Category: General Patient Information
Information on Prostate Supplements and PSA Testing
The Prostate Cancer Foundation (PCF) publishes a highly recommended e mail periodical entitled NewsPulse to which one can subscribe. The October issue contained two articles which I will simply summarize and link.
The first article concluded that popular prostate supplements such as those containing saw palmetto do not benefit prostate cancer patients. They do not decrease the risk of spread of localized disease, affect survival or lower the risk of side effects from radiation therapy. The supplements offered no benefits related to prostate cancer outcomes. However, it should be noted that the article did not address the issue of prostate cancer prevention. The subjects in the study were all prostate cancer patients. As an editorial note, I would not include pomegranate extract in this group of supplements as some positive effects on prostate cancer and PSA doubling time have been observed with the extract (see April 4th, 2011 blog post).
The second article cited a study concerning the effects of the relaxed PSA testing guidelines issued in 2011 by the U.S. Preventative Services Task Force. The current study results indicated that such relaxed screening may delay the diagnosis and treatment of aggressive prostate cancers. Men who could have been eligible for treatment and perhaps cured of more advanced prostate disease may be diagnosed too late. Since 2011, PSA screening has decreased by 28%. The 2011 guidelines did have a positive effect in that diagnoses of new, low-risk cancers dropped by 38%. However, researchers also found a drop of 28% in diagnoses of intermediate-risk cancer and a 23% drop in diagnoses of high-risk cancer one year after the guidelines were published. These finding were consistent with what the researchers hoped would not happen. They concluded that “men will develop more advanced prostate cancer before it is diagnosed and be less likely to be cured.”
Don’t Let Yourself Go! The Benefits of Exercise During Hormone Therapy
A recent article written by researchers from the University of Southern California was published in the August 2015 issue of Prostate Insights from the Prostate Cancer Research Institute. The article discussed how exercise may help with treatment-related side effects of hormone therapy (ADT) and what types of exercise were most effective. Two of the primary side effects of ADT are the loss of muscle mass and increase in body fat within 3-12 months of starting treatment. These effects, termed sarcopenic obesity, also contribute to insulin resistance and greater risk of diabetes. Prevention of muscle loss was observed with exercise programs that were at least three (3) months in duration and involved resistance exercise rather than aerobic exercise although both were recommended. Resistance exercise utilizes weights (machines or free weights), while aerobic exercise such as walking, cycling or swimming, elevates heart rate. Weight exercises should be done two (2) or three (3) times per week targeting the major muscle groups beginning at moderate intensity and progressing to more vigorous intensity with limited rest periods. For example, a chest press exercise which involves more muscle mass is preferred over a biceps curl exercise. In addition, the exercises should start at light weight and high repetitions (>12) and slowly progress throughout the weeks to heavier weight and less (around 8) repetitions. Minimal rest sessions of less than one minute should be taken between sets as a way of keeping the heart rate elevated in a manner similar to aerobic training. It was also found that performing either aerobic or resistance exercise at least twice a week reduced fatigue, another side effect of ADT. In summary, regular exercise incorporating resistance and aerobic training should be carried out 2-3 times per week. Resistance exercise should focus on large muscle groups (e.g. chest press, leg press and leg curl) combined with dynamic movements e.g. squats, lunges. Also, remember to discuss starting any rigorous exercise program with your physician.
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Taking Charge of Your Prostate Cancer Recovery; Old Model Revised.
The following is from the October 7th Prostatesnatchers, as written by Ralph Blum and urinary oncologist, Dr. Mark Scholz. I urge the readers to subscribe to their periodic e mail posts.
In the old model of prostate cancer care, you were rushed into radical treatment–usually surgery or radiation–often without fully understanding all your options, or the risks and side effects involved. The entire process was focused on the tumor; minimal attention was given to you as a person, and little effort was made to explore the benefits of healthy lifestyle choices, immune-enhancing treatments, reasonable delays, and emotional support.
The emerging new model of prostate cancer care recognizes the important role you can, and should, play in your recovery. The emerging model comprehends that simply attacking the cancer is not enough. Greg Anderson, who after surviving “terminal” lung cancer founded the Cancer Recovery Foundation, has said that “Retaining a medical team without doing everything you can to help yourself is like attempting to walk on one stilt.” So what do you need to know in order to take charge of your recovery?
There are three common misconceptions about prostate cancer: a) The assumption that the disease is as dangerous as other cancers; b) The assumption that the urologist who did your biopsy may be a prostate cancer expert; and, c) The assumption that a quick treatment decision is necessary before the cancer spreads.
