Search: exercise and prostate cancer

ADT, Apalutamide and Exercise in the Treatment of Prostate Cancer

Hormone Deprivation therapy, also known as Androgen Deprivation Therapy (ADT) is a common long-term treatment for men with more serious prostate cancer or short-term therapy before undergoing radiation therapy. Either way, when a man’s testosterone levels go down to nearly zero, life is experienced differently.

My partner, David at XY Wellness recalls when he was on short-term ADT  before radiation nearly fifteen years ago;

“ ADT materially alters how you interpret and engage with the world around you. It taught me that there is far more than a mind-body connection by suggesting that they are one in the same.”

He continues;

“While undergoing ADT, it is not so much that the man is disinterested in sex but that it simply does not cross his mind.”

Recently, Apalutamide, trade name Erleada was approved for treating men with rising PSA (recurrence) after treatment for prostate cancer without metastasis. Currently, this is the first standard treatment for a scenario for a rapidly rising PSA without metastasis after a study was published in the New England Journal of Medicine.

Study Details

  • A total of 1207 patients underwent randomization: 806 were assigned to the Apalutamide group(240 mg per day) and 401 to the placebo group in the phase 3 SPARTAN (Selective Prostate Androgen Receptor Targeting with ARN-509) trial

NOTE: It is common for there to be funky names to large trials like this and other ADT studies, i.e, LATITUDE, CHAARTED, etc. It helps physicians (especially when lecturing) and lay people alike mention the studies with ease. Of course, SPARTAN has a warrior kind of implication… as in, are you ready to fight? Clever.

  • Follow up was for close to two years.

 

  • Study participants had confirmed prostate cancer that was castration-resistant and was at high risk for the development of metastasis, which was defined as a PSA doubling time of 10 months or less during continuous androgen-deprivation therapy.

 

  • Patients with evident bone metastasis were excluded from the study.

 

  • RESULTS: Time to metastasis, progression-free survival, and time to symptomatic progression were significantly longer (70% better) with Apalutamide than with placebo

 

  • Apalutamide was associated with higher rates of rash, fatigue, joint pain, weight loss, falls, and fracture than placebo.

(Study Link)

 

My Take on the Use of Apalutamide (Erleada is the trade name) non-metastatic Castrate Resistant Prostate Cancer

Apalutamide is an anti-androgen agent, meaning it lowers testosterone and Dihydrotestosterone (DHT) to almost zero, similar to other forms of Androgen Deprivation Therapy (ADT) except this new drug blocks the genetic formation of androgen receptors.

The study was paid for by Janssen Pharmaceutical, the developer of the drug. I say this because when studies funded by the company that makes the drug questioned, the results are often favorable to the company sponsoring the product. Thus, there seems to be some bias playing a role in such scenario.

That said, the design of the study was good, and it was published on one of the most respectable journals, New England Journal of Medicine (NEJM), so I will proceed with a small air of caution.

Seventy percent improvement from cancer worsening in two years compared to placebo is darn good. Of course, no drug that works well comes without downside (excuse the pun).

Men on Apalutamide showed higher rates of rash, fatigue, joint pain, weight loss, falls, and fracture than placebo.

Long-term treatment of ADT is associated with side effects, such as fatigue, reduced bone mineral density, increased fracture risk, decrease in skeletal muscle mass (muscle wasting), associated with the development of metabolic syndrome/insulin resistance, increase in adverse cardiovascular events effects and increases the risk of anemia, hot flashes, gastrointestinal tract disturbances, loss of libido, impotence, osteoporosis, gynecomastia, deep vein thrombosis, congestive heart failure, myocardial infarction, pulmonary edema, cognitive decline and psychological changes.

As I continue to monitor the well being of many prostate cancer patients on ADT, I can say with very little doubt that men can live long and strong while undergoing hormone therapy.

With one caveat…

You must follow a lifestyle and exercise regimen that supports your body.

Many of my patients on ADT are “crushing it” by practicing a prescribed exercise and nutritional regimen gathered from the science I’ve researched.

Not only is prostate cancer successfully managed when combining ADT with lifestyle, but the quality of life is also exceptional. I am not exaggerating.

Should I be on ADT? What would you do if you were me?

I’m often asked by patients, “What would you do if you were in me? Would you go on ADT?”

Such question reminds me of a line in one of the few books I read from cover to cover in high school (I wasn’t a big reader then), To Kill a Mockingbird by Harper Lee…

“You never really understand a person until you consider things from his point of view, until you climb inside of his skin and walk around in it.”

In other words, I am not you. And I have not been diagnosed with PSA recurrence after initial treatment for prostate cancer with curative intent.

That said, I do read many scientific papers on prostate cancer, have extensive clinical experience with patients battling this disease, and have opinions about prostate cancer treatments and quality of life.

Here’s what I’d say…

I am a sucker for a good quality of life. I’d choose the quality of life over longevity in most cases. Much would depend on the severity and length of time of adverse effects from ADT.

Thus, every case is different.

If God forbid, I am diagnosed with aggressive, stage 4 lung cancer; it is likely that I will choose no medical treatments as experience and data show not a significant survival rate and poor quality of life with the available treatments for such disease and numerous others alike.

But I digress. We are talking about prostate cancer.

Men on ADT in my clinical experience are doing exceptionally well, likely because they are following my nutritional and exercise advice – at least, that’s what I’d like to think. Getting on ADT for the right patient and based on the scientific data supporting its use in improving survival is a good option.

Exercise Prescription for men on Hormone Deprivation Therapy or Androgen Deprivation Therapy (ADT) to treat Prostate Cancer

The goal for men on ADT and applying lifestyle and exercise program are:

  1. Minimize adverse and unwanted side effects from ADT treatment
  2. Create a hostile biological environment for cancer in the body to support medical treatment
  3. Optimize quality of life despite ADT.

Wow! That’s a lot. Can we accomplish all that?

Yes, it is. And yes you can.

The right lifestyle and exercise program like the CaPLESS method can minimize about 80% of those side effects. I am not kidding.

Low libido, impotence (or let’s call it sexual dysfunction. Impotence sounds a bit harsh) and hot flashes are non-life threatening and more difficult to overcome.

Most other life-threatening side effects  are greatly reduced.

Studies on Exercise while on Hormone Deprivation Therapy or ADT.

In one study of 2,700 male health care professionals (average age 70 years) with non-metastatic prostate cancer and found that those participating in vigorous physical activity for a duration ≥3 hours/week demonstrated a 49% lower risk of all-cause mortality and a 61% lower risk of death specifically from prostate cancer, compared with men who did 1 1 hour/week of vigorous activity. (Kenfield et al. 2011)

A systematic review of ten studies (five randomized and five uncontrolled clinical trials) examined the effects of exercise on patients receiving ADT. This paper demonstrated that physical performance was improved by exercise. Randomized controlled trials found exercise to be consistently beneficial for muscular performance: reported as increases in muscular strength and increases in upper and lower limb strength, compared with the control population. (Gardner et al. 2014)

Body composition (the amount of fat compared to muscle in the body) is a component of many studies investigating exercise effects on prostate cancer patients on ADT and resistance training has been shown to either increase lean body mass or not decline. Loss of muscle mass is a common scenario amongst ADT patients. (Galvão et al. 2010)

An observational study reported in 2006 looking at over 70,000 men observed 11% increase in myocardial infarction risk and a 16% increased risk of coronary heart disease and death from cardiac arrest in the study of prostate cancer patients receiving ADT, versus those not on hormone therapy. (Keating et al. 2006)

We would want to avoid those cardiovascular problems while on ADT, right?

