CaPLESS & Prostate Cancer

7 Easy, No BS Ways to Staying Healthy on the 4th of July.

[image above from successfully fit]

 

Stay focused on what’s important on this 4th of July; a celebration of your patriotism to the United States ( if you live in the US) and a time to spend with friends and family.

With that in mind, here are the;

7 Realistic, no BS Tips to Staying Well on the 4th of July

1. Take easy on eating grilled animal products, like burgers and chicken. Look, I like these foods too, I am not going to lie. But you have to admit; often there’s nothing special about these foods. Usually, its just a bunch of unseasoned burgers, chicken, and hot dogs doused in ketchup or mustard. Let’s be real; there’s nothing special about that. Plus, the charring on animal products when grilling is a pro-carcinogen.
Tips: Grill portabella mushrooms. They are meaty in texture and taste delicious when seasoned correctly.

HERE’s a good recipe for making portabello mushrooms..

2. Go easy on the booze. I know the 4th of July is a festive moment but over drinking is not worth it. The World Cancer Research Fund makes alcohol as a pro-carcinogen.

I am not saying you need to be a monk at the holiday party. Just be mindful of your alcohol intake and don’t overdo it. Besides, you will start acting silly and embarrassing yourself. ( I see you :))

3. Don’t forget to exercise. I know, I know, its the holidays and you should take it easy and have fun. Guess what; the disease process doesn’t take holidays. You shouldn’t either. Go for a 30-minute workout, especially if you are going to consume less than optimal foods.

The bottom line is that exercising should be part of the holiday fun. If it’s not, do it anyway. It’s good for you, and we sometimes have to do things we don’t like.

4. Drink 8 to 10 glasses of water. It’s hot out there, and you can quickly dehydrate. If you are craving a beer or soda, drink a full glass of water first. Then have the beer if you wish. (Reread # 2) You know if you are drinking enough water if your urine is clear. The darker yellow the urine, the more dehydrated you are. Keep your urine clear.

5. Eat something nourishing before the party. Do not, I repeat, DO NOT wait for the party to eat. That is a recipe for disaster. Don’t go hungry at the party. Make a nice protein smoothie or something and eat before the event. If you go hungry, all bets are off, and you will go crazy with eating nasty burgers with ketchup.

6. Take your dietary supplements. Pills don’t replace good eating and exercise, I get it, but it does counter some of our nutritional deviations. Be disciplined, and down those protective pills.

7. Enjoy the company. Have a good time with people you love is what life is all about. It’s less about the food and drink (although that is a component of it) and more about connecting with amazing people in your life.

 

Three Recent Blog Posts

It’s time to Exercise. No Excuses.

Testosterone and Prostate Cancer; New Study.

Prostate Cancer: How and Why Brocolli helps.

 

CaPLESS EVENTS

The CaPLESS Eats event was a huge success I think. Thank you to all who came. There will be more. As always, we want to help prostate cancer (CaP) thrivers to live their best life by implementing science-based lifestyle practices.

It’s time to Exercise – No More Excuses.

[Image of me training at 4:36 AM. It’s not what I like doing, but what I have to do.]

 

I’ve noticed people making all sorts of excuses not to exercise.

And it’s not because there is no evidence that exercise helps us live longer and better.

The scientific literature is packed with proof that exercise helps prevent and manage depression, cardiovascular disease, cancer and promote longevity.

Despite the plethora of evidence, less than 25% of people exercise.

That’s insane.

Why is that?

After observing the behaviors of thousands of people at my clinic and in my personal life during the last fifteen years or so, I think I have some answers.

Top 5 Reason’s Men Don’t Exercise and What to Do About it

 

  • When “this happens” then I will exercise. I know someone who has purchased every exercise gadget imaginable to exercise at his home. All the fitness books are appropriately lined up on his bookshelf, pull-up bar ready to go, push up bar – everything he needs. He says, “once I get all the equipment and books I need, then I’ll get started.” It’s been three years and he still hasn’t gotten started. There’s no perfect scenario to get going. The time is now. All you need to do is go.

 

  • Fear of looking weak. Men hate vulnerable situations. The discomfort of going to a gym and pushing weight next to a muscle head lifting 400 pounds can be paralyzing. Same with not having the developed stamina to go for a run and deal with the unconformability of gassing out. Fight your vulnerabilities.

             In fact, I’d argue that your best life will only occur with you facing your discomforts instead of shying away from them.

Of course, I’m not saying to jump out of a plane without a parachute. That wouldn’t be smart and extremely painful (or deadly). I am saying the more you challenge yourself and get out of your comfort the better you will live. Resist comparing yourself to others and focus on achieving your personal best.

I consider myself a physically strong guy – I can deadlift 350 pounds, bench press 250 pounds, etc. And still, when I go train at a gym, I’m often one of the weakest there. That’s OK. I am happy with my mental and physical gains.

  • I’m not the physical type. I have noticed that some people are more cerebral than physical. These are your philosophers, computer geeks, scientists, etc. People in this category were likely a bit nerdy in school. They didn’t play many sports growing up and probably felt awkward doing so. One personality type does not have to exclude the other. While some people are apparently more physical and athletic than others, we all need to be both. Find a particular physical activity you enjoy and do it frequently.

