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. 

The Un-Cancer

BY MARK SCHOLZ, MD

It’s easier to teach a proper golf swing to a true beginner than to someone who has previously developed bad habits that are now ingrained.  The young 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.  The biggest challenge of educating people about prostate cancer is overcoming their preconceived notions—what they already think they know about cancer.

What is prostate cancer?  Many say it’s harmless, that “you die with it, not from it.”  But how does that jibe with 28,000 deaths annually?  One reasonable conclusion is that prostate cancer occurs and acts in a variety of different ways. The Prostate Cancer Research Institute (pcri.org) recommends dividing prostate cancer up into five categories or Shades of Blue. This is helpful both for understanding the varieties of prostate cancer and for guiding the choice of treatment.

However, even though there are many forms of prostate cancer, this fact fails to convey how differently prostate cancer as a whole acts, compared to other cancers.  Why is it so important to understand this difference?  First of all, surgery—which is everyone’s first thought when they hear the word “cancer”—can have dire consequences.  For example, surgery almost always causes partial or complete impotence. Second, new research published by Dr. Timothy Wilt in the July issue of this year’s New England Journal of Medicine, shows that forgoing immediate treatment and embarking on a program of close monitoring known as “active surveillance,” has exactly the same survival rate as immediate surgery.  Bottom line: For far too many men, immediate treatment for prostate cancer is not only damaging, it is often unnecessary.

Forgoing treatment with something called cancer is certainly counterintuitive.  In order to support the case for monitoring, let’s compare the statistics for prostate cancer with those of colon cancer.

	Prostate Cancer:  The “Un-Cancer”	Colon Cancer: A “Typical” Cancer	Difference Factor
Deaths Annually	28,000	26,000	1 : 1
New Cases Diagnosed	241,000	73,000	3.5 : 1
Mortality Rate	8.5%	35.5%	4.2 : 1
Average Survival if Relapse Occurs	13 Years	13 Months	12 : 1

As the table shows, men diagnosed with colon cancer are not only three and a half times more likely to die from the disease, they die twelve times more quickly.  Unfortunately, almost all cancers—lung, pancreas, stomach, gallbladder, kidney, brain, bone, etcetera—approximate the behavior of colon cancer rather than prostate cancer.

The fact remains that it is logical for the general population to be terrified by the very idea of cancer.  When you consider all the different types combined, cancer is the second most common cause of death, just below heart disease. The risk of death from most cancers is high and if a cure is not obtained, death follows all too quickly. The unfortunate men who die from prostate cancer make the “news,” even though it may not be generally understood that it took 13 years for those men to succumb. However, the fact remains that there are 2.8 million prostate cancer survivors presently living in the U.S. That should be news too.

Ninety-one and a half percent of men diagnosed with prostate cancer will have a normal life expectancy, and will die of natural causes. The eight and a half percent who die from prostate cancer will live an average of 13 years, with this number expected to increase dramatically over the next ten years, thanks to continuing improvements in medical technology.  Treatment can definitely improve survival in selected cases.  However, it would seem that only men in the high-grade category are likely to benefit consistently.

The encouraging facts about prostate cancer outlined in this blog have been compiled to help men realize that survival rates with prostate cancer are extremely favorable compared to other types of cancer.  Now that studies show that survival with active surveillance matches that of immediate surgery, a great many men should take heart, and resist all efforts to rush into a treatment with such uncertain rewards but such predictable and devastating side effects. 

“Good” Prostate Cancer, “Bad” Prostate Cancer

BY MARK SCHOLZ, MD

How can anyone call a cancer “Good?” As time goes by, it seems that prostate cancer is becoming more confusing, not less. Many of us have heard the statement that, “Men die with prostate cancer, not from it.” Or another commonly repeated statement, “The treatment is worse than the disease.”

But then we hear about Merv Griffin or Dennis Hopper, men with immense financial resources, dying from prostate cancer.  How can we say that prostate cancer is “Good?”

When someone hears the word CANCER, they think they know what you are talking about.  Cancer is so common that it now vies with heart disease for being the most common cause of death in men. Cancer has touched the lives of most people, usually in a very negative way.

Perhaps the best way to get a feel for prostate cancer is to compare the “Bad” type of prostate cancer with cancer of the lung or colon, the other two most common types of cancer in men. Other cancers of the brain, bone, stomach, pancreas, kidney and bladder tend to behave in a way that is similar to lung or colon cancer.

	Lung, Colon Cancer	“Bad” Prostate Cancer
Blood test available for early detection	no	yes
Hormone therapy available	no	yes
Spreads to liver or brain	Yes	no
10-year survival rate	10-50%	90%
Average survival after relapse	1-2 years	More than10 years

Since the table tells us that it’s far better to have a “Bad” prostate cancer than just about any other type of cancer, imagine how confusing it is when people are told they have a “Good” type of prostate cancer.  What the heck does that mean?

Men are encouraged to refrain from fearing Low-Risk or “Good” prostate cancer because their life expectancy is identical to or even better than that of men who have never been diagnosed with prostate cancer, even without treatment. Since the survival rate is excellent, immediate administration of toxic therapies that ruin sexual and urinary function is inappropriate and often reprehensible.

There is a question that frequently arises: “How accurately can doctors discriminate between the good and bad types of prostate cancer? Do they ever make mistakes and advise men with “Bad” prostate cancer to forgo immediate treatment?

Until fairly recently, men with “Bad” prostate cancer were misdiagnosed because standard prostate biopsy techniques do not routinely sample the front half of the prostate gland.  While cancer in the front of the prostate is uncommon, and because the area is not routinely biopsied, high grade cancers could be missed.  Fortunately, recently developed imaging with multi-parametric Magnetic Resonance Imaging (MRI) can now detect high grade disease in the front or anterior half of the gland with a high degree of accuracy.

Imaging with MRI is so improved that preliminary studies presented in Atlanta at this year’s meeting of the American Urology Association indicate that multi-parametric MRI may be able to replace biopsy altogether.  I am planning to review these exciting reports in my next blog.