Although there are no studies I can find specifically to evaluate the effect of exercise on ADT-induced cardiovascular events, there is a large body of evidence supporting the role of physical activity in the prevention and management of cardiovascular disease in the general population. (Thompson et. Al 2003)

Osteoporosis ( bone fragility), is a major side effect of ADT can lead to bone fractures, and bone fractures lead to 37% of deaths in older men. (Ebeling; 2008)

A study of 8,833 men aged 18–64.9 years used computed tomography to show an inverse relationship between adiposity (BMI and visceral and subcutaneous adiposity) and bone quality (Zhang et al. 2015)

Studies show that resistance training in older men and women, where only high-intensity, and not moderate-intensity, strength training resulted in increased bone mineral density. (Vincent et al. 2002)

METABOLIC SYNDROME WHILE ON ADT

Metabolic syndrome defined by weight gain, especially waist gain; fasting glucose 100 mg/dL or higher, peripheral insulin resistance; and increased diabetes risk increase the risk of heart disease and stroke, in addition to diabetes as is a common side effect when ADT.

Results from a randomized pilot study assessed the impact of over six months of combined metformin, a low-glycemic-index diet, and exercise in 20 prostate cancer patients at ADT initiation and compared this with 20 men who were on ADT alone. The metformin and exercise group had decreased abdominal girth, weight, BMI, and systolic blood pressure, compared with the group on ADT treatment alone, although insulin-resistant biochemical markers were not significantly different. In this small study, however, it was not possible to separate the metformin and dietary effects from the exercise components. (Nobles et al. 2012)

63 prostate cancer patients were randomized to receive either a 3-month aerobic and resistance exercise program or usual care, concomitant to initiation of ADT. Patients receiving the exercise-based intervention demonstrated significant reductions in ADT-associated metabolic effects, including decreased whole body fat mass, abdominal fat, and percentage fat, compared with the usual care control group. (Cormie et al. 2015)

C-reactive protein, an inflammation marker commonly elevated in metabolic syndrome, showed a clinically meaningful reduction in a randomized controlled trial of exercise in 57 men on ADT (Galvão et al. 2010)

Exercise Prescription while on ADT

Exercise four hours a week in moderate to high intensity. Anyone on ADT must include weight resistant exercise, two to three times a week, where you push and pull weight against gravity.

Types of exercises used in some studies include:

Leg presses 

Leg extensions

Leg curls 

Lat pull downs

Biceps curls (with dumbbell)

Triceps extension

These are the main strength training exercises performed on many of the studies listed above showing benefit.

Strength training movements I strongly recommend include:

Kettlebell training – Pavel on this video sounds like a military agent. He is the best at kettlebells and one of the most knowledgeable on physical strength. 

(Me and a friend after Kettlebell training)

Squats

Deadlifts

Benchpress

The Press

Pushups

Pull-ups

 

If the above movements and exercises sound foreign then consider hiring a physical trainer if able to. Not only can a trainer help you with the movements but also help prevent injuries.

If an injury occurs during any movements mentioned above, all bets are off, you will not or cannot get the benefit of the exercise.

Listen…

Fear should not stop you from trying and consistently training with the exercises mentioned.

Prostate cancer has to be fought with courage.

The most important point in doing any of the above exercises is to first master the technique of that movement. That is one of two ways you prevent injuries from doing those exercises. The other is avoiding doing too much weight too soon. Yes, you should challenge yourself and increase the weight you push or pull, but it must be done incrementally.

Again, hiring a personal trainer can be priceless if your pockets allow.

Last 3 Blog Posts:

Traditional Chinese Medicine treatment for Erectile Dysfunction

Why I’m Into Intermittent Fasting

Does Eating Chicken Cause Prostate Cancer

 

Resource:

Much of the research for this blog post is from Moyad et al; 2016

Nutrition while on ADT – Advanced ADT Support

 

References:

Kenfield SA, Stampfer MJ, Giovannucci E, Chan JM. Physical activity and survival after prostate cancer diagnosis in the health professionals follow-up study. J Clin Oncol. 2011;29(6):726–732.

Gardner JR, Livingston PM, Fraser SF. Effects of exercise on treatment-related adverse effects for patients with prostate cancer receiving androgen-deprivation therapy: a systematic review. J Clin Oncol. 2014;32(4):335–346

Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) Circulation. 2003;107(24):3109–3116.

Keating NL, O’Malley AJ, Smith MR. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol. 2006;24(27):4448–4456.

Ebeling PR. Clinical practice. Osteoporosis in men. N Engl J Med. 2008;358(14):1474–1482

Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340–347.

Zhang P, Peterson M, Su GL, Wang SC. Visceral adiposity is negatively associated with bone density and muscle attenuation. Am J Clin Nutr. 2015;101(2):337–343.

Vincent KR, Braith RW. Resistance exercise and bone turnover in elderly men and women. Med Sci Sports Exerc. 2002;34(1):17–23.

Nobes JP, Langley SE, Klopper T, Russell-Jones D, Laing RW. A prospective, randomized pilot study evaluating the effects of metformin and lifestyle intervention on patients with prostate cancer receiving androgen deprivation therapy. BJU Int. 2012;109(10):1495–1502.

Cormie P, Galvao DA, Spry N, et al. Can supervise exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: a randomized controlled trial. BJU Int. 2015;115(2):256–266

DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340–347.

Prostate Cancer: My Takeaway from the AUA 2019 meeting

This is some of the takeaways from the AUA meeting this past week. Today we focus on prostate cancer.

Is metabolic syndrome a risk factor of prostate cancer (PrCa)?

Cosimo De Nunzio, Department of Urology, Ospedale Sant Andrea, Sapienza University, Rome, Italy presented a study of 309 patients with a median age of 68 of which109 patients had a diagnosis of metabolic syndrome. Patients with metabolic syndrome were shown to have a higher rate of PrCa, and PrCa patients were also shown to have a higher rate of metabolic syndrome.

Laslty, metabolic syndrome was shown to be an independent predictor of PC and particularly of high-grade PrCa.

My thoughts:

Metabolic syndrome is a cluster of conditions that occur together, increasing your risk of heart disease, stroke, type 2 diabetes and now we see PrCa.

These conditions include

  • Waist circumference more than 40 inches in men and 35 inches in women
  • Elevated triglycerides 150 milligrams per deciliter of blood (mg/dL) or greater
  • Reduced high-density lipoprotein cholesterol (HDL) less than 40 mg/dL in men or less than 50 mg/dL in women
  • Elevated fasting glucose of l00 mg/dL or greater
  • Blood pressure values of systolic 130 mmHg or higher and/or diastolic 85 mmHg or higher

Having just one of these conditions doesn’t mean you have metabolic syndrome, but having three or more does.

Also, your urologist will not measure MS associated biomarkers, like triglycerides or HDL. That would be done by your general practitioner, internal medicine physician or cardiologist.

The bottom line is to get all the above measured as metabolic syndrome is the most direct contributor to virtually all urological conditions.

Can Germline Mutations predict more aggressive prostate cancer?

Dr.Todd Morgan, MD, from the urologic oncology department at the University of Michigan cited several showing that of 11% of patients men with prostate cancer were shown to harbor germline mutations. BRCA one and two showed more aggressive prostate cancer and ATM was associated with upgrade of cancer status in men on active surveillance

My Thoughts:

All men should know their genetic status with regards to prostate cancer

HERE is a post I recently wrote on how to do so.

In men deemed candidates for active surveillance but with ATM, BRCA 1 or 2 mutations, should follow up more closely and adhere to strict lifestyle practices.

Does Androgen Deprivation Therapy (ADT) for prostate cancer impact cognitive decline?

Dr. Cheng-Yu Huang from Chung-Shan Medical University, Taichung City, Taiwan confirms from other studies that in a group of Taiwanese men ADT was associated with a high risk of overall cognitive dysfunction, dementia, and Parkinson’s disease.

My Thoughts:

My clinical focus with men on ADT is to improve, if not maintain their quality of life as they manage their disease with the treatment. Lifestyle practices work.

With regards to keeping a strong brain while on ADT, exercise and a few nutrients help: Bacopa is an excellent herb for brain function as well as Acetyl-L-Carnitine. I developed this packet specifically for men on ADT and I think it works well. But these nutrients complement a good diet and exercise program, it does not replace it.

