Prostate Snatchers

The Legacy of the Saber Tooth Tiger: A Few Unkind Words About Stress

2012-03-06T09:24:00.000-08:00

BY RALPH BLUM

Whatever the problem—heart, cancer, diabetes—stress is arguably Public Enemy #1 for half of what ails this nation. And when it comes to immune system health, stress rings cash registers. Advertising budgets dedicated to pushing the stress button are worth what Ted Turner would call “serious cash money.” The root briar of an estimated 20 billion dollar a year volume of advertising, stress is Big Business.

It is now more or less common knowledge that the most potent immune system suppressor is stress. Especially chronic stress—the kind suffered by all of us from the moment are diagnosed with prostate cancer. So manufacturers of specialty foods, supplements, herbs and minerals are climbing onto the bandwagon and claiming that their products are “immune system boosters.” However, if you look carefully you will see that 90% of their claims are laced with hedge-your-bet qualifying terms like “might,” “perhaps,” “could” and “can sometimes.” This is the stuff that scams are made of these days.

So when you don’t know whether your job is being abolished, and you are seeing your savings dwindle to nothing, and your anxiety over your children’s future is keeping you awake at night, and then, on top of all that, you are diagnosed with prostate cancer, how can you hope to cope with this kind of chronic stress barrage? What can you do that will genuinely assist your immune system to function efficiently?

The three tried and true stress busters are simple enough. They are diet, exercise, and meditation. You don’t have to pump iron or run marathons, or subsist on tofu, berries, and leafy greens. But in order to fight cancer successfully, you do need to eat a healthy diet and find a type of exercise you enjoy. And, at least as important, you need to find some kind of meditation that you can live with—it can be as little as fifteen minutes a day!—because it does reduce the stress that inevitably ramps up with a cancer diagnosis.

If you’re interested, you might check into the fairly new field of Psychoneuroimmunology. You’ll learn about the legacy of the saber tooth tiger, and how to distinguish the activity of the adrenal system from that of the immune system. Because there are two distinct conditions: there’s growth and there’s protection, but you can’t have both at the same time. And when any threat mobilizes the body with the old “fight or flight” response, the adrenal (stress) hormones directly repress the action of the immune system. Result: almost every major illness has been linked to chronic stress.

It is now fairly well established that what goes on in our minds absolutely affects our bodies. There is no question that our thoughts and our beliefs generate a cascade of chemicals that can act to either harm us or heal us. So my best recommendation to you is to believe wholeheartedly that whatever treatment you decide on will be totally successful. And when the stress gets to you, you don’t have to sit crossed-legged on the floor and repeat a mantra provided by a guru in the Himalayas. Just turn on some relaxing music, breathe slowly and deeply, and imagine yourself walking on a beach, or in a forest—whatever works for you—and see yourself relaxed and healthy. Relieving the chronic stress of living with prostate cancer is arguably taking a long step on the road to recovery.

The First Decision: Screening for Prostate Cancer with PSA

2012-02-28T08:47:00.000-08:00

BY MARK SCHOLZ

Prostate cancer is highly curable when it is identified at an early stage. The PSA blood test, although not foolproof, improves the chance of arresting cancer while it’s still contained within the prostate. Detecting prostate cancer early gives men the power to choose a variety of treatment alternatives.

Surprisingly there are arguments against PSA testing. Since some types of prostate cancer are low-grade, and therefore slow growing, diagnosing them, especially in older men, may only cause unnecessary fear and anxiety. Even more disturbing, men with this low-grade, non-aggressive type may be encouraged to undergo unnecessary treatment that in many cases leads to urinary incontinence or impotence.

PSA elevations also can occur from non-cancerous conditions. Prostate infections, prostate enlargement and even recent sexual activity may cause the PSA to rise temporarily. If none of these reasons can account for an abnormally elevated PSA level, an assortment of scans, blood and urine tests may be required to ferret out what is actually causing the elevation.

So we have a dilemma. Many men are given a PSA blood test without first being educated about its limitations. Advance discussions about the implications of an abnormal PSA, and prostate cancer diagnosis almost never occur. This is no small issue. Even though low-grade prostate cancer is incredibly common, many doctors are still unaware that recent studies show that low-grade prostate cancer can safely be monitored. Instead, when the diagnosis is made, most men are carted off to have radical surgery.

Despite all these daunting issues, I still believe that PSA screening is appropriate so long as men are informed about its limitations, and so long as the doctors who administer the test are well versed in the latest studies. In my next blog I will be addressing an even bigger question—whether to have a prostate biopsy when an elevated PSA occurs.

A Strategy for Self-Empowerment

2012-02-21T08:52:00.000-08:00

BY RALPH BLUM

The slamming emotional impact of learning that you have cancer—that if it is untreated or defies control it may kill you—is difficult to describe, even when you have been though the shattering experience personally. At moments, you forget, and then truth floods your mind and emotions in a rush, and you are suddenly sick to your stomach with fear. Or the knowledge disrupts your sleep, leaves you starkly awake in the darkness, eyes wide open and staring at the ceiling, anguishing about those who depend on you, those who love you, need you. Everything is different. The world is a changed place. And regardless of what the “best authorities” will tell you, some sneaky, menacing part of you is convinced that the world may soon be going on without you. And that it can happen at any time. Because you have been sentenced, and the cancer will be your executioner.

What will you do? Face the music—howl, shudder and weep—and then get on with living? No, nothing of the sort. Actually, there are specific, positive actions you should take. In a previous blog, I described how to deal with the psychological impact of a cancer diagnosis and laid out eight basic rules to help cope with the fear and loss of control that invariably zap you when you are first diagnosed. In this blog I have made a short list of things you need to do in order to become empowered; in order to take back control of your life by adopting a strategy that will play a key role in your recovery. And right up front, let me tell you that acting “brave” or “keeping a stiff upper lip” is not anywhere on that list.

Start by doing the work. Educate yourself. Become an expert on prostate cancer. Learn everything you can about your disease and the various treatment options available to you, the possible side effects, the risks that accompany unwise delay of treatment In effect, become a knowledgeable partner with your doctors in making the best treatment decision for you.

Know the reasons—the pros and cons—for undergoing any test. In particular, make sure that you fully understand the nature of PSA tests, Gleason score, clinical stage and, therefore, your risk category so that you can make a fully informed treatment choice.

Be careful not to let statistics terrorize you. Some prostate cancer survivors I have met would advise you to ignore statistics in any form. You may be given various numerical tables and graphs detailing survival rates; do not feel compelled to read them! Statistics do not determine any individual’s outcome—including yours. As New York Times Science Editor Dana Jennings put it, “I am a person, not a statistic.”

Trust your instincts in selecting your doctor. Do not hesitate to fire any doctor—up to and including world-class specialists with huge reputations—if he or she makes you uncomfortable for any reason, including feeling their lack of sympathy. Choose and stay with doctors in whom you have confidence, and consent only to treatment that you believe in. Consult specialists in urology, oncology, and radiology who have state-of-the-art knowledge and equipment. And who, at the same time, are not “selling” their specialty.

Obtain copies of all your medical records so that you have them for your own understanding, and also to provide them for any specialist you consult. These would include PSA test results, urologist’s notes and reports, biopsy pathology report, written reports and digital copies of any scans, and reports on any of your current other medical conditions.

Do the no-brainer stuff. Adopt and maintain a healthy lifestyle: eat a nutritious diet (with recommended supplements) and obtain sufficient exercise. Like it or not, sweat is a formidable supplement! Boost the quality of your lifestyle and, Scout’s honor, you will not only feel better, more in control, you will actually improve your chances of a good long-term outcome.

And most important, create a supportive environment around you. Surround yourself with positive, optimistic people—both friends and medical professionals—who are convinced that you will get well. And in order to be in touch with others who have survived what you are facing, find a good support group. Behave the way you would knowing you still have a long time to live.

Add all of this together and you have a beginner’s course called “Strategy for Self-Empowerment 101”—a course I have yet to see taught in even the best medical schools!

A New, Improved Ultrasensitive PSA Test: ProsVue

2012-02-14T16:52:00.000-08:00

BY MARK SCHOLZ, MD

The PSA blood test has been much maligned of late. Experts are concerned that blind screening of the general population leads to more harm than good. The apprehension is that many men are getting swept up into unnecessary radical treatment to treat innocuous forms of prostate cancer.

The problem with PSA testing used for screening is that elevated levels in the blood can result from a variety of causes including recent sex, strenuous exercise, an enlarged prostate gland or prostate cancer.

However, PSA testing is extremely useful for monitoring disease progression in men with known prostate cancer. Management of the disease is greatly simplified by this blood test. Rising PSA levels in the blood indicate that the cancer is growing. When levels are declining it serves as a clear signal that the cancer is responding to treatment.

PSA testing is particularly useful because it can be accurately measured in extremely small quantities, down to less than a billionth of a gram. Thus, cancer can be detected and tracked long before metastases become visible on a scan.

Just recently the FDA approved an enhanced PSA test called ProsVue. The test, manufactured by IRIS Molecular Diagnostics, can measure PSA levels below a trillionth of a gram. This new test has proven useful as a diagnostic marker for detecting the presence of residual prostate cancer after surgery.

Such a test has a practical application in men after surgery to help determine who is likely to develop a cancer relapse, i.e. to determine which men have residual microscopic cancer left behind after the operation. Only the individuals with microscopic disease are destined to relapse and will benefit by being treated with immediate radiation. Without the ProsVue, doctors have been giving radiation to everyone with positive surgical margins even though statistics show that only about half of the men being treated actually harbor residual microscopic cancer.

Bottom line: Previously published studies of standard ultrasensitive PSA assays used after surgery have shown some utility for predicting future cancer relapse. Therefore it is likely that ProsVue, which is substantially more accurate than existing PSA technology, will ultimately prove to be a useful and accurate test for predicting which men are at risk for a cancer relapse and are most likely to benefit from radiation.

“Relapse” is Not a 4-Letter Word!

2012-02-07T13:21:00.000-08:00

BY RALPH BLUM

You had surgery, or radiation, or both, and you may have been doing just fine for years, enduring all the anxiety-provoking PSA tests, and regular check-ups without alarms going off. So you thought and hoped that you were cured or permanently in remission. But apparently the treatments failed to wipe out the cancer completely. Because it’s back!

Your first reaction is bound to be shock and heavy panic. But remember: a relapse is not an imminent death sentence. The odds are excellent that with the new drugs on the market, and new ways of thinking about the various treatment options newly available, relapsed prostate cancer can be effectively controlled. You are now among the millions of men who had to learn that they can live with prostate cancer—that with care and management, they will die with the disease, not from it.

I know it’s easy to say, “Try not to panic.” The fact is, you have work to do. Depending on the type of treatment you had initially, and on your age and any concurrent illnesses, and to depending to what extent the cancer has spread, you will now need to select the best treatment for dealing with the cancer in its current stage. Your options will usually include radiation, hormone therapy, chemotherapy, immunotherapy or a combination of therapies.

After undergoing the tests to determine how advanced the cancer is and whether it has spread beyond the prostate, as mine did years ago in order to make an educated decision your best bet is to consult with a urologic oncologist—a doctor who specializes in treating cancers of the genitourinary system. If you ever needed a truly excellent medical ally, it’s now. And be aware—especially if you live at a distance from a major center—that you will find the most highly trained specialists at major medical centers or academic centers. These doctors are in the best position to judge the benefits of the latest therapies based on their experience with a significant number of relapsed prostate cancer cases.

Your fear and frustration are nothing to be ashamed of. Fear of dying, fear of pain, fear of impotence and incontinence, fears about how the recurrence will affect your work and how you will be able to provide for your family—all those fears hammer your immune system and diminish its ability to come to your defense. Fear and the pervasive loss of control that relapsed prostate cancer injects into your life are the hardest things you’ll ever have to deal with. And have no doubt: your fears can be compounded by a lack of knowledge. You need to know that no matter what initial treatment you underwent, a variety of treatment options are still open to you. There are currently more than twenty new promising prostate cancer therapies in development. Go online. Consult with “Dr. Google.” Find out what’s available—in the experimental stage or newly FDA approved—to support you right now.

My wise friend and courageous ally, Harvey, who has been living with advanced prostate cancer (metastasized to two places to his bones) for almost a decade now, said this: “When nothing else is left in your control, you can always decide one thing: Your attitude. And with a good attitude, you will discover that there are freedoms: Especially, the freedom to choose what to do next.”

Above all, remember this: You are not alone. Although the five-year survival rate after initial diagnosis is almost 100 percent, prostate cancer will stage a relapse after the five-year mark in about 20 to 30 percent of cases. So when your anxiety skyrockets, look for knowledgeable allies. Go to your local prostate cancer support group and find a fox-hole buddy who’s been through what you’re experiencing, and who will gladly offer both emotional support and valuable advice based on their own experience. And someday, God willing, you will find yourself providing someone else—someone who is going through what you are now—the counsel and hope only available from a long time relapse survivor.

Technology to the Rescue

2012-01-31T09:36:00.000-08:00

BY MARK SCHOLZ, MD

My dad always told me that good ideas are a dime a dozen. The trick is to put the good ideas into motion so that by perseverance and hard work they come to fruition. This is true of the pharmaceutical industry. Massive investment in basic research has yielded a much better understanding of how cancer “works,” creating opportunities for biochemists to design specific pharmaceuticals that will inhibit cancer growth and spread. However, the fact remains that multi-million dollar clinical trials must be performed before a new medicine can be approved and released by the FDA.

One pharmaceutical company that is making fast progress is OncoGenex. They have developed an elegant solution for blocking an overactive enzymatic pathway that cancer cells use to protect themselves from chemotherapy. For example, blocking the effectiveness of one popular type of chemotherapy commonly used to treat prostate cancer is called Taxotere. The specific overactive enzyme the scientists at OncoGenex have identified is called clusterin. Cancer cells over-produce clusterin to protect themselves from chemotherapy.

OncoGenex has designed a medicine that accurately targets clusterin. This new medicine, called Custirsen, sharply reduces the amount of clusterin inside the cancer cells. A preliminary trial, using Custirsen was added to the regimen of 82 men with advanced metastatic prostate cancer being treated with Taxotere (a chemotherapy drug that is commonly used to treat prostate cancer), showed a 40% improvement in survival rate when Custirsen was added to Taxotere--compared to the survival in men receiving Taxotere alone.

Clinicaltrials.gov reports that 141 centers around the country are currently participating in a larger trial combining Custirsen and Taxotere. This larger trial, involving hundreds of men with advanced prostate cancer, is aimed at proving the effectiveness of Custirsen and getting approval by the FDA for commercial availability. Custirsen is administered as a weekly intravenous infusion.

Over the course of my 20 years as an oncologist many of the common cancer medicines have proven to be major disappointments—not very effective and overly toxic. These earlier agents were discovered and developed through a slow and cumbersome process of trial and error. In that era we had only a vague idea of how the new treatments actually worked. Most of those agents were broad spectrum inhibitors of cellular growth that resulted in considerable collateral damage on the faster growing normal cells of our body like the hair follicles and the white blood cells.

Research leading to the discovery and development of newer agents like Custirsen is completely different. These agents are rationally designed and targeted to attack and destroy a very specific part of the cancer cells. As a result, they are not only more effective, they also have fewer side effects.

At last, it appears to be technology to the rescue.

The Radiation Round-Up

2012-01-24T10:53:00.001-08:00

BY RALPH BLUM

Despite the significant advances in treatment options, there is still considerable uncertainty—even among doctors—about how or even whether to treat prostate cancer. The treatment controversy is the prostate cancer equivalent of a Dempsey-Firpo fight: the proponents of surgery slugging it out with those who favor some form of radiation.

In recent years we’ve seen the arrival of the elegant robotic surgery. Instead of cutting half-blind in a field of blood, with the da Vinci robot a surgeon can observe the anatomy blown up 100 times on a big TV screen and, with the aid of the robot, perform the complex and intricate surgery more precisely.

There are, however, two problems with this sophisticated new surgical procedure. First, it’s hard to justify the significant additional cost of the robot because the results are not that much different from those obtained with traditional surgery.

The second problem is rather disquieting. I have observed the power of the robot as a selling tool—a blend of high visibility, big bucks, slick advertising—with the result that a considerable number of men who really do not (repeat, do not) need surgery in the first place are seduced, Pied Pipered into the O.R. by what one critic called the “bloodless glamor” guaranteed by the da Vinci robot. You might want to consider my earlier blog, “The Robots Have Landed.”

My feeling —depending, of course, on your risk category—is that if you are going to opt for radical treatment you should be lining up for one of the state-of-the-art targeted radiation treatments: either radioactive seed implantation, or intensity modulated radiation therapy (IMRT).

So how do you determine which you should choose?

Not all men are candidates for radioactive seed implants, otherwise known as brachytherapy. It is not recommended for men with enlarged prostate glands, men with pre-existing urinary problems, or men with cancer outside the prostate. If, however, you are eligible, seeds have the advantage of a single hospital visit, whereas IMRT requires daily sessions at a specialized facility for two months. Also, with seeds, the radiation dose is minimally higher, giving you the possibility of slightly better cure rates.

