Let the Buyer Beware

BY MARK SCHOLZ, MD

It’s time to change our preconceptions about prostate cancer and “reboot” the way we think about what typically is a non-life-threatening disease. Ever since the FDA first approved PSA testing in 1987, prostate cancer has grown into an aggressive multibillion dollar industry. Marketing hype has created the impression that treatments like Proton therapy and robotic surgery are universally desirable, even though well-informed patients know this is hardly the case.  How did the prostate cancer world deviate so far off the originally intended tract of helping patients? And what can be done to set things straight?

Ten years ago the experts believed that immediate curative treatment was needed for every man with prostate cancer.  Today, after 20 years of vigorously detecting and treating every case of prostate cancer, it has become clear that almost half of the 230,000 men diagnosed every year are undergoing radical treatment for a cancer that is incapable of metastasizing.  Now it’s time for the medical community to come to grips with the fact that over a million men in the United States are living with impotence and incontinence for no justifiable reason. This is a disaster of gargantuan proportions.

Shockingly, even though we can now readily identify these harmless cancers, the problem of rampant overtreatment continues. In 2015 another 50,000 men will undergo unnecessary radical treatment. The medical industrial complex that has been gaining momentum for 25 years refuses to confess its tragic errors.  The huge investments in enormously expensive medical equipment need to be paid off.  No one is willing to accept responsibility, make apologies or confess wrongdoing for all the overtreatment.  The existing system is entrenched and the doctors are too comfortable with the status quo.

Reversing the momentum of twenty-five years of recommending unnecessary radical treatments is going to require the patients to protect themselves.  They need to become far more medically sophisticated consumers.  Five years ago, Ralph Blum and I fired the first salvo by writing Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency. In our book, we attempted to defang the poisonous and fear-inducing word cancer by renaming the low-risk type that does not metastasize “The UnCancer.”  Our book has been helpful at revamping the gross misconception that every prostate cancer is potentially deadly.  Invasion provides an excellent introduction to men with newly-diagnosed cancer by presenting the important concept that prostate cancer comes in three broad types: low, intermediate and high-risk.  

One of the important themes introduced by Invasion is a healthy mistrust of physician motives. For protection against patients receiving the wrong treatment, Invasion argues strongly for patient empowerment through education. The term, “prostate cancer” is merely an umbrella term for a broad spectrum of illnesses that behave very differently. The book simplifies the treatment decision making process by clearly identifying the three major subtypes of prostate cancer, low, intermediate and high-risk.  Once patients have gained an accurate understanding of where they fit into this individualized schema, an informed treatment decision can be made.  As a medical oncologist, rather than a surgeon, the information provided in the book is unbiased with clear presentation of all the risks and benefits associated with all the different treatments that are available.

In an era now past, physicians were trained to put their patient’s interests ahead of their own.  Today, patients need to adopt defensive tactics that are realistic about how prostate cancer care has become a highly lucrative business. The patient who assumes that their counseling physician represents his best interests, is on the cusp of making a dangerous mistake. Bluntly, the prostate cancer world has evolved into a sophisticated and well-oiled business and the buyer better be on guard.   

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.        

A Closer Look into the Book

MARK SCHOLZ, MD, prostate expert and medical oncologist and Ralph Blum, living with prostate cancer for over 20 years, co-authored "Invasion of the Prostate Snatchers:  Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency."  Written for newly diagnosed men - do research before you take the next step, rather than rushing forward.  They present a closer look into the book with these three videos CLICK HERE

KNOW YOUR OPTIONS

RALPH'S JOURNEY

DOCTOR MEETS PATIENT

Fighting Stress: The Amygdala as Super-Hero

BY RALPH BLUM

Writing about “Stress Management” has been a Pandora’s box for me. I am convinced that, along with taking charge of my own recovery, an understanding of stress—it’s nature, how it operates, how to manage it—has served me well in facing the dragon of prostate cancer. Whether you are newly diagnosed or coping with bone metastases, I hope my exploration of stress will serve you—and give you renewed hope.

 

Stress is a poisonous compound of worry, anxiety, exhaustion, regret, fear, despair, and all the other toxic tourniquets that bind us to the wheel of suffering. In most people’s lives, these negative feelings are registering in our bodies chemically and organically much of the time. So let’s take a close look at the factor of stress in our lives, and see how it weighs down and impedes the process of recovery.

 

Really ancient, the word “stress” is a form of the Middle English destresse, which is in turn derived, through Old French, from the Latin stringere, “to draw tight.” Used first in physics to refer to strain on a material body, by the 1920s stress was being applied in medical circles to refer to mental strain, or harmful environmental “agents” that cause illness.

 

In 1926, Harvard Physiologist Walter Cannon used the term “stress” for its clinical significance, describing external factors that disrupted what he called “homeostasis,” a steady state or  equilibrium ideal for our well-being and healing. Moreover, Cannon’s book, The Wisdom of the Body, was the breakthrough in understanding that we actually have a capacity to self-correct from stress, and restore homeostasis.

 

It goes without saying that a potentially life-threatening situation, like cancer creates the kind of stress that persists over time, taking a significant toll on the body and seriously disrupting homeostasis. So what can we do to alleviate chronic stress?

 

While I was looking for fresh ways to manage stress in my life, I came across an exotic “game” created by high school teacher and psychologist, Justin Galusha.  His game asks you to create 17 “Superheroes, Villains and Sidekicks” for "17 areas of the human brain.” In order to “play,” you need a name for the character, a description of that character’s super powers and/or weaknesses, the brain area where the character is found, and what it actually controls in the brain. Among the areas (and characters) he includes Cerebellum, Thalamus, Hippocampus, Temporal Lobe and the Amygdala. Since we’re not playing the game, we don’t have to look at all seventeen,  focusing on just one—the one that coordinates all the others—the amygdala.

 

I was already aware of the power of the amygdala to process emotions and manages stress, particularly when feelings of anxiety or fear are involved. Seated at the center of an exquisitely tuned and coordinated emergency response system, the amygdala is a small almond-shaped structure, buried deep within the temporal lobe, part of the brain’s limbic system.  For his game, Galusha describes the amygdala as “governing emotions related to self-preservation . . . in particular stimuli that are threatening to the organism.” And he means life threatening, So that’s what this is all about—self-preservation.

 

In Galusha’s brain game, here is how the role of the amygdala—dubbed “Amyg’DaMan”—is described:

Blessed with a heightened amygdala thanks to a freak accident in the Vidal Sassoon mouse testing facility, Amyg’DaMan knows when he can win a fight or when he needs to take flight . . . With only his superhuman ability to read facial features and govern emotions, Amyg’DaMan never gets in over his head. He sports a caveman like costume as a shout out to his ancestors. . .  Had it not been for their amygdalas they wouldn’t have known when to run from predatory trolls with extra arms or stay and slaughter innocent docile foes. This one’s for you Amygdala guy—and the quick judgment that saves your life.

The whole idea—including a hairy caricature of his club-wielding caveman hero—made me laugh. And while the conventional fight or flight options described here are not available to a man with newly diagnosed with prostate cancer, the primitive emotions are the same. Stress is the result. Laughter is one antidote. And self-preservation is the objective.

 

I’d say laughing at the vision of Amyg’DaMan whooping those four-armed predatory trolls is good anti-stress activity.

 

In my next blog I will consider stress as three-tiered, one toxic, one tolerable, and one (I was surprised to learn) both positive and useful, capable of improving the function of the immune function.

First Impressions Can Really Harm You

BY MARK SCHOLZ, MD

The human mind is constantly, searching, analyzing and processing our environs, attempting to make sense of the fluidly shifting situations that surround us. This mental process is healthy, designed to keep us in touch with reality.  “First impressions” are a good example of the powerful and rapid insights provided by these formidable processors we call our brains.  However, while first impressions are for the most part quite accurate, we all have learned at some point that they can also be misleading.

After interviewing thousands of newly-diagnosed prostate cancer patients, I have found that the first impressions of most patients about prostate cancer are almost always wrong.  Why?  There are several reasons.

First, there is no single type of prostate cancer. It is a condition that behaves quite variably. Therefore, it is hard to get your brain around the idea “I have prostate cancer,” and sum it up as a single sound-bite. Even though the word “cancer” would seem to be saying it all, the analogy of the three blind men touching different parts of the elephant works well here.

Second, despite the many variations of prostate cancer, none of these variations are similar to any other type of cancer. You cannot simply point to some other disease and say, “Just think of _____ . . .” (fill in some another cancer type here) and you’ve got it.  Prostate cancer is, arguably, unique among cancers. It has an exceptionally slow growth rate, a pattern of spread that uniquely spares critical organs like brain, lung and liver; it responds to a distinctive method of treatment, hormonal therapy, which commonly induces remission lasting more than ten years.  Moreover, prostate cancer is the only cancer that can be monitored with a one-of-a-kind blood test called PSA.

Third, while surgery is probably the best treatment for most other types of cancers, it is probably the worst (with occasional exceptions) for prostate cancer. And strangest of all, prostate cancer is the only common type of cancer that is exclusively managed by surgeons, rather than by medical oncologists).

As a result of all these one-of-a-kind characteristics, the way that men with newly-diagnosed prostate cancer manage their first impressions has a major impact on the treatment they will receive. Initially, men logically assume that prostate cancer is imminently life-threatening, just like other types of cancer. And for most cancers, surgery is best way to go about getting cured. 

The majority of urologists still tend to repeat their favorite mantra—“Surgery is the Gold Standard”—and to urge men to undergo ill-advised surgery. However though advances in seed implant and radiation therapy technology, the mantra is now outdated.  Newly-diagnosed men can avoid any regrets if they take time and truly investigate their options. “Don’t Rush!” should be their mantra. Men need time to calm their over-stimulated minds, time to regain their emotional bearings, so they can do the research necessary to make an informed decision.