CaPLESS & Prostate Cancer

Sugary Drinks Associated with Cancer

I know many people love drinking soda, especially when paired with a good burger and fries. Or you would never go near soda, but drink tons of fruit juice, because 100% of fruit juice is “better for you.” 

But much like everything in life, too much of a good thing is rarely good, and that is especially true when it comes to our sweet tooth for sugary beverages, even fruit juice.

Study on Sugary Drinks and Cancer

A recent study, by BMJ found a strong link between higher intake of sugary drinks and a higher risk of overall cancer. 

Here, researchers looked at the daily diets of more than 100,000 people, average age 42. They used food questionnaires to collect information on how much the people consumed from a list of 3,300 different foods and drinks. 

In terms of drinks, they examined sugar-sweetened beverages like soft drinks, fruit drinks, 100 percent fruit juices without any added sugar, milk-based sugary drinks, sports drinks, and energy drinks. The researchers also looked at artificially-sweetened beverages, such as diet soda, sugar-free syrups, and diet milk-based products.

The people were then followed for up to nine years. During this time, the researchers looked at the risk of overall, breast, prostate, and colorectal cancer. 

The researchers found that those who consumed the highest amounts of sugary beverages had the highest risks of overall cancer. In fact, a daily increase of just 100 milliliters (a little less than half a cup) increased the overall cancer risk by 18 percent. 

But here’s what’s interesting from this study:  When researchers looked only at the consumption of 100 percent fruit juices, they found a higher risk of overall cancer and breast cancer. Other research has shown a similar sugar-cancer connection. For instance, a  study in the Sept. 28, 2018 issue of the British Journal of Nutrition showed that consuming sugar from sugar-sweetened beverages was associated with a higher risk of prostate cancer among almost 23,000 men. 

Why are sugary drinks so bad? 

The researchers in the BMJ study speculated that too much sugar affects health markers like visceral fat (fat that is stored deep in the abdominal area), blood sugar, and inflammation, all of which have been linked with higher cancer risk.

Plus, other studies have shown that a high intake of sweetened drinks increases the risk of obesity, type 2 diabetes, and cardiovascular disease. 

My advice: leave out sugary drinks from your diet. They are not worth it. One exception is after a hard, vigorous workout. Sometime in that situation, you crave juice.

I always recommend eating the whole fruit (or vegetable) over just drinking the juice.  Fruits and vegetables are loaded with hundreds of protective phytochemicals that can help fight inflammation and free radicals linked with cancer. 

This doesn’t mean that juices are entirely off-limits. Yet, when you do crave juice, always opt for freshly squeezed. 

Of course, juicing can be labor-intensive and somewhat expensive, depending on the produce you use. But there are ways to add more natural health-boosting and cancer-fighting juices to your daily diet. For example:  

Here’s what you can do.

Buy fresh juice. Many health food stores sell freshly squeezed organic juices. If you want to make your own invest in a  good juicer. Prices can vary, but I’ve found good ones for about $300. Make sure they are easy to use and clean. 

Use organic whenever possible. You should especially buy organic for the following produce: apples, celery, spinach, and cucumbers. These often have higher residues of pesticides. 

Begin with more appealing vegetables. For vegetable juices, begin with more pleasant- tasting options, like celery, cucumbers, and not too many carrots (carrot juice is high in glycemic index.) Add an apple to give it some sweetness – but just one apple.

Drink now—or store for later. I like to make batches of juice. Fill a glass jar to the top and then seal with an airtight lid. (Mason jars work great.) There should be a minimum amount of air as oxygen will “oxidize” and damage the juice. Store in the refrigerator and drink within 24 hours. 


Mushrooms Protect Against Prostate Cancer

[Edible Fungi Chart from The New Student’s Reference Work, 1914. Source: Wikimedia Commons]

I love mushrooms. They are one of the most underrated foods, in my opinion. Mushrooms are flavorful and versatile. They can be grilled, sautéed, roasted, and eaten raw.  And on the nutritional side, they are packed with many vital nutrients.

This is why I was particularly interested in a recent study that suggested mushrooms may help reduce the risk of prostate cancer. 

Mushroom Reduce Prostate Cancer Risk

The study, published online Sept. 4, 2019, by the International Journal of Cancer, got much buzz because of its simple message: more mushrooms equals less prostate cancer. 

Here is a look at what the study showed and what it means in the context of prostate cancer prevention. 

Japanese researchers recruited more than 36,000 men ages 40 to 79. They collected detailed health information, including physical activity, smoking and drinking habits, family and medical history, and diet. For the diet information, the researchers recorded how much and how often they consumed 39 specific foods and beverages. The men were then followed for a period ranging from 13 to almost 25 years. 