Bottom line your decision to go for seeds versus IMRT is mainly influenced by your risk category. In my case, if, after all these years of “prostate cancer coexistence,” if I decided on treatment, I would choose IMRT because it can be administered to a slightly broader field, thus creating a wider margin around the gland and even, if necessary, radiating the surrounding lymph nodes.

You will undoubtedly hear conflicting opinions about which treatment is best for you, and your decision will inevitably be complicated by multiple factors. With any prostate cancer treatment there is the risk of side effects, but with targeted radiation therapies the risk is significantly reduced. Moreover, both of these therapies—seeds and IMRT—are at least as effective as surgery at curing the disease without the additional risks of a major operation.

Provenge in 2012

2012-01-17T16:55:00.000-08:00

BY MARK SCHOLZ, MD

Doctors finally seem to be comfortable with starting Provenge, a recently FDA approved immune therapy for prostate cancer. Dendreon, the manufacturer of Provenge, just reported a sharp uptick in their quarterly financials, indicating that the use of Provenge is increasing as doctors increase the amount of the drug they order.

Although, Provenge has been on the market for 18 months but the medical community was slower to embrace this new treatment than was expected. It seems that it has taken time for doctors to make peace with the fact that Provenge extends life, even though there is no lowering of PSA and very few side effects.

At Prostate Oncology Specialists, we recently completed an in-house review of the first 50 men treated with Provenge, I’ll jump right to the simple and somewhat mundane conclusion or our analysis: Provenge is relatively easy to give and side effects are uncommon.

Historically, the effectiveness of cancer treatments—like chemotherapy for example—has been closely associated with notable side effects. Side effects were often equated with effectiveness. Even some of the new immune treatments, like Ipilimumab for example, usually have side effects. It’s ironic that patients receiving Ipilimumab on investigational trials are actually comforted when they get side effects—it confirms that they are not getting a placebo.

It’s also ironic that while doctors look for PSA decline as a measure of success, PSA has been rejected by the FDA as a method for measuring the effectiveness of drugs. The FDA demands a survival endpoint rather than changes in PSA. (Personally, I think the FDA is crazy. I think that both PSA and survival endpoints are valid.)

Nevertheless, doctors and patients alike are confused. Their seemingly logical question is, “How can someone’s life be extended without PSA dropping?” My explanation is as follows: When Provenge strengthens the immune system, is slows the rate of cancer growth. Using the rise in PSA as analogous for cancer growth, Provenge slows the rate of PSA rise.

I am very comfortable with the idea that effective immune therapy slows cancer growth rather than reversing it. This phenomenon of slowing the rate of PSA rise is exactly what we reported to the American Society of Clinical Oncology in 2010 when we presented our results with three medicines with immune activity, Leukine, Low-dose cytoxan and Celebrex. The combination of these three agents caused substantial slowing in the rate of PSA rise.

Since Provenge is so well tolerated, the next logical step is to evaluate Provenge in combination with other immunologically active treatments. MD Anderson is ramping up to do a trial of Provenge with full-dose Ipilimumab. At Prostate Oncology Specialists we look forward to working with treatment options such as Provenge and Ipilimumab for our patients. Hopefully the net result will be greater than the sum of the parts.

Did I Actually Hear You Say “Just-Cut-It-Out?”

2012-01-10T13:16:00.000-08:00

BY RALPH BLUM

On New Year’s Day, I heard from Max, an old friend who, to my surprise, announced, “I’m scheduled for surgery. I just don’t want to have to think about prostate cancer ever again.” His PSA and Gleason score put him at a low-risk level, and the last time we had talked he was planning to monitor the cancer for a while before making any treatment decision. So what had changed his mind?

I’ve said it before and I’m saying it again, because it doesn’t seem to sink in. I have interviewed hundreds of men newly diagnosed with prostate cancer, and an astonishing number of them seem to have failed to make this vital connection: When your family doctor refers you to the urologist, he is sending you to a surgeon.

It’s a feverish sense of frustration that has driven me to revisit this subject. With the advent of safe, modern methods to monitor prostate cancer over the past 36 months, it is disturbing to have to report that radical prostatectomies for the same period are up 50%.

There are three likely reasons for this distressing increase:

First, because a urologist is a surgeon, it is only natural, providing you are under age 75 and your overall health is sufficiently good, that his treatment of choice would be surgery. And while a urologist is legally obliged to acquaint you with other forms of treatment available, not only have urologists made a huge personal investment in learning how to perform a highly complex procedure, but also they genuinely believes that surgery provides your best chance for a cure.

Second, although prostate cancer is typically a non-life-threatening disease, many men (like my friend Max) are highly motivated to be rid of the damn disease, to “just cut it out,” despite the risk of becoming impotent. They find it hard to believe that any kind of cancer can remain dormant for years, even decades, and so they rush into surgery without taking into account that even the most talented surgeon cannot guarantee a permanent cure, let alone know for sure that he can save the nerve bundles that control erections.

Three, probably the main reason why surgery is up 50% is that many men today are lured into undergoing a prostatectomy by the high-tech glamour and all the marketing hype surrounding “the robot that can operate.” But as I pointed out in my blog “The Robots Have Landed,” it is the man behind the robot who is actually performing the procedure, and a good outcome depends on the experience and skill of that surgeon. The learning time is significant—a urologist needs to perform as many as 200 procedures to achieve full competence.

And then there’s this strange irony: If it isn’t necessary for you to undergo an invasive procedure—particularly one where you risk impotence and other surgery-related, irreversible side effects—the fact that the technology available is greatly improved is irrelevant.

So do your own homework. Talk with other men who have faced the choices you are facing. Get a second opinion. Interview a prostate oncologist. There’s one thing to take comfort from despite your diagnosis, and it’s this: For 28 out of 30 men prostate cancer is no more life threatening than chronic asthma.
If there’s a mantra, a battle cry for the great majority of us with non-aggressive prostate cancer, it is this: “Die with it, not from it!” I have those six words taped to my shaving mirror.

Prostate Size Matters

2012-01-03T14:32:00.000-08:00

BY MARK SCHOLZ

Having a large prostate is generally considered to be a bad thing because it is associated with urinary malfunction -- slow urination, getting up frequently at night and, in the worst case scenario, total urinary blockage—an emergency condition that requires insertion of a catheter.

Treating urinary problems such as these is a big business. A variety of herbal extracts containing ingredients such as saw palmetto as well as medications such as Flomax and Proscar are commonly prescribed and used with varying success. When total blockage occurs the urologists swings into action with lasers, microwave treatments or a good old-fashioned TURP, Transurethral Resection of the Prostate, sometimes referred to by laymen as the “rotorooter job.”

It should be made clear that many large prostate glands cause no urinary symptoms whatsoever. Also, urinary problems like those described above can occur in men with normal sized glands. Therefore you need to be aware that the connection between prostate size and urinary symptoms is a loose one.

A normal, healthy prostate gland is a walnut-sized organ that weighs approximately 15 grams in young men and around 30 grams (about an ounce) in men age 50 or older. The prostate gland is the only organ in the body that keeps growing as you get older. Enlarged prostates can weigh as much as 100 grams or more (the size of an orange or small grapefruit), and are more likely to lead to urinary problems.

However, as it turns out, having a large prostate can actually be a good thing, at least as far as prostate cancer concerned. Several studies show that men with big prostate glands tend to have lower Gleason scores. When men with big prostates are treated with radical prostatectomy, studies also show that they are less likely to have cancers that have spread through the capsule or into the seminal vesicles.

No one knows for sure why big (where cancer is concerned) is often better. One theory is that men with bigger prostate glands get biopsied more frequently and at a younger age because their PSA levels run higher. Therefore the cancer is being caught at an earlier stage and monitored.

Another theory is that bigger prostate glands result from hormonal changes within the gland and that these hormonal changes somehow have an inhibitory effect on cancer growth. The particulars of these purported hormonal changes are never specifically elucidated.

Regardless of the cause, men with smaller glands—say with prostate volumes less than 40 grams should be aware that, all other things being equal, their risk of harboring a higher Gleason score or a type of cancer that invades through the capsule is somewhat greater than it is for the men who have larger glands.

Prostate size is an additional factor besides Gleason score, PSA and the percentage of core biopsies involved with cancer that needs to be considered when going through the treatment selection process.

Happy Holidays

2011-12-27T08:41:00.000-08:00

Happy Holidays from Prostate Oncology Specialists.

Partners

2011-12-20T09:41:00.000-08:00

BY RALPH BLUM

When your partner is diagnosed with prostate cancer you will undoubtedly experience a tidal wave of emotions, including the devastating fear that he might die. At the same time as you are trying to get a hold on your own fears, you also want to support and reassure your partner—who is struggling with the same shock and fear. It’s a tough act to balance, and it’s only too easy to repress or ignore your own feelings and needs.

Often, it seems, men are more intimidated by health problems than women are, and when your partner is first diagnosed with prostate cancer you may find that it is up to you to ask the important questions in the doctor’s office while your partner sits there in apparent—usually temporary--shock. Moreover most men are conditioned not to talk about their fears and anxieties, and you may fall into the trap of struggling to remain upbeat, of hiding your own fears from him. While it is helpful to be as positive as you can, it is equally helpful to encourage him to express his feelings, and to talk openly together about his concerns that the cancer treatment is going to affect your relationship. One of his main fears will be of becoming impotent. It is not easy for men to understand that there is more to intimacy than erections.

There are many ways in which you can help your partner, in addition to giving him your love and support as he decides on his best treatment option. You can help him by learning everything you can about the disease and the various treatments so that you can discuss with him the sensitive issues and side effects involved. You can help him with other choices, such as choosing which doctor will perform his treatment. And you can help by driving him to treatments, picking up his medications at the pharmacy, and by keeping track of all his test results, x-rays and medical records, so that if the need arises to consult another doctor, he will have everything ready to take with him.

However, it is vital that you not neglect your own health (which it’s very easy to do!) or give up your own life and center everything around your partner and the cancer. Above all, take time out from thinking about the disease. Go out to dinner and to movies with your partner. Take weekends off and travel to favorite haunts. Enjoy, as much as possible the activities you have always liked to share. Indeed, the vow is “In sickness and in health.” But refuse to permit your whole live be held hostage to this condition.

It would be presumptuous of me to even attempt to address the real loneliness and frustration women feel from the lack of sex. My partner, Jeanne, however, is fierce on the subject.

“The women at the PCRI Conference all complained about it,” she told me. “But they feel they cannot reveal their feelings to a husband who is, I quote, ‘dealing with cancer, for God’s sake!’

When I asked Jeanne what she’d want to tell men, she said, “Curl up and just snuggle. No attempt at sex. Just relax. Hold each other, and listen as you begin to breath together. Try spooning. Meaning, lie curled up tummy to back. It’s called ‘the Embrace Meditation. . .’ There, that’s a start.”

I asked her, “Anything else you’d want to say to all the partners?”

“Yes. Let him know that helping him will actually help you to feel better, more confident, even more safe.”

As I was writing this, I remembered something that really helped me, something Jeanne told me right at the beginning, when I was first diagnosed, “Here’s what I feel,” she said. “We both have prostate cancer. We’re in this together.”

Climactauria

2011-12-13T16:54:00.000-08:00

BY MARK SCHOLZ, MD

Some men—unfortunately, only a minority—are genuinely pleased after prostate surgery. Their erections are maintained, cancer is gone and they don’t leak urine. The excitement of surviving an operation with one’s manhood intact often leads to euphoria with repeated public declarations about the wonders of surgery: “Come on in,” they say, “The water’s fine!”

In reality, there is no “good” treatment for prostate cancer. Sure, some men can luck out and are happy to talk about it. But more frequently, when men are asked how they are doing after surgery, they say they are fine, even when they are not. No man likes going public about his lost sexuality. And there is little value in bemoaning what can’t be changed.

So, does it make any difference which treatment is chosen? Is radiation any better?

Here is my estimate of the latest stats for a 65 year old with Intermediate-Risk prostate cancer with normal sexual and urinary function treated with either state-of-the-art surgery or radiation therapy administered by a world class surgeon or radiation therapist:

	Surgery	Radiation
Cure Rate	80%	85%
Impotence	50%	35%
Incontinence	8%	1%
Urinary Bother	2%	25%
Rectal Burn	0%	1%
Climactauria	12%	0%

As you can see, radiation has its own problems, particularly with what is termed, “urinary bother.” Bother can mean urgency, a need to go RIGHT NOW. It can mean frequency, making multiple trips to the bathroom throughout the day. It can mean nocturia, having to urinate frequently at night. Rectal burns are even more disastrous with unremitting pain, bleeding and leakage. Fortunately this healthcare disaster is quite rare.

What is climactauria? Ejaculating urine instead of semen. One of the world’s top surgeons, Herbert Lepor from New York University reported on the incidence of climactauria in 1,459 men he treated with radical prostatectomy between 2001 to 2007. The percentage of men reporting any degree of climactauria 24 months after surgery was 36%. The percentage reporting severe climactauria after 24 months was 12%. The stats in less eminent surgeons are probably worse.

Men contemplating surgery or radiation need to review the stats. Both surgery and radiation are unappealing. However, to my way of thinking, if a man’s conditionsdictates a need for treatment, skillful radiation appears less daunting than skillful surgery.

Calling All 40 Year Old Black Men

2011-12-06T13:14:00.001-08:00

BY RALPH BLUM

According to the National Cancer Institute, African Americans may have the highest rates of prostate cancer in the world. Furthermore, black men often develop the disease at a younger age than white men, and the cancer is often more aggressive.

Although the National Institute of Health is conducting studies to determine why this is the case, the reason for this disparity between African American and Caucasian men is complex and not yet clear. In part, it may reflect unequal access to quality health care because they tend to be diagnosed at more advanced stages, i.e., they wait till it’s too late.

While all African American men are at significantly higher risk, black men with an immediate family member who had prostate cancer have a one in three chance of developing the disease. The risk rises to 83% when two immediate family members have the disease, and with three family members, the risk mounts to 97%.

So it is absolutely vital to get yourself checked out before symptoms appear that indicate the presence of prostate cancer. Symptoms include: the need to urinate frequently (especially at night); difficult, painful, burning or bloody urination; painful ejaculation; frequent pain or stiffness in the lower back, hips, or upper thighs. Once symptoms appear, it means that the cancer has already reached a more advanced stage and chances of survival are considerably reduced.

In June 2003, Nation of Islam leader, the Honorable Minister Louis Farrakhan, announced the launch of his Prostate Cancer Foundation (LFPCF). Minister Farrakhan, himself a survivor of prostate cancer, apparently saw the high death rate among African American men diagnosed with the disease as a call to action to the black community, and the strongest persuasion for early screening. “If that is not motivation to save your life,” he said, “then nothing can motivate you.”

Despite the lack of conclusive study results, one thing is certain: early annual screening for prostate cancer is critical for African American men and should begin at age forty to forty-five.

Aside from financial concerns, another factor that deters many African American men from getting regular screening for prostate cancer, is that it involves not only the PSA blood test but also the primitive yet effective doctor-inserting-finger-up-your-anus technique known as the Digital Rectal Exam (DRE) to which black men have a serious aversion. Minister Farrakhan put it rather more delicately: “As men, we are difficult in terms of allowing ourselves to be tested.” And that is a problem.

A word of caution: When I alerted two concerned black friends that “free annual pre-screening, educational materials and medical referrals were available” via the Louis Farrakhan Prostate Cancer Foundation in Chicago, they called the number provided on the LFPCF website, and got a Toyota dealership in Houston. It appears that the website has not been updated since 2003.

When I checked with a black minister who is concerned about prostate cancer in his community, he said, “The Rev. Farrakhan sometimes fails to follow through. Usually, it’s a question of funds. The African American community would welcome hearing words of encouragement from black authority figures like Oprah, Tavis Smiley and Rev. Jesse Jackson.”

Meanwhile, it is left to local groups to motive men to get tested. According to Ron Brewington, Associate Professor of Broadcasting Journalism at Santa Monica College, the Trinity Baptist Church on

Jefferson Boulevard

in Los Angeles does provide screenings. Addressing a group of men at the church recently, Brewington said, “I’d rather have a finger up my butt than have them throw dirt in my face. The fact that you’re here tells me you want to live. I applaud each of you.”

Deaths from prostate cancer in the United States have declined, primarily because more than 90 percent of prostate cancers are diagnosed at an early stage However, African American men are still more than twice as likely as white men to die of the disease largely because they continue to be diagnosed at more advanced stages. So if you are a 40 year old African American man, consider this a three-alarm wake-up call.

First Impressions Can Really Harm You

2011-11-29T08:43:00.000-08:00

BY MARK SCHOLZ, MD

The human mind is constantly, searching, analyzing and processing our environs, attempting to make sense of the fluidly shifting situations that surround us. This mental process is healthy, designed to keep us in touch with reality. “First impressions” are a good example of the powerful and rapid insights provided by these formidable processors we call our brains. However, while first impressions are for the most part quite accurate, we all have learned at some point that they can also be misleading.

After interviewing thousands of newly-diagnosed prostate cancer patients, I have found that the first impressions of most patients about prostate cancer are almost always wrong. Why? There are several reasons.

