Testosterone Replacement Therapy (TRT)

BY JEFFREY TURNER, MD


Testosterone (T) preparations have been available for more than 70 years.  In 2013, over 2.2 million Americans were prescribed testosterone.  Interestingly enough, about 1 in 4 men prescribed testosterone do not have a baseline testosterone level drawn as primary care physicians may write the prescription without ordering a blood test first.  In a study of 63,000 men from the Truven Health Marketscan Commercial and Medicare Supplemental Insurance database between 2010 and 2012, 71% of men had their testosterone level checked once, 40% twice, and 29% had no measurement at baseline.  Physicians need to do a better job following men on testosterone replacement. Is testosterone replacement therapy really all that good for anything aside from rejuvenation and virility? 

Let’s break this down to risks and benefits below:

Risks of Prostate Cancer

The most universal risk which has been the controversy of much discussion is the association with prostate cancer.  Clinicians remain concerned that Testosterone Replacement Therapy (TRT) can cause or stimulate prostate carcinogenesis and therefore they are reluctant to prescribe it for the aging male who has a higher risk of prostate cancer.  In the 1940s, Huggins and Hodges discovered the association of testosterone with prostate cancer by demonstrating that castration causes the disease to regress. The reality is that TRT may stimulate the growth of existing prostate cancer cells, but it will not cause cancer to form.  As the general male population grows, so does the risk for prostate cancer--patients should be closely evaluated with digital rectal examinations, PSA checks and prostate imaging such as color Doppler ultrasound.

Risk of Prostate Enlargement

Another controversial topic is the assumption that supplemental testosterone leads to a prostate growth, benign prostate hypertrophy, which leads to worse quality of life due to worsening urinary symptoms.  It has long been assumed that high T levels induce prostate overgrowth, but most studies failed to find the correlation between circulating T levels and BPH.  It has been hypothesized that dihydrotestosterone (DHT) could be more responsible for prostate growth than T.  There have been a number of studies evaluating TRT in hypo-gonadal men with BPH.  The results have suggested that there is actually a trend toward an improvement in urinary symptoms.

Risk of High Red Counts—Polycythemia or Erythrocytosis

Erythrocytosis is the increase in red blood cell mass production which can be the result of testosterone replacement therapy.  This is the most frequent adverse effect associated with TRT.  Recent trials have demonstrated that men on TRT have a 4 times higher chance of having high red blood cell counts.  Some reports have implicated excessively high red blood cell levels with an increased risk for heart attack or stroke. We commonly recommend patients remain on a baby aspirin daily and monitor their blood counts. Some patients may benefit by donating a unit of blood if the levels are too high.

Risk of Obstructive Sleep Apnea

Frequently reported in various literature is the association of worsening sleep apnea symptoms for men on testosterone replacement.  There has been only one randomized control trial to date that addresses this association and it showed that obese men with severe sleep apnea may worsen their oxygenation with TRT at relatively high doses.  This study evaluated injection formulations of testosterone. So far transdermal formulations have not been similarly implicated.

Risk of Infertility

Testosterone replacement leads to inhibition of the pituitary gland located at the base of the brain which can potentially suppress the production of sperm.  Hence, cases of TRT-induced male infertility have been reported. This impact appears to be transient and disappears once TRT is stopped.

Improved Sexual Function

A decreased libido and/or potency remains one of the most common reasons that men desire testosterone replacement.  TRT can certainly improve sexual function in those who have erectile dysfunction primarily due to a low level of testosterone.  Patients need to recognize that there are a series of other reasons for being impotent that are unrelated to low levels of testosterone which must also be investigated as well before concluding that TRT will be the optimal corrective measure.

Improved Cardiovascular Effects

The association of TRT with heart attacks has been very controversial. We must not forget that men with low T levels are at higher risk for poor health due to being more frail and susceptible to other medical issues including obesity and diabetes. As a result, they become more prone to adverse cardiovascular outcomes.  Four out of five of the most recent meta-analyses demonstrated neither a protective or harmful effect of TRT on cardiovascular events. In men with heart failure, it has been demonstrated that low T levels are an independent risk factor for worse outcomes.  Studies also demonstrated that men with heart failure who supplemented with testosterone had a better exercise capacity, oxygen levels, and less fatigue.