 

  • I’m too busy. This is probably the number one excuse. And the biggest BS one of them all. The reality is we all have time for what we value. Once exercising is considered important in one’s life, then doing it is planned for until it becomes a habit. Schedule it in your calendar as if it’s a meeting with the most important person in for your business. Make it so that your life depends on it. Because it does.

 

  • Avoiding physical pain. Some people are trying to prevent pain from soreness, gasping for air on a run or joint pain that sometimes come after working out. Others don’t exercise for fear of getting hurt. Here’s the deal; you can’t live your life in fear. Of course, you can hurt when trying new physical activities. Injuries often occur when one is simply walking down the street too.  However, you can perfect the technique of a particular exercise, don’t do too much too soon and reduce the risk of injury. Also, you are going to experience pain regardless if you opt out of exercising. In fact, the more sedentary you are, the more pain you’ll experience. So, might as well do something that will keep you optimally functional and help you live longer. Make sense?

Lastly, let me say this;

There is no perfect way you should feel before you get going. Frankly, there are many days I’m not up for training. Do it anyway. You don’t always have to be in the best mood to get a workout in. If you are tired from work, life, etc,  go for 10 – 15 minutes and get it in. If the feeling of exhaustion is overbearing, then that’s the only time you rest and not exercise. Know the difference between being tired vs. being exhausted.

If you are starting from zero, the most crucial element of exercising is frequency. In other words, focus less on intensity and duration and more on going out and exercising consistently. Don’t stop.  Just go for a 10-minute brisk walk every day. Or to your gym, you pay or it anyway. Make it a habit of moving your body consistently.

Yes, if you are beyond starting point zero, there’s a prescribed dose on intensity and duration that is important. But even the best exercise regimen only works when you are consistently doing it. The prescriptive dose for exercising is for a different blog post on a different day.

Just do it. – Nike (Best three-word slogan ever)

Testosterone and Prostate Cancer. New Study.

Let’s get right to it.

Study Details on Testosterone and Prostate Cancer

  • A retrospective study observing 147,593 men included 58,617 in men aged 40 to 89 years with low testosterone from 2002 to 2011.
  • 313 aggressive CaPs were diagnosed
  • After adjusting for age, race, hospitalization during the year before cohort entry, geography, BMI, medical comorbidities, repeated testosterone and PSA testing, testosterone treatment was not associated with incident aggressive CaP
  • No association between cumulative testosterone dose or formulation and CaP was observed.

 

My Take on This Recent Study on Testosterone and Prostate Cancer

This PLOS study looked at a large population of close 150,000 men which make provides some validity to the conclusion mentioned despite it being a retrospective study.

A retrospective study looks back to determine risk or protection factors with an outcome that already happened at the start of the study. A retrospective study is the opposite of a prospective study where researchers look forward on a group of subjects before the outcome of interest happens.

Amongst researchers and scientist’ retrospective studies are not held high in its validity because there’s too much room for bias and confounding variables that may influence study conclusion. However, while such studies are not cause-and-effect, retrospective designs provide a vehicle for research using existing and are useful for giving preliminary data and in guiding the development of future prospective studies.

Lastly, one can compare retrospective studies with other better-designed studies to determine its clinical and biological applications.

So, in my opinion, retro studies count in context to the preponderance of other published research.

Let’s look at the overall scientific work done on Testosterone and Prostate Cancer.

Stay with me here. It’s going to get good. ☺

The Relationship between Testosterone and Prostate Cancer (CaP)

Until less than ten years ago it was believed that high endogenous Testosterone (T) led to an increased risk of prostate cancer (CaP) – and treating prostate cancer patients with exogenous T was heretical. In the middle of the 20th century, it was thought that T is the fuel that lit up malignancies in the prostate.

The stark connection that T propelled prostate cancer began in the early 1940’s with Dr. Charles Huggins, a Chicago University urologist and a noble prize winner for his work in demonstrating that prostate cancer growth is dependent on the serum T level. He and his research team observed that dogs with enlarged prostates, or clinically known as benign prostatic hyperplasia (BPH) had their gland shrink after being castrated by surgical removal of the testicles.

Huggins and his research team further noticed that when suspicious, cancerous cells appeared in the prostates of dogs, not only did the prostate shrink after castration but so did suspicious malignant lesions.

The logical sequence for Dr. Huggins is to study the castrating effect in men who had advanced prostate cancer. These men either had their testicles removed or were given estrogen while having the anti-androgenic treatment effects measured by serum acid phosphatase.

Huggins and his coworkers showed that acid phosphatase dropped substantially within days of lowering T in men with prostate cancer, therefore, concluding that high T enhanced prostate cancer growth and reducing T eliminated it. (1)

Finally, there was a viable treatment for prostate cancer in Androgen Deprivation Therapy, it was thought, a disease with almost no cure at the time. From that point forward, lowering T to negligible levels was the standard treatment for prostate malignancies and it is still used today for advanced cases.