Source:

American Urology Meeting 2019 attendance

Urotoday

Medscape Urology

Lastly, check out the new and improved XY Wellness website.

The Exercise Prescription: How often?

[My daughter named all our kettlebells with Harry Potter and Marvel character names:)]

The question comes up often…

How often should I exercise?

I have been pondering that question for a decade.

What is optimal regarding exercise frequency?

Answer: Everyday, 7 days a week.

Before I expand on exercise frequency, let’s review why physical activity is important.

For one, strong people die less.

  • High midlife grip strength and long-lived mother may indicate resilience to aging, which, combined with a healthy lifestyle, increases the probability of extreme longevity.
  • Low muscle strength was independently associated with an elevated risk of all-cause mortality
  • In a large powered study (over 120,000 participants) showed respiratory (aerobic) fitness significantly reduced the risk of dying.
  • For men after prostate cancer diagnosis, there is a 61% lower risk of dying from the disease and a 57% reduction of recurrence after treatment in men who vigorously exercise at least 3-hours a week

[Men and their partners thriving after prostate cancer at the CaPLESS Retreat]

The other benefit and equally important in my opinion,  from physical movement, is mental health.

When looking at over seventeen thousand subjects, researchers noticed both weight resistant exercise and aerobic exercise combined lower depressive symptoms.

How did I come up with the “exercise everyday” idea?

Before I advise my community on lifestyle changes I do it first to assess benefit, side effects, and compliance.

I do that with diets, new dietary supplement formulations I am working on, and exercise.

I’ve been physically training every day for at least one year.

Now, I know this sounds daunting.

“EVERY DAY? Geez, do you have a life?”

I do. Imperfect life still but I do have one.

Here’s how it works;

We all waste time somewhere in our day-to-day, whether in over surfing on the internet, watching too much news or watching a boring baseball game for four hours.

The other thing is that any amount of time exercise counts. In general, you want to hit 4 to 6 hours a week of moderate-intensity physical activity. This morning I felt a bit off, maybe from getting up too early (4 am) too many days in a row, I don’t know. So all I did, literally in my underwear ( TMI, I know) is 46 pushups, cobra to downward dog poses and yoga-like stretches for seven minutes. And that counts as exercise too.

Physical training has to be focused on the movement and activity you are involved in. In other words, be mentally present in the activity. That’s why when New Yorkers tell me they walk every day, going from a to b that doesn’t count. I mean, it is something but we are focused on optimal and not dying prematurely, not the idea that “something is better than nothing.”

For example, I get around the big city on a Citi bike regardless of distance, but I don’t consider that exercise. That’s merely a form of transportation for me.

Create an environment where there are no excuses to not getting it in.

I have the benefit of a garage gym. I wanted to do everything possible to avoid a reason to not exercise.

You may say, “of course its easy for you get it in every day, all you have to do is roll out of bed and go right to your gym.”

True, but before my garage gym we lived in a two-bedroom apartment where I put up a chin-up bar, got four kettlebells and had space to do floor exercises like push-ups.

If your goal is to train first thing in the morning, which I recommend, then sleep in your workout gear. I’m not kidding. I can’t tell you the number of times I hear people say they can’t find their workout shorts or sneaker and that’s the reason why they don’t train. (OK, don’t sleep in your sneakers)

[My Sanctuary]

Three Benefits from Exercising Everyday

1. You will live longer. It is the ultimate fountain of youth as highlighted before.

2. You will create a good habit. By exercising every single day, it will become routine, and nothing will get in the way of your workout. In those sluggish days, just put your sneakers on and go for a brisk walk. The hardest part is often getting started.

3. It is terrific for your mental health. I think this is the main reason why I train every day. I have too much going on too many things to figure out. Exercise gets me in the right frame of mind. And its cheaper than a shrink.

Here are the rules to exercise every day:

1. The focus is on only the activity and your breathing. Keep your mind away from your work, family issues or where you are going next. Let’s call it active meditation.

2. While some days your training session need to be at least 30-minutes with a focus on building strength, flexibility or endurance, other times it can be 10 minutes or less as long as you are actively moving and present in the moment.

3. There are no excuses not to exercise every day. Even if there is no chin-up bar or kettlebells around, use the floor for push ups, sit ups, planks and a plethora of other exercises.

Opinion: Recent Vitamin D and Fish oil Study

A recent study in the New England Journal of Medicine (NEJM) recruited 25,000 subjects, average age 67 and was split into four groups:

  • One group took 2,000 IUs (international units) of vitamin D3 and 1 gram of omega-3s every day. (1 g per day as a fish-oil capsule containing 840 mg of n−3 fatty acids, including 460 mg of eicosapentaenoic acid [EPA] and 380 mg of docosahexaenoic acid [DHA])
  • A second group was given vitamin D and a dummy pill in lieu of omega-3.
  • A third group got omega-3s and a vitamin D placebo.
  • And the final group received two placebos.

Researchers concluded that omega-3’s and vitamin D supplementation do not lower cancer rates in healthy adults, nor reduce the risk of heart attacks, strokes, and deaths from cardiovascular disease. (part of the story published in the New York Times)

The results of the NEJM was not all negative. There seemed to be a reduction in cancer deaths for people who took vitamin D for at least two years, and fewer heart attacks (28% less) in people who consumed omega-3 supplementation.

African-Americans who ate a little fish and took fish oils, in the NEJM study, experienced a 77 % reduction of cardiovascular disease.

So, now what?

Firstly, the trial was well designed: it was a randomized controlled trial (RCT), which is gold-standard (particularly when studying single agents), it studied healthy people (not diseased), and it was the largest-ever RCT of vitamin D supplements.

Many patients and nutritionally minded people are taking fish oils and vitamin D. Is that a waste of money? Is the take of supplements simply expensive urine?

Let’s start with this; The idea that participants in the NEJM trial were “healthy” is incorrect.

The average BMI was 28. A person with a BMI ≥ 25 is overweight or obese.

High BMI increases the risk of cancer and heart disease.

Larger people, for example, need more vitamin D than slimmer people. The amount used in the study (2000 units) will not get most to the optimal range of 40ng to 60ng/ml. I almost never clinically see 2000 units a day of vitamin D work in getting patients to the optimal range of 25- hydroxyvitamin D (how vitamin D is measured in blood).

Also, almost 50% of participants were on hypertensive drugs, and over 7% smoked. What’s healthy about that?

Secondly, eating clean, exercise and healthy behavioral habits are key to prevent and manage disease successfully. Dietary supplements do not replace that.

Lastly, we should consider the preponderance of research, not just the latest study before applying changes to our nutrition regimen.

For example, another study showed among cancer patients, higher 25-hydroxyvitamin D levels at diagnosis lived longer.

Published in one of the most prestigious journals in the world, the Lancet, a dose of 1 g or more of omega−3 fatty acids per day showed significant protection against coronary events.

The Takeaway on Vitamin D and Fish oil supplements 

Vitamin D and Fish oils work best with a lifestyle and behavioral practices that support optimal human functioning. However, many research papers show these nutrients support human health on their own.

Here are some examples:

  • Vitamin D helps with reducing Lower Urinary Tract Symptoms (LUTS)
  • Vitamin D and Fish oils can help with depression.
  • Vitamin D deficiency can lead to aggressive prostate cancer. Though intake of vitamin D was not tested, the implication is it lowers the risk of deadly prostate tumors.
  • Vitamin D helps in men with an enlarged prostate (BPH)
  • Dietary supplements complement that kind of lifestyle very well; it does not replace.
  • Fish oils help lower blood pressure
  • Lastly, a derivative of the Omega-3 EPA recently showed a decrease in lower triglycerides and decrease the risk of cardiovascular events at 4 grams a day. This likely means that a measly 460mg (0.46 g) a day of EPA as studied in NEJM is not enough for protection.

What Should You do?