Improved Metabolic Effects

Large scale data exists to document the association of low T and worsening blood sugar levels along with a higher chance of developing diabetes. TRT can improve body composition and help to reduce fat which can lead to better control of diabetes.

Reversal of Osteoporosis

Lower testosterone levels are associated with a higher risk of bone fractures and worsening bone health.  TRT has been demonstrated to have a positive effect on bone mineral density.

Improvement in Chronic Kidney Disease

Low T is very common (approximately 50%) in men undergoing dialysis for end stage renal disease. Reduced T levels have in men on hemodialysis have been tied to higher rates of all-cause cardiovascular mortality.   Studies suggest that TRT may improve the levels of a hormone called erythropoeitin (EPO). This hormone stimulates improved production of red blood cells which in turn increases levels of red blood cell mass, energy, stamina, and overall well-being.

Conclusion

It is clear to see that testosterone replacement offers a multitude of benefits which span past merely increasing one’s libido or potency.  The bottom line remains that patients on testosterone supplementation must have close follow-up including both clinical and laboratory evaluation to ensure they are gaining benefit and not placing themselves at increased risk from potential adverse effects.  Physicians must clearly discuss the risks and benefits of supplementation along with employing routine monitoring of PSA, testosterone levels, blood counts, digital rectal examination, and color Doppler ultrasound. 

Testosterone for Men and Women

BY MARK SCHOLZ, MD

Testosterone is really cool. It improves concentration, energy, strength, and libido. Both men and women experience enhanced performance with higher testosterone levels.  The problem is that testosterone tends to decline with age.  Also, testosterone-blocking therapy to treat prostate cancer can have lingering effects, even after the treatment is stopped.  For women, testosterone levels often decline sharply after menopause.

Low testosterone causes many undesirable effects including muscle atrophy, weight gain, tiredness, osteoporosis, low libido and impotence.  Absent testosterone in women* is usually a secondary effect of menopause, so it usually occurs in conjunction with low estrogen. In women the loss of estrogen and testosterone causes weight gain, tiredness, osteoporosis vaginal atrophy and low libido.

Judicious administration of testosterone in men and a combination of estrogen and testosterone in women, can dramatically improve quality of life. Bioidentical hormone therapy is the term often used by the doctors who specialize in this area.  The idea is to restore hormone levels back to normal.

Risks of Testosterone Therapy
As might be expected, like any powerful tool, misuse of testosterone can be dangerous. Administering testosterone in men with prostate cancer is controversial (see below).  However, there are also risks even in men without prostate cancer.  One reason is that when testosterone is administered to men estrogen levels also rise.  Higher estrogen in men may increase the risk of heart attacks and strokes. Therefore, estrogen levels should be monitored and compensatory treatment with Femara®, an estrogen blocking pill, may be necessary in some cases.

In men, testosterone may also cause an excessive increase in the red blood cell count (RBC). Overly high RBC levels have also been linked to higher risks of heart attack or stroke. The RBC count, therefore, needs to be monitored by measuring the hematocrit, a component of the complete blood count (CBC). If the hematocrit rises above 50% men should consider lowering their testosterone dosage or undergoing a phlebotomy (donating a unit of blood).  In women, excessive amounts of testosterone can cause masculinization.  Estrogen replacement also slightly increases the risk of breast and uterine cancer.  Obviously a full discussion of all the risks and benefits is essential before starting treatment.

Administering bioidentical hormones is as much an art as a science. The hormones themselves are delivered in the form of creams, pills or shots. Studies show that the measurement of hormone levels in the blood stream or in saliva is moderately helpful for guiding the selection of an appropriate dosage. A better indication of proper dosage, however, is the subjective sense of well-being reported by the person receiving the treatment. Therefore, starting hormone therapy should proceed slowly with an incremental escalation of dose while closely observing for the appearance of side effects.