Is Testosterone the Fuel for Prostate Cancer (CaP)

In test tubes, testosterone demonstrates an increase in prostate cancer in numerous cancer cell lines but apoptosis (programmed cancer cell death) once androgens are removed. (2) A similar response is found in rat studies: androgens promote tumor progression until androgens are withdrawn – then causing regression of prostate tumor cells. (3)

From test tubes and rat studies, one can easily think, “that’s it, case closed. Testosterone fuels prostate cancer, thus low testosterone in men I best for prostate cancer prevention.”

Human studies analyzed.

A meta-analysis of three prospective studies controlling for testosterone, estradiol, Sex Hormone Binding Globulin (SHBG), age and body mass index (BMI) demonstrated an increase in CaP for men in the highest levels of serum testosterone but no association with DHT or estradiol. (4)

A meta-analysis called the Endogenous Hormones and Prostate Cancer Collaborative Group included 3886 men diagnosed with CaP and 6438 controls. The results demonstrated no direct association between endogenous serum androgens and the development of prostate cancer. (5)

Another, well-designed human clinical trial looked at 3255 men in the placebo arm of the Reduction by Dutasteride of Prostate Cancer Events trial, also known as the REDUCE trial. Prostate biopsies performed at two and four years revealed, no relationship between testosterone or dihydrotestosterone (DHT) levels and prostate cancer risk. (6)
Here’s the kicker; not only is there no causal relationship with high endogenous T and CaP but low T may cause the disease.

One such clinical trial demonstrated a high incidence rate of aggressive, more deadly type of CaP among men with low T defined as >7.6nmo/l (220ng/d). (7)
Similarly, a group of Chinese men, 110 total, showed greater high-grade CaP (higher Gleason score) in men with low T. (8)

Beyond analyzing staging with Gleason grade on biopsy, a high-risk disease has been was associated with low T after prostatectomy.

For example, in 673 men undergoing prostatectomy had their morning T levels taken with surgical pathology outcomes and observed a significant risk of advanced disease that included seminal vesicle invasion in severely hypogonadal men. (9)

What should you do?

First of all, let me be clear here; I don’t have any confirmation bias towards the medical treatment with exogenous testosterone therapy. That’s not what I do as a physician. In men with low T, my goal is to prescribe lifestyle and natural methods to help the body make its own natural hormones.

Secondly, while I am not opposed to pharmaceutical testosterone therapy, once still needs to be properly managed by an experienced health care practitioner if T therapy is right for you. External T therapy by itself is a “Band-Aid” to the problem. It’s a good temporary solution (good long-term solution in some cases), but it is not a cure. The long-lasting remedy usually lies in a lasting lifestyle change.

Causes of low testosterone include chronic high-stress mismanagement, poor sleep habits, lack of physical activity, being overweight, metabolic syndrome…you know, the typical culprits to most health problems.

Lastly, T therapy can safely be prescribed for the right patient, only if necessary, even after a prostate cancer diagnosis.

That’s right. Some men can increase their testosterone levels, either naturally, or with an external application, after prostate cancer diagnosis.

Once we look at much of the research, we can see the PLOS study having some validity despite its retrospective design.

UPCOMING EVENT

Learn what food and meals work best for prostate cancer at the live event CaPLESS Eats.

CaPLESS Eats clears up the confusion on what to eat for prostate cancer.

Closing registration at 11:59, Sunday, June 24th.

3 Blog Posts

14 Rules on Being a Good Father

Part 4: PSA Screening after Prostate Cancer Diagnosis

Prostate Cancer: 10 Reliable Tips to Choose Your Best Treatment

Reference:

1. Huggins C, Hodges CV; Studies on prostatic cancer: I. The effect of castration, of estrogen and androgen injection on serum phosphatases in metastatic carcinoma of the prostate. 1941.J Urol. 2002 Jul; 168(1):9-12.
2. Schwab T., Stewart T., Lehr J., Pienta K., Rhim J., Macoska J. (2000) Phenotypic characterization of immortalized normal and primary tumor-derived human prostate epithelial cell cultures. Prostate 44: 164–171.
3. Ahmad I., Sansom O., Leung H. (2008) Advances in mouse models of prostate cancer. Expert Rev Mol Med 10: e16.
4. Shaneyfelt T., Husein R., Bubley G., Mantzoros C. (2000) Hormonal predictors of prostate cancer: a meta-analysis. J Clin Oncol 18: 847.
5. Roddam A.W., Allen N.E., Appleby P., et al: Endogenous sex hormones and prostate cancer: a collaborative analysis of 18 prospective studies. J Natl Cancer Inst 2008; 100: pp. 170-183
6. Muller R., Gerber L., Moreira D., Andriole G., Castro-Santamaria R., Freedland S. (2012) Serum testosterone and dihydrotestosterone and prostate cancer risk in the placebo arm of the reduction by dutasteride of prostate cancer events trial. Eur Urol 62: 757–764.
7. Lane B., Stephenson A., Magi-Galluzzi C., Lakin M., Klein E. (2008) Low testosterone and risk of biochemical recurrence and poorly differentiated prostate cancer at radical prostatectomy. Urology 72: 1240–1245.
8. Dai B., Qu Y., Kong Y., Ye D., Yao X., Zhang S., et al. (2012) Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8–10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer. BJU Int 110: E667–E672.
9. Salonia A., Gallina A., Briganti A., Abdollah F., Suardi N., Capitanio U., et al. (2010) Preoperative hypogonadism is not an independent predictor of high-risk disease in patients undergoing radical prostatectomy. Cancer 117: 3953–3962.

