disease. The most relevant of these is the major impact you can have on your own healing.

Greg Anderson who, after surviving “terminal” lung cancer, founded the Cancer Recovery Foundation, once said, “Retaining a medical team without doing everything you can to help yourself is like attempting to walk with one stilt.”

Your doctors will primarily be focused on attacking the tumor.  It is your responsibility to support your mind, body, spirit—and your immune system.  When I was first diagnosed, my ignorance about the immune system was monumental. Since then I’ve learned that my brain is constantly sending my immune system chemical messages which, for better or worse, influence its ability to function effectively.

A diagnosis of cancer tends to be overwhelming, and can generate feelings of disempowering fear and of loss of control. These responses have a negative physiological impact on the immune system. So reclaiming a sense of being in charge of your own life and health is an important foundation of the healing process.

There is growing evidence that creating high levels of well-being with proper nutrition, adequate exercise, stress management and emotional support is as necessary to your recovery as whichever cancer treatment you choose.

After understanding your diagnosis you will have several treatment options. Depending on the results of your pathology report, your doctor will recommend what he considers to be the best treatment program for you. But you need to play the central role in this decision. A passive, “Whatever you say, doc,” attitude will not serve you.

Before you commit to any treatment it is essential that you thoroughly research it, and are convinced that it is the right treatment for you. It is equally essential that you follow it with conviction, with the belief that it will be successful.  Hope, optimism, and excited belief are the great intangibles. The correlation between belief in treatment and effectiveness of treatment is extremely high.

Remember: Your medical team will be addressing just one part of your cancer journey. It is up to you to focus on your general health, and to examine your attitudes and your beliefs. According to a relatively new field of health psychology called “illness representation,” your beliefs and expectations really do impact the outcome of the disease.

 

The Power of a Word

BY MARK SCHOLZ, MD

At an Active Surveillance Consensus Conference in 2007, it was openly bemoaned that the word “cancer” profoundly overstates the significance of low risk prostate cancer.  The pathology experts who were present, however, shot down the idea of a name change saying, “Under the microscope it looks like a cancer, so it’s cancer.” At that time no one had a rebuttal, so the subject was dropped. Now studies confirm that Gleason grade six prostate cancer never metastasizes.

In retrospect, I wish the conference attendees had been able to rise up to the name-change challenge. Back when the makers of 7-Up wanted to emphasize the distinctness of their product compared to other soft drinks, they came up with the name “Un-Cola,” a stroke of marketing genius. Since the pathology experts insist that low-risk disease is a cancer—we should undo the negativity of this word by renaming it: “The Un-Cancer.” Alternatively, the SHADES of Blue classification system calls this harmless type of prostate cancer SKY BLUE.

Misinterpreting the significance of the word cancer leads everyone to think, “I had better be safe and remove the gland.”  The biggest challenge of educating people about prostate cancer is overcoming their preconceived notions, what they already think they know about cancer.  Random biopsies are detecting cancers that are so small that even if they grow while under observation, they will still be curable.  And for the minority of men on active surveillance who develop progressive disease, at least they have real proof that their cancer truly needs intervention, for this minority, it’s not a paper tiger and undergoing treatment is justified.

Defining the Un-Cancer—The Basic Components of SKY

	Favorable	Ambiguous Zone	Unfavorable
Color Doppler or Multiparametric-MRI	< 10 mm  in maximum tumor dimension	11-17 mm  maximum tumor dimension	> 18 mm max tumor dimension
Highest Gleason Grade	Grade 3 + 3 = 6	3 + 4 = 7	4 + 3 = 7 or higher
PSA Density	Under 0.13	0.14 to 0.17	Over 0.18

Further In-depth Testing for SKY
New technology is also providing new insight into how favorable cancer can be distinguished from unfavorable cancer. The biggest advance is better imaging of the prostate. Other new blood and genetic tests such as Prolaris, Oncotype, MDx, OPKO 4K and Mitomics, can also ferret out the cancers that are prone to behave more aggressively or have been missed on the initial random biopsy.

The Drawbacks for Active Surveillance
The main concern is that the initial random biopsy missed a higher grade tumor somewhere else in the prostate. Most centers address this problem by doing random biopsies over and over. Repeated random biopsies are unpleasant and they can cause serious infections.  Multiple biopsies have also been associated with higher impotence rates and worse urinary symptoms. A better way is to rely on modern imaging with color Doppler ultrasound or multiparametric MRI (MP-MRI). Also, because with active surveillance prostate gland is left intact, there is the possibility of a new, higher grade cancer developing. The privilege of keeping the prostate intact entails the responsibility of close monitoring. Then, if a new higher grade cancer subsequently develops, it can be detected and treated at an early stage.

Anxiety and uncertainty about living with untreated cancer is also a problem, one that is often magnified by the treating physicians, surgeons or radiation doctors who often send an ambivalent and lukewarm message about active surveillance to their patients.  This half-hearted attitude is probably rooted in the doctor’s own uncertainties about untreated cancer. Despite all these very real issues, however, studies show that men on an active surveillance program are no more anxious than men who have had surgery or radiation and are being monitored after therapy to make sure their cancer stays in remission.

It’s Hard to Teach an Old Dog New Tricks
It’s easier to teach a proper golf swing to a true beginner than to someone who has previously developed bad habits.  The mind of a child learns a new language much more easily than the cluttered mind of the adult.  Good first impressions are valued so highly because we all know how hard it is to undo a bad first impression.  Changing the mindset of doctors and patients about how to treat something called CANCER is going to be a slow process.

Men need to realize that survival rates with low-risk prostate cancer managed with observation are extremely favorable.  Studies show that survival with active surveillance matches the survival of men getting immediate surgery. Men need to guard themselves from being rushed into unnecessary treatments that have irreversible side effects.