Giving Testosterone to Men with Prostate Cancer
Denying every man with a history of prostate cancer from receiving testosterone is ridiculous. Studies clearly show that about half the men in their 50s and almost all men in their 80s harbor minor forms of prostate cancer; most is low-grade and harmless.  Almost all of these men have substantial testosterone coursing through their blood (from their testicles).  They seem to do just fine. As long as men are regularly screened to ensure the absence of clinically significant prostate cancer, the risks of restoring low levels of testosterone back to normal should be quite low.

Living Longer and Living Better
Just in our lifetimes we are observing a dramatic enhancement of human longevity.  When I was in oncology training at USC just twenty-five years ago, the attitude toward a patient’s death while in his in early 70s would have been, “He lived a full life.”  That attitude is no longer accepted.  Now men and women are not only living longer, they are retaining substantial youthfulness into their 80s. As part of an overall health program that includes diet, exercise and appropriate healthcare, restoring sex hormone levels back to normal can be transformational.  Since giving small amounts of testosterone to females is a foreign idea to many people, in my next blog I will elaborate on this concept further.

* Premenopausal women normally have testosterone in their blood, albeit at much lower levels than men.

Xtandi as Primary Therapy

MARK SCHOLZ, MD

The largest oncology market in the world is the early-stage prostate cancer market. Every year, 80,000 men undergo surgery. Even greater numbers are treated with IMRT, seed implants, cyberknife and proton therapy.

What about Hormones?
Hormone therapy is another popular treatment approach, especially for older men. For example, the Capsure database indicates that hormone blockade is used more commonly than radioactive seeds.  Randomized clinical trials also indicate that intermittent hormone therapy is feasible:  Men who stop hormone therapy and take “treatment holidays” have identical survival rates to men who stay on continuous treatment.

Standard Treatment is Deplorable
Since PSA screening started in the early 1990s, surgery and radiation have been all the rage.  Aggressive treatment has succeeded in reducing annual prostate cancer mortality by half a percent. Now “only” 2.5% of men die of prostate cancer. Previously, prior to the advent of PSA screening, 3% of men died from prostate cancer. The “cost” of achieving this mortality reduction, however, should be measured in terms of diminished quality-of-life. The frequency of serious side effects is typically under-appreciated. For example, at the highest quality treatment centers only 5% of men recover sexual function similar to what they enjoyed prior to treatment. 7% of men are grossly incontinent; 50% have stress incontinence and 20% chronically ejaculate urine.

The reason for such a minuscule impact of local treatment on survival is obvious: Surgery and radiation are only effective when implemented prior to metastases. Ironically, until metastases occur, local treatment is unnecessary. After metastases, local treatment is ineffective.  Logically, early therapy with an anticancer agent with both local and systemic effects will result in better cancer control.

Active Surveillance is Now Mainstream
It is now known that Low-Risk disease (Gleason 6, PSA < 10, Stage T1c or T2a) can safely be monitored with active surveillance. At worst, active surveillance has the positive effect of delaying treatment and postponing treatment-related side effects like impotence and incontinence. With delayed local treatment, men benefit from the fact that medical technology is continually improving.  The best case scenario of active surveillance is when cancer never progresses and men are able to avoid treatment indefinitely.

Widely-accepted active surveillance methodology relies on periodic random 12-core needle biopsies.  Now encouraging studies are reporting that 3T multiparametric MRI detects high-grade disease more accurately than biopsy.  Also, new computerized imaging technology enables doctors to record the exact location of the cancer within the prostate gland so that areas of known disease can accurately be resampled with targeted biopsies.

Hormone Therapy Causes Remission of Localized High-Risk Disease with Reversible Side-Effects
A study using a six-month induction course of abiraterone (Zytiga) shows complete pathologic remission or close to complete remission in a third of men with High-Risk disease. Logic predicts that complete response rates will be substantially better in men with Intermediate-Risk prostate cancer.

For the most part, side effects of hormone therapy are reversible or preventable—hot flashes, breast enlargement, osteoporosis, and erectile dysfunction respond to DepoProvera, Femara, Prolia and Viagra respectively. Muscle atrophy can be counteracted with strength training. Low libido dissipates after therapy is stopped. Careful diet averts weight gain.

However, the reversibility of hormone therapy depends on the resumption of normal testosterone production after treatment is stopped. Unfortunately, LHRH agonists, the traditional hormone medications employed, often induce lingering low testosterone levels. Some men, particularly those over 70, are saddled with permanently low testosterone.