First, there is no single type of prostate cancer. It is a condition that behaves quite variably. Therefore, it is hard to get your brain around the idea “I have prostate cancer,” and sum it up as a single sound-bite. Even though the word “cancer” would seem to be saying it all, the analogy of the three blind men touching different parts of the elephant works well here.

Second, despite the many variations of prostate cancer, none of these variations are similar to any other type of cancer. You cannot simply point to some other disease and say, “Just think of _____ . . .” (fill in some another cancer type here) and you’ve got it. Prostate cancer is, arguably, unique among cancers. It has an exceptionally slow growth rate, a pattern of spread that uniquely spares critical organs like brain, lung and liver; it responds to a distinctive method of treatment, hormonal therapy, which commonly induces remission lasting more than ten years. Moreover, prostate cancer is the only cancer that can be monitored with a one-of-a-kind blood test called PSA.

Third, while surgery is probably the best treatment for most other types of cancers, it is probably the worst (with occasional exceptions) for prostate cancer. And strangest of all, prostate cancer is the only common type of cancer that is exclusively managed by surgeons, rather than by medical oncologists).

As a result of all these one-of-a-kind characteristics, the way that men with newly-diagnosed prostate cancer manage their first impressions has a major impact on the treatment they will receive. Initially, men logically assume that prostate cancer is imminently life-threatening, just like other types of cancer. And for most cancers, surgery is best way to go about getting cured.

The majority of urologists still tend to repeat their favorite mantra—“Surgery is the Gold Standard”—and to urge men to undergo ill-advised surgery. However though advances in seed implant and radiation therapy technology, the mantra is now outdated. Newly-diagnosed men can avoid any regrets if they take time and truly investigate their options. “Don’t Rush!” should be their mantra. Men need time to calm their over-stimulated minds, time to regain their emotional bearings, so they can do the research necessary to make an informed decision.

How to Find the Right Specialist

2011-11-22T08:50:00.000-08:00

BY RALPH BLUM

When your primary care physician suspects that you have prostate cancer, your first, and arguably most important task, is to find a specialist who is skilled at diagnosing and treating the disease, and with whom you have a good rapport. Meaning, you feel comfortable with that doctor.

Usually your primary care doctor will refer you to an urologist for a definite diagnosis, but before you take this step you need to be aware that all urologists are not created equal. Most urologists—aka surgeons— have a medical practice at least half of which involves treating problems like impotence, incontinence, infections, and kidney stones. The majority perform only a handful of prostate surgeries annually. So ask your primary care doctor if he can recommend an experienced urologist in your area who specializes in treating urologic cancers.

If you are uncertain about your doctor’s referral or want to go beyond your local area to find a urological specialist—perhaps in a larger hospital or major medical center—just remember that you have time. It’s a good idea to take several weeks to network with friends who’ve been through it and support groups.

By all means, do research on the Internet. Make sure that you select a specialist with extensive experience. By consulting “Dr. Google” you can locate the best prostate cancer web sites and doctors. And under the heading “Resources” on the Prostate Cancer Research Institute web site, pcri.org you will see a section called “Finding expert physicians.”

The kind of urologists you want will thoroughly discuss all appropriate treatment options with you—radiation, seed implants, different kinds of surgery available—in an even-handed manner. If board certified, they are obligated by law to do so. And if, for example, you express interest in radiation, they will refer you to a radiation therapist to discuss that option. But unless your age or physical condition make it inappropriate, most urologists likely to recommend surgery. Surgery is, after all, their specialty.

Regarding radiation, the latest studies (although not perfect) indicate that for most men, either permanently implanted radioactive seeds or intensity modulated radiation therapy (IMRT) are at least as effective as surgery, with similar cure rates, and are, in most cases, performed without the risks associated with a major surgical procedure.

You should also, if you can locate one, consult with a medical oncologist who specializes in treating prostate cancer. Not being directly involved in either surgery or radiation, these specialists are not as likely to have any bias in their recommendation.

Whichever specialist you consult there are a few basic questions it’s a good idea to ask:

• How long have you been treating prostate cancer patients with this treatment?

• How many prostate patients have you treated? How many radical prostatectomies and robotic procedures have you performed?

• Why do you recommend this particular treatment for me?

• What are the possible side effects of this treatment?

• What are your success rates for patients with a diagnosis similar to mine?

The following questions which, since they all relate to surgery, apply only to a urologist:

• How many prostatectomies do you perform each year?
• What is your success rate with the preservation of sexual potency
• What about urinary continence? How frequent is it? How do you deal with it?

• Do you perform nerve-sparing surgery? (Nowadays most surgeons do.)

• Do you perform robotic surgery? If so, how many robotic procedures have you performed to date? (Anywhere up to 150 procedures, and you are still part of a surgeon’s learning curve.)

• What percentage of your patients are approximately my age?

This last question is important because if you are in your 50s and most of the doctor’s patients have been over 70, he may be less knowledgeable about preserving your potency and continence than a doctor who treats more men of your age.

Choosing the right specialist is a decision that will have a significant effect the rest of your life. So I repeat, take your time. And make sure that the doctor you choose gives you confidence that the treatment he recommends will be successful.

MDV-3100—An Embarrassment of Blessings

2011-11-15T09:07:00.000-08:00

BY MARK SCHOLZ

Every day in the office, as a practicing prostate oncologist, I confront serious problems: PSA levels that are rising, treatments causing too many side effects, patients desperately worried about their future. And sometimes, given our limited tools, the solutions we can offer are only partial. However, every time the FDA approves a new treatment there is an excitement akin to opening gifts on Christmas morning. All of a sudden we have a shiny new tool in the tool chest to help us do a better job.

I’ve repeatedly gone on record criticizing the FDA for the inflexible format they use to approve any new drug. They insist on survival as the only important measure of effectiveness. There has to be a better way to study new drugs than giving a placebo—an inert substance containing no active ingredient—to unfortunate people who already have a life-threatening illness. But this is the format our government demands—forcing pharmaceutical companies to prove that their new anti-cancer drug works by comparing them with sugar pills. And so the human sacrifices continue.

However, back to the good news, the spirit of Christmas morning. Medivation, the manufacturer of MDV-3100, a new drug that is estimated to be twenty times more potent than Casodex, recently reported a significant survival advantage in their study comparing MDV to the of unfortunate souls who got placebos. In other words, Medivation cleanly jumped over the bar set by the FDA. Since MDV-3100 was not associated with any unexpected side effects, the FDA will be essentially forced to hold up its end of the bargain and release it soon for commercial use.

Some are saying that MDV is just a copycat of Zytiga, one more expensive testosterone blocking pill in an already busy marketplace. I disagree completely:

1. Since MDV has few side effects, it can be easily combined with other popular treatments like Provenge and Taxotere.

2. Since the mechanism of testosterone blockade is completely different from Zytiga, it’s possibly that the anticancer effects of Zytiga and MDV will multiplied if they are given together.

3. Due to its ease of use, it will be popular with the urologists, the surgeons who are charged with managing most men with prostate cancer.

My “Christmases” seem to get better every year. Last year the tool chest was expanded to include Zytiga, Provenge and Jevtana. And there are also some amazing new drugs waiting in the wings—Ipilimumab, Dasatinib, XL-184, Revlimid and more. We finally seem to be entering a new, hopeful era for prostate oncologists—and, most important, for their patients.

In Praise of Life in the Libido Free Zone

2011-11-08T11:48:00.000-08:00

BY RALPH BLUM

Although I don’t subscribe to the idea that we men are exclusively the products of our hormones, our sex life—or lack of it—following cancer treatment is a matter of serious concern to almost all of us.

My own adjustment to being in an unfamiliar, hormonally uncharged space for the first time since puberty has been an education in intimacy, and in what it really means to be a man.

When my PSA began to rise after 14 years of “active surveillance,” I decided on testosterone inactivating pharmaceuticals (TIP), the treatment that blocks the male hormone testosterone. The rule of thumb is: no testosterone, probably no erections; but for damn sure, no libido.

A loss of sex drive is different from impotence. But without sexual drive that translates as “desire,” the vast majority of men lose all interest in the very idea of potency. For many of us, no libido means that our manhood is severely damaged. The actual cost of being without a libido, therefore, is both physical and emotional.

Once you begin TIP, your testosterone level descends rapidly; it really tanks, gets down almost to castrate level. I could hardly believe it, but after only a few weeks my sexual desire was history. I found the female form about as stimulating as covered furniture.

It turns out that through the wonders of modern pharmacology a number of determined men on TIP have managed to maintain an active sex life despite their reduced libido. One man told me, “Hey, I’ve been taking Viagra regularly during TIP, and I get it up like a Trojan!” However, a lot of guys—myself included—couldn’t dredge up enough desire to want sex. I’m sure you’ve seen the commercial pitch for Cialis: “When the moment is right…” Well, for me, there was no such thing as a “right moment.”

Here’s what I wrote before in my blog, “Positive Side Effects of Prostate Cancer:”

A fate worse than death, right? Wrong. To my surprise, I didn’t feel defeated or “less of a man.” I realized it was not the end of the world. In fact, if not getting my libido back is my fate, well and good. Been there, done that. Being without a libido permits a freedom I had not experienced during over half a century of full-blown sexual drive, and a much richer emotional life with my partner—a new kind of intimacy.

However, if against all odds, you’re still “hot to trot,” you’ll find support out there. In fact, there's an ad in a current AARP Bulletin (Page 35) promising “50% off 4 Better Sex Videos" showing couples how to overcome sexual problems including erectile dysfunction, and claiming "100% satisfaction guaranteed!" The website is BetterSex.com. The video, as watched from the Libido Free Zone, elicits a yawn—reduced from jaw stretching to trivial.

Point: Even if you’re not thrilled to find yourself in the libido-free zone, there is your partner to consider. And not being able to “get it up like a Trojan” doesn’t mean that you have to give up sexual pleasures altogether.

So what is this, a postgraduate course in sex education? Hardly. Still, I have to confess that being less self-involved—relieved of the burden of more than half a century of goal-oriented behavior—has actually improved our intimate life. I feel less rushed, less driven. I feel more tenderness for my Jeanne. I believe that I have become more sensitive to her needs, her pleasure. I believe that I have discovered a new kind of satisfaction and a new feeling of emotional commitment—both of which are unexpected and encouraging surprises during the Seventh Inning Stretch.

Hormone Blockade Effectively Controls Prostate Cancer

2011-11-01T11:04:00.001-07:00

BY MARK SCHOLZ

Ralph Blum, my coauthor of Invasion of the Prostate Snatchers, monitored his prostate cancer for 14 years before starting treatment in 2004. Prior to meeting me, Ralph had been living in Hawaii and managing his own case. However, when his PSA rose above 10 he came to Marina del Rey for a consult. I advised him to start treatment with either IMRT or Testosterone Inactivating Pharmaceuticals (TIP). Ralph, after considerable uncertainty and discussion, embarked on TIP for 12 months. So far he has required no additional therapy.

At Prostate Oncology Specialists, back in the 1990s, when radiation was more prone to burn than cure, we commonly treated men with TIP followed by active surveillance. Our first published report on the feasibility of intermittent TIP was presented at the annual meeting of the American Society of Clinical Oncology in 1997¹ and later published in The Oncologist in 2000.² In 2006 we updated our experience with intermittent TIP in the Journal of Urology and reported that Proscar (finasteride) extends the time-off period” after TIP is stopped.³

This December Clinical Genitourinary Cancer will publish our long-term outcome of 73 men treated at Prostate Oncology Specialists with TIP and monitored for a median of 12 years after treatment. A preprint of the article is available on our "publication" webpage found at prostateoncology.com. Here are the take-home messages we reported in the article about using TIP as first line treatment:

1. Almost a third, 21 men, have not required any further treatment.

2. One third, 24 men, have kept their PSA less than 5 with further cycles of TIP.

3. After an average of 5.5 years, slightly more than a third, 28 men, underwent delayed local therapy (surgery, seeds, IMRT or cryotherapy). After an additional six years observation, three men have developed a rising PSA (PSA relapse).

4. Local treatment was administered much more frequently to younger men (whose testosterone recovered more quickly when TIP was stopped)—and to men with D’Amico High-Risk category disease (PSA > 20 or Gleason 8,9,10)—compared to older men and to men who were in the D’Amico Low-Risk or Intermediate-Risk categories.

5. Mortality from prostate cancer was low. After twelve years only three men (4%) died of prostate cancer, and none of the remaining 70 men developed metastatic disease. This result compares favorably to a group of 350 men with similar-stage prostate cancer treated with immediate surgery whose ten-year outcome was reported in the New England Journal of Medicine in 2005.⁴ In this group fifteen percent developed metastases and an additional ten percent died of prostate cancer.

Unfortunately TIP, like all forms of prostate cancer treatment, is associated with a number of undesirable side effects including weight gain, muscle weakness, absent sex drive and hot flashes. However, for most men these side effects are either treatable⁵ or reversible. Even so, as we have reported in the summary above, many men treated with TIP will, at some point, require further treatment, either with additional TIP or some form of local therapy.

All this not withstanding, in my mind there is no doubt that Testosterone Inactivating Pharmaceuticals (TIP), when appropriate and applied in a timely manner, acts effectively to control prostate cancer.

References: Copies of all the articles referenced in this blog are available at our webpage http://prostateoncology.com/education/publications

_________________________

Dispatches from the PSA Front: What You Don’t Know May Be Good for You

2011-10-26T08:58:00.000-07:00

RALPH BLUM

There is a growing sense that those who are medically challenged—in this case the challenge being prostate cancer—are just another population of “consumers” in Big Pharma’s drive to capture market share.

Boil it down and the issue here can be stated in just three words: overtreatment by doctors. It is ironic that the first serious warning came from Thomas Stamey, M.D., formerly Chief of Urology at Stanford University, the man who developed the PSA blood test. Stamey’s dire prediction should be part of the awareness of every urologist and every newly diagnosed man:

“I believe that when the final chapters of this disease are written, it will prove that never in the history of oncology, will so many men have been so over-treated for one disease.”

One rarely sees Stamey’s warning reprinted. Why not? “Bad for business,” one urologist admitted to us.

However, concern for this situation is expanding rapidly. An October 5, 2011 New York Times article by Shannon Brownlee and Jeanne Lenzer quoted one of the major figures in the field, Otis Brawley, currently Chief Medical and Scientific Officer of the American Cancer Society, who the authors describe as “the public face of the cancer establishment. Brawley has become the target for attacks because of “his blunt and very public skepticism about the routine use of the prostate-specific antigen, or PSA, to screen men for early prostate cancer.” Brawley’s position is unequivocal and disturbing to the medical establishment:

“I’m not against prostate-cancer screening. I’m against lying to men. I’m against exaggerating the evidence to get men to get screened. We should tell people what we know, what we don’t know and what we simply believe.”

Otis Brawley, who is also a professor of oncology and epidemiology at Emory University, is foremost among a growing number of urologists and oncologists who recognize the ethical obligation to make certain that men grasp the nature of the radical “downstream decisions” they might have to face as a result of early screening—or any screening at all.

The newly identified risk of knowing too much is redressed when men are given balanced information about both the pros and cons of P.S.A. testing. Studies have found that well-informed men are less likely to opt for screening than men who were merely offered the test. “If a man understands the risks and benefits and does not want to be screened, that decision should be supported,” Brawley says. “But just saying that gets you in trouble.”

Well, that is changing, and changing fast. Since we posted our blog, “Who’s Afraid of a PSA?” the word is out. As I write this blog, I am receiving calls referring me to the latest Oncology Today, and also suggesting I Google: “Breaking News: PSA tests no longer generally recommended. “

It appears that we are entering a time when PSA testing is no longer done automatically as part of a doctor visit or a check-up with your urologist. A time when men will receive explanations as to the necessity for testing—and ask for explanations if they are not forthcoming. A time when there will be more transparency regarding the possible adverse side effects of PSA testing, the most egregious side effect being unnecessary aggressive treatment.

And meanwhile, hats off to Tom Stamey and Otis Brawley!

Discontinue PSA Screening?

2011-10-18T08:50:00.000-07:00

BY MARK SCHOLZ

The recent task force’s recommendation* to discontinue PSA screening has shocked the prostate cancer community. Yet with radical prostatectomy rates up 50% over the last five years their desire to apply the brakes is understandable.

No one disputes that PSA testing leads to earlier detection of prostate cancer. In fact, one could argue that the problem with PSA is that it works too well, diagnosing the disease years before we even need to know about it. Attention, therefore, needs to be refocused on how doctors respond to an elevated PSA rather than recommending the end of PSA testing altogether.

Presently, at the first sign of PSA elevation doctors urge immediate prostate biopsy, taking a dozen needle samples of the gland through the rectum. More than a million men undergo this unpleasant procedure annually, risking the possibility of serious infections, bleeding and temporary impotence.

Rather than triggering an immediate biopsy, an elevated PSA should prompt additional testing with urine tests and scans along with thorough patient education about the risks of biopsy.

Moreover, this would be a good time to educate the medical community about how to judiciously use the information PSA provides. We can’t forget the fact that 30,000 men die annually from advanced prostate cancer, and that twice that many are living and suffering from advanced disease including metastatic disease in their bones. We also need to remain mindful that studies clearly show that early diagnosis leading to the selective use of appropriate treatment reduces mortality rates.

*The public may submit comments to the task force through November 8.

