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

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. 

Predicting Prostate Cancer’s Future Behavior

BY MARK SCHOLZ, MD


Developing an accurate prognosis, i.e., predicting how a man’s cancer is likely to behave in the future, is the first and most important step toward optimal care. Future predictions are often looked at with some suspicion. With prostate cancer, however, our power to anticipate future cancer behavior is quite accurate unless there is a lack of thoroughness in gathering information.

The Size of the Tumor
Tumor size is a universally important prognostic sign for almost all types of cancer including prostate cancer. The method for incorporating tumor size into the Anthony D’Amico’s staging system relies on the degree of PSA elevation, the tumor grade and on how the prostate "feels" with the finger of a trained practitioner. These indicators are useful but don’t incorporate information from modern imaging. Imaging provides accurate information about tumor size and the presence or absence of extracapsular extension. These are very powerful prognostic predictors and it would be foolish to disregard their importance. As things stand presently these indicators are often used to divide the low, intermediate and high risk categories into "favorable" and "unfavorable" subcategories, each with a different spectrum of recommended treatment options.


Knowing Past Treatments Tells Something about Future Prognosis
Historically, since the total number of available treatments is relatively limited, practitioners have used a sequential "trial and error" treatment methodology that administers the standard treatment options in a fairly predictable sequence. For example, it is not uncommon for men to start with surgery or radiation. When a relapse occurs, standard hormone therapy (Lupron) is often started and given intermittently or continuously. Hormone therapy usually controls the disease for an average of 10 years. When Lupron stops working, immunotherapy with Provenge is usually follows. After Provenge, more potent hormone therapy with Xtandi or Zytiga is started. If these two agents prove ineffective, chemotherapy with Taxotere or radiation with Xofigo would be considered next.

The whole point of presenting the treatment sequence described in the previous paragraph is to convey the idea that the number of previous treatments communicates important information about that patients’ future prognosis. Having "failed" Lupron, for example, bespeaks of a much more worrisome prognosis compared to the situation where Lupron continues to be effective.


Response to Lupron, The Mother of All Metrics
The quality of the "response" to Lupron is actually one of the most powerful prognostic metrics available. The degree of PSA decline after Lupron is incredibly important. How low the PSA drops after starting Lupron is called the "PSA nadir." The specific PSA threshold used to determine a "good response" is less than 0.1. Believe it or not, there is a huge difference in prognosis between a man on Lupron for six months who has a PSA of 0.1 versus a man whose PSA levels off at 1.0.

An Established History is also a Prognostic Indicator
Another somewhat obvious prognostic indicator that is often overlooked and almost never discussed in textbooks has to do with the prognosis of men who have been diagnosed years ago -- over time it is apparent that things are turning out much better than what might have been expected based on their initial indicators. For example, take the case of a man who started off with a panoply of bad indicators—tumor is in the lymph nodes and Gleason 10—but after aggressive treatment remains in remission for 5 years. The fact that things have gone well for five years counts bigtime in his favor going forward. Remember, the original prognostic predictors of a Gleason 10 were just that, predictors. No predictor is 100% accurate. Five years of established history is a stronger predictor than the original Gleason score. The fact that things have gone well for five years, strongly indicates that the future is for that individual is bright. Such individuals have "beaten the odds."

The Location of the Tumor in the Body
Another extremely important indicator of prognosis, something that even laypeople anticipate by simple common sense, is the location of the cancer in the body. Location says volumes about how things are likely to progress in the future. For example, consider the following sequence of progressively more serious cancer sites:

•Contained within the prostate
•Extended into the seminal vesicle
•Spread to the lymph nodes
•Bone metastases
•Liver metastasis

Each of these locations is very important for determining prognosis.

This short blog is just an introduction to some of the "profiling" methods utilized in generating an accurate prognosis. Space limitations preclude discussion here about other known prognostic factors such as the size of the prostate gland (discussed in a previous blog), genetic tests and PSA doubling time. The D’Amico risk categories constitute the backbone of useful prognostic information. However, the additional prognostic information beyond the D’Amico risk categories that are discussed in this blog, provide additional useful information necessary for determining an accurate prognosis. An accurate prognosis is the starting point for accurate selection of treatment.

Photons or Protons? You Choose

BY RALPH BLUM


Following in the footsteps of robotic surgeons, prostate cancer continues to go high-tech. Radiation, for instance, is no longer just radiation. There are now numerous different ways to deliver it. But the two methods I want to write about here are Intensity Modulated Radiation Therapy (IMRT), and Proton Beam Therapy (PBT).


The predominant method in the U.S. for the past decade is IMRT, a complex procedure that precisely targets the prostate gland with multiple beams of high energy light (photons) at different angles and intensities while significantly lowering the risk of damage to the surrounding tissues and organs.  This greater accuracy in targeting also allows the therapist to maximize the radiation dose to the tumor.  IMRT has at least as effective a cure rate as surgery, and without the risks and side effects of a major surgical procedure.