Prostate Cancer: Why and How Broccoli Helps

 

Hey, it’s Dr. Geo here!

Have you wondered why cruciferous vegetables are so protective against prostate cancer?

Cruciferous vegetables are those vegetables we call broccoli, cabbage,  bok choy, kale, and Brussel sprouts.

Why are these vegetables particularly so protective against prostate cancer?

One study shows it reduces the risk (of prostate cancer) in those that consume a good amount of cruciferous vegetables by up to 40%.

Another study shows that those who get diagnosed with prostate cancer have a lesser chance of dying from prostate cancer after diagnosis.

The amount to consume is about seven servings of cruciferous vegetables a week.

Why is that? There’s a group of chemicals in cruciferous vegetables called isothiocyanates, and the specific isothiocyanate that is most protective is sulforaphane.  

Another protective compound also in these cruciferous vegetables are indole-3 carbinol.

These are specific chemicals that have anti-cancer properties and stops prostate cancer right in its tracks.

I highly suggest for you to consume seven to nine servings of cruciferous vegetables a week to protect yourself against prostate cancer.

HERE’S THE TRICK though. Cruciferous vegetables need to be steamed or exposed to (some) heat for them to be digested well.

Why is that important?

Well, have you gone to a party or any social function where they have a vegetable platter with the raw broccoli on that platter along with the celery and the white cream dip?

When you eat cruciferous vegetables like broccoli raw is not digested well and that’s why it doesn’t sit well in your digestive system.

So I see so many of my patients eating this broccoli raw and thinking they’re doing something good for themselves.  (They are not)

To best eat broccoli and all cruciferous vegetables they need to be exposed to some heat, not too much, in order to liberate and free up these [anti-cancer] chemicals. And that’s the only way you can get these wonderful phytochemicals in your system to protect you from prostate cancer.

This is Dr. Geo signing off! Until our next video be well 🙂

 

Side note: I find broccoli extracts founds in high-quality supplements to also help in providing the phytochemicals necessary for maximal protection.

UPCOMING EVENT

Learn what food and meals work best for prostate cancer at the live event CaPLESS Eats.

CaPLESS Eats clears up the confusion on what to eat for prostate cancer.

 

Last 3 Blog Posts

14 Rules on Being a Good Father

Part 4: PSA Screening after Prostate Cancer Diagnosis

Prostate Cancer: 10 Reliable Tips to Choose Your Best Treatment

 

 

Part Four: PSA Screening After Prostate Cancer Diagnosis

This is part four 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 used for Prostate Cancer Screening 

Part four: PSA after prostate cancer treatment

 

PSA rising after prostate cancer treatment is a bombshell to a man’s psyche.

A 63-year-old patient, one year after prostate cancer surgery, see’s me at the clinic for his recent diagnosis of recurrence PSA. (His PSA begins to rise after being undetectable for one year) He looks at me strangely. I ask him – what’s wrong? He responds, “ I thought I didn’t have ever to worry this S@#T again since I had it taken out. I expect my PSA to be zero forever, no? I’m confused” – he says.

Why is PSA still Measured after Prostate Cancer Treatment?

That freaking blood marker causes everything from anxiety to depression, even after prostate cancer treatment.

Here’s the deal; men who undergo medical treatment of prostate cancer like prostate removal or radiation, unfortunately, believe they are “home-free” after their treatment.

If this were true, why are patients required to return to their urologist every 3 to 6 months for a PSA test after surgery or radiation?

Men after prostatectomy or radiation even more so need to make lifestyle changes to reduce their risk of prostate cancer recurrence.

Here are two reason’s why:

1. Up to 40% of men experience biochemical recurrence (PSA recurrence) after initial treatment. (Freedland et al. 2007)

2. Men treated initially with Radiation Therapy (RT) have a higher chance of getting secondary bladder cancer or rectal cancer (Nieder et al. 2008)

Secondary cancers after initial cancer treatment should not be a surprise after this New York Times article highlighted this critical point.

What’s Considered biochemical recurrence (BCR) or PSA recurrence mean?

After surgical prostate removal (prostatectomy) – PSA recurrence is defined by a PSA of 0.2ng/ml to 0.4ng/ml within 6 to 13 weeks after the surgery.

Ultra-sensitive PSA assays have recently improved detection levels down to 0.01 ng/mL and may lead to better treatment outcomes through the earlier adoption of salvage radiation therapy following RP

After Radiation therapy (RT) for prostate cancer – PSA recurrence is more difficult to determine as PSA initially increase’s (known as PSA bounce) after RT and does not reach its lowest level for up to 18 months. There is no consensus on the definition of treatment failure, but most agree that the lowest PSA value after RT (referred to as the PSA nadir) plus 2 is the cut-off.

For example, let’s say Mr. Doe completed is RT today. His PSA before treatment is, say, 4.5ng/ml. His PSA may continue to go to whatever, say, 6.0 ( I’m making these numbers up) for another year or so (PSA bounce) before it begins to drop steadily. Two years later his name goes down to 2.5 (the nadir). Once his PSA reaches 4.5ng/ml (plus 2.0) that would be considered a PSA recurrence after RT.