Support Groups: Pluses and Minuses

2011-10-11T16:55:00.000-07:00

BY RALPH BLUM

Most men are uncomfortable talking openly about sensitive issues—painful emotional stuff like their fear of incontinence, or of never having another erection—and many feel that support groups, where such things are talked about, are not for them. However, my own experience in the medical minefield of prostate cancer taught me that finding the right support group is one of the best things you can do for yourself following a prostate cancer diagnosis.

A good support group provides you with an opportunity to discover how other men have resolved the challenges and coped with fears that you are currently facing—men who have actually lived through surgery, radiation, cryotherapy or hormone blockade. What’s more, your local support group is often your best resource for recommendations and referrals, for learning the names of the most experienced (and best liked) prostate specialists in your area.

Often you will find that the volunteer leaders of support groups are unique individuals who, while waging their own battles against prostate cancer, have dedicated countless hours to research, and who willingly share their experiences with those just beginning the journey. Some groups have expert speakers—doctors, social workers, psychologists specializing in intimacy issues that impact both men and their spouses—who can offer helpful information and can answer questions from first hand experiences that relate directly to your problems and concerns.

However, not all support groups are created equal. A group’s effectiveness depends a great deal on its members. Are they mostly upbeat and willing to share their experiences? Do they mainly discuss possible solutions to problems? Do you feel that you can learn something from them? Or do the members mostly complain? Is there an atmosphere of doom-and-gloom? You don’t want to leave feeling more depressed than when you went into the meeting!

Another thing to keep in mind is that every support groups has members in different stages of the disease, ranging from localized and curable, to very advanced. If you have never been to a support group before, you could become frightened or depressed by what you hear. If this is the case, either you are in the wrong group, or you may be simply be more comfortable with an internet site like Prostate Cancer Blue Community website http://www.prcibc.org/ that connects you with other men in your same category of prostate cancer.

In most states you can find support groups that provide treatment advice as well as emotional support. The American Cancer Society’s Man to Man chapters are nationwide; most of them welcome spouses, a few prefer that women and men meet separately. To locate the Man to Man chapter nearest you, contact the American Cancer Society at 800-227-2345. You can also go to http://www.cancer.org/ for their online prostate cancer support group. Other excellent resources include Male Care, “Men fighting prostate cancer together” (http://www.malecare.com/), Michael Milken’s Prostate Cancer Foundation (http://www.pcf.org/) and USTOO International (http://www.ustoo.org/).

So even if you are one of those guys who look down on support groups as crutches for sissies, I suggest that you at least give your local group a try. At the very least, you will be able to query a number of men about their experiences with doctors in your community. At best you may develop, as I did, very special prostate cancer friendships with men you can call at any time of the day or night, men who understand what you’re going through. And if you’re lucky, you might run across a uniquely knowledgeable group leader who can give you exactly the information you need to make the right treatment decision.

No doubt about it. There is strength in numbers.

FDA Roulette

2011-10-04T09:11:00.000-07:00

BY MARK SCHOLZ

The notoriously stingy and demanding FDA gave the go ahead for two new treatments for prostate cancer in 2010. New approvals are rare because of the hundreds of millions of dollars required to undertake the type of studies that the FDA requires. The FDA wants studies that randomly allocate men into two comparison groups. One group gets the new medicine. The other group gets an ineffective fake called a placebo. FDA approval comes when men getting the new medicine live longer than those given the placebo.

Finding volunteers willing to participate in these types of studies is difficult. The men know there is a 50% chance they will get an ineffective placebo. Who wants to take the chance of getting a sugar pill as their treatment? Even so, some men are so desperate, they sign up, hoping to be among the lucky ones who receive the real McCoy.

These studies often run for years because the study ends when the study participants die from progressive cancer. To find men willing to participate, the supervising companies that organize and run these studies need contractual relationships with a hundred or more study centers. Just keeping track of all these different patients, at so many different locations, over a period of several years, is in itself very costly.

Provenge is the first FDA approved treatment for prostate cancer that works by strengthening the immune system. Dendreon is the name of the company that has patented a process of harvesting immune cells out of the blood by means of a technique known as “plasmapharesis.” Plasmapharesis is a three hour process similar to dialysis that extracts immune cells from the blood. The harvested cells are then taken to a special laboratory and mixed with substances that enhance their aggressiveness against cancer. The cells are then re-infused back into the same patient.

Provenge’s primary appeal is the low incidence of side effects. The treatment, which does not rely on chemotherapy, is so revolutionary that at first the FDA was very skeptical. They dragged their feet for years, forcing the company to run their studies over and over. Lo and behold, additional studies again demonstrated that Provenge-treated men were 30% more likely to be three years after their treatment with Provenge compared to the men who received a placebo. Dendreon should be commended for patiently persevering time after time when the FDA kept turning them down. Now men with prostate cancer have access to an effective treatment that has very few side effects.

The other new treatment recently approved by the FDA, Jevtana, falls into the more familiar category of chemotherapy. Jevtana was approved in July 2010 based on a randomized survival study evaluating Jevtana compared to an older, ineffective type of chemotherapy called Mitoxantrone. 755 men were treated with either Jevtana or Mitoxantrone. The survival of men receiving Jevtana was 30% better then the men treated with Mitoxantrone.

This remarkable achievement took some industry experts by surprise because the participants in the trial had all been treated previously and become resistant to another type of chemotherapy called Taxotere. Historically, resistance to Taxotere has been a bad sign predicting resistance to all types of chemotherapy. Jevtana, unlike Provenge has the traditional side effects of chemotherapy such as tiredness, hair loss and increased risk for infection. Even so, reversing cancer in men with Taxotere-resistant disease is quite an accomplishment.

The FDA finally agrees that both Jevtana and Provenge are proven to make men live longer. Studies are ongoing with these newly-approved medicines to see if combining them with other drugs can further enhance their effectiveness. In the meantime, men with prostate cancer need to be aware that these new and effective tools are available.

Making Sense of the TNM Staging System

2011-09-27T12:20:00.000-07:00

BY RALPH BLUM

In my last Blog I described the Gleason grading system, which urologists use to establish the aggressiveness of your cancer based on the pathologist’s analysis of your biopsy. If you are requesting copies of all your medical records (as you should) you may come across a tumor staging code called the Tumor Node Metastasis (TNM) staging system. This code is used to describe to doctors information about whether your prostate cancer is localized, regional, or advanced.

The letter “T” in the TNM system refers to the tumor. Your doctor “stages” the tumor based on how big the tumor nodule feels when he does a digital rectal examination. For example, information about size, on whether it is in one or both sides of the prostate, and on whether it has gone outside the prostate is communicated by the four categories—T1, T2, T3, and T4.

Subtypes of T1 (T1, T1a, T1b, T1c) or T2 (T2, T2a, T2b, T2c) refer to localized cancer, meaning the cancer has not spread beyond the prostate. Any of the T3 subtypes (T3a, T3b) refer to regional cancer, which means that the cancer extends just outside the prostate and may have gone into the seminal vesicles. T4 has only one category, and refers to cancer that has spread to the bladder and/or to other adjacent areas of the pelvis.

The “N” in the TNM code refers to whether the cancer has spread to the lymph nodes in the pelvis. N0 means it has not spread to the pelvic nodes; N1 indicates that it has spread. If the cancer has spread to the pelvic nodes, it is more likely to move beyond the nodes and into other parts of the body, making it harder to treat.

The “M” in the TNM staging system refers to whether the tumor has spread or metastasized beyond the lymph nodes in the pelvis. M0 means zero metastasis. M1a means the cancer has spread into the lymph nodes beyond the pelvic area. M1b refers to cancer that has spread to the bones. M1c means the cancer has spread beyond the lymph nodes and bones to other parts of the body.

At the initial staging of the cancer, your urologist first performs a digital rectal examination to determine the presence and status of the tumor. If he determines that the cancer is at a very low level perhaps he will not order further tests. But if he suspects that the cancer may have spread outside the prostate gland, he will order a CT scan, an MRI, or bone scan. Cautious or conservative doctors are likely to order all three of these imaging tests regardless of their findings in the DRE. So don’t assume that you may have advanced cancer just because your doctor sends you for a CT scan or MRI.

I realize that all this information is somewhat confusing (It begins to sound like loony runaway variations on the British Secret Service MI5, MI6, SIS and Lord knows what else). However, the fact remains that, by grouping your PSA level, Gleason grade, and TNM stage, your urologist can determine your prostate cancer’s risk level and advise you on your best treatment options.

Bottom line, the more you know the better. Yours is really the decision that counts so you have to understand what is going on. You can obtain more information about staging on the PCRI's blue community website at www.pcribc.org.

Whew, It’s Over!

2011-09-20T09:56:00.000-07:00

BY MARK SCHOLZ

I just passed my annual stress test—the Prostate Cancer Research Institute (PCRI) conference. Lots of work, but certainly worth it--we had over 700 attendees from 41 states and 9 countries. I was proud of all the 20 speakers, and particularly grateful for the contribution of Mark Moyad, MD who did a stellar job moderating. Dr. Moyad and I reviewed some of the conference highlights on Sunday morning. They include reports on the following:

1. PET scans improve prostate imaging according to Dr. Dusing from Kansas City University and Dr. Kwon from the Mayo Clinic.

2. National Comprehensive Cancer Network (NCCN) guidelines recommend Active Surveillance for Low-Risk prostate cancer according to Dr. Klotz from the University of Toronto.

3. Multiple new chemotherapy combinations and agents—Carboplatin, Avastin, Xeloda, Custersin and Jevtana—are active against advanced prostate cancer according to Dr. Scholz.

4. Ipilimumab, an new immune treatment from Bristol Myers Squibb can induce dramatic remissions in advanced prostate cancer according to Dr. Kwon from Mayo Clinic.

5. A variety of very promising new agents—MDV-3100, TAK-700, XL-184—are in late stage trials. Provenge, another new agent that works by stimulating the immune system is already FDA approved according to Charles Drake from Johns Hopkins.

The PCRI also announced at the conference, the launch of the Prostate Cancer Blue Community (PCBC); a web based prostate cancer community that is overseen by the PCRI helpline. The PCBC has discussion forums about the conference and the different types of prostate cancer that we have broken down into Shades of Blue so that men can connect with other men in their same category of prostate cancer. The PCBC can be accessed at www.pcribc.org.

“Who’s On First?” Making Sense of the Gleason Score

2011-09-13T09:03:00.000-07:00

BY RALPH BLUM

When you are diagnosed with prostate cancer, you need to understand the grading system that your doctor will use to recommend specific treatments. The grade indicates how aggressive the prostate cancer is, based on the pathologist’s evaluation of cancer cells taken during a biopsy. While all cancer cells look abnormal to a pathologist, low-grade cancers have cells that often look similar to healthy prostate cells. The more aggressive the cancer, the less the cells look like normal prostate cells.

Invented in 1966 by Dr. Donald Gleason, the Gleason grading system is relied on by pathologists worldwide to determine how severe your prostate cancer is. Here’s how it works:

The Gleason system assigns a grade to each of the two largest areas of cancer in the tissue samples from the biopsy. The lowest number on the Gleason grade scale is 1, and the highest is 5. The pathologist examines the biopsied tissue samples to determine where the cancer is the most prominent (the “primary grade”), and where it is next most prominent (the “secondary grade”). Then he assigns one score to the primary grade and one score to the secondary grade. The final Gleason score is the sum of these two grades. So a total score can range from a 2 (1+1) to a 10 (5+5), depending on how distorted the cancer cells look. Obviously, the lower the Gleason score, the better.

Total scores from 2 to 4 are very low on the cancer aggressive scale and, therefore, indicate that the cancer is slow growing and considered low-risk. Total scores from 5 to 6 are mildly aggressive but the cancer is still considered low-risk. A total score of 7 indicates that the cancer is moderately aggressive and considered intermediate-risk. And total scores from 8 to 10 are considered highly aggressive and the cancer is categorized as high-risk.

Hopefully you are still with me, because here comes the tricky part: In order to get clarity on your Gleason score, you need to get a breakdown of the two numbers that make up the total score—the primary grade first, then the secondary grade. The reason for this is that even when total scores are the same, not all Gleason scores are equal. For instance, if your Gleason is 3+4=7 and your friend’s is 4+3=7, you are actually in slightly better shape than your friend. Here’s why: When the primary grade is 3, it means that the cancer cells have not deteriorated as far as the cancer cells with a primary grade of 4.

One other caveat: It is often advisable to get a second opinion on your biopsy slides, because not all pathologists are equal either. A pathologist at a world-class reference center, such as Stanford, the Mayo Clinic, or Johns Hopkins, should preferably give the second opinion, and most insurance programs will cover the cost.

Together with your PSA and tumor “staging” (more about this in my next blog), the Gleason Score is your doctor’s best shot at determining your prostate cancer’s risk factor and, therefore, your best indicator of appropriate treatment options.

Playing “Chicken:” Sometimes You Both Lose

2011-09-06T08:45:00.000-07:00

BY MARK SCHOLZ

I have never seen a real game of chicken where two cars race head on toward each other to see who will swerve first, i.e., who is chicken. However, we are seeing an actual game of chicken being played out before our eyes on the national stage.

In one car in this are the pharmaceutical companies that are charging mind-boggling prices for their new cancer drugs. FDA approval of a new medicine is like hitting the lottery because the insurance companies are legally obligated to pay for the drug. Recouping the cost of developing a new drug is certainly justifiable. Even so, in my recent blog I cited the example of Zytiga (abiraterone), an effective new pill for prostate cancer that retails for $5,000.00 per month.

The other car in this game is the insurance companies, who, to control costs, have begun imposing artificial restrictions on coverage of Zytiga by insisting that chemotherapy be administered first, before Zytiga can be prescribed. By imposing this artificial restriction the insurance companies are getting involved in making decisions about treatment that historically have been left to the doctor. The insurance company’s rationale is that the studies of Zytiga that led to FDA approval were performed in men after chemotherapy, so in theory we don’t know if Zytiga will work before chemotherapy. What a travesty! Any cancer expert—for that matter, anyone with common sense—can tell you that starting treatment earlier works better than waiting until the disease is more advanced.

I really don’t know how this scary game of chicken is going to end. No insurance company has endless resources. Yet, thanks to effective research being performed by the pharmaceutical companies, many new (and expensive) drugs are coming on the market. Presently in my daily practice, people who meet the criteria—men who have had previous chemotherapy—and have adequate pharmaceutical insurance, are getting coverage for their Zytiga pills. Also, Johnson and Johnson, the manufacturer of Zytiga has a generous program for drug access for people who can’t afford the drug. Even so, at some point the costs to society are going to become unsustainable. Just like the game of chicken, if both the parties wait too long to take corrective action, we can anticipate a crash.

The Big Shift: “Eating to Live”

2011-08-30T09:09:00.000-07:00

BY RALPH BLUM

For many men, a diagnosis of prostate cancer is a wake-up call to make lifestyle and dietary changes. If you have been diagnosed with the Low-Risk and even Intermediate-Risk form of the disease, and you have decided to delay radical treatment, it is particularly important to follow a diet known to inhibit cancer growth.

While it is not clear exactly what role diet plays in a man’s getting prostate cancer, once diagnosed, there is increasing evidence to support the effectiveness of diet in counteracting the disease.

Body-weight is a major factor. A number of studies conclude that over- eating and being overweight lead to an increase in the incidence of prostate cancer, as well as the aggressiveness of the disease. But until recently, I had done little to change my diet. What did it take to get this mule’s attention?

Over 50 million people in the United States are obese. I am 5’9” and, as of this writing, I weigh 205, which registers as “obese” on any grading system. My wake-up call was watching a 60 Minutes segment about children in Florida living within sight of Disney World, who were going to bed hungry night after night. It hit me like a sucker punch: Being obese in such a world is more than unhealthy and shameful; it is obscene. That same day I not only changed the way I eat but my attitude where eating was concerned, replacing eating for pleasure with eating to live.

To borrow a phrase from Bette Davis, making serious dietary changes “ain’t for sissies.” The approaches we men take to “the food thing,” as one doc I know calls it, range from rigorous, restricted diets on the one hand, to intelligent and moderate monitoring of their intake on the other. I am not talking here about going on a strict macrobiotic or vegan diet, just cutting out foods that have been shown to accelerate the pace of cancer cell growth. What makes a diet most effective is not what you eat, it’s what you abstain from eating.

According to all nutritionists the worst offender is sugar. Cancer cells are especially greedy for sugar—a fact dramatically illustrated in a PET scan. The PET scan uses radioactive sugar injected into the blood stream to locate tumors. Well, the uptake of glucose into the cancer cells occurs so swiftly that they light up like fireworks within ten minutes of the injection.

Sorry guys, but next on the “foods to avoid” list is red meat. Red meat contains more than 50% fat, and high fat diets increase the level of insulin-like growth factor which in turn increases the risk of prostate cancer. I have gone “cold turkey” on red meat, chicken, and almost all fish.

The National Cancer Institute has spent millions of dollars researching diet in China, where the consumption of animal protein—meat, milk, cheese and eggs—is very low. The most significant finding in these extensive studies was: the more animal protein you eat, the higher your risk of dying of cancer. In the entire Far East, mortality rates from prostate cancer are eighteen times lower than in the U.S.

