CaPLESS & Prostate Cancer

Best PET scan for Prostate Cancer

Many men with prostate cancer at some point after their diagnosis get a PET scan to see where, if at all, cancer has spread.

However, it seems like most people don’t know how PET scans work.

Let’s talk about that…

What is a PET scan?

A PET scan (positron emission tomography (PET)) is an imaging medical exam to determine where the disease is in your body.

In the case of cancer, where cells have a high metabolic rate, a radiotracer is injected into the vein or by swallowing where then the diseased cells sort of gobble up the tracers which causes the cancer cells (which typically have a higher metabolic rate than normal cells) to “light up” on imaging.

The lit up areas indicates where cancer cells are located, if there is a recurrence after treatment, and if treatment is working.

How are PET scans Different than CT scans and MRI?

PET scans show metabolic changes at a cellular level where CT scans (computed tomography)  and magnetic resonance (MRI) don’t, therefore, PET scans show if there is a recurrence of cancer earlier than other scans.

The fears many people have with Xrays and CT scans of exposing the body to excess radiation ( which can also be associated with cancer) do not apply to PET scans.

However, it is possible that you can be allergic to a radiotracer.

What Radiotracers are used in Prostate Cancer?

There are numerous radioactive tracers used during a PET scan that helps locate problem areas in the body after prostate cancer.

The most common is a sugar tracer called F-fluoro-2-deoxy-D-glucose (FDG) as a result of the Warburg effect

Prostate cancer cells vary greatly between slow moving and fast moving cancer cells.

PET Scans using FDG is not useful in detecting primary organ-confined prostate cancer, detecting local recurrence after radical prostatectomy, or in differentiating between post-operative scar and local recurrence for a few reasons.

Prostate cancer is slow growing and may not have a high metabolic rate, which results in low FDG uptake. In addition, FDG-PET cannot reliably differentiate between benign prostate hypertrophy and cancer, and the uptake of the tracer does not correlate with the tumor grade or stage

This glucose (FDG) tracer is useful in detecting bone and soft-tissue prostate cancer metastases, although it is less sensitive, therefore not as good as a bone scan for prostate cancer

Lastly, FDG tracer are now less favorable in use for prostate cancer compared to others discussed below.

Choline

Choline is a nutrient important for human life. It is also used as a radioactive tracer in prostate cancer in the form of 11C-choline and 18F-fluorocholine. Numerous studies have reported choline based PET scans to be up to 85% sensitive to recurrent prostate cancer in several areas of the body including lymph nodes.

Choline radiotracer PET scans are not widely available in the United States.

ProstaScint (indium 111 capromab pendetide)

Prostascint is a radiolabeled monoclonal antibody that binds to prostate-specific membrane antigen(PSMA.)

The positive predictive value ( ability of this test to show a positive response) of ProstaScint is only 25 to 50%, as inflammation and other anatomical changes from surgery may falsely read as a positive scan

Additionally, men with a positive scan after RT have no difference in progression-free survival compared with those with a negative scan.

Axumin

Fluciclovine is a synthetic amino acid (l-leucine) as a radiotracer and was approved in May 2016 for PET imaging in men with suspected prostate cancer recurrence.

Fluciclovine is preferentially taken up by prostate cancer cells and gliomas via specialized amino acid transporters and is commonly known by its trade name Axumin.

Amino acid transporters such as ASCT2 play a critical role in amino acid metabolism in prostate cancer cells. ASCT2 is an important transporter of glutamine, which is known to be an essential tumor nutrient and has been implicated in cancer signaling pathways

Fluciclovine is predominantly transported by ASCT2 and transports in a manner similar to glutamine

Unlike glutamine, however, 18-F fluciclovine does not undergo additional metabolism in the cell, which lends to its intracellular accumulation particularly in prostate cancer cells and at major sites of amino acid metabolism such as the liver and pancreas.

Axumin PET Scans are available in the United States.

PSMA

Prostate-specific antigen (PSA) and PSMA (prostate speficific membrance antigen) are different in several ways.

