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Exercise and Cancer: What Your Prostate Thinks

Hey, guys: If you think exercise is just about pumping iron and getting big traps, six-pack abs and “gun show” biceps, your prostate would like to disagree.

To your prostate, how ripped or shredded you are is not nearly as important as your cardiovascular health.

Now, you may be wondering, why should the prostate even care about cardiovascular exercise? Here’s a very good reason: exercise can lower your risk of getting lethal prostate cancer, or of having cancer come back if it’s already been treated.

Epidemiologist June M. Chan, Sc.D., an expert on lifestyle and cancer, heads a research program at the University of California San Francisco that seeks fixable risk factors for prostate cancer progression – things in your lifestyle that you can change to lower your odds of dying of prostate cancer. I recently interviewed her for the Prostate Cancer Foundation’s website.

In previous work, Chan and colleagues were the first to show that vigorous exercise (such as jogging or bicycling) after diagnosis was associated with a reduced risk of prostate cancer death in men with localized disease. “We observed that three or more hours a week of vigorous activity, as opposed to less than one hour a week, was associated with an approximately 60 percent reduction in the risk of dying of prostate cancer.” Chan and colleagues observed similar results among 1,455 men in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE). These findings suggest that “engaging in relatively vigorous physical activity and/or having higher cardiorespiratory fitness may protect against prostate cancer progression.”

Now, exactly why is this? That’s what Chan and colleagues are hoping to figure out. “We have a number of studies here at UCSF examining lifestyle and prostate cancer,” she says. “One trial is for men on Active Surveillance, and our main goal is to look at changes in prostate tissue.” Investigators are comparing prostate biopsy samples taken at diagnosis and again after a 16-week period in which men are randomly assigned either to continue their usual activities or to take part in a personalized exercise program that is designed to increase their cardiopulmonary fitness. The researchers also are measuring chemical processes involving circulation and metabolism, looking for specific differences in the two groups.

In this study, Chan is not as interested in studying the men who are already exercising a lot. “We anticipated that the biggest benefits would be observed in individuals who are relatively sedentary and who adopt moderate exercise. If men are already highly fit, they’re probably already exercising several hours a week, and we thought it would be harder to ask them to do more or spend more time, so that we could observe a relative change in fitness,” she says. “Our main goal is to increase the fitness levels gradually through a walking program in men who are at low to intermediate levels of fitness at the beginning of the study.”

The idea here is that even moderate exercise can help lower the risk of lethal prostate cancer. We’re talking about the kind of exercise that almost everyone can do. It is “purposely scaled to be relative to someone’s baseline fitness, and we are choosing men who are low- to moderate-fit,” Chan notes. Men in this study start out just by walking, and then walking faster, and then escalating – literally – to walking uphill.

The men aren’t going flat-out, like someone in a high-intensity workout. They’re just doing a little more than they could, and after they get used to that, they do a little bit more – slowly building up their fitness.

Chan speculates that the tissue samples in the exercise group will show changes in indicators of angiogenesis (cancer’s ability to build a scaffolding of blood vessels and other infrastructure so it can grow and move beyond the prostate); in inflammatory processes; in insulin and insulin-like growth factor signaling; in androgen receptor signaling pathways; and in oxidative stress mechanisms. “Biochemically, exercise could help deter metastasis of the tumor by changing the environment for the cancer” – in effect, spraying fire retardant on the tumor. Not necessarily extinguishing the flame altogether, but making it burn slower, and helping the body set up fire breaks to keep the cancer confined to its current location.

Making Prostate Cancer Fat and Happy

“Prostate cancer may be the most common cancer where exercise, used like a drug, can confer an increase in survival,” says medical oncologist Jonathan Simons, M.D., CEO of the Prostate Cancer Foundation. “There is no form of treatment that has this effect, and certainly not one as beneficial to the entire body as exercise.”

It may be, Simons adds, that what exercise does – just as it improves blood flow in the arteries – is give cancer a better blood supply that keeps it happy where it is, “so the tumor has no motivation to leave.” So basically, exercise makes cancer feel like it’s at a nice hotel, with free cable TV, continental breakfast, and a pool. It’s content to stay there indefinitely, ordering room service. “When tumors are stressed” – when they’re in a bad neighborhood, in effect – “they have genes that are programmed to help them survive by getting them to crawl away to someplace that better serves their needs.”