Are you with me?

For men who undergo RT as primary treatment for prostate cancer, the most common treatment after PSA recurrence is cryotherapy (freezing the prostate).

Cryotherapy in this patient population can induce close to 100% impotence but not worsen urinary incontinence.

Men on Active Surveillance also are monitored primarily by PSA value and subsequent prostate biopsies. There’s no biochemical or PSA recurrence here since there is no treatment. The typical protocol for men on active surveillance for prostate cancer is biopsy once a year for up to two to three years to assure there has been no cancer progression. However, the physician may not be aware that in the latest research, they’d consider a follow-up biopsy every two years for active surveillance patients, not once a year. Biopsy every other year is indeed a viable approach for men not needing immediate medical treatment for prostate cancer based on research.

A final note on active surveillance for prostate cancer: Up to 33% of patients on active surveillance (AS) eventually fall out of surveillance and undergo definitive treatment after 2–5 years because of initial understaging or disease progression. Understaging means that the initial biopsy may have missed more aggressive prostate cancer with a Gleason 7 or higher.

I suggest a ProActive Surveillance approach in men on active surveillance for prostate cancer with the goal of the disease not to ever progress and reduce the risk of all-cause mortality.

Lastly, the use of PSA after focal therapy for prostate cancer is not well defined. Focal therapy, which includes cryotherapy, focal laser ablation and high-intensity focused ultrasound (HIFU) is a form of treatment for prostate cancer somewhere in between active surveillance and radical therapy. With focal therapy, the goal is to ablate (destroy) only the tumor and maybe about 1cm around it. PSA does not go down to zero after focal therapy since there is still prostate tissue intact and likely inflammation as well from the procedure. However, the PSA value does tend to decrease by 30% to 60% after focal therapy. A rapid increase in PSA after nadir can indicate biochemical recurrence and may require a biopsy.

Though not preferred by the surgeon, radical prostatectomy is an option after focal therapy if prostate cancer recurs.

PSA Doubling Time and other tests to determine Prostate Cancer Prognosis

In general, to determine a risk of aggressivity of prostate cancer, all pretreatment values are essential after PSA recurrence including, pretreatment PSA, tumor stage (T-stage), including Gleason score, surgical margin status, and lymph node status.

After prostate cancer treatment, PSA doubling time (PSADT) likely has the most prognostic value – this is the amount of time it takes for PSA value to double.

Let me give you another example.

Say my PSA today is 2.5ngml and it goes up to 5.0ng/ml in 6 months. The PSADT is six months.

In general, the longer the PSADT after PSA recurrence, the less likelihood of prostate cancer to be deadly.

As of late, genetic testing like Decipher® can help predict the possibility of metastasis from prostate cancer only after a prostatectomy. The Decipher® test only examines the prostate gland after it is removed surgically; thus, this test is not valuable after other type treatments like radiation.

Another element of prognostic importance is the time when PSA recurs after treatment.

For example, I have patients who have PSA recurrence ten to fifteen years after their prostatectomy. These patients will likely not succumb to prostate cancer.

Now, you don’t want to get your PSA test less than every three months to determine PSADT. Three PSA measurements obtained three months apart is considered a reliable foundation for calculation of PSADT.

Generally, the longer the PSADT, the better.

One study of 8,669 patients with prostate cancer treated with surgery (5,918 patients) or radiation (2,751 patients) found that a PSADT of less than three months was significantly associated with prostate cancer-specific mortality

Again, prostate cancer is an opportunity for nutritional and lifestyle changes that can reduce the possibility of succumbing to the disease.

Does Biochemical Recurrence (PSA recurrence) mean I will die from prostate cancer?

Not necessarily.

All-in-all the odds of dying from prostate cancer, even after PSA recurrence are better than almost any other cancer after relapse. Your chances of living longer with quality are particularly in your favor if a favorable lifestyle is adopted which reduces the risk of prostate and overall mortality.

Average time from PSA recurrence to prostate cancer death is 16 years (Freeland et al. 2007), if one’s fate is indeed from this disease. Most men with PSA recurrence, however, die of other causes than from prostate cancer, i.e., heart disease.

Importantly, PSA increase after prostatectomy may be due to benign, non-cancerous prostate tissue left behind after surgery (Djavan et al., 2005).

Only a small group of men die from biochemical recurrence (PSA recurrence) after prostate cancer. One study looked at over six hundred men for about sixteen years after prostate cancer treatment and noticed a tiny number succumbed to their disease after BCR. Based on the conclusion of this study, the odds of you living after BCR are in your favor.

So, stop sweating the PSA so much. I see men with high anxiety provoked when going for their PSA test.

I am reminded of an old Jewish phrase, “Don’t’ die while you are still alive.”

However, we all need a kick in the behind to do more of the things that help us live our best life. And the PSA test helps with that.

When does Androgen Deprivation Therapy after Prostate Cancer Recurrence?

The term Androgen Deprivation Therapy  (also known as hormone therapy) refers to treatments meant to eliminate testosterone production by surgical removal of the testicles or chemically castrate the patient with drugs such as Leuprolide ( there are many others.)

The negative impact on quality of life in men on ADT can be significant, including hot flashes, bone loss, increased fracture risk, sexual dysfunction, loss of libido, memory loss, increased fat deposition, loss of muscle mass and other metabolic changes (increases in cholesterol and insulin resistance) that may increase risk for heart disease.

Lastly, not everybody with BCR (PSA recurrence) needs treatment. A man with a detectable and low PSA level of 0.05ng/ml after RP may have a persistently detectable PSA without significant change for a long time. Such a patient is unlikely to progress and suffer prostate cancer-related death because as Djavan et al. showed, there can be benign prostate tissue left behind.

Key Takeaway Points on PSA Screening after Prostate Cancer Diagnosis

• Biochemical recurrence (PSA increase) after prostate treatment is more common than people think.
• PSA recurrence is not necessarily a death sentence
• PSA doubling time is valuable to determine prognosis
• Pre-treatment values are also helpful
• Genetic testing only after prostatectomy is useful in determining prognosis
• PSA recurrence is a reminder to stay the course and improve your nutrition and lifestyle so that you can live your best life despite prostate cancer recurrence.

Every prostate cancer recurrence situation is different, and the treatment approach should be individualized.

UPCOMING EVENT

Learn what food and meals work best for prostate cancer at the live event CaPLESS Eats.

CaPLESS Eats clears up the confusion on what to eat for prostate cancer.

My last 4 Blog Posts

Prostate Cancer: 10 Reliable Tips to Choose Your Best Treatment

What’s your doctor’s medical philosophy?

The Anti-Cancer Benefits of Curcumin

Breaking News: USPTSF position on Prostate Cancer Screening

Reference:
Nieder AM, Porter MP, Soloway MS. Radiation therapy for prostate cancer increases subsequent risk of bladder and rectal cancer: a population-based cohort study. J Urol. 2008 Nov;180(5):2005-9;
Djavan B., Milani S., Fong Y. K. (2005). Benign positive margins after radical prostatectomy means a poor prognosis – pro. Urology 65, 218–220.
Freedland S. J., Humphreys E. B., Mangold L. A., Eisenberger M., Dorey F. J., Walsh P. C., Partin A. W. (2005). Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA 294, 433–439.

The Anti-Cancer Benefits of Curcumin

Along with ginger and garlic, curcumin is one of my favorite herbs to prevent and even treat health problems naturally.

This potent herb does not only have potent anti-inflammatory properties, which in at by itself is worth taking, but it also has anti-cancer abilities.

I am not exaggerating.

Now, to be clear, I am not saying just taking curcumin that will cure cancer. It’s not that simple.

But taking ample amounts of this botanical should be part of any anti-cancer arsenal.

That is why when I formulated ImmunoPCTN, it was a no-brainer to add ample amounts of curcumin to the formula.

What is Curcumin

Curcumin is a component in the Indian spice turmeric, and it’s a cousin of ginger – another highly protective herb. Curcumin causes the yellow color in your curry dish. Tumeric is a member of the ginger family (Zingiberaceae). Turmeric’s other two curcuminoids are desmethoxycurcumin and bis-desmethoxycurcumin. Ideally, when consuming curcuminoids, you would want all three health-promoting curcuminoids: curcumin, bisdemethoxycurcumin, and dimethoxy curcumin. I know, it’s getting a little technical, but the bottom line is to get enough of this yellow staining compound from spicing your food and from supplementation.

There are over three hundred research papers suggesting curcumin’s protective effects against prostate cancer and more than to four thousand scientific documents showing its inhibitory results against almost all cancer.

While curcumin can be consumed in food, I recommend have my patients take additional curcumin daily from dietary supplements.

How curcumin protects Prostate cells

Chronic inflammation can cause all kinds of health problems in men from heart disease to certain cancers. Regarding prostate cancer, however, chronic inflammation elevates PSA in the prostate gland, which can build up and eventually leads to tumor formation. A clinical trial examined the effect of curcumin on men and showed a drop in PSA numbers.

Curcumin does not falsely lower PSA. In other words, prostate cancer is not hidden while PSA lowers when taking this herg.

How Curcumin protects against prostate cells

Curcumin protects prostate cells (and breast cells) by slowing down the overproduction of inflammatory chemicals called cytokines.

A particular molecule in the body that promotes cytokine production is Nuclear Kappa Factor –b (NFkB). This ancient yellow spice has shown to inhibit progression of excess prostate cell replication by interrupting the action of NFkB in mice.

Curcumin is an excellent herb to take during radiation therapy for cancer.

That’s right. Curcumin actually helps destroy cancer cells during radiation treatment. This is a big deal because virtually all radiation oncologists would recommend against taking supplements during radiation treatment. This recommendation is based on the flawed theory that anti-oxidant supplements are taken during radiation treatment, it may protect cancer cells from the radiation treatment.

But now we know that curcumin makes cancer cells more radiosensitive to radiation therapy. Indeed, taking curcumin can help cancer cells be more vulnerable to radiation therapy.

