The TEAL Shade of Blue

BY MARK SCHOLZ, MD

People assume that the differences in the way prostate cancer behaves—one man develops symptoms and another doesn’t—is because they are seeing different stages of the same illness.  What’s overlooked, often with disastrous consequences, is that these differences are also due to the fact that distinct varieties of prostate cancer exist.

Receiving optimal therapy depends on matching an appropriate treatment with both the correct stage and the correct type of prostate cancer.  Since blue is the color for prostate cancer, as pink is the color for breast cancer, the PCRI has subdivided prostate cancer into five major Shades of Blue. These shades incorporate both the stage and the type of disease. The five shades are SKY, TEAL, AZURE, INDIGO and ROYAL.

The first three shades, SKY, TEAL and AZURE, represent men who have had no previous surgery or radiation. TEAL is what medical professionals call “Intermediate-Risk.” Men in the TEAL shade have identical characteristics to SKY—PSA under 10, Gleason under 7 and a small nodule (or no nodule) on digital rectal examination. However, in addition, men in TEAL have one of the following: PSA between 10 and 20, or, Gleason of 7, or digital rectal exam with a “biggish” nodule confined to one side of the gland.

Since men in TEAL have a small but real chance of cancer spread, staging scans of the bone and body are needed.  In addition, a multiparametric MRI or a Color Doppler Ultrasound should be done to check for spread around the gland just outside the capsule. If extra-capsular disease is seen, the shade changes from TEAL to AZURE.

Treatment for TEAL
The list of treatment options for TEAL is long.  While occasionally men are candidates for active surveillance— particularly those who are older—one of the following treatments is usually administered: Robotic surgery, open surgery, intensity modulated radiation, temporary high-dose seed radiation, permanent seed radiation, a combination of seed radiation and IMRT, proton therapy, Cyberknife, focal therapy or testosterone inactivating pharmaceuticals (TIP).  Sometimes a short course of TIP is combined with radiation.

Focal therapy “focuses” treatment on the cancer itself rather than the whole gland.  Typical tools used for focal therapy are cryotherapy, HIFU or laser. In general, skillfully administered focal therapy is thought to be associated with a lower risk for side effects and only slightly higher risk of future cancer relapse. However, focal therapy is very new and there are relatively few studies accurately describing long-term results.

Another option is to use TIP. TIP causes the cancer to shrivel up.  Typically TIP is continued for six to twelve months after which men are placed on active surveillance.

One general principle is that treatment success depends just as much on the skill of the administering doctor as it does on the type of treatment selected.

The second general principle is that cure rates with most of the different treatments are so close that for comparison purposes, they should be considered identical. Of course, the truth of this principle is predicated on the assumption that all treatments are administered by equally skilled experts.

Side Effects of Treatment
The prostate gland is so close to other critical organs it becomes very difficult to target the gland without damaging surrounding structures. The most common side effects, therefore, are persistent difficulties with sexual, urinary or rectal function.  For example, after radiation in an average 65-year-old, about 75% of men will recover back to their normal pretreatment level of urinary function. About 50% will recover back to their normal pretreatment level of sexual function. After surgery, about 50% of men have urinary function that is restored but only 20% describe their sexual function as recovering back to baseline.

Predictions about the incidence of side effects after focal treatment are less than certain because this technology is so new. Overall, assuming that the treating physicians are skillful, one would expect somewhat better potency rates and somewhat lower cure rates compared to standard surgery or radiation.

Comparing TIP with others options is even more difficult.  Cure rates are certainly much lower. However, the good news is that permanent side effects are rare.  The three most troublesome side effects during therapy are low libido, weight gain and fatigue. Weight gain and fatigue are partially counteracted with diligent diet and exercise. Low libido only resolves after TIP is stopped. Other common side effects such as hot flashes, calcium loss from the bones, mood swings, breast growth and erectile dysfunction can be prevented with medication.

Final Thoughts
Men in the TEAL Shade of Blue, compared to men in the other shades, face the biggest challenge—making a therapeutic choice.  First, there are so many options. Second, none of the options are attractive.  The “best” choice is only relatively better than the others; it’s never something you want to do. Making the best choice for yourself requires good comparison shopping skills, and that requires extensive homework. There are no shortcuts. Third, the biggest differences between the options are not related to the cure rates, it’s the concern about permanent side effects that needs the most attention.

Therefore, my recommendation for selecting treatment is to create a list of all the reasonable choices and study them closely, especially in term of the potential long-term side effects.  The “worst” choices should be eliminated one by one. The last option left on the list will probably be the best treatment for you. 

Stress Management

BY RALPH BLUM

Shining a light on stress from a different angle always yields new insights. The very term “stress management” is like a suitcase you can unpack layer by layer.

There can be no doubt that emotional factors influence biology. Some studies indicate that stress plays a role in causing the occurrence and recurrence of prostate cancer. In fact, most major illnesses have been linked to chronic stress.

Receiving a diagnosis of cancer, and living with cancer, can cause an enormous burden of stress. While experiencing feelings such as depression, despair, anger and fear is totally understandable, if those feelings are not recognized and  “managed,” they put endless wear and tear on the body until eventually the immune system—our most powerful defense against cancer—is no longer capable of performing its job efficiently.

The body has its own stress inhibitors.  Consider cortisol. Known as the “stress hormone,” cortisol is synthesized from cholesterol, produced in the adrenal cortex, and secreted during a stress response. Among cortisol’s primary functions are: to aid in fat and protein metabolism, and to redistribute energy to those regions of the body that need it most; for example, to the brain and major muscles during a fight-or-flight situation. Most important, cortisol helps to regulate the body’s inflammatory response to stress, which it does by increasing blood sugar through the process known as  gluconeogenesis. However, during long periods of chronic stress, cortisol is over-produced, and when cortisol levels are too high, the result is a disruption of its anti-inflammatory function.

Led by Sheldon Cohen, professor of psychology and director of the Laboratory for the Study of Stress, Immunity and Disease at Carnegie Mellon University, a teamof researchers found that chronic psychological stress was associated with the body losing its  ability to regulate its inflammatory response and fight infection. They found that, over a prolonged period of stress, body tissue becomes desensitized to cortisol and the hormone loses its effectiveness in regulating inflammation. As a result, disease can prosper.

The links between psychological stress and metastatic growth of disease suggest that stress management should be an integral part of cancer treatment—and possibly the treatment of all inflammatory diseases.

After I completed six weeks of Intensity Modulated Radiation Therapy (IMRT) at St. John’s Health Center in Santa Monica, California, part of the post-procedural concern was monitoring levels of inflammation. For that reason I continued to take Avodart, a drug that both inhibits the transition of testosterone to the more pernicious dihydrotestosterone and acts to keep inflammation levels down. At the same time, I began consciously to monitor my own stress levels and mindfully work to diminish them.

Practically speaking, one thing we can we do is to consider the potential benefits of “mind-body medicine,” which embraces such practices as relaxation therapy techniques, yoga, meditation and tai chi, all of which have been found to be useful as de-stressing activities.

For those of you who think of meditation as an exotic eastern exercise, check out Meditation for Dummies by Stephan Bodian (Wiley Publishing). On the other hand, some people respond well to biofeedback or hypnotherapy. Moreover, it seems that just stroking your pet cat or dog for a few minutes each day has a significant calming effect.

At the very least, adding some form of stress management to whatever conventional treatment you elect to undergo will certainly improve your quality of life—and at the same time enhance your chances of recovery.

The SKY Shade of Blue

BY MARK SCHOLZ, MD

The worst mistakes are to believe that prostate cancer is just one disease and that it will always need treatment. The entire physician community has stumbled into this terrible blunder by assuming that every tiny little spec of cancer being found through needle biopsy is equivalent to the long-familiar, deadly metastatic variety.  It was the invention of the spring-loaded needle biopsy gun, not just the discovery of PSA that launched the modern prostate cancer industry as we know it today.

Tragically, over the last twenty years, millions of men have had their sex lives ruined by unnecessary surgery or radiation. Only recently has it come to light that the Gleason six type of prostate cancer is harmless, that it never metastasizes.

Yet to this day, practically all men with Gleason six are still being treated. Justification is that since it’s called “cancer” we need to be safe and remove the gland. While many men and their doctors continue making this tragic mistake, now that we know how to differentiate between the harmless and dangerous types of prostate cancer, you can be spared.