One of those genes, Simons found in research at Johns Hopkins, not only pipes in more blood to supply the tumor; it gets rid of waste products – the cancer cells’ sewage, in effect. “When tumors try to turn on blood vessel growth to get more nutrients, they also build their own plumbing for both intake and waste disposal. Angiogenesis is not just about getting oxygen and food – glucose and protein – to the cancer. It’s getting rid of byproducts, too. That kicks off a genetic program so the cancers can relocate” – start to spread.

But giving the cancer a better blood flow might subvert the cancer’s need to boost its own blood supply. It just may be that exercise makes cancer, rather than head for the door, sit back in the recliner and reach for the remote. A contrary notion, isn’t it – that in order to turn your prostate cancer into a couch potato, your best chance is not to be one yourself?

This doesn’t mean, of course, that men who exercise are immune to prostate cancer. “There are very fit athletes who have had forms of prostate cancer that are so aggressive, so genetically mutated, that have proved fatal,” notes Simons. However, those men are at one end of the spectrum of prostate cancer. There are many thousands of men at the other end or in the middle, for whom exercise may make a real difference. “What if you have a Gleason 8 cancer, you had surgery, your PSA was undetectable, and now it’s starting to creep up. And what if you could exercise and delay its colonizing in your bones by eight or nine years, because you so shifted the chemistry in your body that the cancer cells just sat there? That’s a very abstract concept, one that’s still not widely appreciated. But if we could get even three times as many men right now exercising, we could change the overall survival of the disease.” And if scientists like Chan can figure out precisely why this is happening, it may lead to development of new treatments that could make exercise even more effective in deterring the return or spread of prostate cancer.

Is it ever too late to start to exercise? No!

In other trials, including one funded by Movember, Chan and colleagues from around the globe are studying the benefit of aerobic exercise and also strength training in men with castrate-resistant prostate cancer, to see if these interventions can help men at a later stage of cancer live longer. “There are data in men with advanced disease also suggesting that exercise may impart not only quality of life but also clinical benefits” she says.

Body Size and Prostate Cancer

Prostate cancer loves fat. Fat increases inflammation in the body, lowers insulin resistance, and just generally makes a more inviting environment for prostate cancer.

But exercise burns fat. And this, in turn, lowers your body mass index (BMI).   “Increasing evidence suggests that being overweight, either before or at the time of diagnosis with prostate cancer, is strongly associated with the risk of cancer progression and of dying from prostate cancer,” says Chan. “For example, among 2,546 men diagnosed with localized prostate cancer in the Physicians’ Health Study, a one-unit increase in BMI before cancer diagnosis was associated with about a 10-percent increase in a man’s risk of dying of prostate cancer.”

BMI calculators are available on the internet, but briefly, if you are at a healthy weight, your BMI is between 19 and 24.9 kg/m2.  In the Physicians’ Health Study, having a BMI of 30 kg/ m2 or greater “was associated with a nearly twofold increased risk of prostate cancer death,” notes Chan. Further, “a meta-analysis of six studies in prostate cancer patients reported that a 5 kg/m2 increase in BMI raised the risk of dying of prostate cancer by 20 percent, and of biochemical recurrence (having the PSA start to rise again after treatment) by 21 percent.”

 More of this story and much more about prostate cancer are on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.” The PCF is funding the research that is going to cure this disease, and they have a new movement called MANy Versus Cancer that aims to crowd-fund the cure, and also empower men to find out their risks and determine the best treatment. As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

What is Prostatitis, Anyway?

Thousands of men are diagnosed with prostatitis every year.  But guess what? Most of them don’t actually have it.

Maybe you’re one of those men, and you’ve been taking antibiotics for weeks because your doctor told you that’s what you had. How are your symptoms? Are they any better? And here’s an important question: Did your doctor get a culture to make sure there’s a bacterial infection in your prostate?  