Having said that, I have recently been checking out Proton Beam Therapy, a form of radiation that targets the tumor with charged particles called protons. Several decades ago, Loma Linda University in California was the first to begin administering PBT. At that time, I had a friend who, at 55, developed prostate cancer and was one of the first patients at Loma Linda when proton therapy was at a very early stage.  Bill has been free of cancer for over twenty years, and only recently had a rise in PSA and is discussing further treatment.


Since then, thanks in part to marketing hype, PBT is becoming increasingly popular.  Now, M.D. Anderson, Harvard, and the University of Florida in Jacksonville, are among the major medical centers that have made PBT available. And The Mayo Clinic is building two proton therapy centers (one in Rochester, one in Arizona) at a cost of $380 million. Naturally PBT costs considerably more than IMRT.


When weighing treatment options, patients generally consider two main factors: potential side-effects, and successful outcome. So how do these two therapies measure up? Well, there is considerable controversy in the urologic community. The good news is both therapies have a high cure rate. Studies that have tried to compare IMRT with Proton therapy indicate that the outcomes are quite similar and that the side effects are comparable.  No large randomized trials have been published that directly compare patient outcomes with the different techniques.  So in the end, a treatment decision usually depends on such variables as patient preference and doctor preference.


It is reasonable, therefore, to keep in mind that any medical center that has invested an astronomical amount of money on equipment will end up wanting to use it.

Biopsy, Not PSA, Leads to Prostate Cancer

BY MARK SCHOLZ, MD

Prostate cancer is way over treated, and the problem starts with over diagnosis.  Once men are diagnosed, the fear of cancer naturally drives them toward radical treatment. In 2011 the US Preventive Services Task Force intervened, trying to stop overtreatment, argued that PSA testing causes more harm than good.

Some have questioned the expertise of the panel because of the lack of representation by urologists, radiation therapists or medical oncologists --the types of doctors usually responsible for treating prostate cancer.  Actually, the credentials of the panel constituents appear entirely appropriate to comment on screening, because this is an area of medicine usually handled by primary care doctors.  The panel members consisted of twelve MD’s and four PhD’s trained in primary care, public health and statistics.

The Task Force agrees that PSA screening may save lives. Their judgment, however, was that too few lives are saved to justify thousands of men getting unnecessary radical treatment. One statistic indicates that a thousand men must be screened to save one life within the next 12 years.

Personally, I agree with the panel in regards to over diagnosis is a root cause of over treatment. However, simply discarding PSA is an oversimplification. PSA can detect a variety of problems infection and benign prostate enlargement. Actually, the majority of men with elevated PSA, don’t have prostate cancer.

No, the real problem is after a PSA test rises. Every year, a million men are advised to have a dozen, large-bore needles jabbed into their rectums “Just to be sure there is no cancer.”  Such behavior sounds ridiculous, but really, it is just the survival instinct in action. People will do practically anything when they fear for their lives.

So if not a biopsy to evaluate an elevated PSA, what’s next?

First, the fear must be faced. Ralph Waldo Emerson says “Knowledge is the antidote to fear.” So let’s look at some basic facts:

• One out of 38 men die of prostate cancer
• One out of seven men are diagnosed with prostate cancer
• In men who are “diagnosed”
  • Five-year survival is 100%
  • Ten-year survival is 99%
  • Fifteen-year survival is 94%
    

Considering it is cancer, survival rates are great! At least these numbers should overcome any urge to rush. Clearly there is plenty of time is to study and learn more. Confusion arises because a minority of prostate cancers can indeed be dangerous. Not as dangerous as lung or pancreas cancer which kill within months. However, demise from prostate cancer certainly qualifies as “dangerous,” even if it is rather infrequent and much postponed.

These statistics reveal something else that is quite useful. Prostate management issues are of long-range nature, like saving for college or for retirement. Just as expert financial planners are limited in the ability to make predictions about economic activity ten years in the future, doctors should be equally humble in their pronouncements about the future of prostate cancer. We don’t know for sure, but we strongly suspect there will be substantial breakthroughs in the diagnosis and treatment of prostate cancer in the next ten years.

For the short term, I think the best way to proceed is with imaging the prostate with a 3Tmulti-parametric MRI or color Doppler ultrasound. Scans are about as accurate as a random biopsy for detecting aggressive cancers and they usually fail to detect the harmless low grade types, which is a good thing. However, if there is a worrisome abnormality, a targeted biopsy with just a couple cores is needed.

Over-diagnosis and over-treatment is not due to PSA. It’s the misguided policy of rushing into an immediate random biopsy whenever there is a slight elevation.  .The random biopsy procedure should be abandoned.  PSA abnormalities should be evaluated with prostate imaging A targeted biopsy can be considered in men who have a distinct abnormality detected by imaging.    

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

BY 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 15% will eventually die from it, usually over a decade down the line, 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.

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.

Beware of Medical Witchdoctors

BY RALPH BLUM

Words don't just have an impact on our thoughts and feelings, they have direct implications for our bodies, a fact that all of us should keep in mind every time we step into a doctor's office. What is said to us in times of stress can positively or negatively affect our health and well being.