Lastly, Curcumin has shown to stop spreading of aberrant prostate cells in the body.

The Takeaway on Curcumin and Prostate cells

Here’s the bottom line: spices of all kinds should be consumed daily with food. The scientific community now realizes that the best pharmacy is indeed in the kitchen. Rosemary, Oregano, garlic, turmeric all have anti-cancer properties.

Smart and judicious use of dietary supplements should be an essential part of any health routine if the interest is in preventing or slowing the development of abnormal prostate and breast cells.

Optimal amounts ranges of curcumin vary from 400mg to 4000mg a day. Science daily has suggested up 8 grams a day (8000mg) is safe. Typically, the more aggressive the health challenge, the more curcumin should be consumed.

I consume about 1000 to 2000 mg curcumin from this formula for maximal protection, reduce soreness from workouts and for prostate health. And you should too.

 

 

 

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.

Your Smartphone May Cause Prostate Cancer

There’s no question that modern technology has improved our lives.

If wasn’t for the Internet and your electronic device we would not be connected right now. Of course, there’s also inaccurate content online that can misguide us. And that’s not good.

Another aspect of technology that is imperfect and can cause health problems is excess exposure to the type of light coming out of your technological devices.

A recently published study associates nighttime exposure to blue light with an increased risk of prostate cancer and breast cancer.

Study details on Blue light connection with Prostate & Breast Cancer:

  • Evaluating the Association between Artificial Light-at-Night Exposure and Breast and Prostate Cancer Risk in Spain” was published in the journal Environmental Health Perspectives on April 23.
  • About 4,000 men and women were studied in Spain.
  • All the participants were enrolled in 2008–2013 and were between 20 and 85 years of age.
  • According to results for both the cities, those exposed to higher levels of blue light had a 1.5 times higher risk of developing breast cancer and a two times higher of developing prostate cancer when compared to the less-exposed population.
[Link to study]

What is Blue Light?

Blue light is a form of visible light we get from smartphones, computers, televisions, and lights. Anyone using modern devices is exposed to blue light. Other forms of light include, yellow, red, purple, etc. and each is labeled based on their wavelength.

Exposure to blue light during the day is not a problem and improves alertness, but reading from your smartphone, for example, at night, as many of us do, can contribute to health problems and interfere with quality sleep.

Simply, we have a circadian rhythm in our bodies that is regulated by our exposure to light (also regulated by when we eat).

Naturally, when our eyes are exposed to light, we create hormones and chemicals than we do a night when there should be more darkness. The main hormone that helps us sleep and restore at night, only in darkness is melatonin. If there is blue exposure at night, say, working late night on your computer, melatonin is shut off.

The Association between night workers and Prostate cancer (CaP)

While I am empathic to prostate cancer patients who work the night shifts, ironically also known as graveyard shift, I strongly prescribe them to change their work hours to daytime.

In over 2.5 million individuals studied from this meta-analysis, a significantly increased risk of prostate cancer was associated. The reason for such a strong association may be due to the inability for the body to release melatonin when eyes are exposed to light at night.

A prospective study of over 900 men in Iceland who did not have CaP and measured first-morning void urinary levels of 6-sulfatoxymelatonin (6-STM), a melatonin metabolite. During the study period, about one-hundred men were diagnosed with prostate cancer, including 24 with advanced disease. Men with low morning 6-STM levels had a 4-fold increased risk for advanced prostate cancer compared with men with levels above average. The average follow-up time from urine collection to CaP diagnosis was 2.3 years.

Researchers from another older but relevant study observed less CaP in men with higher nighttime melatonin secretion with longer sleep duration.

While I clinically don’t see nearly as much breast cancer patients as I do men with prostate cancer, the breast cancer research is appealing because it is known for the two cancers to be “cousins.” In other words, both breast and prostate cancer are formed and progress in similar ways.

Also, the nutrition habits and lifestyle behaviors that work for one works for the other

A study looking at 13 studies noticed a with a significant increase of breast cancer risk among nighttime female workers, mostly airplane workers and another showed a link between light exposure at night and breast cancer among nurses who worked night shifts.

What is Melatonin and how it works?

Melatonin is a hormone released from an area in the middle of your brain called the pineal gland only when the eyes detect no light. In other words, the darker the environment, the more melatonin produced. This super hormone has many protective qualities including protection against cancer development through several pathways, including antioxidation, stops excess replication of cells (apoptosis), interfering with new blood vessels in cancer cells (anti-angiogenesis), and the strengthening of the immune system.

Changes associated with shift work, including sleep disruption, circadian disruption also causes melatonin disruption. There is plenty of evidence in animal and human models to suggest the carcinogenicity of artificial light during the night, which causes circadian, sleep, and melatonin disruption.

In prostate and other cancers, shift work shows an increased the risk of diagnosis among pilots and airline occupations, in support of a potential effect of circadian and melatonin disruption.

My Take and Suggestions on the Link between blue light exposure and Prostate cancer

I tell my teenage kids all the time, “you have to control your phone. Your phone can’t control you.” That might be good advice for adults to practice as well.  Come to think of it, I often suggest to them things I need to improve on. Hmmm.

About three months ago I turned off all notifications and alerts from my phone.