If you got a culture of your prostatic fluid, you would know it; it’s not like swabbing your throat looking for strep or taking a simple urine test.  No, checking the fluid that is inside the prostate begins with a rectal exam.  “We push on the prostate, fluid comes out the tip of the penis, and we capture this on a slide and look at it under the microscope,” says Sarah Flury, M.D., urologist at Northwestern University, one of the world’s experts on prostatitis and one of the experts we interviewed in the newest (2018) edition of our book on prostate cancer (prostatitis is NOT prostate cancer, but because it involves the prostate, that most troublesome gland, we put it in there).

If you didn’t have a culture of your prostatic fluid, but your doctor told you that you have prostatitis and put you on a powerful antibiotic like Ciprofloxacin, then it’s no wonder if your symptoms haven’t gotten any better. (Actually, taking a long course of antibiotics could even be bad for you; keep reading.)

Imagine if you had chest pain, and you went to the hospital, and the doctor in the Emergency Room said: “Chest pain? That’s a heart attack.” But in fact, your particular chest pain is because you have acid reflux – major backup of your stomach acid into the esophagus – and it hurts so bad that your esophagus is having a spasm. What you really need is a heavy-duty acid reducer or even a proton pump inhibitor, but instead you’re getting pumped full of blood thinners and expensive medicine to dissolve a nonexistent blood clot.

This is a terrible example, but it makes the point: In medicine, you can’t assume, and you can’t put people on medication that isn’t going to help them. If you don’t actually have prostatitis that is caused by bacteria, all the antibiotics in the world aren’t going to help you, and they may cause other serious problems.

Prostatitis is a grab-bag diagnosis; a catch-all where a variety of symptoms are often chucked together when doctors “don’t know what is going on,” says Flury. Pain in the testicles? Prostatitis. Pain in the penis? Prostatitis. Pain in the bladder or rectum? You guessed it. Burning when you urinate or ejaculate? Prostatitis. It’s like the diagnostic Island of Misfit Toys from the classic TV special, “Rudolph the Red-Nosed Reindeer.”

And yet: “Bacterial Prostatitis itself is actually very rare,” says Flury.

Which begs the question, what is it? For the vast majority of men, “prostatitis” is just what the symptoms sound like: Chronic Pelvic Pain Syndrome (CPPS). But what’s causing the miserable symptoms in one man with CPPS might not be what’s causing them in another man. Everybody’s different, and you need to see a doctor who specializes in this, at a medical center where they see a lot of men with these symptoms and know how to treat them.

For example, in some men the cause of pain or tenderness in the scrotum or lower back is actually the pelvic floor muscles in spasm– like a hard muscle knot in the neck or back, except it’s close to the rectum. “There’s treatment for it,” says Flury, “specialized physical therapy, where they do a pressure point release.” Other men have bladder symptoms that are related to interstitial cystitis, which is the “irritable bowel” of the bladder, with muscle spasms. Some men with frequent or burning urination get better with Flomax or another drug in the category of “alpha blocker.” These drugs relax the muscles in the prostate and bladder and help relieve symptoms. Some men get better by changing their diet – because for them, spicy foods seem to set off the symptoms. Men who have difficulty or pain when urinating are often helped by biofeedback and physical therapy.

“Chronic pelvic pain is the broadest diagnosis,” says Flury. “It’s the base of the pyramid. Prostatitis is one of the diagnoses that can cause pelvic pain – not the other way around. Prostatitis is completely misunderstood and misused as a diagnosis. There are many different causes, and it is incredibly rare that it’s actually a bacterial infection in the prostate.”

So, if you have these symptoms, or if you’ve been told that you have prostatitis, what should you do?   “First, know that you’re not alone,” says Flury. “You have something real, but it’s quite possible that you’ve been given the wrong terminology for your diagnosis. CPPS is a heterogeneous syndrome; it’s not a specific disease, and ‘one size fits all’ doesn’t work. It’s a framework, and men have different symptoms within that framework: urinary symptoms, psychosocial symptoms like depression, muscular problems, neurological symptoms, organ-specific problems – in the penis, or testicles, or bladder, or prostate. All those things fit into CPPS.”

Flury is troubled by the number of men who have come to see her after another doctor told them, “You have prostatitis. Try these antibiotics for six weeks and see how you feel.” It’s not that easy. “People treated for six weeks on Cipro, without a diagnosis of infection? It’s terrible. You have to take a history. There may be 10 different causes for these symptoms, and 20 possible treatments.” Many of these men never even had a culture to confirm the diagnosis; they just got put on antibiotics.