So what to do? Start by throwing out the sugar cookies and Krispy Cremes, and cut way down on the booze (Did I forget to mention booze? Sorry). Next, take that steak off the barbie, and chow down on a plate of delicious and creatively seasoned steamed veggies, with a side order of adzuki beans for a shot of pure protein. It took my sense of shame to move me to act. But I’ve stuck with it. And, yes, it’s a little bit boring. But nothing to compare with being dead.

Two “Positive Side Effects” of Prostate Cancer

2011-08-23T09:13:00.000-07:00

BY RALPH BLUM

There is an aspect of being diagnosed with prostate cancer that has proved to be, for many men, quite literally, a life-saver, and that is being compelled to undergo a physical. For example, men who had always avoided getting regular physical exams learned that they had dangerously clogged arteries, making that checkup, literally, a life saving event. So that although prostate cancer is no day at the beach, and every treatment comes with a stiff price, there can be unexpected benefits. What I think of as “positive side effects.” Getting a check-up is one such.

The second positive side effect concerns the loss of sexual drive. Aka the loss of libdo. So is there life without libido? Wrong question. Better ask, “After a life lived entirely with sex as your objective, what happens when your libido is gone?”

I spent 24 months with no libido. When I was diagnosed with prostate cancer, given my aversion to being sliced open, fried by radiation, or poisoned by chemotherapy, my choice of treatment was hormone blockade. At the same time, I was far from enthusiastic about becoming a chemical eunuch. So instead of the suggested three drug protocol—Proscar, Casodex, and Lupron—with the approval of my oncologist, Mark Scholz, I decided on “monotherapy,” a single drug treatment with Lupron. In less than four weeks my PSA had dropped from 18 o 5.3, so I knew that the Lupron was working. With no testosterone, however, my libido was zip. Nada.

A fate worse than death, right? Wrong. To my surprise, I didn’t feel defeated or “less of a man.” I realized it was not the end of the world. In fact, if not getting my libido back is my fate, well and good. Been there, done that. And then I got another big surprise: Being in this unfamiliar, hormonally uncharged space, permits a freedom I had not experienced during over half a century of full-blown libido. And a much richer emotional life with my partner. A new kind of intimacy.

In his play, Testosterone: How Prostate Cancer Made a Man out of Me, Hal Ackerman confessed that when he was on hormone blockade he found women’s bodies about as exciting as covered furniture. But through the wonders of Big Pharma, Ackerman discovered that having sex, love-making without libido, was a completely different and very rewarding experience: During their love-making, he focused totally on his partner’s pleasure instead of on his own.

When I was doing research for Invasion of the Prostate Snatchers, I interviewed a number of men who expressed their own surprise as the result of having no libido. As one man put it, “Remove the ‘slam-bam-thank-you, Ma’am’ routine and what’s left? I guess you could call it taking pleasure in giving pleasure.”

Now there’s a positive side effect if there ever was one.

Summertime

2011-08-16T11:55:00.000-07:00

BY MARK SCHOLZ

The PCRI Conference is less than month away! Every summer I scurry around making preparations. Speakers have to be coordinated, exhibitors lined up, registrations fulfilled, entertainment scheduled.

For this year we have significantly expanded the agenda:

Friday: We have added introductory sessions that will be presented by our seasoned helpline facilitators, Jim O’Hara and Nathan Roundy.

Saturday Morning: Features the treatment of localized disease with various forms of radiation including seed implantation as well as covering high intensity focused ultrasound (HIFU). In addition we will hear from the preeminent expert in the world on Active Surveillance, Dr. Laurence Klotz. The morning will be rounded out with an update on the latest breakthroughs in imaging.

Saturday Afternoon: Will cover a multitude of recently FDA-Approved treatments for advanced prostate cancer presented by Eugene Kwon from the Mayo Clinic and Charles Drake from Johns Hopkins and yours truly. Amazing improvements have been made into medications that block testosterone, stimulate the immune system and poison cancer cells.

Saturday Evening: PCRI presents AdMeTech Foundation's “Dance for a Cure” with a LIVE performance by Jonathan Roberts and Anna Trebunskaya from the ABC hit series "Dancing with the Stars".

Sunday Morning: Our esteemed conference moderator Mark Moyad presents his latest thoughts on diet and supplements. Snuffy Myers will talk about PSA Relapse. Stephen Auerbach discusses sexual rehabilitation. Tim Wilson from the City of Hope updates us on robotic surgery.

Sunday Afternoon: Breakout sessions with extensive Q & A will address the following topics: Diet, Focal Therapy, PSA Relapse, Active Surveillance, Radiation and Surgery. We will close with a round table of experts answering questions from the audience and discussing a selected clinical case.

I hope the rest of you are getting sand in your bathing suits and a mildly irritating sunburn. See you in September.

Why Choosing Treatment for Prostate Cancer is so Difficult

2011-08-09T08:43:00.000-07:00

BY MARK SCHOLZ, MD

Selecting the right treatment for prostate cancer is unbelievably challenging. With other cancers, where survival is paramount, the choice is simple—do everything that can be done! But with prostate cancer, quality-of-life considerations play a much larger role, since the treatments available at this time can seriously impact the quality of your life. For some men, once their type of prostate cancer is determined, choices are somewhat easier. For example, Low-Risk prostate cancer is relatively harmless and can be safely monitored. Treatment is often deferred because the cure is worse than the disease. Decisions about treating High-Risk prostate cancer are also fairly straightforward. Most experts agree that treatment with combination therapy is appropriate. The men faced with the biggest dilemma, however, are the 60,000 to 80,000 men diagnosed every year with Intermediate-Risk prostate cancer.

All too often, prostate cancer treatment causes some degree of impotence and incontinence. Who wants to face sexual dysfunction unless it is absolutely required for survival? Men with Intermediate-Risk disease often feel like they are in limbo because withholding treatment for their cancer is slightly risky, but so is the treatment.

The situation is even more confusing because if you talk to men who have already been through treatment, some seem to have weathered surgery or radiation just fine. Unfortunately, if you keep inquiring, you will come across men who feel their lives have been ruined. Men reflecting on these issues face a hard reality: choosing one of the existing treatment options can immediately destroy quality of life, while forgoing immediate treatment means having to live with the ongoing possibility that delaying treatment might someday translate into fewer years of life.

Even after careful analysis, lingering questions are inevitable, since the very best that medical science can offer is an estimate of risk. The ambiguity of these circumstances, however, leaves a lot of room for personal preference. Once a man is thoroughly educated about all his options, he, rather than the physician, is in the best position to select treatment. After all, he is the one who will spend the rest of his life living with the consequences.

Still, there is good reason to expect things to change, hopefully in the near future. Effective ongoing research is progressing rapidly in the areas of imaging, genetics, immune therapy, and targeted pharmaceuticals. The fact that prostate cancer, in the majority of cases, is a slow-growing condition, also works to the patient’s advantage. Every year that goes by we are one step closer to less toxic solutions. As Ralph and I always emphasize, “If waiting makes sense, time is on your side.”

*See the What’s Your Type brochure at PCRI.org for a full explanation of the difference between Low, Intermediate and High-Risk prostate cancer

The Robots Have Landed

2011-08-02T17:01:00.000-07:00

BY RALPH BLUM

Nearly every industry on God’s good earth has become mechanized in some form or another over the past 200 years, and the Prostate Cancer Industry—yes, it’s an industry, folks—is no exception. Enter the da Vinci Robot.

In 2009, according to Intuitive Surgical Systems (the company that manufactures the da Vinci robot), 85,000 American men, 86% of those who underwent prostate cancer surgery that year, had robot-assisted surgery. Furthermore, roughly 75% of today’s urologists are being trained in robotic surgery, and the da Vinci robot is now found in more than 1000 hospitals and clinics across the country, snipping, slicing and dicing the family jewels. These are fairly staggering statistics. So let’s examine this infatuation with the robot.

Undoubtedly robotic surgery is currently the most advanced treatment option for men with localized cancers who still belong to the “just cut it out” school of prostate cancer. In the hands of an experienced robotic surgeon, you will experience less blood loss, less pain, a shorter hospital stay—usually only one or two nights—and faster recovery. Some men claim to be teeing off in a week. All great selling points. But what is the downside?

Obviously recovery varies from man to man depending on age, general health, and cancer stage. However it is not at all clear whether the long-term results or survival rate after robotic surgery are better, worse or the same when compared to the traditional open prostatectomy. And despite the marketing frenzy surrounding robotic surgery, studies to date show that rates of incontinence and impotence are virtually identical to the results obtained with the traditional methods, and ultimately depend on the skill and experience of the surgeon.

According to a recent study, a year after robotic surgery only one out of four men had recovered the ability to have intercourse. Another new survey showed that half of the men who undergo robotic surgery experience a greater incontinence problem and less sexual function than they anticipated.

A radical prostatectomy, whether traditional or robotically assisted, is a complex and intricate surgery. The prostate is located within millimeters of the bladder and the rectum, giving the surgeon very little room in which to work. And blood pooling in the operative field makes it seriously challenging to avoid damaging the nerves—thinner than a human hair—that run along each side of the prostate and control erections. Even in the hands of the most highly skilled surgeon you are fortunate if you achieve what Dr. Peter Scardino, Chief of Urology at Memorial Sloan-Kettering calls a “Trifecta:” negative margins (meaning no cancer left behind after the operation), maintained potency, and preserved urinary control. However, in less skilled hands such good results are extremely unlikely.

Remember, it’s the surgeon behind the robot who is actually performing the operation. Even the best surgeons report impotence rates of up to 50% and incontinence rates of 10%. And not all surgeons are created equal. Too often, operations are being performed at community hospitals by surgeons without sufficient experience.

Opinions differ widely about how many robot-assisted operations a surgeon needs to perform in order to be considered “proficient.” Some researchers estimate as few as 150 to 200 procedures. Others claim that as many as 1,600 operations are required in order to gauge with 90% accuracy how much tissue surrounding the prostate needs to be removed to get all the malignant cells.

Bottom line: A good outcome depends on the experience and skill level of your surgeon. So choose carefully. And before you decide, be sure to ask how many robot-assisted prostatectomies he has performed. You do not want to be part of your surgeon’s learning curve.

The lure of the robot is high-tech glamorous. The promise of a less invasive surgery with faster recovery time, plus the expectation of a better long-term outcome (based more on marketing hype than on actual studies), has almost doubled the number of radical prostatectomies performed each year in this country. So before you make what is sure to be a life-changing decision—and especially if your prostate cancer is the low-risk variety or you are 70 or over—don’t let all the publicity, or your urologist’s bias in favor of robotic technology, persuade you that surgery is your best treatment option.

Data from the recent Prostate Cancer Intervention Versus Observation Study (PIVOT) indicates that a vast majority of the 85,000 prostate cancer surgeries performed in 2009 were simply unnecessary. In other words, most of those men would live just as long without any surgery at all, and would be spared the risk of impotence and incontinence. Clearly men are failing to get the full picture of the risks and benefits of all the different options—Surgery, Seeds, IMRT, Testosterone Deprivation, Hormone Blockade, Focal Cryotherapy, Active Surveillance—before they commit to robotic surgery.

So, yes, the robots have landed. And whatever else is still uncertain, one thing is for sure—they employ first-rate Madison Avenue publicists.

Important News on Active Surveillance

2011-07-26T11:07:00.000-07:00

BY MARK SCHOLZ, MD

For men with prostate cancer on active surveillance or (“watchful waiting,” as it is often known), new and compelling data from a large study called the “PIVOT Trial” was presented at the annual meeting of the American Society of Urology this May. In this trial, which started in 1994, 731 men volunteered to get either watchful waiting or immediate surgery based on a coin flip. The goal of the trial was to determine if immediate surgery prolongs life compared to watchful waiting.

The men in the study had a median PSA of 7.8. One strength of the study was the fact that 75% of the men were diagnosed after biopsy for a rising PSA (as opposed to feeling a lump on the prostate). This means that these study results can be more easily compared to the situation men face in this modern era. The weakness of previously published watchful waiting studies was that they were done on men with more advanced disease, cancer that was diagnosed by feeling an abnormality on the prostate gland during a digital rectal exam (DRE)—so called palpable disease, a situation that is far less common these days.

The breakdown of the risk categories of the men participating in the study was similar to what is commonly reported in men with newly-diagnosed prostate cancer in the modern era:

· 43% Low-Risk

· 36% Intermediate–Risk

· 20% High-Risk

The surprising finding, after 12 years, was that there was no difference in survival between surgery and watchful waiting in the Low-Risk or in the Intermediate -Risk group. On the other hand, men who were in the High-Risk category did benefit with improved 12-year survival when treated with immediate surgery compared to the men with High-Risk disease who did watchful waiting.

The results of the Pivot Trial are very important because up till now only men with Low-Risk prostate cancer were thought to be safe candidates to do watchful waiting.

We eagerly await the final publication of all the data from the PIVOT trial since expanding the recommendation for watchful waiting to men with Intermediate-Risk disease would essentially double the number of men in the United States who would be eligible for monitoring. Additionally, this new discovery that men with Intermediate-Risk prostate can be safely monitored provides even stronger assurance to men with Low-Risk disease who have been experiencing trepidation about forgoing immediate treatment.

The Diagnosis: Eight Basic Rules for Coping with Unwelcome News

2011-07-19T09:19:00.000-07:00

BY RALPH BLUM

There is no easy way to receive the news that you have cancer, but it is important to realize that prostate cancer is typically not a death sentence. In fact the vast majority of men diagnosed with prostate cancer have the low-risk form of the disease, and will live a normal life span. Even those men diagnosed with the more aggressive kind of prostate cancer have effective treatment options available to them today.

Nevertheless, the psychological impact of receiving a cancer diagnosis can leave you reeling. You’re in shock, disoriented, and filled with fear. As one urologist told me, “Once a patient hears the word ‘cancer,’ most of what I tell him after that won’t be absorbed.” So when it comes to being an informed patient, here are some basic rules:

Rule #1: It is critically important to understand clearly your diagnosis and proposed treatment options. So always have your spouse or a friend accompany you to your appointment with the urologist, to take notes and to ask the crucial questions which, in your state of shock, may not occur to you at the time.

Rule #2: Recognize and resist your natural desire to rush into treatment. A combination of the urologist’s preference for surgery and most men’s terrified “just get it out” attitude, leads to tens of thousands of unnecessary radical prostatectomies every year—unnecessary because all of 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.

Rule #3: Do not to waste your energy asking yourself, “How did this happen? Did I bring this on myself?” Regardless of your 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, for many of us it comes with advancing age. In the words of one well-known prostate oncologist, “If you are over seventy, and you don’t have prostate cancer, chances are you’re a woman.”

Rule #4: Be proactive. The days of the passive patient with a “Whatever-you-say-Doc” attitude are over. When it comes to obtaining the best care and treatment, the single most influential decision maker is you. Do your own research, and become totally involved with your doctor in the decision-making process. And remember: this is the tortoise of all cancers. In most cases, time is on your side. So take whatever time you need to educate yourself. Learn what questions to ask your doctor about all your treatment options. Make sure you are aware of their short-term and long-term side effects.

Rule #5: Attend prostate cancer support groups. The leaders of many of these groups have dedicated countless hours to research; they are a fund of valuable information about different treatment options. Equally important, they are a trustworthy resource for locating the best doctors in your area. It can also be helpful to talk with men who have successfully navigated the medical minefield of prostate cancer. Never forget: every cancer case is different; what worked for other men may not be the right treatment for you.

Rule #6: Stay calm, be cool. Beware of terrifying yourself by thinking that every negative aspect of this disease applies to you. The very process of gathering the information you need to make an informed decision can be scary as hell. Do not be panicked by all the numerical tables, statistics, and graphs. Statistics measure populations; they do not apply to individuals. Statistics and pathology reports only tell part of the story. What is missing is the influence exerted by all the variables and intangibles that make you an individual.

Rule #7: Prostate cancer is a complex disease with many treatment options. So be prepared to take conflicting opinions from reputable experts in your stride. I have yet to encounter two urologists who agreed on everything. Which is why you need to trust your own instincts in determining which doctor and, if called for, which treatment is right for you.

Rule #8: Get a second opinion. Even if you are satisfied with your urologist, it is vitally 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.

Finding an oncologist is a cinch. Finding the right oncologist may require traveling to a major cancer center to talk with a leading edge specialist. Insurance will almost always cover the cost of a second opinion. You will need to take with you a complete transcript of your medical records, including all pathology reports and slides. And in order to get the best out of your appointment, take a written list of questions. And a friend. And a tape reorder.

Finally, I have to say it again: If you have just been diagnosed with prostate cancer, resist the impulse to rush into radical treatment that is quite possibly unnecessary and almost guaranteed to adversely affect the quality of the rest of your life. But if you do decide that your cancer calls for immediate treatment, have absolute belief in the effectiveness of the treatment you choose.

Screening for Prostate Cancer Can Be Risky Business

2011-07-12T17:03:00.000-07:00

BY MARK SCHOLZ

PSA Screening is Defensible and Essential

The majority of radical treatment decisions are made on the basis and results of PSA testing. PSA or Prostate-Specific Antigen, is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. Due to the dangers of overtreatment some experts have proposed forgoing PSA testing altogether. However, this attitude is like throwing the baby out with the bathwater, since early diagnosis and treatment of high-grade prostate cancer unquestionably improves survival and quality of life.

