Prostate cancer: desicion making in younger men

Here’s a new study highlighting the decision making process in younger men diagnosed with low risk prostate cancer:

493 prostate cancer patients, Gleason 6, 50 years old or younger, responded to questionnaire’s to determine what treatments if any were undertaken and why.

All men involved were diagnosed between 2001 and 2005.

Results:

• 397 (81.4%) chose surgery
• 52 (10.7%) chose radiation
• 26 (5.3%) chose Active surveillance (AS)

 

Main points of the study

Young patients actively seek information from multiple information sources and multiple physicians before ultimately deciding on their therapy. Men with higher education and income consulted an increased number of physicians while making a decision.

The information sources used by the participants were primarily urologists. Secondarily, the internet and consulting with family and friends were common sources of information.

Non-married men in this study found treatment-related decisions more difficult to make and were more worried about their decision, further highlighting the importance of social support.

Urologists typically recommend surgery in young men with prostate cancer due to their long life expectancy and the assumption that this offers the best chance of long-term cure. The most common reason patients chose surgery was the perception that it provided the best chance of cure, similar to studies in older patients.

Surgery was discussed as a treatment option in 99% of cases, brachytherapy (seed implantation)  external beam radiotherapy, and AS were discussed in only 88%, 78%, and 75% of cases, respectively.

Physicians recommended against AS in 75% of cases.

Previous data indicate that prostate cancer patients in their 60s fear incontinence more than impotence. (Ha! They have not met my 60 year old plus patients). Not surprisingly, this study revealed that younger patients placed more importance on sexual function than urinary function when choosing treatment.

Finally, despite the distress associated with being diagnosed with prostate cancer at such a young age, there was an overall very high satisfaction rate (89%) with their treatment regardless of the therapy chosen. (Sidana et. 2012)

 

My Take On This

 

Active Surveillance (AS) is a viable, safe and feasible approach to prostate cancer in men 65 years and older there is plenty of scientific data with 10 to 15 year follow up that shows this (Klotz et al 2009,  Carter et al. 2007, DallEra et al. 2008).

Is AS a reasonable option for men with low-grade disease under 60?

This is a matter of opinion since a conclusion has no objectively been reached – so I will give you mine.

First of all, let’s define AS:

In the past, the term used was watchful waiting which means no treatment until the development of metastatic disease, at which time androgen ablation (hormonal) therapy was initiated.

AS means that men undergo periodic evaluations including PSA tests, digital rectal examinations, and prostate biopsies. If there is evidence that the cancer is progressing, treatment is recommended with the intention of curing the disease.

What’s considered low risk?

There is no unified consensus at this point of what is low risk disease. A general definition used among urologist includes: a PSA of 10ng/ml or less, Gleason of 6 or less, a third or less of biopsy cores positive and 50% or less involvement of any 1 core.

 

AS vs. Active Holistic Surveillance (AHS)

 

AHS is a term Dr. Aaron Katz and I coined when I was at Columbia University Medical Center researching on naturopathic and holistic treatments for prostate cancer. AHS proposes the idea that if prostate cancer patients exercise, eat correctly and consume certain supplements, this can slow down the progression of the disease. Side benefits to an AHS approach are better heart health and improvement quality of life.

Dr. Dean Ornish study

Ornish and his team looked at 93 men with early biopsy-proven prostate cancer who volunteered to forgo radiation, chemo and surgery. He then randomized the cancer patients into lifestyle modification group, which included a strictly plant-based diet along with other healthy behaviors such as walking 30 minutes six days a week, or a control group which just watched and waited.

By the end of the year-long study, six of the control group patients (those not in the lifestyle group) had dropped out because their tumors were growing.

MRI’s or diagnostic tests of cancer activity showed that their tumors were growing at such a rate that they decided they could wait no longer and opted for a combination of radical surgery, chemotherapy or radiation.

Not one of the lifestyle diet group suffered the same fate. In fact, while on average cancer activity increased in the control group, as measured by PSA tests, the cancer markers DECREASED in the lifestyle modification group. By the end of the year the cancer growth rate, as measured by these tests, was highly significantly different between the two groups. (Ornish et al. 2005)

This is the first randomized trial showing that the progression of prostate cancer can be stopped or perhaps even reversed by changing diet and lifestyle alone,” Ornish told the Washington Post.

 

Let’s bring it home

Younger patients with low risk disease should at least consider an AHS approach despite of the fact that most participants in the Sidana et al. study were satisfied with their decision. Human nature dictates that people are more likely to be satisfied with decisions they have made themselves, and this forms one of the key elements of cancer survivorship. This is known as “avoidance of cognitive dissonance” in psychology.

There are some challenges that come with this:

• Not too many urologist are on board with this approach
• Most urologist will strongly recommend surgery because of your age
• Your personality may not be able to handle the psychological burden that comes with knowing you have the “C word”
• Many urologist will suggest a yearly biopsy regardless of the results of other parameters like PSA kinetics and physical exam
• Biopsies do not come without risk

Here’s the deal. It’s is your body. You need to be an active participant in this process. If your urologist is not cooperating with you – fire them and get another. There are about 11,000 urologists in the US. Regardless of all the statistics that are thrown at you, there are very few definite’s with prostate cancer in younger men. There’s still much we don’t know.

Also, some may find AHS to be too hard. At some point soon I will write details about this approach. But for now, it consists of a plant-based diet; high in fish and lean protein, low-simple carbohydrates, exercise with moderate intensity and smart supplementation. It’s not too hard. Living with disease is too hard. AHS surveillance is not a diet or a fad; it’s a lifestyle that improves your overall wellness.

I’m not suggesting the science with AHS is conclusive. It’s not. But the evidence that does exist supporting the different components of holistic approaches for prostate cancer cells is compelling.

Lastly, there are numerous focal therapies under investigation that will possibly be an option sometime in the near future. One of them is HIFU, for example.

 

So if you’re newly diagnosed prostate cancer patient under 50, what should you do?

 

• Consider all your options

 

• Take your time –  there’s no rush. This is likely the biggest decision of your life

 

• Talk to at least 3 urologist. If possible, try to see one affiliated to a reputable academic institution like Mayo clinic, Cleveland clinic or NYU

 

• Know that all practitioners have biases – including me. Surgeon’s, especially younger ones want to operate. Radiation oncologists like to radiate, etc. My bias is naturopathic and holistic treatments for the right patient or together with medical treatments.

 

• Consult with your family and friends. However, this is sometimes counter productive because your loved ones will likely be emotional in their advice and they may not understand the significance of low-grade prostate cancer  all they hear is “cancer.”

 

• Analyze the pro’s and con’s of all treatments combined with what’s important to you. If you live in the US and are financially able to, consider HIFU – at this point people pay out of pocket ( about 25K).

 

• After you have analyzed, shut your brain and spend some quiet time for about 1 week “ no more reading on prostate cancer and treatment options. The answer to what’s the best treatment will come to you

 

• Once you commit to a treatment be committed – 100%.

 

• Always seek a doctor that practices naturopathic or nutritional medicine despite your treatment of choice. Your outcomes will be much better. Your quality of life will be extraordinary.

 

Stay tune for more on topics like this.

 

References:

 

1. Klotz, L. et al. Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J. Clin. Oncol. 28, 126–131 (2009).
2. Sidana A, Hernandez DJ, Feng Z, Partin AW, Trock BJ, Saha S, Epstein JI.
3. Treatment decision-making for localized prostate cancer: what younger men choose and why. Prostate. 2012 Jan;72(1):58-64. doi: 10.1002/pros.21406. Epub 2011 Apr 25.
4. Ornish D, et al. 2005. Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology. 174:1065-70.
5. Carter, H. B. et al. Expectant management of prostate cancer with curative intent: an update of the Johns Hopkins experience. J. Urol. 178, 2359–2364 (2007).
6. Dall’Era, M. A. et al. Active surveillance for the management of prostate cancer in a contemporary cohort. Cancer 112, 2664–2670 (2008).

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