Xtandi is Well-Suited to Intermittent Administration
Xtandi has several potential advantages over LHRH agonists.   First, it is more potent.  Studies show that Xtandi has notable activity even after cancer had developed resistance to LHRH agonists. Second, Xtandi blocks testosterone activity rather than suppressing testicular production. Therefore the risk of delayed testosterone recovery or long-term testicular atrophy is circumvented.  Third, though perhaps this is a relatively small issue, most men would rather take a pill than a shot.

An Observational Trial of Intermittent Xtandi Could Revolutionize Intermediate-Risk
Laurence Klotz, M.D. prospectively accrued men with Low-Risk (and some Intermediate-Risk) prostate cancer to a simple observational trial starting in the mid-1990s.  By simply reporting a very favorable ten-year mortality rate he brought about a total change in clinical practice patterns in the United States and throughout the world.

Intermittent hormone therapy as primary treatment is certainly feasible for localized prostate cancer.  Active surveillance methodology has been refined with improved imaging.  New genetic tests can estimate cancer aggressiveness with more accuracy. The animus to delay treatment, even for a few years, is increasing as the pace of technological innovation accelerates and the hope for the discovery of less toxic treatment increases. Now, with the recent FDA approval of this more potent, more convenient oral agent that is free of lingering effects, the impetus for men to embark on a six-month induction course of Xtandi followed by active surveillance will be even greater.

Selecting a Meaningful Endpoint for an Observational Clinical Trial
Published studies already document excellent survival with primary hormone therapy (see attached). Hence, the most meaningful clinical outcome measure of Xtandi efficacy would be its capacity to forestall or delay local treatment. The objective endpoint, therefore, should measure the number of months or years before local therapy is required, starting from the date of initiating Xtandi and ending when (and if) local therapy is ultimately implemented.

While complete avoidance of local treatment may be a frequent occurrence (in the men who show durable responses to a single cycle of Xtandi) it can be anticipated that men who have locally recurrent disease and whose initial experience with Xtandi was tolerable, may elect to use repeated cycles of Xtandi at the time of recurrence rather than risking the potentially irreversible side effects of local therapy. Conversely, the men most likely to select local therapy are those who experience a particularly short treatment holiday or suffer more severe hormone-related side effects.

A six-month course of Xtandi can also function as a “disease-related stress test.” Men in the subgroup manifesting either high PSA nadir or rapid disease recrudescence after treatment are those most likely to harbor an aggressive prostate cancer variant. Thus, this initial “test” using Xtandi will help ensure that men referred for radical local therapy are those who actually need it.

Osteoporosis Basics for Men

BY MARK SCHOLZ, MD

Osteoporosis is the medical term for “weakened bones” resulting from the slow leaching of calcium over time. Osteoporosis is incorrectly thought to happen only in females. However, one-third of hip fractures occur in men and are associated with higher mortality rates in men with prostate cancer. Calcium loss is a silent process until a fracture suddenly occurs. Common fracture sites are spine, rib, wrist, and hip. Compression fractures of the spine can be quite painful and result in loss of height with forward curvature of the spine.  

Cause of Osteoporosis
Just as there is a link between lack of estrogen and osteoporosis in women, studies show that there is also a relationship between a lack of testosterone and osteoporosis in men. Other causes of osteoporosis are thyroid or parathyroid hyperactivity, excessive alcohol, cortisone, lack of exercise, low vitamin D and low calcium intake. Osteoporotic fractures also occur more frequently in men taking testosterone inactivating pharmaceuticals (TIP).

Detecting Osteoporosis
Osteoporosis, when it is diagnosed at an early stage, is easier to treat. Unfortunately, the most common scanning technique for diagnosing osteoporosis, the DEXA scan—grossly underestimates the degree of bone mineral loss from the spine in men. Why? Because almost all men over fifty have calcium deposition in the ligaments surrounding the spine. When the DEXA is used to measure bone density, the excess calcium in the ligaments causes an incorrectly “normal” bone density reading.