Too Many Biopsies and Too Much Treatment

In a perfect world the diagnostic process would detect all high-grade disease early and ignore all low-grade disease. Is such a goal attainable? The way things stand, it is unlikely. The present system relies on an immediate prostate biopsy when the PSA passes a specific threshold. Unfortunately, when cancer is diagnosed, regardless of the grade or risk level, immediate surgery or radiation usually follows.

Primary Care MD’s to the Rescue

Primary care physicians can alter this landscape in two ways: First, by taking a more measured and insightful approach to selecting men for biopsy (see below). Second, by not delegating the treatment selection process to urologists after a biopsy shows cancer. Urologists and radiation therapists do not always provide unbiased advice. An overview of how to select treatment has been published in a brochure available at the PCRI, entitled, Treatment for Newly-Diagnosed Prostate Cancer.

Estimating Risk of High-Grade Disease Starts with Prostate Size

PSA is only “normal” in relation to prostate size. Prostate volume in cubic centimeters is measured with ultrasound or with MRI. A normal PSA reading is one-tenth of the prostate volume. Abnormal PSA is when the reading is 50% above normal. For example, an abnormal PSA for a 30cc prostate is 4.5, for a 50cc prostate, it is 7.5 and for a 100cc prostate, 15 is considered abnormal.

The PSA Test Is Not Perfect

Infections, lab errors and recent sexual activity can all cause an elevated PSA, If there is an infection, a course of antibiotics will bring the PSA down. However a false reading can be ruled out with repeat testing. Recently, a new urine test called PCA-3 became commercially available. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size of the tumor and the aggressiveness of the cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate.

Imaging

Prostate imaging with endorectal MRI or color Doppler ultrasound is improving rapidly. These imaging techniques are useful for measuring prostate size and for detecting high-grade prostate cancer. While imaging is not 100% reliable, studies indicate that larger amounts of high-grade cancer can be detected fairly consistently. In situations where the need to do a biopsy is debatable, a high quality ultrasound or MRI study may provide additional assurance that a biopsy can be safely delayed.

Look Carefully Before You Leap

Rather than rushing into a biopsy at the first sign of an elevated PSA, screening should be seen as diagnostic process combined with an ongoing dialogue with the patient. As information is gathered by repeat PSA testing, PCA-3 levels and prostate imaging, the likelihood of a biopsy diagnosing either low-grade or high-grade prostate cancer can be presented to the patient and compared with the risks of a biopsy.

There are many mistaken fears about prostate cancer. These unwarranted concerns need to be addressed before diagnosis, before the word cancer becomes personal, and a man’s capacity for rational thought is impaired.

Most elderly men have prostate cancer and don’t know it. And most are better off not knowing. Diagnosing low-grade prostate cancer can be a curse. Frightened patients are ill-prepared to navigate a powerful medical system predisposed to over-treatment. How bad is it? One New England Journal of Medicine study estimates that our system is so skewed that 48 men receive unnecessary treatment for each individual who truly benefits.

Part 2. Self-Hexing

2011-07-05T10:02:00.000-07:00

BY RALPH BLUM

There is only one other form of abuse that approaches medical hexing for its pernicious influence, and that is self-hexing. When you are diagnosed with any type of cancer it’s natural to ask, “Why did this happen to me?” Or “Could I have prevented it?” Or most pernicious, “Did I do something to bring this on myself?”

To some extent we are all responsible for maintaining our own health—for watching our diet, exercising regularly, and avoiding, to the best of our ability, the emotional stressors that negatively impact our immune system. But there are those who cross the line from responsibility into the zone of guilt and self-blame, who believe it is their fault they got cancer.

While no evidence exists to indicate that prostate cancer is some kind of “retribution” for sexual misconduct, I have met intelligent, rational men who, although they rarely discussed it, genuinely believe that they had brought on their cancer by being “bad boys.” After telling me about his promiscuity, one man said ruefully, “I guess I got what I deserved.” Logical? No. But in his mind, the just measure of “let the punishment fit the crime.

This kind of negative and irrational belief causes feelings of guilt and self-blame which, over time, create stress hormones that will weaken the immune system. As I have learned more about our ability to tilt the scales toward either healing or illness with our beliefs, I have become increasingly aware that those who blame themselves for getting cancer are sabotaging their chances of recovery.

Nor is this guilt-driven form of self-hexing exclusive to men. According to psychologist Carolyn Conger, there are women who blame themselves and who feel that they deserve their cancer. After her hysterectomy, one woman told Conger: “I let too many strangers into my body.”

Although I logged many miles as a bad boy myself, I was fortunate that it never occurred to me to connect my prostate cancer to my less than exemplary sexual history. However, I can see now that the way I was living for so many years made me a likely candidate for some life-threatening disease. Simply put, I did not take good care of my health. But instead of feeling guilty and blaming myself, I chose to see the cancer as a serious wake-up call. Rather than dwelling on how I may have participated in getting prostate cancer, I decided to participate in my own healing. I took the cancer as a heads-up, an urgent message from my body that I needed to review and reshape my life on all levels—physical, emotional and spiritual.

So if any of you reading this have impaled yourselves on the punji stakes of mindless old behavior, I say be done with self-hexing. “Reframe” your cancer: See it a catalyst for change. And give yourself a break. Go mountain climbing. Take your sweetie on a road trip. Go out and buy yourself a new putter. Expect a miracle—and talk to guys who have experienced one.

There

Adjuvant Hormone Blockade (HB) after Surgery for Men with Aggressive Disease

2011-06-28T11:26:00.000-07:00

BY MARK SCHOLZ

The term "adjuvant" means treatment “added to” the primary or initial treatment. When the primary treatment is surgery, even when all detectable disease is removed, there remains a statistical risk that the cancer will return due to microscopic cancer cells left behind. Men with high-risk features such as extra-prostatic extension or high Gleason score face a higher risk of recurrence.

We need to understand the rationale for considering hormone blockade (HB) in treating aggressive prostate cancer. However, the scientific studies supporting this approach are still preliminary. Patients who have aggressive prostate cancer now are forced to make the best treatment decision possible with the data currently available.

In May 2011 the Journal of Clinical Oncology, Dr. Tanya Dorff and others reported on 351 men, average age 60, who were treated with two years of Casodex & Zoladex initiated immediately following surgery. The average PSA prior to surgery for men in the study was 7.8. PSA had to be less than 0.2 after surgery to be eligible for participating in the study. After completing two-years of hormone blockade half the men recovered normal testosterone within a year. By 18 months, 89% had recovered. After five years, relapse free survival rates of over 90% are impressive for these high risk patients where “high risk” is determined by historical relapse rates that approach 50%.

Almost all previous studies evaluating the benefit of adding HB to surgery showed no benefit. The resultant lack of benefit was probably due to the very short duration of HB—usually for only three months. There is one study by Dr. Martin Gleave at Vancouver General Hospital, comparing three months with eight months of HB after surgery, and showing a slightly better outcome for men with aggressive disease when HB was continued eight months.

The most compelling previously published study of adjuvant HB, authored by Edward Messing was performed in 98 men with proven node metastasis, half of whom received immediate HB. In the case of men who did not get adjuvant HB, the relapse rate was quadrupled.

Adding HB to radiation for men with bad prognostic factors is standard because several large randomized prospective trials show that HB reduces relapse rates and prolongs survival. Given these indisputable benefits, it is surprising that a similar study to evaluate the benefit of longer duration HB after surgery has never been undertaken.

Long-term HB after surgery results in a much lower incidence of PSA progression compared to historical PSA relapse rates that have been reported in multiple studies. However, actual proof that long-term hormone blockade after surgery will enable men to live longer will require a randomized prospective trial. The table below lists the projected five year outcome in the study by Dorff et al. depending on the different stages of the men participating in the study.

CLICK TABLE FOR LARGER VIEW

Medical Hexing

2011-06-21T21:22:00.000-07:00

BY RALPH BLUM

This report is about a disgrace in the practice of American medicine. It is not an objective report. Because I have been subjected to it, I cannot hope to be dispassionate in my approach to the subject of medical hexing.

The stress of a diagnosis of cancer can throw patients into an “altered state” in which they are particularly vulnerable to suggestion—good or bad. And because most of us, as children, are taught to believe in the infallibility of doctors, the manner in which a doctor delivers a life-threatening diagnosis has a profound effect, and actually has the power to influence the course of the disease.

If the doctor’s words are positive, they can plant within you, at a very deep level, positive expectations that you will beat the cancer, that you can be cured. Unfortunately, the reverse is equally true. The doctor can literally sentence you to death by using the dreaded word “terminal,” and telling you to go home and “set your affairs in order.”

This reprehensible behavior is a form of “hexing,” the medical equivalent of a voodoo curse. If a witch doctor leaped out of the jungle, pointed a bone at you and told you that you were going to die within six months, you’d probably laugh, albeit a trifle nervously. But when a modern-day witch doctor, wearing a white coat, carrying a stethoscope, licensed by the all-powerful American Medical Association, and supported by state-of-the-art scans and test results, tells you that you have only six months to live, his “curse” can significantly raise the chances that you actually will die. And often, right on schedule.

Everyone has heard of the placebo effect, the beneficial results that a sugar pill or some sham medical procedure can produce if the patient is told by his doctor that it will bring relief or healing. However, the placebo (Latin for “I will please”) has a less known evil twin, the nocebo (Latin for “I will harm”), which can produce equally powerful adverse effects. Medical hexing is a prime example of a nocebo at work.

In his breakthrough book, The Biology of Belief, cell biologist Bruce Lipton examines the mechanisms by which both our positive and negative beliefs control our biology. According to Lipton, our biology adapts to our beliefs—something all of us should keep in mind every time we step into a doctor’s office.

A significant part of any doctor’s job is to create a relationship with his patients based on trust, confidence and hope. Fact: regardless of his or her experience, no physician can predict the future for a specific individual, or the outcome of their disease. So if you are unfortunate enough to receive a “death threat” from your doctor, just remember: That’s his belief, not mine. And head for the door.

Andrew Weil, M.D, was among the first doctors to bring medical hexing to our attention, pointing out that it was a daily occurrence practiced by the entire medical profession—in hospitals, clinics and doctors’ offices. Weil called this behavior “unconscionable,” a term defined in The Concise Oxford Dictionary as “Not guided or restrained by conscience.”

At its most reprehensible, medical hexing becomes a form of “iatrogenics,” from the Greek iatros meaning “physician” and genic, meaning “caused by,” the term used to identify physician- or drug-induced illness; illness attributable, at least in part, to negative suggestions by doctors, drug companies or other health care professionals.

To some extent, physicians and pharmaceutical companies are in a bind. Out-of-control malpractice suits have obliged them to protect themselves legally. Before surgery, for instance, patients are required by law to sign a consent form that describes everything that could conceivably go wrong as a result of the procedure. And the form you receive from your pharmacist, along with your drug prescription usually contains a depressing list of warnings about the drug’s possible appalling side effects (“Tell your doctor immediately if any of these rare but very serious side effects occur” . . . “increases the risk of death” and on and on). The problem is that once these warnings have taken root in a patient’s mind, they can bear toxic fruit and become the stuff of self-fulfilling prophecy, the modern equivalent of a voodoo curse.

There is, in surgeon Atul Gawande’s words, “an art to being a patient,” and practicing that art must include protecting ourselves against medical hexing. But what about the art of being a doctor, which begins with the oath every doctor takes to “First do no harm?” What puzzles and disturbs me is why more doctors haven’t spoken out against the insidious practice of medical hexing.

Fifteen-Year Outcome of Very Delayed Hormone Therapy (DHT) vs. Immediate Surgery

2011-06-14T12:32:00.000-07:00

BY MARK SCHOLZ

In May 2011 the New England Journal of Medicine reported on 695 men from Sweden, Finland and

Iceland

, average age 65, who were randomly allocated to either immediate surgery or delayed hormone therapy (DHT) between 1989 and 1999. The median PSA for the 695 men was 13. Eighty percent of the men had palpable disease on digital rectal exam. In the men treated with DHT, hormone therapy was initiated if and when bone metastasis occurred. Bone scans were performed every other year.

The following Table summarizes the findings of the study:

The results of this study are updated and republished every three years since it is the only randomized prospective trial that reports long-term survival figures for surgery. Surgeons commonly refer to the study to bolster their claim that surgery saves lives. However, the survival difference between the two groups is only 6%. In other words, by undergoing surgery, only one man benefits from delayed death from prostate cancer for every fifteen men who have unnecessary surgery.

The message from this study would seem to be that the survival advantage from surgery is real, just not very big. However, there are two problems with this conclusion. First, the way men in this study were treated would probably be considered malpractice by most doctors in the United States. Few doctors recommend forgoing therapy altogether in otherwise healthy men starting with a PSA of 13, as was the case in this study. And delaying hormone treatment until bone metastases occur is generally frowned upon as well.

This study documents a modest longevity advantage as a result of surgery in men with relatively advanced disease compared to men who undergo no treatment whatever. However, the longevity benefit will probably be much smaller or absent in men with earlier-stage disease who are watched closely and treated at the first sign of disease progression, the option commonly termed “active surveillance.”

One potential benefit of immediate surgery should be noted: The men treated with surgery had a 24% lower incidence of requiring hormone therapy down the line. This advantage should be factored into the quality-of-life decision-making process.

Romancing the Immune System

2011-06-07T10:50:00.000-07:00

BY RALPH BLUM

Mark Scholz, MD, recently posted a blog reporting that harnessing the immune system to fight cancer is a rapidly advancing area of research and new drug development. As I don’t have Dr. Scholz’s scientific background, my take on how to utilize the immune system revolves more around mind-body-interaction—how our thoughts and beliefs can influence immune function, and how we can contribute in subtle yet significant ways to our own recovery process.

As I understand it, the immune system is the body’s equivalent of the Department of Homeland Security. Its primary task is to provide constant surveillance and, when necessary, seek out “terrorists”—defective and cancerous cells—and destroy them. However, when immune surveillance breaks down or is compromised, it is usually as a result of environment pollutants, poor diet, lack of exercise, and an array of emotional suppressors.

We can’t do too much about environmental pollutants, so apart from finding a medical team you can trust, and improving your diet and exercising regularly, I suggest, somewhat tentatively (I’m aware that mind-body communication is not a hot topic with most guys!), that you at least consider the possibility that what you believe and think and feel might manifest in your body.

There is a significant amount of anecdotal evidence to support the whole mind-body-connection theory. Pioneering research by neuropharmacologist Candace Pert, Ph.D., demonstrated that the mind and body are one interconnected system that carries information—via messenger molecules known as peptides and neuropeptides—from the brain to the body and then back again in a continuous feedback loop. Bernie Siegel, MD, summed up the whole amazing process in three words when he famously said, “Feelings are chemical.” And Deepak Chopra went one step further: “Every cell in your body is eavesdropping on your thoughts.”

Emotional-Chemical Text Messages

Whoa! I thought, what does all this mean? What it seems to mean is that we have a simple choice: through this complex interconnected system we can either send our immune system messages that evoke a positive biochemical response, or we can send messages that downgrade or even suppress immune function.

The most potent immune suppressor is prolonged emotional stress—unrelieved grief, unresolved anger and resentment, persistent feelings of fear, anxiety and hopelessness. All these toxic conditions, in varying degrees, transmit negative Emotional-Chemical Text Messages to the immune system.

On the other hand, we can choose to “romance” the immune system by sending it loving thoughts, messages of hope and peace and, above all, our gratitude for the amazing job it performs, and for all the good things in our lives. And we can further support it by staying, as much as we can, in the present moment—by letting go of past regrets and grievances and refusing to squander energy worrying about the future.

Laughter—the Best Medicine

My favorite immune booster and also God’s favorite music (or so I’ve heard), is laughter. Here’s how the Discovery Channel Web site describes the impact of laughter on the immune system: “When we laugh, natural killer cells which destroy tumors and viruses increase, along with Gamma-interferon (a disease-fighting protein), T-cells (important for our immune system) and B-cells (which make disease-fighting antibodies). Laughter may well be the ultimate antioxidant.”

Everyone I know who has done well in the cancer wars has, to some degree, supported their immune system by sending it positive messages. Three thousand years ago, King Solomon declared: “A joyful heart is good medicine, but a broken spirit dries up the bones.” As Dr. Scholz pointed out, the “wet part of the bones, otherwise known as the marrow, is the place where the immune system originates.” Score one for King Solomon!

So I do my best to avoid stressful situations. I eat sensibly and exercise at least semi-regularly. Above all, I laugh a lot, indulge in loving thoughts, and keep a editorial eye on the content of the Emotional-Chemical Text Messages I’m sending my immune system.

Newly-Diagnosed Prostate Cancer

2011-05-31T11:02:00.000-07:00

BY MARK SCHOLZ

Now that prostate cancer has become a treatable disease—like hypertension or diabetes for example—new problems have surfaced. Selecting effective treatment has become complicated by plethora of different treatment options you are presented. Here is a very brief introduction to the types of therapy available for men with newly-diagnosed prostate cancer.