PSMA is a type II glycoprotein,  found to be overexpressed in prostate cancer cells, and its expression level has been correlated with disease aggressiveness

Bostwick and colleagues described PSMA immunohistochemical expression in 184 prostate specimens examined, all of which had PSMA expression and demonstrated a correlation between this expression and severity of cancer. There was an increase in the percentage of PSMA staining from benign epithelial tissue (69.5% of cells positive) to high-grade prostatic intraepithelial neoplasia (77.9% of cells positive) to malignant cells (80.2% of cells positive)

Prostate-specific membrane antigen (PSMA) ligands, have shown greater cancer sensitivity and specificity.

PSMA PETs are only available in the United States for research purposes at this time (March 2019).

Why are PET scans important for prostate cancer?

After definitive treatment for prostate cancer, there can be a recurrence up to 50% of the times but the patient may not know where the recurrence is occurring until the PSA is very high, 20ng/ml or higher. Again, this is after either radiation treatment or surgery. PET scans, especially those with improved radiotracers can detect cancer cells much earlier after prostate cancer treatment.

Which PET scans work best for Prostate Cancer and When should they be considered?

Numerous studies have compared Choline radiotracers with PSMA and Axumin showing better imaging in men with biochemical recurrence from PSMA and Auximin compared to choline radiotracers.

At this point the types of PET scans I recommend after prostate cancer recurrence is either PSMA or Axumin. PSMA PET is not yet commercially available in the United States but it is throughout Europe.

 

 

Reference: Practical Radiation Oncology, Feb 2018

Note: New York University (NYU) Langone Health offers Axumin (fluciclovine) but it is not on the list.

 

 

 

 

 

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.

Genetic Testing for Prostate Cancer

(image from NEJM)

Overview of Genes and Mutations

Your genes contain DNA, which carries instructions for every chemical process in your body. Literally, everything, including the color of your eyes to finding an ridding the body of cancer cells.  As your cells grow and divide, they make copies of their DNA and it’s not uncommon for some minor mistakes to occur.

Normal, healthy cells have mechanisms to recognize mistakes and repair them. But people who inherit one of the abnormal genes lack the ability to repair these minor mistakes. An accumulation of these mistakes leads to increasing genetic damage within cells and eventually can lead to the cells becoming cancerous.

The DNA can become mutated, meaning damaged, from what is inherited from your parents or environmental chemicals like radiation, and all sorts of different chemicals.

So, for instance, a gene called PTEN is supposed to protect your body from cancer cells. When this gene stops working, that can be one of the causes of cancer. Same with the BRCA gene and many others.

These are the main genes associated with potentially aggressive prostate cancer when mutated:

BRCA 2, BRCA 1 (BRCA 2 mutation is about 70% more significant in aggressive prostate cancer than BRCA 1), ATM CHEK2  BRCA1, RAD51D, PTEN, and PALB2.

On this post, I’d like to discuss material I lectured on to a group of naturopathic oncologist on February 17, 2019.

The focus was on how to use genetics ( and other tests) to better make decisions on what is next for men who may have (or diagnosed with) prostate cancer.

Here we go…

Testing Before a Prostate Biopsy

No man wants a biopsy. And many are unnecessarily done.

How can we determine who should undergo a prostate biopsy where, if we find it early, that person can be cured?

The first thing is to determine the genetic risk. One test that I know use for cancer is called COLOR.

The COLOR cancer genetic test looks at the following genetic mutations to determine the risk of cancer: (the bolded ones are specific to prostate cancer)

APC, ATM, BAP1, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A (p14ARF), CDKN2A (p16INK4a), CHEK2, EPCAM, GREM1, MITF, MLH1, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, POLD1, POLE, PTEN, RAD51C, RAD51D, SMAD4, STK11, TP53

To order this genetic mutation test, speak with your physician.

Then there are the more prostate cancer-specific tests:

The 4K score

The 4K Score by OPKO is not a genetic test.

It measures four kallikreins (thus 4K): total PSA, free PSA, intact PSA and hK2.

Briefly, kallikreins are a group of proteins enzymes throughout the body. There’s at least 15 of them throughout the body. The prostate has two of them, hK2 and hK3 (PSA).