Fortunately there is a better technique called QCT that measures bone mineral density in the center of the vertebral column. Awareness of the DEXA scans' limitations in men is under appreciated by many physicians even though these limitations have been well documented in a study from Massachusetts General Hospital. In this study 41 men underwent both DEXA and QCT scanning. QCT detected osteoporosis in 26 of the men (63%) but DEXA only diagnosed it in two (5%).

Preventing Osteoporosis
Osteoporosis treatment begins with an exercise program. Supplementation with calcium and vitamin D should also be considered routine. We recommend 500 mg of calcium at bedtime and a starting dose of 1,000 units of Vitamin D. Blood levels of vitamin D should be checked and oral intake of vitamin D adjusted accordingly.  Studies show that using TIP intermittently (compared to continuous TIP) results in less bone loss. Treatment with bisphosphonates or denosumab (see below) can prevent TIP-induced bone loss.

Osteoporosis Medications
Osteoporosis can be reversed with bisphosphonates or denosumab. Normal bone metabolism is a balance between the rate of bone breakdown and the formation of new bone. Osteoporosis occurs when the formation of new bone lags behind the rate of bone breakdown. Bisphosphonates and denosumab function by slowing the rate of bone breakdown, allowing the osteoblasts, the cells that form new bone, to increase the net amount of bone matrix.

Oral Medications: Boniva, Actonel and Fosamax
Bisphosphonates come in both oral and intravenous forms. Absorption into the blood of oral forms is enhanced when they are administered with an empty stomach. The most common side effect from oral bisphosphonates is stomach or esophageal irritation which can be minimized by maintaining an erect position for an hour after taking the drug.

Intravenous Bisphosphonates: Zometa (zolendric acid)
Intravenous administration of Zometa has the advantage of bypassing the stomach thus avoiding concerns about stomach irritation. Also with the intravenous approach 100% of the drug gets into the system as compared to the oral preparations that are only 1-2% absorbed. The most common side effect from Zometa is a brief flu-like muscle soreness lasting a day or so. These symptoms do not usually recur on subsequent infusions. For the treatment of osteoporosis the infusions are repeated every three to six months.

Denosumab Injections: Prolia and Xgeva
Like Zometa, denosumab inhibits the osteoclasts, but by a different mechanism.  Denosumab is marketed in two strengths for injection. A half-dose shot called Prolia is administered every 6 months for osteoporosis.  A full dose shot called Xgeva is given monthly for cancer metastasis to the bone.

Medication Induced Jaw Problems: Osteonecrosis
Zometa and denosumab and to a much lesser degree, oral bisphosphonates can rarely induce damage to the jaw, a condition termed osteonecrosis.  The risk of developing osteonecrosis is much higher when a tooth is extracted. When osteonecrosis occurs, the gum tissue recedes leaving exposed bone which is susceptible to recurrent infections. The risk of osteonecrosis becomes higher as the lifelong cumulative medication dosage increases. In my experience, osteonecrosis almost always reverses, albeit slowly, after the medication is stopped.

 

Bone Metastases

Zometa and denosumab are also FDA approved to treat cancer that has metastasized to bone. Their anticancer effect is believed to occur because by inhibiting bone breakdown, cancer cell access to the growth factors and cytokines that are normally locked up in the bone matrix is blocked. So these medications that inhibit bone turnover by stopping osteoclast activity not only help osteoporosis but also help to prevent bone metastases from progressing.

Final thoughts

Eventually some degree of osteoporosis occurs in most men as they age.  Regular exercise, calcium and vitamin D help delay bone loss.  Bone density screening in men should probably begin when they are in their 60s, so the condition can be detected early.  Bone density augmentation with denosumab or bisphosphonates seems to be more effective when osteoporosis is not too severe at the start of therapy.   

 

 

Preventing Hormone Therapy Side Effects

BY MARK SCHOLZ, MD

Side effects vary from patient to patient and are influenced by types of testosterone inactivation pharmaceuticals (TIP) used, and by the duration of treatment. However, a number of interventions are available that can substantially reduce these adverse side effects.

Loss of Libido
Libido is an emotional attraction to the opposite sex (in most cases). Libido is not the same thing as potency, which is defined as the ability to get an erection. TIP causes loss of libido about 90% of the time.  Libido returns when TIP is stopped though some men say libido after TIP is chronically diminished. Loss of libido and the cessation of sexual activity has wide ranging ramifications far beyond the intended scope of this blog. Specialists in sexual counseling are available and can be of great assistance.

Erectile Atrophy
Whether or not couples continue to have sexual intercourse after treatment, we counsel men to induce daily erections to counteract the risk of penis shrinkage. Cialis or Viagra should be taken daily.  If this fails to restore the normal pattern of nighttime erections then either a vacuum pump or injection therapy should be considered.  

Muscle Atrophy
Muscle mass can be maintained with a strength training program. Walking, aerobics, and stretching are healthy but accomplish little toward building muscle mass. Strength training that is effective requires a program similar to that undertaken by body builders.  Ideally, strength training requires a minimum of two, one-hour sessions weekly during which all the major muscle groups are exercised: Pectorals, Deltoids, Biceps, Triceps, Latissimus dorsi, Upper and lower back muscles, Abdominals, Gluteus, Quadriceps, Hamstrings, and Calf muscles. Three sets of 10-12 repetitions should be undertaken with weight selected to result in muscle failure toward the end of the third set.

Fatigue and Lassitude

Tiredness and weakness from TIP are a direct result of muscle loss and reversible with strength training. Strength training is very effective for counteracting fatigue. Men who begin strength training when they initiate TIP will not only forestall tiredness, they can actually increase their strength.

Osteoporosis
TIP causes accelerated calcium loss from the bones, termed osteoporosis. Untreated bone loss can result in hip and spine fractures. Osteoporosis can be prevented with medications such as Prolia, Xgeva, Zometa, Boniva, Actonel and Fosamax which should be initiated when TIP is started.  See the booklet titled Osteoporosis available** soon at www.prostateoncology.com for further details.  

Hot Flashes
Hot flashes occur in about two-thirds of men on TIP. When severe, a progesterone injection (depo provera) can dramatically reduce hot flashes. Other prescription medications, which are effective about half the time, are low dose Effexor, a medication approved for the treatment of depression, and Neurontin, a medication approved to prevent seizures. Transdermal estrogen patches are very effective but sometimes cause breast enlargement or nipple tenderness.

Weight Gain
TIP slows metabolism causing weight gain. Keeping a stable weight is easier than trying to lose weight. It is wise to evaluate your diet at the time of starting TIP to see if fat and sugar intake can be reduced. See the brochure about diet from the PCRI for more details.

Breast Growth
Breast growth (even without estrogen patches) occurs frequently in men treated with Casodex monotherapy and less frequently, about one-third of the time, in men treated with other forms of TIP. If there is any evidence for breast growth or nipple tenderness, therapy with an estrogen blocking pill called Femara should be started immediately.  Alternatively, a short course of radiation to the nipples can be administered prior to starting TIP.  

Anemia
Blood is a mixture of red cells and "serum" (water). When the proportion of red cell is diminished it is termed anemia. Severe anemia can cause shortness of breath. Milder degrees cause fatigue. Anemia reverses when TIP is stopped. If anemia is severe, it can be corrected with a medication called Aranesp. Iron is not beneficial.

Arthritis
Joint pains particularly in the hands but sometimes in other joints are common and often improve with glucosamine, Motrin or Celebrex.

Liver Changes
Casodex and Flutamide occasionally cause serious liver problems. This is detected by blood tests that need to be done routinely after starting TIP. The problem is easily reversible if detected early and the medication is stopped.  

Mood Swings
Men on TIP occasionally mention increased intensity in their emotions. Some find this effect unpleasant whereas others enjoy it. For men with the former attitude, low doses of medications such as Zoloft or Paxil can reverse the unpleasant feelings.

Final Thoughts
My general impression after many years treating men with TIP is that treatment is quite tolerable if side effects are expertly managed. Preventative measures such as weight lifting and diet are critically important. Checking blood tests for anemia and liver function is essential. Side effects like joint pains, hot flashes, depression, emotional swings, breast enlargement and impotence can be greatly reduced with judicious medical care.

**email us to receive Osteoporsis booklet -- mail@prostateoncology.com

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.