Consider seeing a nutritionally oriented doctor. Such physicians are trained in naturopathic and functional medicine and are experts in prescribing lifestyle practices and quality supplements therapeutically.

Also, there are numerous factors to consider when taking dietary supplements:

  • Manufacturing practices matters. Not all dietary supplements are created equal. The good ones are regulated by cGMP(Good Manufacturing Practices). The better ones go beyond cGMP testing.

 

  • Consume the right ingredients that are specific to your needs. I can’t tell you the number of patients I see taking more supplements than what they need. Some take toxic amounts of certain vitamins. For example, high vitamin E intake (400units) in the form of dl-alpha tocopherol (not high in gamma tocopherol or mixed tocopherol) can increase the risk of prostate cancer. To be clear, vitamin E, high in gamma tocopherol may protect against prostate cancer while alpha-tocopherol alone is unnatural and can increase its risk.

 

  • The dose is important. And there’s a difference between a maintenance dose and a therapeutic dose. For example, when taking vitamin C to fight a cold, about 500mg every two to three waking hours work best. The body cannot absorb more than 500mg at one time. So, taking 1,000mg of vitamin C at one time might be a good maintenance dose but will not do the trick.

Preventing and Treating the Flu Naturally

 

While many reading this may have already gotten the flu, others have not and are yet in the clear until May.

The recent flu is an  H3N2 strain that’s particularly aggressive.

Vaccine companies have updated their medicine to match this years virus. (There is plenty of disagreement if flu vaccines work at all or if they are safe, but that’s a different story for a different day.)

We have exposure to influenza (flu) virus by touching surface’s that are contaminated or by microscopic viral droplets in the air that make their way to our lungs – typically by infected people coughing or sneezing around us.

Here’s the deal: there’s virtually no way to avoid exposure to the flu virus. There are people with no symptoms who have the flu virus and don’t know it and will transfer viral droplets to you. Your job (and mine) is to maximally strengthen the immune system so that our body rids itself of the virus before it penetrates into our lungs and “camp out.”

To protect yourself against the flu is all about strengthening your terrain, the microenvironment, and your body.

What is the flu?

The “flu” is short for the influenza virus. Technically speaking, one gets the flu anywhere between October and May. This period is called the flu season.

What should you do to fight the flu?

Well, you may have already gotten the flu shot. The problem is that the vaccine is developed based on scientists’ prediction of which type of influenza virus (there are many) will be around during the next flu season. Therefore, you may still get the aches, fever, sore throat and drowsiness that come from the influenza virus.

Don’t just vaccinate.

I’m not suggesting for or against vaccinations. However, if you do it the flu vaccine alone will likely not be enough.

  • Wash your hands often. A little OCD here is not a bad idea. And use regular soap. Antibacterial agents are not necessary.

 

  • Skip midnight shows and sleep more. Record the Stephen Colbert show or Nighttime news if that’s your thing. You’ll find that those around you that sleep less are more vulnerable to getting the flu.

 

  • Don’t run marathons (literally) during this time. Extreme exercise weakens the immune system.  (Yikes, the NYC marathonis this weekend. Good luck to all runners) Don’t make up your own stories though. 😉 – I’m not saying don’t exercise. I’m suggesting no extreme, ultra-endurance exercises until the flu season is over around May.

 

  • Consider immune enhancing dietary herbs like Astragalus, Andrographis, Echinacea and Larch arabinogalactanthat has proven to be excellent immune boosters and has anti-viral properties. You may need to see a natural medicine oriented doctor to help you.

 

  • Active Hexose Correlated Compound (AHCC)has been well studied demonstrating immune modulating capabilities. I would try the above-mentioned herbs and vitamins first. AHCC is more expensive; however, if one is elderly or has a weak immune system then it should be considered and taken until May.

When to go to the hospital when getting the flu.

Feeling achy and feverish is normal. Having a hard time breathing or a relapse of fever after feeling better is not – go to the emergency room. More information HERE on what to look out for before heading to the ER.

Which dietary supplements help prevent and fight the flu?

Vitamin C

You may think that Linus Pauling discovered vitamin C, but it was Albert Szent-Györgyi who won the Nobel Prize for discovering it. Linus Pauling, another Nobel laureate, popularized the use of vitamin C for disease prevention and longevity. Vitamin C has antioxidant properties, regenerates glutathione, and might stimulate neutrophil and monocyte activity. One trial found that patients who took 8 g of vitamin C at the onset of symptoms had more “short colds” (lasting less than a day) than those who took 4 g.

Take 500mg of vitamin C  every two waking hours during flu season (total of 4 to 6 g). Taking more than that is not absorbable and greater than 10 g can cause diarrhea. Also, it is best to take vitamin C with other antioxidants like alpha-lipoic acid and zinc, or with bioflavonoids.  Always take vitamin C with bioflavonoids , such as hesperidin, which is found with vitamin C in citrus fruits .  This is not to say that you should stop consuming fruits and vegetables that contain hesperidin  (or other bioflavonoids), because these vital and healthful foods contain many other constituents (antioxidants and others) that are protective against cancer and possibly cardiovascular disease as well.

Note: sometimes you hear people say that vitamin C does not work to prevent colds and flu. Almost always, the people who say this are taking too low of a dose – usually about 500 mg (0.5g) a day.

For flu risk reduction, vitamin C has to be taken more aggressively.

Garlic (Allium sativum)

The part of the garlic that does the protective magic is allicin. Allicin is released when garlic is chopped or chewed, but cooking deactivates it. Allicin has demonstrated antiviral properties in vitro against rhinovirus (common cold) and several other strains.

One study of 146 healthy adults compared a high-dose of allicin extract (180 mg daily) with placebo for 12 weeks during the winter months. The results were dramatic; the treatment group had 64% fewer colds.

Take 180 mg of allicin. Fresh garlic contains 5 to 9 mg per clove, and most extracts contain less than this. So, that’s about nine cloves of garlic. (The only side-effect reported in the trial was malodorous belching.)

Note: Garlic supplements should be discontinued before a surgical procedure due to their anti-coagulant (blood thinning) effects.

Zinc

Zinc is an essential mineral essential to hundreds of biochemical pathways, and deficiency is associated with infection risk.

Take 15 to 30 mg a day. If you take more than 30 mg a day, you need about 2 mg of copper to avoid a copper deficiency.

Do not take more than 100mg of zinc in supplement form.

Selenium

Supplementation with selenium can stimulate the immune system in many ways, like increasing the proliferation of activated T cells. Selenium deficiency is linked to the occurrence or disease progression of some viral infections.

I would recommend taking 200 μg (that’s micrograms) selenium per day to achieve noticeable immune enhancing effects. Taking more than 800 μg per day is not recommended.

Astragalus

Astragalus is a botanical that seems to work mainly with antiviral properties and appears to have a beneficial influence on T-cell activity, which is an important immune modulator. A member of the pea family, this root can be stirred into soups to bolster your immune system during cold and flu season.

Take 2 to 6 grams of astragalus in capsule form daily. Less if it is in a comprehensive formula.

Oscillococcinum

You have seen this homeopathic remedy in health food stores and have wondered if it works, right? Or do you just wonder how to pronounce it?

As with any homeopathic remedy, Oscillococcinum restores health by delivering a highly diluted dose of a substance that produces symptoms of the illness being treated. Here, that substance is the extract of Muscovy duck heart and liver, identified by homeopaths as reservoirs of the influenza virus. A 1998 study from the British Homeopathic Journal gave either Oscillococcinum or a placebo to 372 patients with the flu, finding that the remedy both lessened their symptoms and shortened the duration of sickness. I have no personal experience taking Oscillococcinum (because I stay protected by upgrading my supplement regimen during flu season) but I know many who do and who live by it.

Take one or two tubes of Oscillococcinum once or twice weekly for the flu.

Medicinal mushrooms

Asian traditional doctors have understood the magic of mushrooms for centuries, using shiitake, reishi, maitake, and others to both prevent and treat a variety of ailments. Numerous studies have shown that certain friendly fungi can stimulate immune function. While many medicinal mushrooms are helpful, reishi mushrooms are my favorite as research has found that they have immunostimulant effects.