Afterward, the researchers found that men who consumed mushrooms once or twice a week—an average of about 3 ounces per serving—had an 8% lower risk of prostate cancer compared with those who ate no mushrooms. When men ate mushrooms three or more times per week, their risk dropped to 17%. 

The researchers noted that mushrooms contain high levels of an amino acid called ergothioneine, which works as a powerful antioxidant and may play a factor in fighting cancer. 

The study only showed an association and not cause and effect, yet the findings still stand out because they included such a high number of men that were studied for up to 25 years.

White mushrooms Reduce Prostate Cancer Recurrence.

Also, this is not the first study to show a connection between mushrooms and prostate cancer. Research in the September 2015 issue of Cancer found that taking white mushroom powder helped men reduce the risk of PSA recurrence after treatment for prostate cancer.  

So what does this mean? I’d argue that it appears mushrooms may play an essential role in prostate cancer prevention and co-management.

My advice is to enjoy mushrooms both in food and in quality dietary supplements whenever you can. Shitake, oyster, maitake, and king oyster mushrooms have the highest concentrations of ergothioneine, according to the Japanese study. 

Ganoderma or Reishi Mushroom

I frequently prescribe reishi mushrooms to my patients with prostate cancer. One meta-analysis found that people who added reishi extract to their regular anti-cancer regimen were 1.27 times more likely to respond to chemotherapy or radiotherapy than those who did not take the extract. The scientists believed that reishi may stimulate immune cells and help create a powerful microenvironment that is more hostile to cancer.

Another popular anti-cancer therapy in Japan for immune strengthening is the fermented mushroom extract active hexose correlated compound or AHCC*

Dietary Supplements with Medicinal Mushrooms

A dietary supplement with Reishi mushroom I formulated and recommend is ImmunoPCTN*.

I also recommend AHCC *for many patients.

Lastly, a plant protein I use made from pea and brown rice protein is ImmunoProtein*, which also contains a variety of mixed mushrooms in powder form.

[Disclosure: I am co-founder and Chief Medical Officer at XY Wellness.]


Body Fat, not only Weight or BMI, Linked to Prostate Cancer

[Image from recent CaPLESS Retreat]


Where your extra fat lies in your body may predict the seriousness of your cancer.  

One of the first areas I address with my patients is fat management, and how important it is to lose excess weight from fat, if needed. 

The reason? Fat gain is not only linked with a higher risk of prostate cancer but can make your cancer grow and spread more quickly. Extra weight increases inflammation in the body, which acts as fuel for cancer cells.  This is why proper diet and exercise is the cornerstone of the CaPLESS Method. 

Yet, a new study published in the journal Cancer looked closer at this link between prostate cancer and weight gain and found that fat distribution, that is where your excess fat lies may determine the seriousness of your cancer. That’s right! It’s not only a matter of having extra layers of fluffy tissue around the body but the location of the fat matters.

Research from the Harvard T. H. Chan School of Public Health recruited more than 1,800 cancer-free men from Iceland  and measured their abdominal and thigh fat with CT scans. Measurements were also taken of their waist and their body mass index (BMI), which estimates a person’s risk of obesity using height and weight.

After about 13 years, approximately 170 men got prostate cancer. Those with larger waist size and higher BMI number had greater risks of both advanced and fatal cancer. 

No surprise there. But exactly where their extra fat was stored increased their risk even more. 

The researchers found that a build-up of visceral fat—the fat that lies deep in the abdomen and surrounds the major organs—and subcutaneous fat—the pinchable kind that lies just under the skin—were both linked with worse cancer outcomes.  

Specifically, each unit increase of visceral fat was associated with a 31% higher risk of developing advanced prostate cancer. Each unit increase of subcutaneous fat in the thigh was associated with a 37% higher risk of dying from prostate cancer. 

But what I thought was most interesting was that the fat-cancer connection was strong even among those with a low BMI. In other words, even men with a normal BMI—which suggests they were not clinically overweight—were still at risk for aggressive prostate cancer because of where they carried their fat. 

What does this mean for you? 

For the longest, I’ve clinically  noticed that measuring BMI is not enough to determine patients health status. Sometimes patients have low BMI but high visceral fat. Such patients are called “skinny fat” – they look skinny but hold excess fat on their bodies..

There are three ways of reducing visceral fat, interval exercise, and weight resistance movements, eating clean, and intermittent fasting.

Interval exercise is simply alternating short bursts (approximately 30 seconds) of intense activity with longer intervals (one to three minutes) of less intense activity. 

Weight resistance is the action of pushing and pulling weight against force. You can use machines, your own body weight, resistance bands or free weights. You would want to graduate to free weights at some point as that form of exercise stimulates stabilizing muscles.

Intermittent fasting can mean anything from not eating for 16 hours and consume all your food within 8 hours to fasting two days a week and eating for the remainder 5 days. The goal is to abstain from eating macronutrients (carbs, fat and protein) for a prolonged period of time. You can have water, tea, and coffee (no milk or sugar).


Exercise prescription for prostate cancer

It has been my research and clinical experience that Four to Six hours a week of a mix of moderate to high-intensity exercise is required for men diagnosed with prostate cancer. And this goes for any stage of disease including while undergoing any medical treatment including Androgen Deprivation Therapy (ADT). 


Make it happen!


Spending Time in Nature is Healing

No matter where you are with your prostate health—from monitoring your PSA to undergoing treatment—dealing with this new chapter of your life can be stressful. 

And any extra stress can make your situation even worse.

Extreme stress can flood your body with inflammation, which creates a fertile environment for prostate cancer to grow and spread. Stress can also weaken your immune system and make it harder for it to find and fight cancer cells.

Stress also raises your risk of anxiety and depression, which can make managing your prostate cancer more of a challenge since you are less motivated to follow your regular healthy behaviors like eating right and exercising.

This is why stress management is one of the foundations of my CaPLESS Method. Anything that can help control stress is a winner. 

Thankfully, there are many proven ways to reduce stress—from exercise to meditation to listening to music. Yet, two recent studies found that another easy stress-buster is to simply hang out with Mother Earth for a while. 

And the great news is that you don’t have to be Mr. Outdoorsman and spend long weekends camping in the woods or hiking mountains to bask in nature’s healing powers. 

Study #1: Being in Nature Lowers Stress Hormones

The first study found that connecting with nature can lower stress hormone levels. 

But what I found most interesting was that you don’t need to devote much time to your nature outing—20 minutes can do the trick—nor does the environment matter as long as you find it appealing. 

Over an eight-week period, the researchers had people spend at least 10 minutes, three days a week, in an outdoor venue of their choosing, such as  backyards, parks, and urban green areas. 

The people also refrained from any physical or emotional stimuli beforehand, like exercise and engaging in social media. 

Saliva samples were taken to measure levels of the stress hormone cortisol. The researchers found that those who spent at least 20 to 30 minutes in their nature setting saw their cortisol levels drop the most. After that time, the stress-reduction benefit declined. 

Study #2: Being in Nature Improves Health & Wellbeing

The second study had a similar conclusion and found that spending at least two hours a week in nature was linked with good health and well-being. Like with the first study, this one also showed that the benefit peaked by a certain time (in this case, two hours total per week). 

Another bonus: It didn’t matter how you got in those two hours either—one long visit or several shorter ones. 

Implementing the Conclusions of These Studies

Of course, nature spots are not always readily available, so take what you can. For instance, I live in a city (well, the outskirts of New York City) so being in nature can be tough. Still, there are parks everywhere. There’s one five minutes from my house. While I don’t yet spend two hours a week there, any time I can visit is time well spent.  

Taking a nature personal day is also good. I spent the 4th of July holiday on the beach and I felt awesome in that environment even if it was just for the day. 

You could also try to pair your nature time with workout time. When you exercise outside, you get the best of both worlds. And if you do this with someone else, or a group, you connect more with other people, which has health benefits of its own.

So when you need a stress break, spend some quality time with a favorite nature spot. It’s a small effort with a big reward.


Red Meat & Prostate Cancer: What the Science Really Says!

I’m going to cut to the chase. (I think there’s a pun here :))

Eating red meat does NOT cause prostate cancer and does NOT make prostate cancer worse after diagnosis.

But there’s a caveat.

Here’s what you need to know:
  • Processed meats, maybe due to nitrites in them used as preservatives, can increase prostate cancer risk and progression. Limit cold cuts, hot dogs, sausage and the like.
  • Eating overcooked red meat can increase prostate risk and progression likely due to the heterocyclic amines formed from high heat exposure.
  • When you can, eat grass-fed, organic meat, though no studies to support eating this type of meat is protective against prostate cancer. Grass-fed meat is more nutrient dense than conventionally, grain-fed meat, however.
  • You DO NOT need to eat red meat for any reason whatsoever. It’s not necessary for health maintenance or cancer protection. One exception might be in patients losing rapid weight from cancer progression. Red meat is high in glycine which may prevent muscle wasting.

Bottom line: It’s OK to occasionally enjoy a good medium rare steak if you want to. No pressure. It’s a matter of preference. And when you do have it grass-fed, organic when available – then add rosemary.

Bon appetite. 
Related Posts:

2019 Dirty Dozen list & On Eating Organic Foods

New 2019 Dirty Dozen list

The Environmental Working Group (EWG) recently announced the 2019 Dirty Dozen list.

The EWG dirty dozen are those fruits and vegetables most contaminated with pesticides and herbicides that might be harmful to your health.

The biggest surprise here is Kale, now part of the dirty dozen, meaning, if you want to eat kale, eat it organically.

Chemicals used in pesticides for Kale are possible carcinogens.

Here’s the list from the EWG.

Organic vs. Natural

Unlike the word “natural” which is not regulated, the label “organic” is. Congress passed the Organic Foods Production Act in 1990, which led to the National Standards on Organic Agricultural Production and Handling rule in 2000. Today the organic industry is regulated by The National Organic Program (functions within the USDA).

So, when a food is labeled “organic,” it has been deemed so through a federal approval process that regulates the food so that it has;

  1. no genetic engineering (no GMO)
  2. no synthetic pesticides or fertilizer
  3. no antibiotics or growth hormone and
  4. has not been irradiated

The word “natural” when applied to meat, poultry, and eggs, is regulated by the United States Department of Agriculture (USDA) stating that a “natural” food contains no artificial ingredient or added color and is only minimally processed.

“Natural” in meats, poultry, eggs, etc does not mean hormone or antibiotic-free.

The “Organic” label for livestock products means the food they eat is organic (as defined above) plus with the freedom to move around, have access to fresh air and sunlight.

Here’s the catch; you can eat organic beef where the animal’s feed before sacrificed for food eats organic corn and soy, not grass.

The best diet for cows is grass and hay, not corn and soy, even if organic.

That’s why the best source of beef is that from grass-fed, not only organic.

Are Organic Foods Worth the Extra buck?

The higher cost for organic foods might be worth it, but it can be up to 80% more than conventional foods.

The organic food market in the United States hit $45.2 billion up from
$26.7 billion in 2010.

But let’s get right to the point; is organic food better, yes or no?

I think the answer is yes and no.

Allow me to explain.

The word “Organic” unlike the word “Natural” actually means something in food production.

Foods containing plant-derived substances like sweeteners, for example, can be labeled natural. List of “natural” labeled foods include; highly processed high fructose corn syrup (HFCS)  and foods containing genetically engineered or modified (GMO) ingredients. Although far from an exhaustive list of what can be labeled a “natural” food, these are a few examples of how “natural” may mean something different than you think.

Organic food is seemingly more nutritious; contain more protective antioxidants, contain 4 times fewer pesticides and lower amounts of unhealthy metals like cadmium.

While not everything that’s labeled organic is healthy or local, buying organic produce, especially the dirty dozen foods (really dirty 15)  may be worth the extra buck.

Like I tell my patients;

Don’t be cheap with your food.

OK, that’s nice that organic food has more anti-oxidants and less unwanted chemicals in them, but is it healthier for you?

Yes, it is.

Studies show organic food reduces the risk of cancer

A recent study from the Journal American Medical Association (JAMA) showed an association with less cancer risk and the consumption of organic foods.

This study looked at close to 70,000 adults for nearly five years and showed that those who ate more organic foods had a  25% lower risk of getting cancer.

Three possible culprits were discovered to be associated to cancer risk in pesticides used to spray food crop: glyphosate, malathion, and diazinon.

My Thoughts on Organic Foods

While I promote the consumption of organic food, mainly fruits and vegetables, not all organic food is good for us.

For example, organic packaged dry products such as cookies, and breads, etc. are still crappy foods.
Bad food is bad food – it being organic does not always make it healthier.

Here are some helpful tips:

  • Eat local foods from nearby farms or farmers markets if they are local and organic – great. If foods are not labeled organic, it still might be, but small farms are reluctant to play the political “organic” game.
  • Don’t be fooled. Just because something is organic doesn’t necessarily make it better for you. Packaged organic products are NOT healthier.
  • Real organic foods – are natural foods (right from nature), with organic farming practices and if possible, from a local farm.
  • Eat good quality, wild caught fish as the primary animal source
  • With vegetables, organic is certainly better. But, don’t use this as an excuse to avoid non-organic vegetables. If for whatever reason you don’t have access to organic vegetables, non-organic vegetables are better than no vegetables
  • Eat the top “dirty 15 foods” organically, don’t worry much about the others.
  • Again, don’t be fooled. Just because something is organic doesn’t necessarily make it better for you. Packaged organic products are NOT healthier. Fruits and vegetables are.







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 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.


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.


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)


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.