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.

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. 

PSA Screening for Prostate Cancer

BY MARK SCHOLZ, MD

Most elderly men already have prostate cancer—they just don’t know they have it.  And they might be better off remaining ignorant. Newly-diagnosed men are thrown into an eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that a New England Journal of Medicine study estimates that forty-eight men are getting unnecessary surgery or radiation for each individual who truly benefits from them.

Random Biopsy, Not PSA is the Real Problem
When PSA is elevated, primary care physicians usually refer to a urologist for an immediate 12-core random prostate biopsy. One million men are biopsied annually in the United States. Few people realize that even when the PSA is normal, the biopsy will be positive 20% of the time. The problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads to surgery or radiation.

Biopsies Are Not Benign
Over-diagnosing Low-Risk prostate cancer, and the attendant risk of over-treatment, is not the only problem caused by random biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men are literally frightened to death by the discovery of prostate cancer: The first week after diagnosis, the risk of suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced infections resulting in hospitalization. Fatal infections are estimated to occur in approximately one-thousand men undergoing random biopsy per year.

Stop PSA Screening?
Due to all these mounting negatives, the US Preventative Services Task Force now recommends that routine PSA testing cease altogether. The Task Force’s conclusion was that unnecessary treatment to over a hundred thousand men annually is too big a price to pay even though PSA screening saves lives. The Task Force fails to understand that overtreatment isn’t caused by PSA, it’s what physicians do with the information PSA provides—they automatically refer every patient for immediate random biopsy.

PSA Is Heavily Influenced by Prostate Size
Most PSA originates from the prostate gland, not from cancer. Therefore, when the cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA normally averages one-tenth of the prostate volume. For example, the average PSA for a 30cc prostate is 3; five for a 50cc prostate and 10 for a 100cc prostate with size determined by ultrasound or MRI.

Therefore, PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a 50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such as low-grade infections, lab variations and recent sexual activity can also cause PSA to vary.  Repeat testing helps average out these variations so the “real” PSA can be determined.

Primary Care Doctors Are the Source for Balanced Counsel
Only the primary care physicians can stop the mindless rush to random biopsy. Instead of referring for random biopsy they can send their patients with elevated PSA for prostate imaging with multiparametric MRI or Color Doppler Ultrasound. Imaging can put the PSA elevation into context by determining the prostate size. Also, in the hands of an experienced radiologist, using state-of-the-art, three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.

If imaging detects a high-grade lesion, primary physicians can then counsel their patients about whether a targeted biopsy directed at the abnormal lesion should be performed. Alternatively they can recommend simple monitoring with a repeat imaging study six to twelve months down the road to determine if the lesion is growing. Lastly, if a targeted biopsy shows cancer, rather than being guided by a urologist, who is, after all, a surgeon, patients can obtain counsel from their primary physician, a non-surgeon who can provide unbiased assistance in selecting the best treatment.

Estimating Cancer Risk
If men are concerned about the risk of forgoing an immediate random biopsy they can estimate the percentage likelihood of harboring low-grade or high-grade disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”

Imaging Rather than Biopsy
Prior to PSA screening men should be informed that if PSA is high, the first step should be imaging rather than random biopsy. Random biopsy can cause serious infections. It also diagnoses Low-Risk prostate cancer, a harmless condition that nevertheless, often leads to unnecessary treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled improperly, lead to unnecessary treatment with many lifelong side effects.