Most of us, as children, are taught to believe in the infallibility of doctors, so the manner in which a doctor delivers a potentially life-threatening diagnosis can have a profound effect, and actually has the power to influence the course of the disease.

The stress of a cancer diagnosis can throw patients into an "altered state" in which they are particularly vulnerable to suggestion--both good and bad. During these critical intake moments, if the doctor's words are positive, they can plant within us, at a very deep level, positive expectations that we can beat the cancer, that we will be cured. Unfortunately, the reverse is equally true. When we are in this altered state the doctor can adversely affect our healing  and, in some cases, literally scare us to death by quoting negative statistics, relating the gruesome side effects of treatments, or worse, by using the dreaded word "terminal."

This latter behavior is a form of "hexing," the medical equivalent of a voodoo curse. If a witch doctor leapt out of the jungle, pointed a bone at you and told you that you were going to die in two months, you'd probably laugh, albeit a trifle nervously. But when a modern-day witch doctor, wearing a white coat, carrying a stethoscope, and supported by state-of-the-art scans and test results, tells you that you have only two months to live, his "curse" can significantly raise the chances that you will die. And often right on schedule.

Everyone has heard of the placebo effect, the beneficial results that a little sugar pill can produce if the patient is told by an authority figure (usually a doctor) that it will bring relief or healing. The mere suggestion actually causes the body to manufacture the chemicals necessary for the desired result. However, the placebo (Latin for "I will please") has a lesser known evil twin, the nocebo (Latin for "I will harm"), which can produce equally powerful negative effects. Suggestion can be a formidable tool, and a significant part of any doctor's job is to create a relationship with his patients based on trust, confidence and hope.

Hippocrates, the father of western medicine said, "A patient who is mortally sick may yet recover from his belief in the goodness of his physician." Although it is our own thoughts, our own beliefs that can either harm or heal us, it is often the doctor's words that start the process. And when the doctor arouses negative expectations, that is medical hexing.

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/
 

Alternatives to Immediate Prostate Biopsy

BY MARK SCHOLZ, MD

Your PSA is elevated. Now your doctor recommends a needle biopsy, 12 cores through the rectum to check for cancer in the prostate.  Sounds icky, but also logical; after all who wants to miss cancer? But come on, do you really have to do 12 stabs via the rectum?

Each year over a million men submit their prostates for a biopsy.  At an average cost of around four thousand dollars, the prostate biopsy business is a 4-billion-dollar-a-year enterprise.  But it’s not merely the cost that gives pause.  Three percent of men end up hospitalized with life-threatening infections.  Around a 100,000 men every year get a confounding diagnosis of Grade 6 prostate cancer, a truly harmless entity, unless you get suckered into an unnecessary radical prostatectomy.

Obviously, prostate biopsy is an unpleasant proposition with notable risks.  However, ignoring a high PSA incurs the risk of missing a diagnosis of a higher grade prostate cancer. As things stand now, of the million biopsies being done annually, over a hundred thousand men with Grade 7 or higher cancers are being detected. For these men, their early diagnosis is beneficial, leading to early, curative treatment in a timely fashion.

How can we detect the 100,000 men with higher-grade cancers that need to be detected without doing 900,000 “unnecessary” biopsies?   The answer to this question continues to evolve as technology marches forward. Our latest thinking at Prostate Oncology (assuming the PSA is not wildly elevated, say over 20) is a three step process:

1.    Simply repeat the PSA to confirm it is indeed abnormally elevated.  All sorts of things can cause temporary elevations of PSA ranging from nonspecific inflammation of the prostate, to recent sexual activity, to simple laboratory errors. 

2.    If the PSA remains elevated with repeat testing the next step to consider is an OPKO-4Kscore blood test. The OPKO test reports a percentage estimate of the likelihood of higher grade cancer being present.  The test is not perfect, but it performs pretty well.  For example, if a specific patient receives an OPKO report with an estimated risk of high grade disease of less than 15%, a standard random biopsy (if he elected to do one) will confirm the absence of high grade disease 92% of the time. Not bad.

3.    Our next step at Prostate Oncology, in the cases where a patient has an OPKO test indicating that the risk of high grade disease is over 15%, is to obtain a prostate scan with high-resolution color Doppler ultrasound or with a 3-Tesla multiparametric MRI. With scanning, the location of the high-grade disease can be determined over 90% of the time so that a targeted biopsy with 2 or 3 cores can be substituted for the traditional 12-core biopsy.       

The business of prostate biopsy has become so out of control the US Preventative Services Task Force advocates against PSA testing altogether.  The Task Force’s scientifically-based arguments that PSA testing is causing more harm than good are really quite convincing.  However, back in 2011 when they published their recommendations, the OPKO test and 3-Tesla multiparametric prostate MRI were unavailable. With the advent of these new technologies, PSA screening to detect higher grade prostate cancers at an early stage when they are still curable makes perfect sense. 

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.

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.

Xtandi and Zytiga, The Future is Now

MARK SCHOLZ, MD

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.