How to order a 4K Score? 4k Score is a blood test managed in office by the physician (blood draw, paperwork, and mailing of the specimen) or through Bioreference Labs. I don’t believe other major lab companies like Quest labs for Labcorp offer 4K at this time (02/17/19).

The Science on 4K

The 4K score has shown to help advise against biopsy in men with elevated PSA is a safe strategy.

What does the 4K Score tell you? If the 4Score is less than 7.5 that means there is very little likelihood one has aggressive prostate cancer and likely no biopsy needed.

Anything higher than 7.5 implies a higher likelihood of prostate cancer and it is variable

The Prostate Health Index (Phi)

Phi, an in an office blood test, is not a genetic test and includes total PSA, free PSA and −2proPSA using the following formula: ([−2]proPSA/fPSA) × √PSA.

Proenzyme PSA (proPSA) is a cancer-associated form of free PSA found primarily in the peripheral zone of the prostate, where 80% of prostate cancer occurs, as well as in the circulation.

What does the Phi score tell you? Phi score between 0 to 26.9 suggests a very low probability of significant prostate cancer. The higher the phi score the likelihood of serious prostate cancer. A phi score of 55 + suggests a 50% chance of aggressive disease. Phi is significantly a better marker for prostate cancer than PSA.

A comparative study from Sweden found that phi and the 4-kallikrein (4K Score) panel were equally helpful in improving the discrimination of high-grade prostate disease on biopsy.

How to order the Phi test? Phi is a blood test managed in office by a physician (blood draw, paperwork, and mailing of the specimen) or through AccuReference Labs. I don’t believe other major lab companies like Quest labs for Labcorp offer 4K at this time (02/17/19).

Select MDx

Select MDx is a genetic urine test.

A validated urinary three-gene panel (HOXC6TDRD1, and DLX1) showed higher accuracy for significant prostate cancer.

What does the Select MDx score tell you? The results of the Select MDx reveal one of two things: Very low risk of prostate cancer, therefore, less need for biopsy or High Risk of prostate cancer, therefore a prostate biopsy may be needed.

How to order the Select MDx test? The test is done in an office and does not require a prostate massage prior to urine collection.

Testing After Prostate Biopsy

If a prostate biopsy is negative but one wants to confirm the results are a true negative, a Confirm MDx test can be performed.

What do I mean by a “true negative?”

Sometimes patients present with a high PSA but when a biopsy is performed the result is no cancer. The problem is there can be hidden prostate cancer the biopsy needle did not catch.

Confirm MDx

The Confirm MDx  is a genetic (really epigenetic) test that helps determine the likelihood of missed cancer in the prostate from a biopsy.

How to order the Confirm MDx test? The physician completes the requisition form, sends in for the pathology report to MDxHealth, and the prostate sample is sent in by the pathology lab where biopsy prostate tissue is stored.

What does Confirm MDx tell you? The results of the test tell you where there is what the company calls a “halo effect” indicating there is cancer that might have been missed somewhere in the prostate.

Confirm MDx is only for prostate tissue from biopsy that was shown to be negative (no cancer found) in the prostate.

After a Positive result for prostate cancer

Oncotype Dx by Genomic Health

The Oncotype is a genetic test that provides a Genetic Prostate Score (GPS) after prostate biopsy.

In studies performed at UCSF, this 17-gene signature was a reliable and helpful tool in assessing candidates for treatment or active surveillance without re-sampling or removing the entire prostate

The GPS is on a scale of 1-100, where higher scores are more suggestive of less than optimal pathology.   It is important to remember that a GPS score is a measurement of gene expression within prostate tumors and must be interpreted within the context of other relevant clinical factors.

In 395 prostate cancer patients with low and intermediate risk who underwent a radical prostatectomy was validated for its ability to predict men who have high-grade or high-stage prostate cancer at diagnosis and may help men diagnosed with PCa decide between active surveillance and immediate definitive treatment.

