Metformin and Statins for Prostate Cancer

BY MARK SCHOLZ, MD

As an internist and an oncologist, throughout my long career treating prostate cancer patients, I have periodically been asked by patients, “What do you do?  Surgeons (urologists) operate, and radiation doctors give radiation, but what do prostate oncologists do?”  My day-to-day, bread and butter is giving medical advice and prescribing oral medications. Unfortunately, I think this leads to some patients seeing me as a “pill pusher.” As such, I think I need to explain my motives for recommending the use of metformin and statins to my patients with prostate cancer.

One of the things that the last 20 years of my career treating prostate cancer has taught me is that a good diet has a favorable effect on inhibiting prostate cancer progression.  What converted me from a nonbeliever to a believer?  My patients.  A number of men have come to me through the years whose PSA was rising after surgery and who subsequently embarked on stringent vegan or macrobiotic diets. Lo and behold, as long as they stayed on their diets their PSA levels would stabilize. Subsequently, T. Colin Campbell published a very convincing book called The China Study that evaluated the connection between increased animal protein intake and cancer rates.  His findings conclusively demonstrated that high animal protein intake increases cancer risk.

How can diet make such an impact?  We don’t have all the answers but there are some very logical suppositions.  First, cancer cells “hurt” people by the process of cellular multiplication, ultimately spreading throughout the body and causing organ malfunction. It’s logical to assume that “better fed” cancers, the ones that get plenty of protein and energy, will grow faster and better than cancers that are relatively deprived.  Animal protein not only provides all the necessary amino acids for the construction of new cells, animal protein is invariably accompanied by substantial amounts of a potent energy source—fat (People forget that the average hamburger is over 50% fats). High protein diets also increase the level of insulin in the blood. And high insulin levels drive sugar and protein uptake into the cancer cells, further promoting growth. And lastly, dietary cholesterol is not only a type of “fat,” but it is also a hormonal precursor, a building block for DHEA and testosterone.

Unfortunately, few of us have the ability to follow strict vegan diets. It’s a lot of work and requires constant self-denial.  Certain medications, however, can achieve some of the same effects. Metformin, a generic medication approved for the treatment of diabetes, suppresses insulin levels in the blood. Studies in diabetic men with prostate cancer who are treated with metformin have shown lower prostate cancer mortality rates compared to diabetic men who are treated with other types of diabetic medications besides metformin.  Statins pills, medications such as Lipitor and Crestor, dramatically lower cholesterol levels.  Numerous studies have reported higher cure rates in prostate cancer patients receiving radiation who are treated with statins compared to radiation-treated patients who don’t receive a statin.

Regular exercise prolongs life in cancer patients.  If we had a pill that could accomplish what exercise can do—improved energy levels, sleep, digestion, memory, longevity and less depression—everyone would take it.  Many patients are lukewarm about prescription pills like metformin and statins, probably mainly due to concerns about side effects.  But side effects can be anticipated with careful monitoring.  When a medication side effect occurs it can be detected early and when the medication is stopped the problem is almost always resolved.  Following a rigorous macrobiotic diet for the rest of your life is beyond the reach of most of us. Taking an FDA-approved pill, while using careful precautions against potential side effects, is achievable for almost all of us. 

WANT TO LEARN MORE ABOUT PROSTATE CANCER?
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Medications for Prostate Cancer that Might Help and Probably Won’t Hurt

BY MARK SCHOLZ, MD

Do we have confidence in our prescription pills?  How can we really know that they are helping?   It partly depends on whether or not there is a benefit.  Fever disappears soon after starting an antibiotic.   PSA declines in men with prostate cancer who undergo hormone blockade.  Blood pressure is better after starting a new blood pressure medication.

We have confidence in these medications because there is a measurable benefit.  Seeing a benefit offsets our suspicions about potential side effects. Medication choices really boil down to a simple equation: balancing the benefit against the risk of side effects.

But sometimes it’s difficult to see the benefit, especially if the medication is being used because of the benefits were only reported in a population study showing and advantage of one group of people over another.  Baby aspirin is a good example. How do you really know that the pill you took today helped you dodge a heart attack?

Science and the Media
Interpreting scientific studies requires skill and training. But these days, the challenge is even greater because scientific studies are primarily reported in the media.  Unfortunately, media experts face tremendous temptations to make their stories more interesting. So they tend to overstate their importance.  As a result the general public is becoming very wary of supposed scientific finding.   

Considering Risk, What about Low Risk Medications that “Might” Work?
Few people have the time or skills to do their own research. But deciding “yea” or “nay” on a new medication can also be based on its perceived risk. If a medication is considered relatively safe, people with a chronic illness like prostate cancer may start thinking along the following lines: “I can’t be sure it will help, but at least it won’t hurt.”  This is a common mindset with vitamins and supplements because they are generally perceived to be harmless.*

Modifying the Down-Side Risks
This “why not” mindset comes into play when considering certain common generic medications that have been on the market so long their potential side effects are well known.  Specifically I am referring to four medications—aspirin, metformin (a diabetes medication), 5-alpha-reductase inhibitors like Avodart and Proscar, and Lipitor (a cholesterol drug).

In previous blogs I have presented arguments in favor of aspirin, Avodart and Proscar. In my next blog I’ll review some of the arguments for using metformin and Lipitor in patients with prostate cancer.

However, in the remainder of this blog I would like to outline an approach for reducing the risk of experiencing serious side effects:

1)     The greatest vigilance is necessary in the first few weeks after a new medicine is started.  When a medication causes side effects they usually appear fairly quickly.

