BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

The co-authors of Invasion of the Prostate Snatchers, blog alternate posts weekly. We invite you to post your comments.

Tuesday, April 14, 2015

Scare Tactics about the “Symptoms” of Prostate Cancer

MARK SCHOLZ, MD

In this week’s blog I was supposed to finish out the “Helpful Medications” theme started at my last blog. Specifically I need to make a case for using statin drugs and metformin, a generic diabetes drug, to help suppress prostate cancer.  However, that blog has been temporarily postponed in place of the following:

When Ralph and I wrote Invasion of the Prostate Snatchers we knew our highest priority was to calm people down so they could begin to think rationally.  Obviously the word “cancer” freaks everyone out. People get so scared that all rational thought ceases.  They immediately jump into the arms of the nearest doctor who is willing to offer a quick fix.  With prostate cancer that just happens to be a surgeon.

Scare tactics are effective from a business point of view since in business “time is money.” Frightened people act quickly and decisively, thus saving everyone time.  The psychology of fear is also quite commonly used in advertising.  You have heard these mottos and mantras many times before: “Time is Running Out,” or, “Space is Limited.”  No one wants to miss a one-time opportunity.

The threat of losing a one-time chance for cure naturally drives newly-diagnosed prostate cancer patients to act quickly. And there is after all a certain type of logic to people unfamiliar with prostate cancer.  With almost any other type of cancer a delay in treatment will reduce cure rates. Surprisingly with prostate cancer this is only rarely the case. However, the idea of a “harmless cancer” is certainly foreign to us all. It will take some time for newly-diagnosed patients to absorb this unexpected fact.

That’s why it is critically important to encourage men to take time to gather their senses and calm down.  Given some space to reflect they will learn that with prostate cancer they need to weigh the potential for treatment-related side effects against the tiny amount of increased survival surgery or radiation offers in men with low-risk disease.

As noted above, the fears and confusion incurred by a recent prostate cancer diagnosis have a certain type of logic. But what is totally illogical is the proliferation of articles I keep coming across on the internet that purportedly describe the “Symptoms of Prostate Cancer.”  Invariably these articles present a long list of symptoms such as urinary frequency, nighttime urination, slow urination, and blood in the urine as possible indications of prostate cancer.

These articles are completely false! EARLY PROSTATE CANCER ALMOST NEVER HAS SYMPTOMS.  This is why the PSA blood test has been so revolutionary.  PSA can detect prostate cancer before symptoms of advanced disease occur. The most common symptom of prostate cancer—bone pain—only occurs after the disease has spread to the bones. Prostate-related symptoms, when they are present, signal another diagnosis such as prostatitis or prostate enlargement. These prostate problems have nothing to do with prostate cancer. Symptoms such as these may need evaluation and treatment but there is no reason to scare people with the suggestion of cancer.

Competition on the internet has become so fierce that just about any scare tactic is considered acceptable, up to and including bald-faced lying.  But let’s put this falsehood to rest.  The myth that early-stage prostate cancer causes urinary or sexually related symptoms is an exploitative tactic that can lead to all kinds of harm, creating anxiety and fear that results in unnecessary diagnostic testing such as random needle biopsies that lead to the over-diagnosis of low-risk prostate cancer.

Tuesday, April 7, 2015

Robot, Robot, Burning Bright …

RALPH BLUM

If you have read some of my previous blogs you probably will be aware that I am not an advocate of radical prostatectomies in any shape, way or form. But since the robot-assisted laparoscopic prostatectomy (RALP) is the flavor of the month with both prostate cancer patients and their urologists, it seems pertinent to zero in on some of the information you need to know if you are considering this procedure.
 
There is something alluring about the idea a surgeon sitting at an attached console and manipulating a robot’s mechanical arms to perform this highly complex and intricate operation. But if you are under the impression that it is the robot making those small incisions in your abdomen to perform the operation, think again. It is the skill of the surgeon that will preserve (or not) your sexual function by avoiding damaging the miniscule nerves that run along each side of the prostate and control erections.  It is the surgeon’s experience that will (or not) protect the sphincter that allows you to retain urinary control. And it is the surgeon’s expertise that will ensure a positive, long-term outcome.
 
RALP has advantages over other forms of radical prostatectomy in terms of pain, blood loss, and recovery time. No small thing. But keep in mind that any complex surgery comes with risks: the small risk of heart-attack, stroke, blood clots in the legs that could travel to the lungs, reactions to anesthesia, and infection of the incision sites. And because there are many blood vessels near the prostate gland, there is also the risk of prolific bleeding, in which case blood transfusions might be necessary—which carry their own risk. But your risk level depends primarily on your overall health, your age, and the skill of your surgical team.
 
Having said that, I realize how tempting it is to go for closure. But is surgery—robotic- assisted or otherwise--really closure? Statistics show that is debatable.  And in terms of the side-effects that most men are concerned about (urinary incontinence and impotence)  there is little difference between robotic-assisted surgery and laparoscopic surgery performed without the robot. Bottom line, the most important factor with either procedure is the surgeon’s experience and skill.
 
Opinions differ about how many robotic-assisted operations a surgeon needs to perform to become really proficient, but surgeons at community hospitals rarely have sufficient experience. And you do not want to be part of a surgeon’s steep learning curve. Dr. Vipul Patel, of the Global Robotics Institute in Celebration, Florida, appears to be leading the pack having performed some 8,000 robotic prostatectomies.
 
It’s apparently hard to resist the lure of a robot. But any kind of radical prostatectomy is both costly and risky, so don’t let your natural desire for closure blind you to the risks of such a challenging surgery—especially if you are 70 or over.  In fact if you have low-risk prostate cancer and are over 65, you have a 20% chance of dying of cancer in the next 20 years compared to a 60% chance of dying of something else. So buyer beware!

Tuesday, March 31, 2015

Medications for Prostate Cancer that Might Help and Probably Won’t Hurt

BY MARK SCHOLZ, MD

Do we have confidence in our prescription pills?  How can we really know that they are helping?   It partly depends on whether or not there is a benefit.  Fever disappears soon after starting an antibiotic.   PSA declines in men with prostate cancer who undergo hormone blockade.  Blood pressure is better after starting a new blood pressure medication.

We have confidence in these medications because there is a measurable benefit.  Seeing a benefit offsets our suspicions about potential side effects. Medication choices really boil down to a simple equation: balancing the benefit against the risk of side effects.

But sometimes it’s difficult to see the benefit, especially if the medication is being used because of the benefits were only reported in a population study showing and advantage of one group of people over another.  Baby aspirin is a good example. How do you really know that the pill you took today helped you dodge a heart attack?

Science and the Media
Interpreting scientific studies requires skill and training. But these days, the challenge is even greater because scientific studies are primarily reported in the media.  Unfortunately, media experts face tremendous temptations to make their stories more interesting. So they tend to overstate their importance.  As a result the general public is becoming very wary of supposed scientific finding.   

Considering Risk, What about Low Risk Medications that “Might” Work?
Few people have the time or skills to do their own research. But deciding “yea” or “nay” on a new medication can also be based on its perceived risk. If a medication is considered relatively safe, people with a chronic illness like prostate cancer may start thinking along the following lines: “I can’t be sure it will help, but at least it won’t hurt.”  This is a common mindset with vitamins and supplements because they are generally perceived to be harmless.*

Modifying the Down-Side Risks
This “why not” mindset comes into play when considering certain common generic medications that have been on the market so long their potential side effects are well known.  Specifically I am referring to four medications—aspirin, metformin (a diabetes medication), 5-alpha-reductase inhibitors like Avodart and Proscar, and Lipitor (a cholesterol drug).

In previous blogs I have presented arguments in favor of aspirin, Avodart and Proscar. In my next blog I’ll review some of the arguments for using metformin and Lipitor in patients with prostate cancer.

However, in the remainder of this blog I would like to outline an approach for reducing the risk of experiencing serious side effects:

1)     The greatest vigilance is necessary in the first few weeks after a new medicine is started.  When a medication causes side effects they usually appear fairly quickly.

2)     Generally, there is no rush. So why not begin at half dose? If after a few weeks or a month there are no negative side effects, the dosage can be gradually increased.

3)     Medication side effects follow specific patterns. Aspirin, for example, can cause intestinal bleeding.  So patients need to be carefully informed about the significance of any new symptoms of heartburn and the meaning of having black stools should they appear.

4)     Some side effects are only detected with blood tests.  Everyone who starts a cholesterol drug—Lipitor for example—needs to have liver function tested within a month or so.  Liver problems heal quickly if the side effects are detected and the medication is stopped in a timely fashion. It can be dangerous if negative effects persist undetected.       
*Ironically, in the absence of overt deficiency, when vitamin supplementation is subject to careful testing it sometimes has been shown to be deleterious.   Vitamin E is one good example. In a large randomized, double-blind placebo-controlled trial, prostate cancer mortality was higher in the men who took vitamin E compared to those who took a placebo. 

Tuesday, March 24, 2015

Risk

BY RALPH BLUM

Prostate cancer is the most common non-skin cancer in the U.S. affecting one in seven men. It is estimated that there are nearly 3 million American men currently living with prostate cancer and it is still not known what causes the disease. However, here are the main factors that might affect your risk level of risk.

Age
Age is the most significant risk factor. Your risk increases exponentially as you get older. In old age, up to 8 out of 10 men harbor microscopic amounts of the disease in their prostate, live with it, and die of something else. In the opinion of one well-known urologist, “If you are over seventy and you don’t have prostate cancer, chances are you’re a woman.”

A Family History of Cancer
Generally speaking if you have a father or brother who was diagnosed with prostate cancer you are twice as likely to develop the disease compared to the average man, while men with two or more relatives with the disease are nearly four times as likely to be diagnosed. If your relatives were diagnosed before the age of 60, this increases the risk slightly. And the younger the age at diagnosis, the more likely it is you have a faulty gene called BRCA2 in the family. Cutting edge research is ongoing to read and interpret the genetic code of prostate cancer.

Race & Ethnicity
Prostate cancer is more common in black Caribbean and black African men than in white or Asian men. The difference seems to be a mixture of inherited genes and environmental factors. African American men are 56% more likely to develop prostate cancer than Caucasian men, and nearly 2.5 times more likely to die from the disease.

Height & Body Weight
Research has shown that taller men have a higher risk of getting aggressive prostate cancer, or prostate cancer that has spread. And there are a number of studies confirming that men who overeat and who are overweight display increased incidence and aggressiveness of the disease.

IGF-1
Insulin growth factor is involved in the regulation of normal cell growth and death. Some studies have shown that men with a higher level of IGF-1 in the blood have a higher risk of developing prostate cancer. So it is not high blood sugar, but rather the high level of insulin triggered by high blood sugar that stimulates rapid cancer growth.

So what can you do to inhibit prostate cancer growth?  Unfortunately, the days of eating everything you want are over. There has never been a more important time in your life to eat sensibly.  Your diet can no longer be rich in animal fat, processed and fast food and low in fruit and vegetables. We did not evolve and develop to eat this way.  This doesn’t mean you can never have another piece of pizza.  But it does mean that having less than 10% of calories from animal protein can result in a dramatic reduction in cancer risk.

Bottom line, you are not without power in influencing your level prostate cancer risk.