It is worth it, Flury adds, to go to a center of excellence. She recommends that you start with this link: http://www.mappnetwork.org. There is a network of centers across the country, where physicians and scientists are doing research on the entire spectrum of CPPS. Even if you don’t want to participate in a clinical trial, physicians at those centers know how to figure out what’s actually causing your symptoms, and plan the treatment accordingly. “CPPS is a common condition, but many traditional therapies fail,” she says. Undoubtedly, that’s because the wrong thing is being treated. Find a doctor who can figure out what you really have. If you’ve been given a diagnosis of prostatitis, the first thing to do is to make sure you actually have it. If you have an infection, you need antibiotics, but if you don’t, you don’t need antibiotics. Many more men have CPPS than prostatitis.”

            Antibiotics: There Are Risks

Some people have the idea that – because in the 1940s when they first came out, these truly were miracle drugs – everything’s better with antibiotics. But here’s why it’s not good to be put on six weeks of a powerful antibiotic if you don’t really need it:

In July 2016, the FDA issued a warning to doctors. It advised restricting the use of fluoroquinolone antibiotics for certain uncomplicated infections – because the “serious side effects … generally outweigh the benefits for patients.” People with some conditions – such as sinusitis, bronchitis, and a simple urinary tract infection – have other options; there are lots of antibiotics that treat those problems. However, men with acute or chronic bacterial prostatitis don’t have as many other choices, so for them, the risks of fluoroquinolones are probably worth it.

But you sure don’t want to be taking these drugs if you don’t need them – and if you haven’t even had a proper culture to determine if you even have an infection.

“An FDA safety review has shown that fluoroquinolones, when used systemically… are associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system.” Some of these side effects include “tendon, joint and muscle pain, a ‘pins and needles’ tingling or pricking sensation, confusion, and hallucinations. Patients should talk with your health care professional if you have any questions or concerns.”

  

What if You Actually Do Have Bacterial Prostatitis?

No getting around it: if you do have bacteria-caused prostatitis, you need to take antibiotics for six weeks.

Acute Bacterial Prostatitis. If you have this, you know it, because it’s debilitating – so much so, that you are probably reading this in the hospital. You most likely also have a fever, chills, and extreme pain. This is not the time to be a macho man and suffer through it. You need immediate treatment. Go to the doctor or, after hours, an emergency center.   This is very important: If you have acute bacterial prostatitis and you don’t get help right away, you could develop a life-threatening infection in the blood (called sepsis), or not be able to urinate (urinary retention, which requires a temporary catheter), or develop an abscess within the prostate (an infected area of pus under pressure; as you can imagine, this is very painful).

“Acute bacterial prostatitis is an infection that can have very severe symptoms,” says New York University urologist Stacy Loeb, M.D. “It requires immediate treatment with antibiotics. It is also one of the potential risks of a prostate biopsy: this is why all men who undergo a prostate biopsy require antibiotics before and after to reduce the risk of a symptomatic urinary tract infection – and acute bacterial prostatitis is really an acute urinary tract infection. In fact, recent studies show that acute prostatitis after a biopsy can be more severe than other cases.”

The good news is that once you start taking antibiotics – usually in the category called fluoroquinolones; an example is Ciprofloxacin – you will start to feel better fairly quickly. The thing is, you will need to stay on antibiotics much longer than you might expect. If you just take a course of antibiotics for a week to 10 days and then stop, and even a tiny amount of infection remains in the prostate, guess what? It is likely that the prostatitis will come back – this time as a chronic infection, which is harder to get rid of.   If you have an episode of acute bacterial prostatitis, then, you should stay on antibiotics for about six weeks. Be steadfast with the antibiotics and wipe it out the first time. You don’t want to go through this ever again if you can help it.

Chronic Bacterial Prostatitis. This is rare. Here, too, the treatment is antibiotics. The “chronic” part is that this form of prostatitis can come back every so often for years if an episode of acute bacterial prostatitis is not adequately treated the first time. The treatment is the same: six weeks of antibiotics.

More about prostatitis and much more about prostate cancer are on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington