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

Tuesday, October 14, 2014

Avodart & Proscar


Frequently I am asked about Proscar and Avodart, two medications that are FDA approved to reduce urinary side effects from prostate enlargement (BPH).  It turns out that these medications have a much wider spectrum of application than simply treating BPH. They function by blocking a type of testosterone called dihydrotestosterone (DHT) that occurs primarily inside the prostate. A short blog can’t summarize this vast field.  However, I think even a brief review might be helpful.  Here is a list of their potential applications:
  • Lower the risk of being diagnosed with prostate cancer
  • Improve the detection rate of high-grade prostate cancer
  • Cause Gleason 6 cancer to regress or be suppressed
  • Synergize with other hormone therapy medications (such as Casodex)
  • Help maintain men on active surveillance to avoid surgery or radiation
  • Prolong the “holiday period” in men on intermittent hormone therapy
  • Reduce male pattern baldness
  • Delay orgasm in men with premature ejaculation

The occasional side effects that can occur, such as reduced libido, impotence and breast enlargement, are manageable or preventable as long as the medication is stopped in a timely fashion when side effects occur.

In a randomized study comparing Proscar with placebo, 10,000 men underwent a prostate biopsy. The Proscar-treated men were diagnosed with cancer 25% less frequently compared to placebo. However, enthusiasm for the routine use of Proscar to prevent cancer was dampened when the same study reported a 1% increased incidence of diagnosing high-grade prostate cancer. Even though many experts hypothesized that Proscar was increasing the detection rate, not causing high-grade disease, Peter Scardino, a prominent urologist from Memorial Sloan Kettering published an opinion that Proscar could be causing high-risk cancer, raising all kinds of consternation and inciting the FDA to place a warning. Fortunately, subsequent follow up published in the August 15, 2013 issue of the New England Journal of Medicine showed that after 18 years of observation there was no increased prostate cancer mortality from Proscar.

Much of what is known about Proscar can also be said about Avodart. Both agents block 5- alpha reductase (5-AR), an enzyme that converts testosterone into DHT.  A possible advantage of Avodart is that it blocks two of the three forms of 5-AR whereas Proscar only blocks one.  No clinical trials, however, have been performed to compare clinical efficacy of the two agents.  In our in-house trials we have found that DHT blood levels are lower with Avodart than Proscar.

Since both Proscar and Avodart lower PSA by about 50%, the question arises, “Are they masking the capacity of PSA to signal cancer progression?”  Briefly, the answer is no. These medications do not stop a PSA rise in men with progressive cancer. However, after starting Proscar or Avodart the PSA baseline does reset 50% lower. On average, a man with a PSA of 6.0 before starting Proscar will drop to 3.0 within a few months. Subsequently, if the PSA rises consistently above 3.0, cancer progression should be entertained as a possible cause.

The rationale for concluding these agents are beneficial when added to other hormonal agents is based on the known fact that no pharmaceutical drug by itself can totally eradicate or block testosterone. So logically, the addition of a nontoxic 5-AR inhibitor to further lower DHT is likely to be helpful. Studies show that these agents suppress PSA in men with relapsed disease, delaying the rise in PSA, on average, for a couple of years.  It has also been shown that these agents can double the duration of the “holiday period” in men on intermittent hormone blockade.

Proscar and Avodart—mild agents with mostly reversible side effects—almost never interact with other medications.  They can be taken anytime of the day, with or without food. Proscar is available as a generic called finasteride and is very affordable. There is certainly an important role for these well-tolerated medications though in this era of new, high-powered hormonal agents such as Zytiga and Xtandi, Proscar and Avodart often get forgotten.  

Read another Prostate Snatchers blog written on Avodart & Proscar here:

Tuesday, October 7, 2014

How to Cope with a Prostate Cancer Diagnosis


There is no easy way to receive the news that you have cancer of any kind, but—and I cannot say this too often‑—it is important to realize that prostate cancer is typically not a death sentence. The majority of men diagnosed with prostate cancer have Low-Risk disease and will live a normal life span. And even more aggressive High-Risk type is now being successfully treated with a combination of therapies.

Having said that, a diagnosis of prostate cancer is daunting, and once you join the ranks of the newly diagnosed, you enter into what Mark calls “a medical minefield.”  While you are still reeling from shock you are required to make treatment decisions that can permanently affect your quality of life, and there are no easy answers. There are, however, a few basic things to bear in mind while you navigate the prostate cancer minefield.

1)    Don’t waste energy asking yourself, “How did this happen? Did I bring this on myself?” Because regardless of your lifestyle—eating habits, exercise regime, or anything else that might contribute to getting this disease—you did not cause it. Prostate cancer is incredibly common. Like diminished sight and hearing, it comes with advancing age.  In the words of one prostate oncologist, “If you are over seventy, and you don’t have prostate cancer, chances are you’re a woman.”

2)    Stay as calm as possible. The very process of gathering the information necessary to make an informed decision can be scary. But do not be panicked by all the numerical tables, statistics and graphs. Statistics measure populations. You are not a statistic. You’re a person. And statistics and pathology reports do not take into account all the variables and intangibles that make you an individual.

3)    Be proactive. The days of the passive patient with a “Whatever-you-say-Doc” attitude are over. The single most influential decision maker when it comes to obtaining the best care and treatment is you. Do your own research, and become actively involved with your doctor in the decision-making process. Ask your doctor about all your treatment options, and make sure you understand their short-term and long-term side effects.

4)    Recognize and resist your natural desire to rush into radical treatment. Be aware that a combination of the urologist’s preference for surgery and most men’s “just get it out” attitude, leads to tens of thousands of unnecessary radical prostatectomies every year. These men would have lived just as long without surgery, without the risk of losing both potency and normal urinary function and greatly compromising their quality of life.

5)    Even if you are satisfied with your urologist, it is critically important to get a second opinion, preferably from an independent board-certified medical oncologist—a cancer specialist—and if possible, an oncologist with a specialty in prostate cancer. Obtaining a second opinion doesn’t imply that you don’t trust your doctor. On a decision this important, you owe yourself the benefit of more than one person’s thinking.  Be prepared for conflicting opinions, and remember to trust your instincts about which doctor is right for you. Finding the right doctor may require traveling to a major cancer center to talk with a leading edge specialist.
Above all remember: if you are diagnosed with Low-Risk disease you do not require any immediate radical treatment. You can be safely monitored with “Active Surveillance.” When you are watched closely, treatment can be safely delayed until there is some sign of progression.
Even then, the cancer will still be manageable. Multiple studies clearly show that survival rates of men on Active Surveillance match those of men getting immediate surgery. Also, be particularly careful if you are in your 70s or 80s.  Men in this age group are rarely at risk of disease that will be clinically significant in their lifetime, and these men have the highest incidence of overtreatment. As you start out on your prostate cancer journey, be very aware that overtreatment of this disease is rampant, and do not become a needless victim of unnecessary treatment.

Tuesday, September 30, 2014

Too Many Pills


It’s a painful reminder of failing health to be taking handfuls of pills every morning. Frustration mounts and the question often arises, “Are these pills really necessary?” Have I become the victim of a multibillion dollar medical establishment?

It’s logical to have questions. After all, what happens when your pills are stopped for a couple days—usually nothing! One can’t help but wonder, maybe some of these pills are necessary but all of them?  There must be some “extras” in there someplace. And what about interactions? Some patients intuitively suspect the human body has a maximum pill quota—they believe exceeding that maximum must be dangerous.

As a practicing physician, I have conversations about “too many pills” all the time. It makes me think of the movie Amadeus when the Emperor Joseph complained that Mozart’s music had, “Too many notes,” he said,” just cut a few and it will be fine.”

Patients often don’t understand the reason for their medications. Everyone agrees that the game of selecting medications is played by balancing benefits with risks. But this type of analysis requires homework beyond most people’s capability.

Yet when people unquestioningly defer to their doctor they feel powerless. They often have second thoughts.  Sometimes they feel resentment. Managing one’s health is a really high-stakes game. How can one attain greater peace of mind?

Bill Clinton famously stated, “Character doesn’t matter.”  But character is all we have to go on when we appoint a leader to make important decisions on our behalf. So actually, the opposite is true.  Character is very important.

While no human is perfect, physicians (and politicians) need to be held to a higher standard because in their position of power mistakes are much more damaging.  It may seem obvious to state, but the best way to find peace of mind is to look for a physician with exemplary character.

Making accurate character judgments is challenging, but for most of us, the alternative of running our own medical care is practically unattainable. I don’t mean to impugn doing some background medical research to take your conversation with the doctor to a higher level. But God forbid you discover in the course of your conversation that you know more about the subject than your doctor. Is there any revelation of character deficiency more devastating than that?

You can’t place all your trust in an Ivy-league degree or a Beverly Hills address. It’s the overall picture of the physician’s character that matters most. What type of people does the doctor hire for his office? What kind of doctors does he refer to?  Does his billing department behave in an ethical manner? Does he respect your time?   Does he listen to your questions? Realize that people can justify just about any kind of behavior if they consider themselves more important than you.

All of us practice character analysis in our daily life. Some of us are better judges than others. Ask friends or family members to come with you to the doctor visit and get their opinions as well. My co-author Ralph Blum who successfully dodged the prostate snatchers for twenty years has stated many times, “Patients must trust their instincts about their doctor and be willing to act on them.”

Tuesday, September 23, 2014

The Billion Dollar Question: Aggressive or Not?


The billion-dollar question facing the approximately 240,000 men in the U.S. diagnosed each year with prostate cancer is: Do I get treated? Or not?

Overtreatment of prostate cancer is both a major problem and extremely costly both financially and physically.

Financially, because of the high cost of radical treatments and physically because most treatments can cause unpleasant and long-lasting side effects. Overtreatment was also the most important driver of the 2012 decision by the United States Preventive Services Task Force to recommend against routine screening for prostate cancer. Approximately 30-40% of men who have previously undergone surgery or other radical invasive treatment likely had indolent, slow-growing tumors that would never have become a threat to the man’s lifespan or health.  However, there is hope.

At the AACR-PCF conference in January 2014, Dr. Matthew Cooperberg, a urologic oncologist at the University of California, San Francisco (UCSF) warned, “If we don’t fix the problem of prostate cancer overtreatment, we will lose screening.” And losing screening would almost certainly mean more prostate cancer deaths—reversing a nearly 45% decline in mortality rates since screening started.

The crux of the problem is the supposed uncertainty about the accuracy of current predictors of tumor aggressiveness, leading physicians and patients alike to opt for a better-safe-than sorry approach that in turn results in extensive overtreatment. However, the vast majority of prostate cancers do not change their stripes. Cancers that appear to be slow growing when diagnosed are unlikely to cause serious problems during a man's lifetime. On the other hand, cancers that appear high-risk at diagnosis are indeed more likely to behave aggressively. So identifying them remains vital in deciding whether to treat or not to treat.

Some physicians and researchers are currently combining this clinical information with genetic information. Adding biomarker tests to clinical predictors further improves the identification of which prostate cancer patients could undergo Active Surveillance versus immediate treatment.

Now that Active Surveillance is a valid and safe way to treat low-risk prostate cancer men should not shy away from PSA screening.  We can’t return to the era prior to PSA screening.  Back then half the men diagnosed had cancer that was already outside the prostate.