What does the Oncotype Dx tell you? The probability of more aggressive disease in the prostate, say, Gleason 7 (4 + 3) or higher,  that was not picked up by needle biopsy. The report provides a GPS score from 0 to 100. The lower the score, the less likelihood there is advanced prostate cancer somewhere in the prostate.

How to order the Oncotype Dx test? The physician completes the requisition form, sends in for the pathology report to and the prostate sample is sent in by the pathology lab where biopsy prostate tissue is stored.

Who qualifies for the Oncotype Dx?

Patients who have had a prostate biopsy within the last three years and had a positive result for prostate cancer with a low to intermediate grade disease – meaning, in general, a Gleason 6 or Gleason 7 (3+4).

Prolaris by Myriad Genetics

Prolaris is a genetic test showing expression of 31 genes involved in cell-cycle progression (CCP), an important regulatory step in the development of cancer.

A study examining the Prolaris panel in prostate biopsy specimens from 582 men with prostate cancer demonstrated that the test was a very strong predictor of later clinical outcomes including disease recurrence and progression to metastasis following surgery

What does the Prolaris test tell you? The probability of more aggressive disease in the prostate, say,  Gleason 7 (4 + 3) or higher, that was not picked up by needle biopsy. Also, the Prolaris test helps determine if patients are a candidate on active surveillance and the 10-year risk of developing metastasis following definitive treatment (prostatectomy or radiation. The report provides a Prolaris score which will fall between 0 and 10 with a higher score indicating more aggressive cancer. For every one unit increase in the Prolaris Score, the patient’s mortality risk doubles.

Who qualifies for the Prolaris test? Patients who have had a prostate biopsy within the last three years and had a positive result for prostate cancer with a low to intermediate grade disease – meaning, in general, a Gleason 6 or Gleason 7 (3+4).

How to order the Prolaris test? The physician completes the requisition form, sends in for the pathology report to Myriad, and the prostate sample is sent in by the pathology lab where biopsy prostate tissue is stored.

After a Prostatectomy

Decipher is a genetic test by GenomeDx Biosciences (Vancouver, BC, Canada) and Mayo Clinic (Rochester, MN, USA).

Decipher is used when the prostate is removed for prostate cancer then analyzed to determine the probability of recurrence and the risk of metastasis after prostatectomy.

To be clear, this test can only be used after the prostate is removed, not when any other treatment is performed.

A recent meta-analysis of five different studies examined the performance of Decipher to prognosticate the risk of metastases in 855 men with adverse pathology at the time of radical prostatectomy (RP).

What does the Decipher test tell you? Decipher generates a score between 0-1 in increments of 0.1. The close to one (1) the likelihood of recurrence or aggressive disease.

How to order the Decipher test? The physician completes the requisition form, sends in for the pathology report to the lab, and the prostate sample is sent in from where the prostate was removed. Details on ordering test here.

Prolaris by Myriad Genetics

Prolaris can also be used after prostatectomy.

What the test tells you and how to order is similar when testing biopsy tissue as explained above.

 

 

 

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.

The King of Medicinal Mushrooms: Reishi

[Image from Collective Evolution website]

 

Billions of dollars are sold in medicinal mushroom are sold yearly as these nutritional organism become the hottest functional food to consume.

I too take this dietary supplement everyday which contains ample amounts of my favorite protective mushroom of them all, Reishi.

While we can’t say mushrooms cure or mitigate disease, we know they have protective properties that are useful.

Out of many of the medicinal mushroom consumed by people for nutrition support, including, chaga, cordyceps and turkey tail, Reishi has the most robust science to support its use.

Ganoderma lucidum, commonly known as Reishi, is a favorite medicinal mushroom that has been used for centuries in Traditional Chinese Medicine (TCM) for the prevention or treatment of a variety of diseases.

Reishi mushroom is used by many cancer thrivers to strengthen the immune system.

Some of the published research indicates Reishi has activity against prostate cancer and breast cancer cells.

This published scientific article demonstrate that Reishi inhibits active transcription factors nuclear factor kappa B (NF-kappaB) and AP-1, which resulted in the inhibition of expression of urokinase-type plasminogen activator (uPA) and its receptor uPAR.

In human language that means Reishi mushroom inteferes with numerous pathways that can promote cancer cells.

A meta-analysis study on the use of Reishi in cancer treatment reported immune stimulating effects with this ancient mushroom. This same report indicates a positive response in about 50 percent of patients consuming Reishi mushroom while undergoing radiation or chemotherapy, as compared to those treated with chemo or radiation alone.

One of the conclusion of this reputed conservative journal is this;

Ganoderma lucidum could be administered as an alternative adjunct to conventional treatment in consideration of its potential of enhancing tumor response and stimulating host immunity.

Frequently Asked Questions on the Use of Medicinal Mushroom for Nutritional Support in Prostate Cancer Patients

 

Q: I heard good things about Turkey tail, Chaga and other popular mushrooms, can I take them too?

A: Yes. They are all helpful and have some science to support their use.

 

Q: Why do you have only Reishi mushroom in your formula and not any of the others?

A: I can only fit so many ingredients in one capsule. Reishi, after extensive research and clinical experience, is the king of mushrooms in my opinion and it’s backed by the best quality science for immune function and many other health properties. 

 

Q: Can I take medicinal mushrooms during radiation therapy for prostate cancer?

A: Yes you can, along with numerous others. I recently wrote this article on the use of dietary supplements during radiation and it might be a useful read. Your radiation oncologist will be opposed to you taking ANY dietary supplements during radiation, however.

 

 

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.

 

9 Reason’s For Firing Your Doctor

Yesterday I got fired from one of my patients.

This is the third time (that I know of) in my 15-year career that I don’t meet a patient’s expectations and they fire me as their doctor.

His email to me reads like this:

“I’ve decided to go elsewhere and decided you may have a conflict of interest in not addressing supplements RXed by others that are not yours… “

“Conflict of interest in not addressing supplements that are not yours” is likely referring to dietary supplements I prescribe from XY Wellness. That is confusing considering I prescribe supplements from other sources often. Additionally, I don’t ever discontinue patient care when they consume dietary supplements from different equivalent sources.

But this blog post is not about defending my position on yesterday’s occurrence.

Today’s article is about when to fire your doctor, which I believe should happen when the trust is damaged.

Your doctor is fallible. I am too.

Most physicians work hard for their patients. Sometimes I discuss with colleagues the sleepless nights we experience when thinking about our patients. But even then, we never bat 1000, to use a baseball analogy.

In baseball, any player that hits to get on base safely three out of ten times as a batter (hits .300 average), that’s an outstanding player.

One player in the history of baseball ever hit .4oo in one year. That is Ted Williams from the Boston Redsox in 1941 where he hit .406. That’s nearly a perfect average.

Physicians are expected to hit 1000, which, of course, is not possible.

Still, I am the first one to recommend people to fire their doctor if they are not connecting.

There are also other problems with some doctors. I am fully aware that not everyone is perfect and some doctors can and will make mistakes. That’s why it is so important to trust your gut instinct if you think that something is still wrong with you or a loved one. You don’t want to experience a wrongful death just because a doctor told you were fine when you knew that you weren’t. If something like this has happened to you then you should make sure to get yourself a lawyer. If won’t bring back the person but it will provide you with some justice.

My imperfections as a health care provider are not my (ex)patient’s problem. It’s my problem.

While I don’t believe the patient is always right, trust is essential for a good doctor/patient relationship. Once the trust is broken, all bets are off; healing becomes difficult for the patient.

9 Reason’s When You Should Fire Your Doctor

1. When the doctor says your health problem, “ Is all in your head.” While the mind can contribute to disease, it is often not the cause of disease.

2. Physician death sentence. You have X months (pick a timeline) to live. No doctor is God to give a death sentence. A competent physician should always provide reasonable hope. I have patients with stage 4 prostate cancer living way beyond what they supposed according to their oncologist.

3. Physician frustration from your questions. Most patients ask great questions these days. They have access to much information via the internet. Yes, some of the info is crap, but some are good. The physician should answer all questions and provide clarity of the action plan.

4. The physician should look at you in the eye when he/she speaks to you – something becoming less frequent these days with Electronic Medical Records (EMR). Docs typing as they talk to you should not be a deal breaker, everyone’s clinical practice is backed up and avoiding getting behind with patients is the name of the game in most clinics. But there should be some eye contact.

5. Holistic medicine is not scientific – fire your doctor. I’m a little biased here. But all biases aside, there is a plethora of evidence on the benefits of holistic medicine. Your doctor may not care to look into it. Or in fairness has no interest or time to research on anything else. They are struggling to stay abreast on their specialty. Still, to say holistic methods are not scientific or BS is grounds to fire your doc.

6. Listen to your gut, not your brain. Your gut instict will tell you if your doc is the right fit for you.

7. Know what you want from your doctor – have appropriate expectations though. Understand the medical system is squeezing physicians to spend no more than 15 minutes per patient. You, the patient, also have to be efficient with your questions. If he / she does not meet your expectations, that doc has to go.

8. Fear mongering. “You will die if you don’t undergo surgery now” type of statement is an out for me. And it should be for you. Nothing is 100% in medicine.

9. Your physician does not respect your time. Some patients wait one or two hours before their 15 minute face-to-face with the physician. Every person’s time is valuable and should be respected. Yes, emergencies happen where a physician may get delayed, but those are anomalies. At minimum patients should get an update on how much longer they need to wait by someone, if not the physician himself.

For any physician reading this post; when a patient is dissatisfied with our service as health care providers that is a moment to break any complacency one may have and improve on how you practice. Maybe communicate more clearly. Or perhaps listening better.

After my recent incident with my disgruntled patient, I am stepping back to look at my clinical holes and fix them.

As a physician, it’s emotionally brutal getting fired by a dissatisfied patient, but it can be an opportunity to improve on what we are meant to do – optimize the health of the sick. And healing patients will help alleviate the sting.

The Three Recent Blog Post

The CaPLESS Thriver Mindset

A Thriver After Prostate Cancer [VIDEO]

Does a Keto Diet Work for Prostate Cancer

 

CaPLESS EVENTS

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.

 

The CaPLESS Thrivers Mindset

 

There’s a misconception between Cure vs. Survival as it relates to cancer.

To most people cure means “ cancer free.” To physicians specializing in cancer, it means “5-year survival.”

That’s absurd.

So, if one is diagnosed with aggressive cancer but they live five years and one-day, poorly lived life mind you, that therapy was a success.

Here’s the reality; complete cancer cure, as in no more cancer, ever, is never the case because there’s always residual malignant cells lingering in one’s body. That’s why long-term survival is uncommon.

In prostate cancer, there’s a very high rate of recurrence. That’s no secret. And cancer’s of the prostate that doesn’t relapse many experts would question if treatment was needed in the first place.

There’s one very famous urologist (will remain nameless) who surgically treated only low-grade non-aggressive prostate cancer. If the Gleason score was an 8 or higher, he’d sent them to another physician. As a result of him “gaming the system” he became known as a famous prostate cancer urologist who “cured” patients from this disease. Crazy!

The bottom line is this; the spreading of prostate cancer (and most tumors) requires the perfect microenvironment. Metastatic cancers go back to an old concept called the “Soil and Seed theory.”

Cancer cells, which typically can only kill when they grow and spread, need a “favorable, dirty terrain” to metastasize. If you manage the microenvironment ( the terrain) the likelihood of cance spreading is minimal.

Of course, I have way too much respect for the “C-word” to oversimply.

But based on extensive, tireless research and experience of seeing patients with PSA from 1.8 with aggressive prostate cancer (yes, despite low PSA) to men with PSA of 3000 (yes, it goes up that high, even higher), the common denominator is continuously applying the lifestyle and behaviors that create a microenvironment hostile to cancer.

And such lifestyle beginnings with a thriver’s mentality, not a survivor one.

If you read my book, you know I am not a big fan of the word “survivor” as in “I am a cancer survivor.” The words you use to describe your experiences matter. Survivor implies, just making it. I am alive, sort of, but just hanging by a thread.

Here’s the bottom line (no really, this is it); For you to live your best life after prostate cancer, you need to be a thriver, not only a survivor. Such a concept is not just a silly, rah rah title of a book; this is real. And it starts with your mindset, then with what you eat, how often you move your body with what intensity, your ability to manage stress and to improve your sleep. These are the pillars of the CaPLESS Method that has worked now for thousands of patients and readers.

Of course, you don’t have to bat one-thousand (to use a baseball analogy) to benefit, but if you improve in one, it will have a domino-effect on another resulting in an unfavorable cancer environment in your body.

7 Main Concepts of the CaPLESS Method for Prostate Cancer:

  1. Eat colored fish, cooked in low heat not too charred.
  2. Eat Plants and unprocessed foods.
  3. Simple sugars, processed grains and flour are the enemy – don’t eat them, even if they are organic.
  4. A high-fat (ketogenic) diet may not work for prostate cancer.
  5. Exercise four hours a week with moderate to high intensity. That means your heart rate will go up to about 120 to 140 beats per minute, depending on age. Everyone needs weight resistance exercise, but those on hormone therapy need at 3 days a week of weight resistance movements.
  6. Consume supplements specific to the condition. Up to 4000mg of curcumin is safe and likely beneficial.
  7. Learn how to calm your brain to better manage stress. Mindful Based Stress Reduction is a good program. We have an expert on this at the CaPLESS Retreat.

The Three Recent Blog Post

A Thriver After Prostate Cancer [VIDEO]

Does a Keto Diet Work for Prostate Cancer

L-Citruline: The Heart and Penis Connection.

CaPLESS EVENTS

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.

 

A Thriver After Prostate Cancer

Chris is one of the most amazing CaPLESS Thrivers I know. When I first met him about six years ago, he was 47 years olds with a PSA of 27.0. After biopsy, we discovered he had Gleason 9 prostate cancer all over his prostate.

But that’s not all.

Three months after his prostatectomy, his PSA was 20.0. [there is no error where the decimal point is placed] This could have been a gloom and doom situation but Chris made a 180 degree change to his lifestyle and today he is a Thriver!

He does Cross Fit at CF 140 in Atlanta with his amazing trainer David Argel who I had the pleasure of speaking with recently.     Check out this video of Chris doing Cross Fit. If you are not inspired by Chris and ready to get going, nothing will. Thrive, Don’t Only Surivive!

 

Does a Keto Diet Work for Prostate Cancer?

[ image from Natural Living Ideas]

 

All cells of the human body require energy in the form of Adenosine TriPhosphate (ATP) to support life. If you remember way back in high school, you learned that the mitochondria are the “powerhouse” of the cell as it produces the majority of ATP. When the mitochondria are impaired, its malfunction is implicated in the majority of today’s most concerning chronic and degenerative diseases including obesity, cardiovascular disease, cancer, and diabetes, to name a few.

What is the ketogenic, mitochondria and health connection?

Initially, ketogenic diets were used to treat seizures, but recent research indicates that benefits related to the management of epilepsy, weight loss, metabolic syndrome, and type 2 diabetes can be achieved with an approach that is less restrictive in carbohydrate and protein, and therefore more satisfying, sustainable, and feasible for the general population.

What is a Ketogenic Diet?

Ketogenic diets (KDs) are diets that mimic the metabolic state of fasting by inducing a physiological rise in the two main circulating ketones, acetoacetate and beta-hydroxybutyrate (BHB).

This is a simple version of how the ketogenic diet works.

When your cells are deprived of glucose (sugar) as its primary source of energy, your body kicks in the next gear and utilizes fat for fuel in the form of ketones.

One can create ketones from either fasting for a prolonged period, anywhere from 16 hours a day or for several days, or from eating a high-fat diet, which is what a ketogenic diet is.

To be clear, a ketogenic diet (KD) is not a high protein diet like paleo form of eating. It is a fat diet where lard is in, along with other oils, coconut being a favorite, butter, avocados, etc. Although, it isn’t uncommon for people to use a keto supplement alongside their diet.

The Ketogenic Diet and Cancer Connection

KDs target the Warburg effect, a biochemical phenomenon in which cancer cells predominantly utilize glycolysis (burns sugar) instead of oxidative phosphorylation (OXPHOS) to produce ATP (energy). Don’t get caught up on what OXPHOS means or how it works for now but know that healthy cells work by using this metabolic pathway.

Thus, the rationale in providing a fat-rich, low-carbohydrate diet in cancer therapy is to reduce circulating glucose levels and induce ketosis such that cancer cells are starved of energy while normal cells adapt their metabolism to use ketone bodies and survive.

To date, the most reliable evidence for KD in suppressing tumors has been reported for glioblastoma (a type of brain cancer).

The proposed mechanism for how the Ketogenic diet works for cancer is like this.

Cancer cells have dysfunctional mitochondria and lack specific enzymes necessary for effective ketone body utilization. In other words, malignant cells can’t use ketones for energy but healthy cells can.

Free fatty acids and ketone bodies are considered to become a significant fuel for normal tissues of cancer patients as a consequence of developing insulin resistance. Additionally, ketone bodies have been shown to suppress protein catabolism during starvation (more on this further down.)

Ketogenic Diet and Prostate Cancer: Yes or No?

There have been no studies on a KD and prostate cancer.

However, there is a small pilot, non-randomized study going as we speak looking and this dietary approach among a sample of 12 overweight or obese prostate cancer patients on active surveillance. The result will not be available until the Spring of 2021.

Besides there being no studies, should a man with prostate cancer implement a KD?

Yes and no.

Here’s the deal;

In one mice study looking at the effects of a no carbs keto diet (NCKD), 10% carb diet and a 20% carb diet on prostate cancer showed is no difference between low-carbohydrate and no-carbohydrate diets regarding prostate cancer growth and progression.

The other important point is that most types of prostate malignancies are not glycolytic cancers like glioblastoma’s thus the Warburg effect does not apply. Clinically this is relevant, as these cancers will not appear on fluorodeoxyglucose (FGD) PET scans. However, in the late stage, more aggressive metastatic prostate cancer there may be more of a Warburg effect and have a high glucose uptake.

In other words, low-grade prostate cancer and high-grade metastatic prostate are two entirely different animals in how they behave.

Dr. Geo’s Take On the Ketogenic Diet and Prostate Cancer

A low carbohydrate diet, which is what promote in the CaPLESS Method, of about 50 to 60g of carbs total (not sugar, carbohydrates) a day is still, eliminating refined; processed carbs is still essential for early-stage prostate cancer without metastasis or positive FDG PET scan.

The reason why a low carb diet is vital to beat non-metastatic prostate cancer is not that of glucose uptake of cancer cells, but the problems excess insulin and insulin resistance cause in promoting disease. In fact, there are data to suggest that patients with early-onset, type one diabetes mellitus (not type two) whose pancreas is no longer able to produce insulin are significantly less likely to develop prostate cancer, independent of diet changes.

If a huge guy is diagnosed with prostate cancer, then his high basal metabolic index (BMI) increases the risk of not only getting prostate cancer but dying from it.

It is a good idea for an overweight person with prostate cancer to restrict carbs more than most as low carb diets, and a KD has shown to help with weight loss.

Intermittent fasting of 12 to 16 hours a day is an excellent practice for prostate cancer and overall longevity.

Lastly, ketones from fasting would be contraindicated in cancer patients with rapid weight loss (cachexia) unless higher fat intake is consumed to avoid further weight loss. Additionally, ketone bodies have been shown to suppress protein catabolism during starvation – meaning that one can maintain muscle from breaking down while utilizing ketones for energy.

Adding medium-chain triglyceride (MCT) to KD in a study to five severely cachectic cancer patients for one week induced a significant weight gain of 2 kg and improved their performance status.

The bottom line is this: A low-carbohydrate, non-ketogenic diet is recommended for prostate cancer with few exceptions: one if the patient has a high BMI, or if prostate cancer is more advanced and shows on glucose dependant PET scan.

My Favorite Books on the Warburg Effect, Metabolic Approach, Ketogenic Diet on Cancer

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.