No Treatment

It is now becoming clear that thousands of men undergo aggressive treatment every year for a type of prostate cancer that will never be life-threatening. Active Surveillance, which means that treatment is only administered if the cancer continues to grow, is becoming more and more popular for men with the Low-Risk type of prostate cancer.

Local treatment

Surgery, radioactive seed implantation, targeted beam radiation and cryosurgery are all local treatments, which when administered by experts, can be expected to eradicate the cancer within the prostate with a high degree of consistency. There are two potential drawbacks with all of these options. First, these treatments can cause irreversible side effects to adjoining structures such as nerves that control erections, urinary, and rectal function. Second, if the cancer has already spread outside the prostate the treatment may not cure the cancer.

Systemic treatment

Other options are designed to treat cancer both in the prostate and throughout the rest of the body. These options include herbal, hormonal, immune and chemotherapy treatments. The disadvantage of systemic treatments is that while they suppress the cancer, they usually fail to eradicate it completely. Systemic treatment aims to convert prostate cancer into a chronic, non-progressive condition and keep it stable for many years. Each type of systemic treatment is associated with its own unique spectrum of side effects.

Combinations

This approach—systemic plus local treatment—is used for selected patients with aggressive prostate cancer who have a high risk of relapse with local therapy alone. Combination treatment offers the best chance for cure in patients with disease that has already spread or metastasized outside the prostate.

Selecting Treatment

The aggressiveness of each individual’s cancer is determined by typing. The extent and grade of the cancer can be estimated with blood tests, biopsy information and scan results. For more details about “typing” your cancer see the brochure titled What’s Your Type available at pcri.org.

Prostate cancer patients are more involved in treatment selection than those diagnosed with any other type of cancer. This is because with early-stage disease the best choice is based on quality of life considerations, not merely with survival. Therefore only by examining the potential side effects of each treatment option, and comparing it with the other choices, can important distinctions and decisions be made among the alternatives.

Even though patient involvement in the treatment selection process is an absolute requirement, there are potential pitfalls. Clear and objective reasoning may be difficult during a time of shock and grief brought on by the diagnosis of cancer. Strong emotions are also stirred up as one is forced to face the possibility of treatment-related, life-altering side effects that impact sexual, rectal, and urinary function. Patients can be prone to hurried treatment decisions instead of waiting until they have a full understanding of all the information. Despite reassurances, it is hard for patients to escape the lingering fear that unless they act swiftly, the cancer will grow and spread.

Specific Recommendations for Selecting Treatment

Don’t rush into immediate treatment!
Obtain thorough and proper staging to determine the likelihood that the cancer has spread to a location in the body distant to the prostate.
Educate yourself thoroughly about this disease via sources such as the Internet, books, and support groups focused on prostate cancer.
Whenever possible, seek advice and treatment from doctors who specialize in treating prostate cancer.

The Screening Paradox? Or Is It Just a Dilemma?

2011-05-24T15:08:00.000-07:00

BY RALPH BLUM

Maybe it’s shabby of me to immediately think: It’s all about money. The pot of gold at the end of the prostate cancer rainbow. Well, the first dip into that pot is billing for all those PSA tests, DREs and biopsies. Standard screening procedures, right? Only it’s not that clear cut. More and more these days, I tend to consult with Dr. Google. Turns out there is disagreement in high places.

The American Board of Family Practice regards screening as less than effective; they don’t recommend it for prostate cancer. Meanwhile the American Urological Association staunchly maintains that screening saves a lot of lives—even if, as one urologist told me, “Thanks to screening, I may end up doing 38 unnecessary radical prostatectomies to save one life.” When you get a specialty board at odds with a family practice group, it makes you think.

Then you have both the American Urological Society and the American Cancer Society discouraging screening for men whose life expectancy is 10 years or less. Why? Because the cancer, in most cases, is so slow growing that it can take that long for screening to prove useful. And besides, those men will probably die with it, not from it. Gina Kolata, science reporter for the New York Times, published an article “Screening Prostates at Any Age.” The piece opened with the question: “When, if ever, are people just too old to benefit from cancer screening?” Apparently never.

A recent study published in The Journal of Clinical Oncology reported that men in their 70s are being screened at almost twice the rate of men in their 50s. What’s that all about, given the life expectancy at that age? The study also found that men from 80 to 85 are screened as often as men in their 50s. Can you hear the chorus of clanging cash registers in the background?

Perhaps there is a more tolerant way to look at what, at first glance, appears to be blatant over-screening. Is it possible, Kolata wonders in her Times article, that late and continued screening provides a psychological “boost” for older men? A kind of placebo effect in the form of “evidence that death is not waiting in the wings?” (Some kind of Botox treatment for us sagging old geezers?) Obviously the cancer industry profits handsomely from that “delusive obsession.”

Fact: Some 50-year-olds do not require screening; some 75-year-olds may benefit from it. Certain prostate cancers are highly aggressive but do not produce much PSA. At the same time, since prostate cancer is usually asymptomatic until well advanced, plenty of doctors I respect consider it dereliction of duty not to screen for and detect it when it is still curable. Hard to argue with that logic. The burden is on the doctor to prove the guy doesn’t have cancer. Which is why he orders the screening tests just like he orders a cholesterol test or CBC (Complete Blood Count) for anyone over 50. And then there are all the “diagnostic tests. . .” Still, as the saying goes, ‘Better safe than sorry’.” Your doc doesn’t want to hear from the lawyer for your estate.

As my departed friend, NBC White Paper producer Fred Freed never tired of saying, “There are no easy answers.” To confirm the truth of that dictum for this cancer, you ought to attend a monthly meeting of the Prostate Cancer Club at Michael Milken’s Santa Monica Headquarters, and listen to 30 or more of LA’s top urologists, prostate and radiation oncologists and diagnostic radiologists arguing over a dozen or so current papers on all aspects of prostate cancer, none of which command widespread consensus.

Why should screening be an exception? Keep it simple: If you have reason to think you may be at risk for prostate cancer, get screened. If not, go fishing. Or buy yourself a new putter. If you’re rising 80 and off having fun with your sweetie, ignorance may not be bliss, but it sure can contribute to your quality of life.

Avodart & Proscar for Men on Active Surveillance

2011-05-17T10:08:00.000-07:00

BY MARK SCHOLZ

More and more men are embarking on active surveillance—close monitoring of their prostate cancer—rather than implementing immediate radical therapy. Of course, only individuals with carefully selected low-grade prostate cancer are eligible for this approach. During the extended observation period many men enquire if there are nontoxic interventions to improve their odds that the cancer will stay dormant. The important issue of diet often arises though that is not the subject of today’s topic. Hormonal treatment, on the other hand, is a treatment that calls for further discussion.

Targeted Hormone Blockade

Blocking testosterone production with testosterone inactivating pharmaceuticals (TIP) is an amazingly effective anticancer maneuver unique to prostate cancer. However, TIP is generally reserved for treating the more aggressive types of prostate cancer since it has potentially unpleasant side effects like impotence, weight gain and reduced muscle strength. However, there is a way that hormonal therapy can be targeted to specifically block testosterone activity inside the prostate while sparing the rest of the body from negative side effects. Proscar and Avodart—both FDA-approved medications to shrink the prostate gland function by this very mechanism. They block a special form of testosterone called dihydrotestosterone (DHT) that only occurs inside the gland. The general public is familiar with these medications due to their ability to reduce the size of the prostate gland and ameliorate a common problem familiar to aging men: the need to get up frequently at night to urinate. Yet thanks to their lowering effect on DHT, these drugs also have anti-cancer effects.

The Benefits of Proscar and Avodart for Fighting Prostate Cancer

The effect of Proscar and Avodart against cancer have been evaluated in several double blind placebo controlled trials. In one trial 18,000 men¹ were treated with Proscar or placebo for seven years. Ten thousand of these men then underwent a prostate biopsy. The Proscar treated men were 25% less likely to be diagnosed with prostate cancer, compared to the men treated with placebo. In two other double blind placebo controlled trials, Avodart was also shown to reduce the risk of a prostate cancer diagnosis by about 22%.^2,3

More recently, in a study reported in abstract form at the American Society of Clinical Oncology in March this year, 302 men on active surveillance were given either Avodart or placebo for 3 years. As is typically the case with men on active surveillance, repeat prostate biopsies were performed 18 and 36 months after the initial diagnosis to determine if the cancer was progressing. Men who received Avodart had a progression rate that was 38% less than the men on placebo.

Another study published in European Urology retrospectively evaluated 288 men on active surveillance who received Avodart or Proscar that were compared to men who received neither. After three years of observation, the biopsy progression rate was 50% lower—18% for the men on treatment vs. 36% for the men on no treatment.⁴

Is There a Downside Risk?

Given that Avodart and Proscar lower PSA by about 50%, the question becomes: “Are they masking the capacity of PSA to detect cancer progression?” The answer is no. PSA still rises in men with progressive disease. In fact, studies show that Avodart and Proscar improve the accuracy of the PSA monitoring process, enhancing the likelihood of detecting High-Risk cancer.⁵ The standard approach in our practice is to offer Avodart or Proscar to all our patients on active surveillance.

When taking these pills, about one out of five men will notice a modest reduction in their sex drive. This reduction in libido may fade away after a few months with continued treatment. Even so, if a reduction in libido occurs, we often simply advise stopping the medication since these medications are not essential to the active surveillance approach but rather an optional enhancement.

References

Ian Thompson, The influence of finasteride on the development of prostate cancer. The New England Journal of Medicine, July 2003.
Gerald Andriole, Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia. UROLOGY, 2004.
Gerald Andriole, Further analysis from the REDUCE prostate cancer risk reduction trial. The Journal of Urology, April 2009.
Antonio Finelli, Impact of 5-Alpha-Reductace inhibitors on men followed by active surveillance for prostate cancer. European Urology, Vol. 59; 509.
Ian Thompson, Effect of finasteride on the sensitivity of PSA for detecting prostate cancer. Journal of the National Cancer Institute, August 2006.

Wanted: Safe Places Where Women Whose Men Have Prostate Cancer Can Talk About What Really Matters

2011-05-10T09:15:00.000-07:00

BY RALPH BLUM

Fact of life: The presence of even a single man in any support group changes the nature of the conversation about prostate cancer.

As one woman told me, “When the men aren’t there, we talk much more freely about how the disease is affecting both of us psychologically—our worries, our fears, our need to put on a brave face. And how we feel about everything that is happening— or not happening—in the bedroom.”

I assumed that support groups for women whose partners have prostate cancer were plentiful—meetings where women can talk openly about the things men won’t talk about. As it turns out, in the entire

United States

, there is not one prostate cancer support group for women only.

At first, I couldn’t believe it, so I consulted Dr. Google, plugging in “Prostate Cancer” and “Women” and “Support Groups.” Nothing. I scanned the American Cancer Society, CancerCare, National Cancer Institute, Women Against Prostate Cancer (WAPC). More nothing. I checked out UsToo International, with its over 300 support groups nationwide, and came up with a handful of groups tagged “For Women Only.” To my dismay, I learned that those meetings served as preludes to regular family support groups, and that they only lasted half an hour!

A Light in the Darkness

Then my remarkable friend, Celestia Higano, MD, a prostate oncologist at the Seattle Cancer Care Alliance, put me in touch with Sylvie Aubin, Ph.D., who had created just what I was looking for: a support group that focused on the psychosocial issues that impact both men and their partners following a diagnosis of prostate cancer. She called it a “Spousal Support Group.”

According to Dr. Aubin, only in a Spousal Support Group, with no men present, are women able to talk unashamedly about their sadness and their fears. When a man is diagnosed with prostate cancer, woman must face the question: How will this change our lives? A big concern is financial survival, true enough. But they are actually more fearful of losing his emotional support—the agonizing possibility of life without him, without his companionship. Women need to hear from other women about how they how they are coping—what they are going, through and how they have survived.

“At home,” Dr. Aubin told me, “women always feel the need to put on a brave face, to contain their emotions, to become—like their men—solution oriented. That’s why the Spousal Support Groups are so desperately important. Men’s support groups are very focused on treatment options. My women’s group is entirely about the experience and the challenges. Men are uncomfortable looking at or dealing with intimacy issues. They’re socialized to ‘fix the broken chair.’ It’s almost impossible to get them to open up about how they feel. They seem to think that if they talk about their emotions, people will think, ‘Oh, so he probably can’t perform.’”

Dr. Aubin also emphasized women’s essential role as providers of accurate information, especially when it relates to a man’s emotional state. “We ask him, ‘Have you been feeling sad or depressed?’ And he goes, ‘No, not at all.’ Then we ask the spouse, and she says, ‘My God! He’s depressed all the time!’ It’s the rare man who feels comfortable bringing up his emotional problems in a group. But then a lot of women are also reluctant to talk openly about their intimate lives, even when it’s just among other women. Which probably explains why groups like mine are practically non-existent. And why, I regret to say, my group no longer meets.”

A Safe Place of Your Own

More than any other cancer, prostate cancer is a family disease. This country needs Spousal Support Groups, meetings exclusively for women and as plentiful, as available as 12 Step meetings. All I can do is urge you, the women who play such a huge role supporting us after we are diagnosed, to create a nationwide array of Spousal Support Groups.

And while you’re at it, you might want to start a Spousal Support Newsletter. And a Spousal Support website. Make the Internet your bush telegraph to put out the word.

Dr.Aubin nailed it when she said, “Believe me, a multitude of men owe their lives to their partners. I’d say to women, Come together and share your experiences. You are going to be his best helper. No urologist will ever love him like you do!”

Zytiga (abiraterone): A Breakthrough for Men with Prostate Cancer

2011-05-03T08:54:00.000-07:00

BY MARK SCHOLZ

One of the unique characteristics of prostate cancer is its responsiveness to the withdrawal of testosterone. This “Achilles Heel” of prostate cancer was discovered in the 1940’s when surgical removal of the testicles was shown to induce cancer remissions. In 1985, Lupron, an injectable medication that works by tricking the testicles into ceasing testosterone production, was FDA approved. Orchiectomy, or surgical removal of the testicles, has been declining in popularity ever since.

Lupron works for an average of 2-6 years in men with metastatic disease, and for more than ten years in men without metastasis. When Lupron stops working, other hormonal agents such as Casodex or Nilutamide are commonly employed. Their effectiveness is measured by monitoring prostate specific antigen (PSA). A good response is signaled by a declining level of PSA in the blood.

Controversy has raged in academia about the significance of these PSA responses and whether or not they are an indication of extended survival. Before approving new drugs, the FDA mandates that pharmaceutical manufacturers document improved survival in prospective placebo-controlled trials. A trial of abiraterone (Zytiga) in men with a rising PSA while on Lupron has shown just that—volunteers who received abiraterone lived 33% longer than men who received a placebo.

Zytiga is a designer drug that exploits the relatively recent discovery that cancer progression is a result of prostate cancer cells manufacturing their own testosterone instead of feeding on testosterone originating from the testicles and reaching the prostate cancer cells via the bloodstream. Zytiga works inside the cancer cell by blocking the function of an essential enzyme in the synthetic pathway of testosterone. On April 28, 2011, the FDA approved Zytiga, a product of Centocor Ortho Biotech which is owned Johnson & Johnson. We have conducted one phase early access protocol (EAP) and two phase III trials of abiraterone in our Marina del Rey office.

Side effects of Zytiga can include changes in potassium levels in the blood and rare cases of liver irritation. Zytiga has to be administered with prednisone, a form of cortisone. Cortisone can be associated with gastric irritation and occasionally stomach ulcers. People with diabetes may experience higher blood sugar levels.

Since Zytiga will be offered at a cost of $5,000.00 per month, many men will be interested to know that its chemical mechanism of action is very similar to another more affordable medication already on the market—ketoconazole. And a month’s supply ketoconazole is only $60.00. However, there has been subdued enthusiasm for ketoconazole due to a very high frequency of adverse interactions with other common medications like Lipitor, Zithromax, Norvasc, Glipizide, Paxil, Prozac, Coumadin, Coreg and antihistamines. It can also cause side effects such as stomach upset or liver problems. To be used safely, close monitoring on therapy is essential. Even so, if used cautiously, after close to 20 years of experience with ketoconazole, I have found that many men can tolerate it quite well.

For men who can afford it, or at least have insurance to cover the cost, Zytiga will be popular thanks to the much lower incidence of side effects. Even with the major cost considerations I predict Zytiga will become the standard of treatment for men who are resistant to Lupron. And just as Lupron is continued indefinitely, even after PSA begins to rise, Zytiga will probably be used indefinitely as well, even if the cancer is progressing. After all, now that we know that Zytiga can deny the cancer cells the capacity to manufacture their own testosterone, why would we want to stop the medicine and allow those out-of-control cells to start producing testosterone again?

Part 2. So Why So Many Biopsies?

2011-04-26T09:41:00.000-07:00

BY RALPH BLUM

“No More Unnecessary Biopsies . . . ” The first four words of the sub-title of our book, Invasion of the Prostate Snatchers,” are a clear statement of our objective. I am no fan of biopsies. At the same time I know that a biopsy is an essential diagnostic tool when appropriately used. The problem is that too many doctors schedule an immediate biopsy if there is only a slight rise in PSA, when it would be more appropriate to explore less invasive diagnostic methods first.

The Liability Factor: More and More Biopsies

One million men are biopsied annually in the United States. Yet only about one in five will be diagnosed with prostate cancer, and the majority of those will have Low-Risk disease—the type that will never become life threatening. Even so, most of these men will undergo some form of radical treatment. Having a biopsy is like opening Pandora’s box.

Doctors know that biopsies actually miss cancer about 20% of the time, especially in men with enlarged prostates. Which is one reason why, when an initial biopsy is clear of cancer, urologists often want to perform a second or even third biopsy, in order to confirm their initial findings. Naturally urologists are concerned about missing cancer in their patients; they don’t want to be responsible for a delayed diagnosis. They are also concerned about their vulnerability to lawsuits. In 2010, according to the Physicians Insurers Association of America (PIAA) the leading cause of malpractice claims against urologists was the failure to diagnose prostate cancer in a timely manner. When in doubt, perform the biopsy. “Better safe than sued.” So the number of biopsies continues to mount up.

If you and your doctor have done your due diligence, and the indicators suggest the possibility of an aggressive cancer, you need to get a biopsy. Transrectal Ultrasound (TRUS), preferably with color Doppler, is the most common method used to provide visual guidance for biopsy. A small ultrasound probe, inserted in the rectum, emits sound waves that bounce off the prostate and return to the probe with an image that is developed on a TV screen. Since cancer cells produce less reflection of the sound waves (a condition referred to as hypoechoic) the area will look different from normal prostate tissue, and thus show the urologist the precise locations to biopsy. The procedure, usually done in the urologist’s office, lasts approximately 20 minutes, should cause minimum discomfort., Total it up: a million of those procedures produces a gross revenue approaching half a billion dollars annually. Prostate cancer is a multi-billion dollar a year industry and growing. A significant portion of that industry’s growth is biopsy driven.

Prostate Oncologists: A Special Breed

After reading my first Biopsy blog (To Biopsy or Not to Biopsy—That is the Question) my screenwriter friend, Harvey Frost, reminded me that he was diagnosed with metastatic prostate cancer in 1996, and warned twice by his urologist that he had less than 5 years to live. “Since then,” Harvey told me, “I have been treated at USC’s Norris Cancer Center by a world class prostate oncologist. I was sentenced to death from prostate cancer when I was in my forties. Well, I plan on dying from something else in my 80s—no, make that my 90s!”

My best advice to any man newly diagnosed with prostate cancer is to find himself a prostate oncologist, if only for a consultation. The problem is that out of more than 15,000 medical oncologists practicing in the continental US, fewer than 60 appear to have taken a particular interest in prostate cancer, which makes them almost as rare as hen’s teeth. And even if the nearest prostate oncologist is 150 miles from where you live, make an appointment for a consultation, pack a lunch, gas up, and go!

Bottom line, when a biopsy is recommended, do your own research, and be aware of what you’re getting into. If there is any indication that your cancer is the aggressive type, a biopsy is still the best diagnostic tool available.

Harnessing the Immune System to Fight Cancer

2011-04-19T09:05:00.000-07:00

BY MARK SCHOLZ

Using the immune system to fight cancer is a rapidly advancing area of research. The immune system (as it relates to fighting cancer) is made up of three components: 1) regulatory cells (T_Regs),2) killer cells, and 3) detector cells otherwise known as dendritic cells. Dendritic cells activate the killer cells and help them “home in” on the cancer.

Over the last 30 years, immune treatments have proven disappointing time after time due to a failure to address the immune system’s natural propensity of self-regulation. Self-regulation—inhibition of immune over-activity—is a normal aspect of immune function that prevents diseases such as lupus or multiple sclerosis.

However, recent research reveals that some cancers, prostate cancer being one of them, “cloak” themselves from immune attack by “kidnapping” T_Reg cells and using them as a shield to diminish or inhibit killer cell activity. This new understanding provides a good explanation of why the immune system fails to attack and eliminate cancer. Rather than being a type of weakness, immune inactivity is a type of blindness.

Two new treatments, one that is already FDA approved and another that is in Phase III trials, are designed to counteract this blindness; they are Ipilimumab and Provenge. Ipilimumab is a new drug from Bristol Myers that blocks an “on/off switch” on the surface of T_Reg cells. When the switch is in the on position T_Reg activity is up-regulated, suppressing the immune system. When the switch is locked in the off position by Ipilimumab, the inhibitory action of the T_Reg cells is taken off line. Ipilimumab was approved by the FDA in March 2011 to treat advanced melanoma. Preliminary studies of men with advanced prostate cancer have shown some dramatic results. In addition, Dr. Eugene Kwon from the Mayo Clinic has reported surprisingly good results against advanced prostate cancer using small doses of Ipilimumab in conjunction with hormone blockade. Presently two phase III trials of Ipilimumab in advanced prostate cancer are ongoing.*

Provenge was FDA approved to treat advanced prostate cancer in 2010 after two separate phase III trials showed that Provenge-treated men lived 20% longer than men treated with a sham infusion. Provenge works by providing a cancer “scent” (via a common cancer protein called PAP) to activate the dendritic cells and enable them to better home in on the cancer. Provenge is the ultimate individualized therapy because dendritic cells are filtered from the blood of each patient and exposed to PAP in the laboratory. Each patient’s own activated dendritic cells are then reinfused back into the blood stream.

As exciting as both these intelligently designed therapies are as stand-alone treatments, the irresistible next step is to use them together. It is natural to assume that the effectiveness of a well-tolerated treatment like Provenge will be further enhanced when used in combination with a therapy like Ipilimumab that will keep the regulatory defenses of the T_Reg cells in check. I contacted Bristol Myers this week to inquire about the status of research into the effectiveness of a Provenge/Ipilimumab combination. I was assured that such a study is in the works and anticipated to become a reality in the near future.

*Prostate Oncology Specialists is conducting two Ipilimumab trials in advanced prostate cancer. Parties interested in participating in one of these trials in Marina del Rey, may contact Jennifer at (310)827-7707 or jennifer@prostateoncology.com. Additionally, you may visit http://ResearchForProstateCancer.com

Who's Afraid of a PSA?

2011-04-12T11:06:00.000-07:00

The straight answer? Every guy who’s ever been told his PSA was elevated for his age, and that he needs to have a biopsy. Because from that point on, things can happen fast. It’s the prostate cancer version of baseball’s famous Tinker-to-Evers-to-Chance double play—PSA Test-to-Biopsy-to-Surgery.

The PSA is a simple blood test for prostate-specific antigen, a protein produced by normal prostate cells. Cancer cells, however, produce more PSA per unit volume than benign cells, so an elevated PSA can be cause for concern. Since 1986, PSA testing, although not perfect, has served as the gold standard for widespread screening and early diagnosis of prostate cancer. Controversy arises from the fact that, at the first sign of an elevated PSA, your family doctor is likely to send you to a urologist who will almost certainly perform a biopsy—all too often opening the door to unnecessary radical treatment.

Avoiding False Readings

There are other factors besides prostate cancer that can influence PSA test results. Here are some of them:

BPH: Benign prostatic hyperplasia, prostate enlargement caused by age or infection, induces an elevated PSA not indicative of cancer.

Infection: Consider the possibility of infection. Some years ago, when my PSA spiked unaccountably from 7.4 to 20.3, my wife, Jeanne, who is a medical intuitive and practices Traditional Oriental Medicine, suggested to our family doctor that he put me on a course of the antibiotic Cipro. Which he did, and after ten days my PSA had dropped back to 9.25.

The 48 Hour Rule: It is possible that strenuous exercise, heavy lifting (like lugging suitcases through airports), sexual activity, and even bicycle riding before a PSA test will negatively effect the result. However, a false elevation is guaranteed if you get your PSA checked immediately following a Digital Rectal Exam (DRE) or too soon after intercourse. So don’t have a blood test for at least a week after a DRE, and avoid ejaculation for 48 hours before the test.

Inconsistent Lab Work: Standardization of tests, or assays, from one lab to another, is still lacking. This makes comparisons between PSA tests done in different labs unreliable. If you have two or more PSA tests, make sure they go to the same lab for analysis.

If any of these factors apply in your case, ask for a repeat PSA.

When a PSA Makes Good Sense

Early PSA testing makes the most sense if you fall into any of the following categories:

Family History: If you have a family history of prostate cancer, it’s advisable to begin PSA testing at 40 and repeat the test at six-month intervals.

African Americans: All African-Americans are advised to begin tests by age 40 regardless. The death rate from undiagnosed prostate cancer for African-Americans is currently two-and-a-half-times that for Caucasian men. This is partly for genetic reasons, and partly from reluctance to submit to a DRE—85% of cancers occur in the peripheral zone of the prostate gland, and therefore can be felt by the doctor performing the exam. A DRE is an essential diagnostic procedure.

Men Over 75: Nowadays, men over 75 are apt to be spared testing entirely. So you can always avoid the anxiety, and have a good time. On the other hand, you might just go for the PSA test anyway, and while you’re at it, have a thorough physical. I know a number of grateful men who never would have discovered that they had a serious heart problem or high blood pressure, if they hadn’t started with a PSA check. How long has it been since your last physical?

The Politics of PSA Testing

The best clinicians do not mindlessly screen all of their male patients. They decide which men should be tested based on age, symptoms, family history, expected longevity, general medical condition, physical examination findings, and—a significant factor—the patient's own request for the test. The goal of early detection remains to identify patients who have clinically significant cancers at a time when treatment is most likely to be effective.

Remember that, ultimately, the big decisions are all yours to make. Trust is crucial. So never hesitate to go for a second opinion. Bottom line, regardless of its shortcomings, the blood test for prostate-specific antigen is still the most useful and widely available method for detecting the presence prostate cancer. And if you want an encouraging statistic, here’s the really good news for men over fifty: 28 out of 30 of you who are reading this blog, and who do have prostate cancer, will die with it, not of it.

As you probably noticed, there is no “MD” after my name. Which means that my experience, my facts, and my emotional involvement are open to scrutiny and comment. In these blogs, I will be writing about matters that I know are of concern to men with prostate cancer, and to those who love them. You don’t need an MD after your name either, to point out something I’ve missed, or correct me if I’m off base. I welcome any PSA questions, advice or stories—reassuring or cautionary—that you’d care to share.

BY RALPH BLUM

Sex, and Life after Surgery

2011-04-05T09:26:00.000-07:00

BY MARK SCHOLZ, MD

After prostate surgery only 5-15% of men describe their sexual function as unchanged.¹ And I’ll venture that zero percent describe it as improved. For an average man with good preexisting sexual function, the best surgeons preserve some level of function about half the time—with the aid of copious Viagra. (Just so you know, the medical definition of function is anything adequate to “be stuffed in.” Seriously!) And erectile dysfunction isn’t the only way to ruin intimacy. Dr. John P. Mulholl, author of the excellent book, Saving Your Sex Life: A Guide for Men with Prostate Cancer, has coined the term “climacturia” to describe the distressing news that, after surgery, some men ejaculate urine rather than sperm.

Prostate Cancer Surgery is Difficult, Robotic or Otherwise
These sad results are not due to lack of effort. Over the last five years, prostate operations are up 50%. Every year, more than 70,000 men are taking a ride on the wild side.² The primary reason for all the excitement is robotic surgery. Can the robotic approach justifiably claim any advantages over older methods? Yes, scars are smaller; hospital stay is shorter and serious bleeding less frequent. However, for all its popularity, studies confirm that robotic surgery serves to preserve bedroom bliss just as poorly as the older standard techniques.

What About the “Average Surgeon?”
Quality control for prostate cancer surgery is nonexistent. The above statistics are for the most practiced and skilled surgeons. Studies show that with average surgeons, results vary widely. For example, at reputable large academic institutions the likelihood incomplete removal of the cancer varies between 11 and 50%!³

What then might we anticipate from the “silent majority” of urologists at the community hospitals? If the number of operations is any indication, we need to be seriously concerned. In New York for example, for the whole year of 2005, one in five urologists only performed a single prostatectomy, while 80% of the urologists did less than 10.⁴

Does Surgery Save Lives?
The frightening risks of prostate surgery would certainly be justified if survival was increased dramatically. Yet despite an explosion in the use of surgery, prostate cancer death rates in the

United States

have only improved about half of a percent compared to 30 years ago. And experts aren’t entirely sure that surgeons can take credit for these slight benefits. Estimates indicate that on average surgery adds at most a couple months to a man’s life expectancy.

If Not Surgery, What?
Almost any other kind of treatment—seed implants, radiation, focal cryotherapy, hormone therapy, or active surveillance—is just as effective as and considerably less dangerous than surgery. Consider that prostate cancer is the only remaining type of cancer where surgeons (urologists) are acting as the primary doctor. Men with other common cancers, say of the lung or colon, benefit by consultation with cancer experts called medical oncologists. Beware of indulging your initial gut reaction to “just cut it out.” Instead of saving your life from cancer, all you may be accomplishing is the eradication of your sex life.

1. Harin Padma-Nathan, Journal of Urology, Abstract 1402, 2003.
2. Barbash, Gabriel, New England Journal of Medicine, 363:701, August 2010.
3. Eastham, James, Journal of Urology, 170:2292, December 2003.
4. Savage, Caroline, Journal of Urology, 182:2677, December 2009.

To Be or Not to Be Biopsied—That Is the Question

2011-03-29T17:14:00.000-07:00

BY RALPH BLUM

“When the final chapter of this disease is written, it will prove that never in the history
of oncology will so many men have been so over-treated for one disease.”

That’s Dr. Thomas Stamey talking. Formerly Chief of Urology at Stanford University, he is the man who developed the PSA blood test, a remarkable tool that has transformed the management of prostate cancer over almost two decades. It is also the first stop on the Over-Treatment Express.

Your ticket to ride is the biopsy.

The Big Question: When your PSA rises unexpectedly, how do you keep from becoming a statistic among the legions of the over-treated?

First, repeat the PSA. If it is still abnormal, rather than scheduling a biopsy, consider further testing with PCA-3, color Doppler ultrasound and/or spectrographic endorectal MRI. If these tests fail to reveal anything worrisome, frequent monitoring may be preferable to an immediate biopsy.

Second, before you agree to a biopsy, be sure you have done your research and are up to speed on prostate cancer, the treatment options and the potential negative side effects.

Facts of Biopsy Life

A biopsy is a medical test in which cells and/or tissue are removed from some part of a living body—in this case, the prostate—for examination under a microscope by a pathologist, in order to establish the presence and extent of cancer. When only a tissue sample is removed, the procedure is called an incisional biopsy or a core biopsy.

Prior to being biopsied, you need to be aware that almost half of all men diagnosed with prostate cancer have a chronic Low-Risk type, a condition which, according to my writing partner, prostate oncologist Mark Scholz, doesn’t really deserve to be called “cancer” and can be safely monitored without immediate treatment. This reassuring knowledge helps to diffuse the inevitable fear that comes with a cancer diagnosis.

So what is the problem? The prostate cancer world is run by urologists. Urologists—and remember, a urologist is a surgeon—are the specialists to whom primary care physicians refer their patients for evaluation when the PSA rises. Nor is it an exaggeration to say that, to most urologists, an elevated PSA calls for a biopsy. And that a modest number of cancer cells in a few biopsy cores will be sufficient reason to reserve time for you in the operating room. The next time you see him, your urologist will probably be scrubbing up.

Don’t get me wrong: I know a number of urologists I’d trust with my life. Moreover, I am aware that urologists have an obligation to detect any prostate cancer at the earliest possible stage because long-term survival is threatened if the cancer has spread beyond the confines of the prostate, into the regional lymph nodes or the bones. Before that happens, a biopsy serves to establish tumor grade and Gleason score which, along with the number of cores involved and the volume of cancer cells in each core, are useful indicators of aggressiveness.

What Scares Us Most?

Over the past five years, while writing Invasion of the Prostate Snatchers, I have talked with hundreds of men to get a sense of what worries them most about “that damn biopsy.” First, there’s the likelihood of serious pain. When performed by skillful urologists and interventional radiologists, the trauma is all but absent. When Dr. Duke Bahn, who is one of my heroes, performs a biopsy, I have experienced a small pinch when he “harvested” (a doc word) the tissue. However, if you fall into the hands of what one often biopsied veteran calls “the Class B urologists” (where “B” stands for “Butchers”), the experience can range from gross to grizzly.

Then, there’s the rampant suspicion I share with many men that bleeding from a biopsy, or the needle itself, might spread the cancer. While multiple studies have shown that migrating cancer cells rarely result in metastasis, the suspicion and the fear it creates, persist.

Finally, there’s the matter of impotence. The odds are pretty well established: In one study, a month after undergoing a biopsy, 41% of the men experienced erectile dysfunction. Six months later, 15% were still impotent. The results of another study are not quite so grim, but I have heard from men who still suffered from erectile dysfunction for 18 months following a biopsy.

One of the Most Important Decisions You Can Make
Before you even consider undergoing your first biopsy, find yourself a prostate cancer expert. Then have him or her (rather than your family doctor as is usually the way it’s done) select a urologist for you.

I’ll have more to say about biopsies. And if any of you reading this has a biopsy experience that could be useful to other men, we look forward to hearing from you. Urologists welcome.