Now, I don’t get instant notices of the news or updates in sports. And I am much happier and more productive. You’d be surprised how much time you have when you are less distracted with things that are less important.

The grand majority of time should be spent improving your health, taking care of your business and finances, improving relationships with people you love, and connecting spiritually with God, the universe or nature (some would say it is all the same but I’m no expert here.)

 

The other deleterious habit I discontinued was reading from my iPad or smartphone at night. As a dad, I know the use of electronic gadgets at night is contributing to poor quality sleep in kids causing them disruption in school and likely the cause of excess diagnosis of ADHD (Attention Deficit Hyperactivity Disorder). Kids need to sleep for better cognition, productivity and lowering the risk of disease. And so do we.

Data shows subjects reading light-emitting devices (e.g., eBook) before sleeping compared with a printed book, took longer to fall asleep, had reduced evening sleepiness, reduced melatonin secretion, later timing of their circadian clock, and reduced next-morning alertness.

 

I firmly believe that prostate cancer prevention and management is successfully improved by better lifestyle, nutritional and behavioral habits. And there is plenty of scientific evidence to prove it.

 

By improving lifestyle, nutritional and behavioral habits, one can optimally live longer – even if after a prostate cancer diagnosis.

Here are suggestions to improve your health with managing blue light exposure:

  • Sleep in a completely dark room. If there is fear of falling when going to the bathroom at night, place a small night light far from your bed.

 

  • Resist the urge of Fear of Missing Out (FOMO). We are easily hooked to our gadget with the FOMO. I recently learned I don’t need to know the score of my New York favorite teams in real time anymore.

 

  • Get into the habit of leaving your smartphone far away from your bed. Control your FOMO.

 

  • If your work hours are late nights, do your best to change your schedule to daytime hours.

 

  • If working nights is what you have to do, consider taking melatonin supplement before going to sleep. About 3mg is good a day, before bedtime is goo.

 

  • If sleep is poor and you have cancer, you may benefit from 20mg of melatonin, but best to see an integrative, functional or naturopathic medicine doctor when increasing the dose of melatonin.

 

  • Give yourself one to two hours of technological shut off time before bedtime. If poor sleep is an issue, consider two to three hours of no blue light before bedtime.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 

 

Part Two: Benign, Non-Cancerous Reason’s why PSA rises

Part one: What is PSA and what it does

Part two: Benign reason’s why PSA goes up

Part three: PSA as a screening tool for prostate cancer

Part four: PSA after prostate cancer treatment

 

More often than not, PSA rises for reasons other than cancer. Still, this biomarker continues to stress men all over the world who get tested for it.

Here are non-cancer reasons why PSA goes up:

  • Ejaculating about 48 hours before the blood draw can cause a false increase in PSA by up to 1.3ng/ml.

 

  • PSA may be higher in smokers compared to non-smokers.

 

  • Inflammation of the prostate, or prostatitis, may cause an elevation in PSA. Symptoms of prostatitis include; pain or discomfort in the perineal area (between the scrotum and the anus), feeling of “sitting on a golf ball,” lower abdominal pain, lower back pain, burning, pain or discomfort after urination and/or ejaculation. Urinary frequency and urgency also appear in men with prostatitis. Treating prostatitis lowers PSA by close to 40%.

 

  • A digital rectal exam (DRE) before the PSA blood draw can increase PSA by 0.4ng/ml, which many physicians think it’s not a big deal. However, when a biomarker like PSA cause so much anxiety when elevated, anything you can do to keep the number low is a good idea, don’t you think? Also, the more vigorous the exam, PSA can go higher than 0.4 points.

 

  • Needle biopsy of the prostate raises the PSA level by seven times its normal value and stay elevated for up to 4 weeks.

 

  • Benign Prostatic Hyperplasia (BPH) or enlarged prostate cause an increase in PSA. One of the best methods to determine if PSA is high from BPH and less likely from prostate is by doing a PSA density. This is a simple calculation where the prostate size, best measured by an MRI, second best by ultrasound, is divided over PSA value. If the result of that calculation is higher than 0.15, the elevated PSA is likely from an enlarged prostate. If it’s less than 0.15, it is likely from prostate cancer. PSA density should not be the only determining factor for prostate cancer diagnosis. Lastly, a group of pharmaceutical drugs called, 5-alpha reductase inhibitors (5-ARI), falsely reduces PSA by about 50%, meaning, that one can harbor prostate cancer and have a low PSA when being on these drugs. Finasteride and Dutasteride 5-ARI’s are the two main drugs used for BPH.

 

  • Riding a bicycle for long distance can increase PSA score by up to 10% by putting pressure on the perineum area close to where the prostate is located. Cycling for short distances may not make a difference. Similar to after ejaculating, it is best to abstain from riding for at least 48 hours before the blood draw.

 

  • Any form of vigorous exercise a day or two before a blood draw may result in a false increase in PSA.

Next week you will learn the use of PSA as a screening tool for prostate cancer and uncover the confusion associated with it.

Last 3 Blog Posts:

What is PSA and what it Does

ADT, Apalutamide, Exercise in the treatment of prostate cancer

Traditional Chinese Medicine treatment for Erectile Dysfunction