First of all, prostate cancer is unique among cancers because the mortality rate is so low. Around two hundred thousand men in the U.S. alone are diagnosed with the disease every year, and less than 15% will eventually die from it, usually over a decade down the line, while a majority of men who have the far more common low-risk, slow-growing prostate cancer can anticipate living a normal life span, or dying of something else.
Your local urologist has a busy medical practice that involves treating multiple problems like impotence, infections, incontinence, and kidney stones. He also does biopsies. But the average urologist may perform fewer than five prostate removals (prostatectomies) a year–far too few to be considered proficient. He may be a talented doctor, but he may be an unlikely prostate cancer expert. So once you have your biopsy results, it is best to consult a prostate cancer specialist, either at a major medical center, or at a high-volume prostate cancer clinic.
As for the third misconception, it is essential, before committing to any form of treatment, that you do your own research, and are convinced the treatment you choose is the right one for you. Do not let anyone rush you into making a bad decision. Once your category of prostate cancer is identified (Low, Intermediate, or High Risk), get on the Internet and learn about every treatment option–including no treatment whatsoever–for your type of disease. If you are over 70, and have low-risk disease, my advice to you is to find a doctor who has experience monitoring an active surveillance protocol.
Your role in your recovery, however, doesn’t end with choosing your treatment. The emphasis on lifestyle changes has been one of the most significant shifts in cancer care in the last decade. A study at UCSF showed that improving your nutrition, reducing stress and getting more exercise, can lower PSA levels. According to a relatively new field of health psychology called “illness representation,” your beliefs and expectations also impact the outcome of your disease. So take charge of your recovery, and have faith in your choice of treatment. (Added note from this website: Make sure you have a personal relationship with God and then place your faith in His hands.)
Men With Low-Risk Prostate Cancer In Active Surveillance Program Not Likely To Succomb To The Disease, Study Shows.
The post below comes from a multi-year study at Johns Hopkins in Baltimore. It should be noted below that repeat biopsies performed on men undergoing active surveillance were performed using MRI-guided technology and pathologists checked biopsy tissue levels of proteins made by the PTEN gene, a biomarker for prostate cancer aggressiveness.
Men with relatively unaggressive prostate tumors and whose disease is carefully monitored by urologists are unlikely to develop metastatic prostate cancer or die of their cancers, according to results of a study by researchers at the Brady Urological Institute at Johns Hopkins, who analyzed survival statistics up to 15 years. Specifically, the researchers report, just two of 1,298 men enrolled over the past 20 years in a so-called active surveillance program at Johns Hopkins died of prostate cancer, and three developed metastatic disease.
“Our study should reassure men that carefully selected patients enrolled in active surveillance programs for their low-risk prostate cancers are not likely to be harmed by their disease,” says H. Ballentine Carter, M.D. , the Bernard L. Schwartz Distinguished Professor of Urologic Oncology and director of adult urology. Carter acknowledges that outcomes in the current study may be due to doctors’ careful selection of patients for active surveillance. “With longer follow-up, the data may change, but they’re unlikely to change dramatically, because men in this age group tend to die of other causes,” he says. Most of the men in the study were also Caucasian, and Carter cautions that these outcomes may not apply to African-American men, who tend to have more aggressive cancers.
For the study, described online Aug. 31 in the Journal of Clinical Oncology, men with prostate tumors classified as low or very low risk for aggressiveness opted to enroll in an active surveillance program at The Johns Hopkins Hospital. Their risk level was determined, in part, by Gleason scores, in which pathologists evaluate the aggressiveness of the cancer from prostate biopsy tissue. When the study began in 1995, Carter says, urologists performed annual biopsies on the men in the program until they reached age 75. Now, doctors no longer require annual biopsies among the lowest risk groups, but when they do perform a biopsy, they use MRI-guided technology and will often ask pathologists to check biopsy tissue levels of proteins made by the PTEN gene, a biomarker for prostate cancer aggressiveness. Of the 1,298 men, 47 died of nonprostate cancer causes, mostly cardiovascular disease; nine of the 47 had received treatment for their prostate cancer. Two men died from prostate cancer, one after 16 years in the active surveillance program. In the second man’s case, Johns Hopkins doctors recommended surveillance, but the patient sought monitoring at another hospital and died 15 months after his diagnosis. Three men in the program were diagnosed with metastatic prostate cancer.
Overall, the researchers calculated that men in the program were 24 times more likely to die from a cause other than prostate cancer over a 15-year span. After 10 and 15 years of follow-up, survival free of prostate cancer death was 99.9 percent, and survival without metastasis was 99.4 percent in the group. Some 467 men in the group (36 percent) had prostate cancers that were reclassified to a more aggressive level within a median time of two years from enrollment in the active surveillance program. For men with very low-risk cancers, the cumulative risk of a grade reclassification to a level that would have generally precluded enrollment in the program over five, 10 and 15 years was 13 percent, 21 percent and 22 percent, respectively. For men with low-risk cancers, this risk increased to 19 percent, 28 percent and 31 percent. Over the same time frames, the cumulative risk of a grade reclassification to a level that would be considered potentially lethal in most cases but still curable was no more than 5.9 percent for both very low and low-risk prostate cancers, Carter says. Also among the group, 109 men opted for surgical or radiation treatment despite the absence of significant change in their prostate cancer status. In those whose cancers were reclassified, 361 opted for treatment. “The natural progression of prostate cancer occurs over a long period of time, some 20 years, and most men with low-risk prostate cancer will die of another cause,” says Carter, a member of the Johns Hopkins Kimmel Cancer Center. “There is a careful balance, which is sometimes difficult to find, between doing no harm without treatment and overtreating men, but our data should help.” Carter estimates that 30 to 40 percent of U.S. men with eligible prostate cancers opt for active surveillance, compared with Scandinavian countries, where use of the option is as high as 80 percent. The reasons for less use in the U.S., he says, could stem from fear of losing the opportunity for a cure.
Carter says one of the benefits of active surveillance is reduction in the rates of complications and costs of prostate cancer treatments. In a recent report, 20 percent of men undergoing a prostate cancer treatment – radiation or surgery – were readmitted to the hospital within five years of treatment for a complication related to the original treatment. “Our goal is to avoid treating men who don’t need surgery or radiation. The ability to identify men with the most indolent cancers for whom surveillance is safe is likely to improve with better imaging techniques and biomarkers,” says Carter. Active surveillance is included in best practice guidelines for doctors developed by the National Comprehensive Cancer Network, a group of the nation’s top cancer centers. Carter recommends that men see urology specialists to be monitored in an active surveillance program.
More Evidence for the Positive Effect of Statins and Metformin in High-Risk Prostate Cancer.
A total of 22,110 high-risk prostate cancer patients were evaluated of which 1,365 died of prostate cancer. The study authors concluded that the use of a statin medication in combination with metformin was associated with a 43% reduction in prostate cancer mortality. The benefit was present in all men but was present to a larger degree in men with obesity.
The preceding abstract was presented at the 2015 meeting of the American Society of Clinical Oncology (ASCO) by Dr. Grace L. Lu-Yao of the University of Medicine and Dentistry of New Jersey.
Radiation Cystitis – An Undesirable Potential Side Effect of Radiation Therapy
I was recently made aware of an unexpected, undesirable side effect of prostate cancer radiation therapy called radiation cystitis which first occurred more than ten years after radiation treatment. This can be caused by the incidental irradiation of the bladder during radiation therapy for prostate cancer. Radiation cystitis is characterized by blood in the urine (hematuria) and can manifest itself from 2 months to greater than ten years after treatment. A teaspoon of blood can easily color the urine but more significant amounts of blood can be a sign of more serious conditions including bladder cancer. Radiation treatment of the pelvic area can cause inflammatory changes in bladder tissue and its vasculature. This particular patient suddenly encountered heavy bleeding for several hours during urination. Eventually he could not urinate at all due to blood clot blockage which was accompanied by severe abdominal pain. He had to undergo catherization and his bladder was irrigated to flush out any clots. A subsequent CT scan and cystoscopy revealed bladder vascular changes but showed no pathological evidence of bladder cancer. There are a number of possible treatments for radiation cystitis including hyperbaric (greater than atmospheric pressure) oxygen therapy consisting of significant number of daily treatments. Useful links providing additional information include: a) an overall review of radiation cystitis; b) a series of testimonials from actual patients; c) a urology textbook review of radiation cystitis. Unfortunately, I could not find any reviews suitable for the layman. In summary, any unusual bleeding upon urination after radiation therapy should be discussed with your health care provider to differentiate mild causes from more serious ones.
Western Diet is Harmful for Prostate Cancer Patients
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According to a new study published in Cancer Prevention Research (June 8th, 2015), prostate cancer survivors who consume a typical Western diet consisting of red meat, refined grains, processed foods and high-fat dairy products may be at an increased risk of death from recurrent prostate cancer as well as other causes. Researchers at Harvard T.H. Chan School of Public Health studied 926 men aged 40 to 84 who were diagnosed with prostate cancer that had not spread. Subjects answered questions about their diets five years after receiving a prostate cancer diagnosis and were monitored for approximately 10 years. The men diagnosed with non-metastatic prostate cancer who ate a diet that was more Westernized were 2.5 times more likely to die of prostate cancer than those who ate the healthiest diet and 1.5 times more likely to die of any cause. The healthiest diet was a Mediterranean-style diet rich in fruits, vegetables, and fiber with fewer dairy products and less red meat. The researchers concluded that their “results suggest that the same dietary recommendations that are made to the general population primarily for the prevention of cardiovascular disease may also decrease the risk of dying from prostate cancer among men initially diagnosed with non-metastatic disease.”
An Alternative to Immediate Prostate Biopsy
The following article dated August 6th came from a site entitled Prostatesnatchers authored by a noted prostate oncologist, Dr. Mark Scholz. He suggests that a commercial OPKO-4Kscore blood test and a high-resolution color Doppler ultrasound or a 3-Tesla multi-parametric MRI can help identify aggressive cancers and minimize the use of standard 12-core prostate biopsies and their potential side effects. The OPKO-4Kscore blood test is comprised of measurements of total and free PSA coupled with proprietary tests for intact PSA and a panel of four kallikrein (a specific group of enzymes) blood markers. My own prostate oncologist commented favorably on this test. “It won’t be the last word, but it is a productive departure from single-lab-value (PSA) technology, which is over 30 years old.” Remember the contents of this website are not intended as personal recommendations but the potential use of this information should be discussed with your personal physician. You should also check on the cost and insurance coverage of the tests described below.
“You PSA is elevated. Now your doctor recommends a needle biopsy, 12 cores through the rectum to check for cancer in the prostate. Sounds icky, but also logical; after all who wants to miss cancer? But come on, do you really have to do 12 stabs via the rectum?
Each year over a million men submit their prostates for a biopsy. At an average cost of around four thousand dollars, the prostate biopsy business is a 4-billion-dollar-a-year enterprise. But it’s not merely the cost that gives pause. Three percent of men end up hospitalized with life-threatening infections. Around a 100,000 men every year get a confounding diagnosis of Grade 6 prostate cancer, a truly harmless entity, unless you get suckered into an unnecessary radical prostatectomy.
Obviously, prostate biopsy is an unpleasant proposition with notable risks. However, ignoring a high PSA incurs the risk of missing a diagnosis of a higher grade prostate cancer. As things stand now, of the million biopsies being done annually, over a hundred thousand men with Grade 7 or higher cancers are being detected. For these men, their early diagnosis is beneficial, leading to early, curative treatment in a timely fashion.
How can we detect the 100,000 men with higher-grade cancers that need to be detected without doing 900,000 “unnecessary” biopsies? The answer to this question continues to evolve as technology marches forward. Our latest thinking at Prostate Oncology (assuming the PSA is not wildly elevated, say over 20) is a three step process:
1. Simply repeat the PSA to confirm it is indeed abnormally elevated. All sorts of things can cause temporary elevations of PSA ranging from nonspecific inflammation of the prostate, to recent sexual activity, to simple laboratory errors.
2. If the PSA remains elevated with repeat testing the next step to consider is an OPKO-4Kscore blood test. The OPKO test reports a percentage estimate of the likelihood of higher grade cancer being present. The test is not perfect, but it performs pretty well. For example, if a specific patient receives an OPKO report with an estimated risk of high grade disease of less than 15%, a standard random biopsy (if he elected to do one) will confirm the absence of high grade disease 92% of the time. Not bad.
3. Our next step at Prostate Oncology in the cases where a patient has an OPKO test indicating that the risk of high grade disease is over 15%, is to obtain a prostate scan with high-resolution color Doppler ultrasound or with a 3-Tesla multiparametric MRI. With scanning, the location of the high-grade disease can be determined over 90% of the time so that a targeted biopsy with 2 or 3 cores can be substituted for the traditional 12-core biopsy.
The business of prostate biopsy has become so out of control the US Preventative Services Task Force advocates against PSA testing altogether. The Task Force’s scientifically-based arguments that PSA testing is causing more harm than good are really quite convincing. However, back in 2011 when they published their recommendations, the OPKO test and 3-Tesla multiparametric prostate MRI were unavailable. With the advent of these new technologies, PSA screening to detect higher grade prostate cancers at an early stage when they are still curable makes perfect sense.“