Vitamin D3

Because your are mostly indoors with little sunlight exposure, your vitamin D levels are likely extremely low. Take between 4000 and 5000 units of vitamin D with food. Always have your doctor check vitamin D levels and make sure you are about 40 to 60 ng/ml.

Protective dietary supplement formulas from excellent manufacturing companies to protect you against the flu.

Designs for Health –  Immunotone plus

Pure Encapsulations – Daily Immune,  Immune Herbs

Vital Nutrients  – Viracon

Thorne – Arabinexvitamin C with flavonoids, and Phytogen

What my patients take?

XY Wellness– my patients, taking the following supplements for prostate health or stop the formation of aberrant cells are noticing fewer colds and flu’s as a favorable side effect. That’s because these formulations are jammed packed with botanicals / nutrients with anti-viral and immune stimulating properties.

GDtoxSel

INGREDIENTS: Reduced Glutathione, Selenium (SelenoExcell), Alpha Lipoic Acid, Vitamin C, BroccoRaphanine, Zinc, Milk Thistle, Vitamin E mixed tocopherols

ImmunoPCTN

INGREDIENTS: Modified Citrus Pectin, Reishi Mushroom, Green Tea Extract, Curcumin, Pomegranate, Grape seed extract and Boswellia

Advanced Prostate Support (APS)– contains two pills of DFH Immunitone plus in it.

Ingredients and what they do:

  • Immune stimulant– Mushrooms, Beta 1,3 glucan, arabinogalactan, Diindolylmethane (DIM), Astragalus, Elderberry, Andrographis, all spice, garlic, basil, sage, Acerola, echinacea,
  • Anti-inflammatory– Curcumin, quercetin,
  • Anti-Cancer– Green tea (EGCG), curcumin, Resveratrol, lycopene, BroccoRaphanine (SGS), rosemary, garlic, grape seed extract
  • Antioxidant– Vitamin E (Complete form), Acid, Lutein, Lycopene., Zinc, goldenseal, acerola, garlic
  • Anti-microbial– Astragalus, garlic, goldenseal, clove, Allspice

As always, these are my recommendations based on my research and experience. I urge you to seek the help of a licensed holistic practitioner for personalized help. Again, go to the hospital if you or someone in your family is experiencing a difficult time breathing or other severe signs and symptoms are present.

Reference:

Hobbs C. Echinacea, a literature review. HerbalGram 30:33-48, 1994.

Zhao KS, Mancini C, Doria G. Enhancement of immune response in mice by Astragalus membranaceus extracts. Immunopharmacology 20: 225-34, 1990.

Douglas RM, Hemilä H, Chalker E, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2007;(3):CD000980.

Jackson JL, Lesho E, Peterson C. Zinc and the common cold: a meta-analysis revisited. J Nutr 2000;130(5S Suppl):1512S-5S.

Ankri S, Mirelman D. Antimicrobial properties of allicin from garlic. Microbes Infect 1999;1(2):125-9.

L Kiremidjian-Schumacher, M Roy, HI Wishe, MW Cohen, G Stotzky. Supplementation with selenium and human immune cell functions. Biol Trace Elem Res, 41 (1994), pp. 115–127

EW Taylor, RG Nadimpalli, CS Ramanathan, Genomic structures of viral agents in relation to the biosynthesis of selenoproteins. Biol Trace Elem Res, 56 (1997), pp. 63–91

Jin X, Ruiz Beguerie J, Sze DM, Chan GC.Ganoderma lucidum (Reishi mushroom) for cancer treatment.Cochrane Database Syst Rev. 2012 Jun 13;6:CD007731.

 

 

Exercise Lowers Prostate Cancer Death & Improves Mental Health – Study

[ My garage gym. Serves as a meditation area for me too]

 

This recent study of over one million people demonstrates that those who exercise experience 43% more mental health than those who don’t.

Let me say that again, 43% better mental health.

Folks, imagine a drug that improves depression by 43%?

By far that would be the most successful pharmaceutical drug for depression to date. The news would be all over the news – headlines everywhere, the top story on CNN and Fox, the front cover of the New York Times (NYT).

But you likely don’t know about this strong association between exercise and mental health until now.

Crazy!

While all exercise in this study decreased what authors called “mental burden,” the most significant associations were seen for popular team sports like soccer and basketball, cycling and aerobic and gym activities.

Activities like yoga and tai chi had a nearly a 23% reduction in poor mental-health days.

For maximal benefit exercise duration was about 45 minutes a day, three to five times per week, according to the study.

Mental health is generally defined as depression, anxiety, post-traumatic stress and general stress.

This recent study was published on one of my favorite and most prestigious journals, the Lancet Psychiatry.

By the way, the association between exercise and mental health is not new. Actually, the science is ridiculously old.

A few months ago in another prestigious journal, JAMA, they looked at close to eighteen thousand middle-age people noticed a significant decrease in depression, death from heart disease and death from heart disease specifically associated with depression.

In addition to mental health, exercise is also linked with lower risk of dying from prostate cancer.

A study that tracked tens of thousands of midlife and older men for more than 20 years has found that vigorous exercise and other healthy lifestyle habits may cut their chances of developing a lethal type of prostate cancer by up to 68 percent. While numerous lifestyle factors such as eating tomatoes, not smoking, eating fewer process meats and exercise contributed to less prostate cancer-related deaths, the connection with exercise was most substantial.

Again, 68% less prostate cancer mortality! Lord!

In addition, I have talked about the benefits of exercise in men undergoing hormone therapy for prostate cancer – HERE is the link.

How to start an Exercise Regimen right for you.

The first thing is to quit making excuses for why you are not physically active.

HERE is a list of common excuses why you are not physically active, and I suggest you stop making them and get going. Seriously.

Physical activity is real medicine and one of the most powerful types to not only prevent many disease but also to treat it.

The other point here is that as one ages building strength becomes essential.

You see, the body wants to muscle waste as one age – a process called sarcopenia – and you need to fight that as your life depends on it because it does.

The best method to fight that is by practicing weight resistant exercises.

Research shows the stronger you are, the longer you live.

 

Two years ago, along with my regular strength training routine, I began Krav Maga (KM), an Israeli martial art.

The reason I began training in KM was because I was itching for something new and completely out of my comfort zone. Additionally, I always enjoyed combat sports so why not try it.

And I love it. There is a community element that is pretty cool. While my fighting partners and I don’t necessarily have drinks together, we do talk about life, fighting, and current events when we are at our KM school.

Interestingly, a recent NYT article demonstrates and aging researcher from Harvard, Dr. Kirk Daffner, trains in Greek Karate ( known as Pankration) with his teacher who is 90 years old. In martial arts, Dr. Daffner explains, not only is there mental stimulation and movement but also social engagement and connection, which is likely therapeutic.

The takeaway for today is to get out of your comfort zone, quit making excuses and start consistently moving your body. Join a group of whatever you like, yoga, cycling, running, martial arts, whatever.

The other thing is to exercise every day. That’s right. Every single day you should do 20 to 60 minutes of something physical. One day you can do stretching, the other day, say, yoga, third-day weight resistance, day four tennis, etc.

Even if its ten minutes a day, that’s good for now. Just go!

You get as much benefit from the volume of exercising (doing it often) as you do from the intensity.

 

Lastly, while I like lifting weights by myself – as it is a form of active meditation for me – my neighbor Scott (above pic) joins me on Sunday mornings for a session we call “lift and learn.”

We made this “lift and learn” thing up. Primarily, we do either barbell squats or deadlifts, with pull ups and push ups then talk about improving our lives as men. Anything from religion to philosophy to raising kids is on the table. I have to say this one of the most enjoyable events of my weeks, and I feel empowered after our Sunday morning sessions. I think Scott does too.

Here’s the bottom line; Implementing the science it what it’s all about. Team activities seem to be extremely beneficial for your health and longevity. But if for whatever reason joining a fitness group is not an option, just put on some sneakers and go for a 10-minute walk. Start somewhere, and you will see how beautifully you will progress and fee.

The Three Recent Blog Post

Nine Reasons to Fire Your Doctor

The CaPLESS Thriver Mindset

Does a Keto Diet Work for Prostate Cancer

Related Posts on Exercise and Prostate Cancer

A Thriver After Prostate Cancer [VIDEO]

Apalutamide, Hormone Therapy and Prostate Cancer

Lifestyle and Exercise prevents Prostate Cancer Mortality – study

Another Study on Exercise and Prostate Cancer

CaPLESS RETREAT (will close for registration tonight, August 26th at midnight)

The CaPLESS Retreat is coming in September 14 – 16, 2018 to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. Prostate cancer is an opportunity to live healthier than before your diagnosis. Learn how. There is limited space.

 

L-Citrulline: The Heart and Penis Connection

The penis is a barometer of male health. Since erectile dysfunction (ED) is closely linked to various forms of heart disease, failure to keep an erection may be a sign of an incoming cardiac event.

STUDY DETAILS

According to the Massachusetts Male Aging Study, conducted in 1994, erectile dysfunction is a common problem for aging men. More than half of men over 50 and more than two-thirds of men over 70 have ED.

A recent review article in the European Heart Journal showed that ED has a strong connection to heart disease.

In patients who had ED;

• Cardiovascular events were 44% more common
• Cardiovascular mortality rose by 19%
• Heart attack was 62% more likely in patients
• Cerebrovascular events (such as stroke) were 39% more likely
• All-cause mortality (death, period) was 25% more likely.

What connects the Heart to the Penis?

Poor arterial health, and an important compound called Nitric Oxide.

Nitric Oxide (NO) links Erectile Dysfunction with Cardiovascular Disease

NO is mainly responsible for widening the arteries during physical activity, but it also plays a role in sexual activity. It opens the arteries in the penis so that blood can flow in and cause an erection. Without NO, the arteries don’t expand as they usually would.

Plaque ends up forming in the walls of the arteries, and this leads to a variety of heart problems including heart attack and stroke.

This plaque doesn’t just form on the walls of arteries in the heart and around the brain. It collects on all of the arteries in the body, and the penis is no exception.

Plaque formation in the pelvic area blocks blood flow and is one contributing factor to ED

What’s different about the penis, though, is that you can easily see whether or not the organ working (It’s harder to look inside the arteries of your heart). And since erections depend on healthy arteries, an erect penis a significant marker of a robust cardiovascular system. And you can really see that cardiovascular system work it on websites like porn7.xxx.

 

In Chinese Medicine, the Heart and Penis are Connected

In Chinese medicine, the Heart channel is related to the Kidney channel within the Shao Yin channels. It is also indirectly related to the Kidneys through the Du Mai and Ren Mai, both of which flow through the Heart and originate from the space between the Kidneys. Both the Du and Ren Mai have a profound influence on sexuality and the sexual function including sexual desire, sexual arousal, erection, maintenance of erection and ejaculation. Furthermore, the Chong Mai also starts from the space between the Kidneys and goes to the Heart and, also, it controls the zong muscles in the abdomen which many interpret as being the penis. (Giovanni Maciocia, February 2013)

I know, now I am talking Chinese (haha)

My Take on Erectile Dysfunction Connection to the Heart

Erectile Dysfunction (ED), or impotence, is a common problem, but, for reasons I will explain, I would not say it’s normal. Because of the strong links between erectile dysfunction and cardiovascular issues, and then perhaps stronger links between cardiovascular health, diet, and exercise, I see the penis as a kind of barometer of male health. When the fluid transport systems in the body are working correctly, erections are a natural result. When arteries are clogged and hardened by an unhealthy lifestyle, the arteries in the penis take a hit just as much as the arteries in the heart and erections are blocked.

So, how many erections should you be getting? What’s a “day in the life” of a healthy penis? If you’re not sexually active, you should experience morning erections at least 3 to 4 times a week. During regular REM sleep each night, the average man has between three and five erections. (Yes, that many.)

And, of course, it should not be difficult to gain an erection leading up to sexual activity.

 

L-Citrulline for Erections and Heart Health

What do we learn from this? First, frequent and regular erections are a sign of good cardiovascular health.

Of course, this link does not apply to men who have undergone prostate cancer treatment like surgery or radiation as they would experience less to no erections normally.

Keep in mind, though, that ED is not necessarily a sign of a heart problem; it can be caused by anxiety as well, and a failure to rise could stem from fear, discomfort, or other stressors. But if these are not your problems, then I’d advise taking a look at your lifestyle.

The best thing you can do is to prevent or resolve metabolic syndrome by changing your lifestyle. Get out and exercise. Cut out processed foods from your diet. To make sure your body produces enough NO, get some extra L-Arginine from animal protein and nuts.

Better yet, consider L-Citrulline which is a nutrient that makes more L-Arginine in the body than L-Arginine itself and has shown to help with sexual function. Eating pomegranate and taking Resveratrol can help with endothelial dysfunction.

How L-Citrulline Works?

L-Citrulline is an amino acid not found in proteins but found mainly in watermelon. The health-related applications of l-citrulline supplementation due to the ability of l-citrulline to increase l-arginine availability for NO production.

l-citrulline increases NO biosynthesis indirectly by increasing l-arginine synthesis, which in turn may lead to improved endothelial vasodilator function. In other words, it helps open up arteries.

One small study showed L-Citrulline improved penile hardness.

When Not to Use L-Citrulline

I prescribe L-citrulline in the formula of XYVGGR to help men with sexual function.

However, after using XYVGGR successfully for over seven years, I have had to take about three patients off of it because of a lowering blood pressure effect. Due to the dilating arteries effect of L-Citrulline, a desirable response when needing a pelvic lift, it opens up the arteries of the whole body reducing blood pressure.

When a patient has normal low blood pressure, say 90/60 mmHg or less, they DO NOT get XYVGGR or anything with L-Citrulline. The typical complaint of unwanted lower blood pressure is dizziness. On the other hand, if there is a sexual problem in a man and he also has high blood pressure, using L-Citrulline in a formula like XYVGGR may have a duo effect.

 

Three Recent Blog Post

The Real Cause of Prostatitis and How to Treat it Naturally

Prostate Cancer: Late night eating increases the risk.

How to Prevent a Heart Attack: Part one

 

CaPLESS EVENTS

The CaPLESS Retreat is coming in September to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. Prostate cancer is an opportunity to live healthier than before your diagnosis. Learn how. There is limited space.

Prostate Cancer: Late Night Eating Increases the Risk

I spend much of my clinical time talking to patients about nutrition and helping them choose what to eat.

As always, I challenge my knowledge to do better for my patients and my family.

As of late, the conversation on eating has shifted a bit not only on the what to eat but also on when to eat.

Here’s the deal; it turns out the earlier your meals, the less likely you will get prostate cancer or breast cancer based on this new study.

Study Details:

  1. Case-controlled based study conducted in 12 Spanish regions in 2008–2013
  2. 1,738 breast and 1,112 prostate incident cancer cases
  3. People working night-shift (which increases prostate and breast cancer risk) were excluded from the study to control for the possibility of night shift work being the cause of cancer and not nighttime eating

CONCLUSION: Those who ate their last meal of the day before 9 p.m. was found to have a 20 percent lower risk of breast and prostate cancers than compared to those who ate after 10 p.m. or went to bed right after dinner, those

Dr. Geo’s take on Late Night Eating for Cancer

This is not the first study suggesting against late night eating for disease prevention.

In a group of over four hundred overweight participants, late eaters had a more difficult time losing weight compared to early eaters despite having similar age, appetite, hormones values, food intake, sleep duration, etc.

Another study observed that those who ate late at night had 55% higher risk of heart disease compared to the early eater.

Interestingly, in Traditional Chinese Medicine (TCM), which I trained in as well, digestion is a yang activity, and nighttime is yin – doing a yang activity doing yin time contributes to disease in TCM.

The ill effects of eating late are not necessarily what I want to hear as nighttime eating can feel soooo gooood.

Here are some holistic but realistic tips:

  • Know that doing the right things, i.e., exercising, last meal early, taking good supplements it’s not supposed to be always fun, but its essential to do if the goal is to live longer and function optimally. Some pain, psychological or physical is OK.

 

  • Life happens. Sometimes is a toss-up between coming home late from work and not eating or having a meal with your family even though it’s 10 pm. I would opt with eating with my family, eat light and not eat again for 12 to 16 hours later (intermittent fasting). Implement this same advice with late-night dinner meetings and holidays.

 

  • Eat less protein at night and more carbs. Yeah, I know this is tough to do at a steakhouse and anti-paleo but here’s the story; protein gives you energy, carbs have a calming effect by secreting more serotonin, a precursor to the sleep hormone melatonin. Now, if you eat too many carbs, especially processed carbs (i.e. bread, pasta, etc.) you will have a carb hangover the next morning – that awful, dragging feeling as if you downed ten shots of tequila. Eat small portions of whole carbs like sweet potato, rice, etc.

 

  • Get to bed early. The longer you’re up, the more you will want to eat.

 

  • Take the dietary supplement, 5-hydroxytryptophan (5-HTP) if you crave food at night. Tryptophan is an amino acid precursor to serotonin, and it has been my experience it reduces cravings at night. There might be some sleep benefit there as well.

You only get one shot at living your best life. You don’t always have to like doing the right things – do them anyway. Don’t eat after 8 pm, most days of the week. Change is good. Purposeful, smart pain is good too. Enjoy the benefits. Trust the process. Also, often what is good for prostate (and breast cancer) prevention is also good after the diagnosis of these diseases as well.

Three Recent Blog Post

How to Prevent a Heart Attack: Part one

Prostate Cancer: The Truth on Dietary Supplements During Radiation Therapy

It’s time to Exercise. No Excuses.

 

CaPLESS EVENTS

The CaPLESS Retreat is coming in September to help prostate cancer (CaP) thrivers live their best life by implementing science-based lifestyle practices. I to connect with you there. There is limited space.

BREAKING NEWS: USPTSF Position on Prostate Cancer Screening

The United States Preventive Service Task Force (USPSTF) on PSA screening

The United States Preventive Services Task Force (USPSTF)  is a government supported panel composed of national medical experts in primary care and researchers (no urologist or oncologist on the panel) who collectively review the evidence for what screening tools and treatments are most useful for patients.

The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. (see below chart).

In 2012 the United States Preventive Services Task Force (USPSTF) issued a report opposing the use of PSA in screening for prostate cancer and gave a grade “D” recommendation, discouraging physicians to screen for prostate cancer and that there is more harm than good with the use of the PSA test.

Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.

Today, published in the Journal of American Medical Association (JAMA), the USPSTF concludes that there is a small overall benefit with the use of PSA in screening for prostate cancer, but continues to note that damages may occur during this screening process.

There is still a major age-related problem in this current recommendation because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.

This new screening grade is important because the task force has an influence on how clinicians practice on what health insurance companies pay for.

Now Three Studies Driving Prostate Cancer Screening Controversy

Initially, the two main trials influencing the USPSTF’s grading on prostate cancer screening are The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study. Now there is a more recent study, the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) that reinforces the task force position on screening.

The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP)

This British study was conducted in the United Kingdom, where about five hundred primary care practices in the United Kingdom were offered to screen men aged 50 to 69 years an invitation to a single PSA test (271 practices) and a control group that did not offer PSA testing (302 practices).

In an average of ten years follow-up, there was no all-cause mortality difference between the screened and the non-screened group.

In other words, men who were screened for prostate cancer died from any cause, not just prostate cancer as much as men who were not screened at all. As one would expect, there was an increase in low-risk prostate cancer detection in the screening group in the CAP study.

The European Prostate Cancer Screening Trial (ERSPC)

The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.

More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on study subjects continued to be followed, there will be more benefit from PSA screening.

On the other hand, ERSPC trial continues to show a major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors.

In fact, in the ERSPC study, the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.

The American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study

Lastly in the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.

The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.

The problem in the PLCO trial was the control group. Since “usual care” in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.

When researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality.

They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms.”

The Takeaway from the USPSTF on Prostate Cancer Screening

The task force grade recommendation for prostate cancer screening stays at a “C” which mostly means that you, the patient, can dictate whether or not you want to be screened for prostate cancer. If you do not want a PSA test taken, then you can decline, and in theory, your physician should be fine with it.

Essentially, there is no grand change in the USPSTF recommendation from 2014, other than they are doubling down on their “C” grade reinforced by the CAP study.

The Dr. Geo’s Guide to Prostate Cancer Screening & Protection

I am all for patient empowerment and for men partnering with physicians to improve his health. Furthermore, many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.

I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and had blood come out their urine and semen for up to two weeks.

The evidence is clear that most men with high PSA scores who get biopsied, do not have prostate cancer (what we call a false positive). It is also obvious, based on volumes of research that there is overtreatment of prostate cancer, meaning, most men with prostate cancer will not die from it making prostate cancer treated with either surgery or radiation obsolete.

Why not screen for prostate cancer and not treat if the outcome is low-grade disease?

Because that diagnosis is daunting to your brain. It’s the “cancer” word. In other words, the problem in many cases is the diagnosis itself – it provokes anxiety and unease – so rather than letting those feeling linger “taking it out” is what many men opt for.

The problem is not the PSA test. And ignorance is not bliss. Before the late 1980’s most men diagnosed with prostate cancer had advanced disease, and those numbers went down drastically after the commercial use of PSA test.

The problem is how the PSA number is used (or abused). As the CAP study revealed, just one PSA number that is relatively high does not dictate you have prostate cancer or that a biopsy is needed.

When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:

  • Age of the patient
  • Family history
  • Race
  • PSA relative to age
  • PSA free percentage
  • PSA density
  • the blood test 4K score
  • the urine test Select MDx.

If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI. Still, no biopsy needed up to this point.

If the MRI highly suggested suspicious cells, typically of Gleason 7 or higher, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.

The bottom line is how a physician uses a PSA test matters most, as imperfect of a biomarker for prostate cancer screening as it is, it saves lives.

At a minimum, an elevated PSA can tell you if something wrong in the prostate, even if it’s not cancer, maybe inflammation or other benign development.

The ultimate goal of prostate cancer screening is this:

• Find a cost-efficient method of locating tumors that have the most life-threatening potential.

• Leave tumors that are not deadly alone, or better yet, not find them in the first place.

• Have a treatment that can remove the possibly deadly cancer without sacrificing quality of life.

The methods of the screening I highlight above provide the best chance of accomplishing the ultimate goal for prostate cancer screening.

Also, prevention is the best medicine.

When I say prevention, I also mean prostate cancer recurrence prevention or, if it returns, preventing spreading of cancer.

Nutrition and Lifestyle is real medicine.

My recommendations:

  • Eat protective foods. A plant-based, Mediterranean method of eating is protective, and it’s the cornerstone of the CaPLESS method of eating.
  • Exercise four hours a week with moderate intensity.
  • Consume selected, targeted supplements from companies that exceed governmental quality manufacturing practices. My favorite supplements for ultimate protection are what I call my one-two punch: ImmunoPCTN and GDtoxSel.

Part Three: PSA use for Prostate Cancer Screening

This is part three of a four-part series on the PSA test in an attempt to demystify the most feared blood marker in men.

 

Part one: What is PSA and what it does

Part two: Benign reason’s why PSA goes up

Part three: PSA use for Prostate Cancer Screening 

Part four: PSA after prostate cancer treatment

 

The Prostate Specific Antigen (PSA) test is the number one used biomarker for prostate cancer screening. In other words, the PSA blood test starts the unpleasant process of biopsies, prostate cancer treatment when malignant cells are found and side effect treatment from the cancer treatment. Many people think PSA is an expensive waste. One of those people is Dr. Richard Ablin, the discoverer of PSA who called this test in a New York Times article, The Great Prostate Mistake. He also wrote the book the Great Prostate Hoax condemning the PSA test for prostate cancer.

Should we stop PSA testing for prostate cancer screening?

No. I will explain. Stay with me.

How does PSA work?

As we learned in the previous article of this series, PSA breaks through the wall of the glandular portion of the tissue and seeps into the bloodstream for many malignant and mostly benign reasons. Ideally, the PSA molecule is only found in the semen. In fact, there are one million times more PSA in the semen than in the blood.

PSA in men before Prostate Cancer diagnosis

The “normal” range of 0.0ng/ml – 4.0ng/ml you see in lab reports is absurd.

Anything under 4ml/ng does not mean you don’t have prostate cancer. In fact, 15% of men with a PSA under 4 develop prostate cancer (Thompson et al. 2004)

Generally speaking, PSA is age-related. For example, a 40-year-old “should” have a PSA well under 1.0ml/ng (exception to the rule, this individual may have an infection of his prostate or other non-cancer causes to his PSA to be above 4).

A 60-year-old with a PSA of 2 may be fine.

A steady trend upward, even if the number is under 4, after three or four PSA tests may be more connected to prostate cancer once prostatitis or other benign conditions are ruled out.

On the previous article, we spoke about non-cancer reasons why PSA is elevated, but there are also numerous reasons why PSA is falsely low, meaning, one can have cancer while there PSA is “low.”

There are two things that cause a false lower PSA:

  1. The meds Finasteride (Proscar) and Dutasteride (Avodart) – falsely lowers PSA up to 50%.

2. Obesity: estrogen activity (which big men have more of) causes a decrease in PSA.

FYI: Obese men typically have worse cases of prostate cancer and higher changes of prostate cancer relapse after treatment. (Cao, 2011) Yet another motive for overweight men to get in shape.

The Good with PSA Screening for Prostate Cancer

Over the past 28 years, since the introduction of prostate-specific antigen (PSA), the incidence of metastatic prostate cancer and dying from this disease has significantly decreased. Although it is hard to connect the cause of prostate cancer decline to PSA, the five-year cancer-specific survival increased from 69% in the 1970s to now more than 95%, associating longer survival in diagnosed men to PSA examination.

 

The United States Preventive Service Task Force (USPSTF) on PSA screening

The United States Preventive Services Task Force (USPSTF) is a group of non-urologists or oncologists; mostly experts in primary care and researchers who collectively review the evidence for what screening tools and treatments are most effective for patients.

The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. I stand for insufficient evidence to recommend for or against a service.

In 2011 the United States Preventive Services Task Force (USPSTF) issued a report opposing the use of PSA in screening for prostate cancer and gave a “D” grade recommendation, meaning that existing scientific data demonstrate that there is more harm than good with the use of this test.

Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.

The USPSTF concludes that there is a small overall benefit after a decade with the use of PSA, but continues to note that damages may occur during this screening period. However, there is still a major age-related problem in this current recommendation, because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.

The Two Main Studies Driving PSA controversy

The two main humongous trials influencing the USPSTF where the PSA controversy is derived from is The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study.

The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.

More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on and study subjects continued to be followed, there’s benefit from PSA screening.

On the other hand, ERSPC trial continues to show major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors.

In fact, in the ERSPC study the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.

The other influential study on prostate cancer screening is the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.

The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.

There is a major problem in the PLCO trial, however.

The “usual care” subjects ( the control group) in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.

This is a multi-million dollar study with a major flaw in it that influence how physicians practice.

That’s freaking insane!

When another group of researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality.

They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms.”

Other Big Studies on Prostate Screening to Note

Other studies on prostate cancer screening that I find valuable but do not get the attention of PLCO and ERSPC are these two Swedish trials:

In the Gothenburg, in Sweden, 20,000 men were randomized 1:1 for PSA screening every two years or control without PSA. Their average age of participants were 56. The PSA value used to indicate the biopsy was between 3.0 and 4.0 ng/mL. After a 14-year follow-up, there was a relative decrease in prostate cancer mortality of 44%. Prostate cancer was diagnosed in 12.7% of the patients in the screening group and 8.2% of those in the control group.

Again, there was a high rate of overdiagnosis and overtreatment in this trial as well.

Researchers concluded that 293 cases needed to be screened and 12 treated for prostate cancer to prevent one tumor-related death.

[These figures are similar to those for breast cancer screening by the way]

Lastly, this study from Malmo Sweden of over 21,000 patients demonstrated that PSA levels in patients around 45 years of age with no family risk factors could provide data on the chance of developing aggressive prostate cancer and risk of death from the tumor in the coming decades.

When the baseline PSA values were below the population median according to the different age ranges:

  • up to 42 years: ≤ 0.6 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.1%
  • up to 50 years: ≤ 0.7 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.5%
  • up to 55 years: ≤ 0.9 ng/mL the chance of death from prostate cancer in 25 years was estimated at 0.8%

These authors suggest that only three PSA measurements, the first performed at around 45 years, the second at the beginning of the fifth decade of life, and the third at 60 years may be sufficient for a safe risk assessment for half of the population.

My Take on the Science of PSA use on Prostate Cancer Screening

There’s no question that the majority of men screened for prostate cancer will not die from it. In other words, there is indeed over-diagnosis and over-treatment of prostate cancer from PSA screening. No one will argue that.

However, many lives have been saved from prostate cancer screening since the beginning of clinical use in the early 1990’s.

If I am the one in the unfavorable percentage of developing aggressive prostate cancer, I want to know as early as possible and do something about it.

The idea of beginning PSA testing at the age of forty as suggested by the Swedish trial is appealing as I have seen many men in their forties with aggressive prostate cancer.

Prostate cancer screening is a case-by-case process. Every case is different, and the approach has to be individualized to the one patient in the office, not only to what researchers conclude as there are design flaws in all studies.

The Dr. Geo’s Guide to Prostate Cancer Screening

Many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.

I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and have blood come out in their urine and semen for up to two weeks.

When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:

If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI.

If the MRI highly suggest aberrant cells, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.

Additionally, I recommend men to get a PSA reading at forty years of age, regardless of family history and use that as their baseline. If there is no family history and PSA is normal relative to age, do a PSA every five years. If there is a family history (father, brother, etc) then PSA should be taken once a year.

The PSA number is not the problem. What you do with that number is what matters. 

Not all elevated PSA requires a biopsy.

The bottom line is that PSA is decent, though imperfect marker for prostate cancer screening and have saved lives.

At a minimum, an elevated PSA can tell you if something is going on in the prostate, even if it’s not cancer, maybe inflammation or other benign reasons.

The ultimate goal of prostate cancer screening is this:

Find a cost-efficient method of locating tumors that have the most potential to be deadly. Leave tumors that are not deadly alone, or better yet, not find them in the first place. (The “C” word diagnosis, even for indolent tumors prokes anxiety and unnecessary worry). Have a treatment that can remove the potentially deadly tumor without sacrificing quality of life.

Well, maybe one exception, some tests like the MRI are expensive, and health insurances don’t always cover it despite evidence indicating that MRI testing reduces the risk of overdiagnosis.

Yep, that frustrates me too. HERE is what I found to work to get your prostate MRI covered.

The methods of the screening I highlight above are not perfect by themselves but better collectively in providing the best chance of accomplishing the goal of better screening practices to finding and treating deadly prostate cancer.

Last 3 Blog Posts:

[Not part of this series]

ADT, Apalutamide, Exercise in the treatment of prostate cancer

Traditional Chinese Medicine treatment for Erectile Dysfunction

Why I am into Intermittent Fasting