2)     Generally, there is no rush. So why not begin at half dose? If after a few weeks or a month there are no negative side effects, the dosage can be gradually increased.

3)     Medication side effects follow specific patterns. Aspirin, for example, can cause intestinal bleeding.  So patients need to be carefully informed about the significance of any new symptoms of heartburn and the meaning of having black stools should they appear.

4)     Some side effects are only detected with blood tests.  Everyone who starts a cholesterol drug—Lipitor for example—needs to have liver function tested within a month or so.  Liver problems heal quickly if the side effects are detected and the medication is stopped in a timely fashion. It can be dangerous if negative effects persist undetected.       

*Ironically, in the absence of overt deficiency, when vitamin supplementation is subject to careful testing it sometimes has been shown to be deleterious.   Vitamin E is one good example. In a large randomized, double-blind placebo-controlled trial, prostate cancer mortality was higher in the men who took vitamin E compared to those who took a placebo. 

Men’s Health, The Big Picture

BY MARK SCHOLZ, MD

As a specialist in prostate cancer, I am in constant contact with men who are exerting prodigious efforts to get appropriate treatment for their disease. However, as many people are learning, low-risk forms of prostate cancer rarely lead to death.  Therefore, I am concerned that many men are missing the big picture regarding their overall health.  They have a greater risk of dying from other causes than from prostate cancer (Table 1).  Many of these common diseases are preventable by early detection.
The obvious place to start is with an annual physical with standard blood tests. Testing should include evaluation of liver and kidney function, mineral levels in the blood, evaluation of vitamin and hormone levels and testing for anemia and serum glucose. The specific blood tests are explained in more detail at http://prostateoncology.com/files/pdf/Standard_Laboratory_Tests.pdf
 
Heart Disease, the #1 Killer
The root cause of heart disease is cholesterol plaque, otherwise known as “hardening of the arteries” or atherosclerosis. Cholesterol infiltrating the arterial wall causes inflammation and scarring. Over time, scar tissue becomes calcified.  When plaque progresses to arterial blockage, a heart attack occurs. Similarly, a stroke occurs if an artery supplying blood to the brain is blocked.
 
Only Scans Can Measure Plaque
Cholesterol blood tests answer the question, “How much cholesterol is floating in the blood?" The real question that needs to be answered is, “How much cholesterol is sticking to the wall of the artery?”  Modern CT scans accurately measure coronary plaque with a dose of radiation similar to a set of dental X-rays. Color Doppler ultrasound measures plaque in the carotid arteries leading to the brain without any radiation exposure at all.
 
What if Plaque is Detected?
1. Obtain an exercise stress treadmill
2. Lower cholesterol and blood pressure
3. Inhibit blood coagulation with aspirin and fish oil
4. Follow a sensible diet and exercise regularly
 
Osteoporosis
With age, bones weaken from calcium loss. Osteoporosis is mistakenly thought to occur only in women.  However, one-third of hip fractures occur in men of advanced age.  Bone fractures have dire consequences associated with shortened survival, chronic pain and loss of height. Causes of osteoporosis include over-activity of the thyroid or parathyroid glands, excessive alcohol, caffeine or tobacco. Cortisone use, excess vitamin A, lack of exercise and vitamin D deficiency are additional potential causes. Hormone therapy used to treat prostate cancer can also cause osteoporosis.
 
Only Scans Can Detect Osteoporosis
Osteoporosis needs to be identified and treated before a fracture occurs. There are two types of scanning technology used to detect osteoporosis, DEXA and QCT.  While both types of scan are accurate in women, only QCT is accurate in men.  In men, DEXA seriously underestimates the degree of osteoporosis. 

Osteoporosis Treatment Protocol
1. Calcium 500 mg with dinner or at bedtime
2. Vitamin D 1,000 units daily.  Adjust dosage according to measured blood levels
3. Weight bearing exercise
4. Consider prescription medication with Fosamax, Boniva or Prolia
 
Colon Cancer
Colon cancer is easily curable when detected early. Screening can be accomplished with colonoscopy (a scope performed by a physician called a gastroenterologist), or with a CT scan, which is termed a virtual colonoscopy. 

Beware of Sarcopenia Muscle mass and strength automatically decline with age. Studies in otherwise healthy individuals indicate that poor fitness is more dangerous than smoking! Table 2 shows the dramatic difference in predicted 10-year survival of men age 65 depending on their fitness level. Muscle loss can be prevented with regular exercise consisting of weight training for an hour twice a week.

Lung Cancer Smokers who forgo lung scans are taking a huge risk. Lung cancer is almost universally fatal if diagnosed after symptoms such as cough, chest pain, or weight loss appear. CT scans can detect small lung cancers at an early stage when it can still be surgically removed and cured.  Smokers (and any ex-smokers who quit in the last 10-15 years) are crazy not to spring for $300 each year to have a lung scan done.

Flu and Pneumonia Flu is easily recognized by the sudden onset of fever, sore throat and body aches. Most people know about vaccines but forget that Tamiflu, an antibiotic, is effective if started within 24 hours of initial symptoms. The risk of pneumonia can be reduced by Pneumovax given every ten years. It is recommended for men who are over age 65 or who have a chronic illness. 

Conclusion The screening and early prevention program outlined in this article relies more heavily on scans, vaccines and prescription pharmaceuticals than many men would prefer. However, the serious health conditions listed above have a propensity to incubate silently until the day they suddenly explode on the scene as a full-blown disaster. The old aphorism, “An ounce of prevention is better than a pound of cure” certainly applies when there is an opportunity to detect and prevent life-threatening illness at the earliest possible stage.