Blue is the color for prostate cancer as pink is the color for breast cancer. So the PCRI has labeled the major subtypes of prostate cancer with different Shades of Blue. The five shades are Sky, Teal, Azure, Indigo and Royal.

Sky is the first and most favorable shade of blue, the type that can be safely monitored without treatment. Men in the Sky shade category are defined by having the following four characteristics:

1.       A PSA less than 10

2.       A Gleason score under 7

3.       A tiny nodule on digital rectal or no nodule at all

4.       Color Doppler ultrasound or multiparametric MRI scans showing no extra-capsular extension

Treatment for Sky

Studies show that initial observation, termed Active Surveillance, is a safe way to manage favorable forms of prostate cancer like Sky. In a ten-year observational study at Johns Hopkins out of1,000 carefully selected men it was reported that not a single man died of prostate cancer.  In fact there was not even a single case of metastasis.

Observation is preferred because even with the most skilled doctors, standard therapy with surgery or radiation is frequently associated with permanent impotence and incontinence.

A typical Active Surveillance program consists of PSA testing three or four times a year, a digital rectal examination once or twice a year, and periodic random prostate biopsy every one to three years. Bone scanning is not recommended.

Recently, the policy of performing routine random biopsies is being reconsidered. Biopsy is unpleasant and can occasionally be dangerous. Certain centers, those with access to quality imaging, are substituting an annual multi-parametric MRI or color Doppler ultrasound.  Biopsy is reserved only for the men whose imaging shows a new or growing lesion in the prostate. And rather than doing 12-core random biopsy, one to two targeted cores are used.       

|+| Dr. Scholz will be periodically emailing regarding the topics of Imaging, Active Surveillance, the dangers of prostate biopsy and the existence of safe alternatives.

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In Praise of Olive Oil & Avocados

BY RALPH BLUM

Nearly 2.5 million men in the United States currently live with prostate cancer, and a recent study led by UC San Francisco has found that these men may significantly improve their survival potential with a simple change in their diet.

The study, involving some 4,600 men who had been diagnosed with non-metastatic prostate cancer, found that by substituting healthy vegetable fats—olive and canola oils, nuts, seeds and avocados—for animal fats and carbohydrates, the majority of the men in the study lowered their risk of disease progression.

In the June 10, 2013 online issue of JAMA Internal Medicine, lead author Erin L. Richman, ScD, a post-doctoral scholar in the UCSF Department of Epidemiology  and Biostatistics wrote, “Consumption of healthy oils and nuts increases plasma antioxidants and reduces insulin and inflammation which may deter prostate cancer progression.”

In our book, Invasion of the Prostate Snatchers, Mark put the spotlight on insulin in a chapter entitled, The Insulin Connection. In it he explains that insulin deficiency inhibits the development and progression of cancer. However, even more significant, Mark pointed out that excess insulin in the blood acts as high-octane fuel for cancer growth, and is associated with the development of more aggressive forms of prostate cancer.

Dean Ornish, MD, of cardiac management fame, studied 93 men with prostate cancer.  Half of these men were randomly allocated to the Ornish diet program, while the remainder served as a non-treated comparison group. After twelve months, the men on the program had a statistically significant reduction in their PSA levels. Furthermore, extracting serum from the blood of men in both groups, Ornish fed it to prostate cancer cells kept alive in Petri dishes.  The cancer cells that were fed serum from the men not on his program grew eight times faster than those cells receiving serum from men who were on the program.

 

Returning to the “fat intake” study, the authors also uncovered a striking benefit: Men who replaced only 10 percent of their total daily calories from carbohydrates with healthy vegetable fats, had a 29 percent lower risk of developing lethal prostate cancer. Ornish’s dietary recommendations were simple enough: a diet that was vegan or vegetarian, non-diary, supplemented with anti-oxydents such as lycopene, selenium and vitamin E, supported by  moderate aerobic or other exercise.

Clearly further research is needed. There is rather too much “may improve,” and “may lower the risk” in many of the existing studies on the role of diet in the treatment of prostate cancer for my taste. However for now, guys, following a heart-healthy diet seems to be the safest way to go if you want to keep your cancer in check.

 So I say bring on the olive oil and avocados!