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Time to Shape Up

I am so happy.  I’ve been writing for the Prostate Cancer Foundation for several months now; everything I’m writing is for men with prostate cancer and their families.  It’s right up my alley – telling men what they need to know, what their doctors might not tell them or may not even know, and most of all, doing my best to be upbeat because there is so much hope out there for men at every stage of this disease.  When the PCF says the website is a “go,” I will be able to tell you more, and share all that with you.

But here’s a preview: One story has me so fired up that I just want to give you the highlights.  It turns out that prostate cancer is a disease of inflammation, just like diabetes.  You know what inflammation is – when you skin your knee, and it gets all red and hot around the wound.  That’s your body’s way of attacking the germs, and in the case of a skinned knee, it’s a good thing.

Unfortunately, the same process gets triggered on a much smaller scale within your cells.  A lot of things can cause inflammation within the cells, including fried foods and even sexually transmitted diseases. Those are topics for another post.   

Fat can trigger inflammation, too. It turns out that people who are overweight tend to have higher glucose levels, higher insulin levels, and to produce cytokines – immune system boosters, which can encourage inflammation; sometimes inflammation is good, if it helps you fight off infection, but other times, it can put added stress on the body and perhaps tip the balance toward cancer,

healthy foodThe good news is that it is never too late to change your lifestyle – and to have this change instantly lower your cancer risk.  If you lose weight and start to exercise early in life, you may delay or even stop some of the processes that lead to prostate cancer.  If you lose weight, and if you exercise after you are diagnosed with cancer, you will certainly be in better shape for treatment.  You will also help lower your risk of having the cancer come back.  If you are battling cancer right now, losing weight and exercising may help deprive the cancer of some of the things it needs to thrive.

This is not just happening in prostate cancer.  Yale scientist Melinda Irwin, Ph.D., M.P.H., presenting her research at the big yearly meeting of the American Society of Clinical Oncology (ASCO) in Chicago, announced that she and colleagues found a “strong connection between exercise after (breast cancer) diagnosis and mortality.”  Even in women who had never really been active previously, starting regular exercise “seemed to show a great impact.” 

Irwin, an epidemiologist at the Yale School of Public Health, is probably not the favorite of the pharmaceutical industry; she has gone on record in the past pointing out that most large-scale drug trials don’t include a lifestyle component.  That’s because big Pharm “has no incentive to fund lifestyle behavioral interventions.  Why would they?  There’s no pill to take.”

And yet the connection between obesity and cancer keeps getting stronger.   ASCO, in a paper published in the online edition of the Journal of Clinical Oncology, has stated that being overweight “is associated with worsened prognosis after cancer diagnosis.”  It also said that if you are overweight and are diagnosed with cancer, chemotherapy or other treatment might not work as well; you may have more complications from treatment, may be more likely to have cancer develop somewhere else, and you have a higher risk of dying from cancer. 

ASCO estimates that as many as 84,000 cancer diagnoses each year are due to obesity, and that being overweight or obese is the cause of as much as 20 percent of all cancer-related deaths.  The National Cancer Institute has linked being overweight to “poorer outcomes in cancer patients,” and to raising the risk cancers including breast, colon, prostate, kidney, pancreas, esophagus, and gallbladder.

In a different study, European scientists just showed that having “central obesity” – fat in the belly, around the heart – makes you more likely to develop more aggressive prostate cancer.   The EPIC (for European Prospective Investigation into Cancer and Nutrition) study followed nearly 142,000 men from eight European countries for 14 years; the average age of the men when it began was 52.  Nearly 7,000 of those men were diagnosed with prostate cancer, and 934 of them died of it.  The scientists looked particularly at the men with the worst tumors.  They found there was a 14 percent greater risk of dying from prostate cancer for every 5-unit increase of Body Mass Index, and an 18 percent higher risk for every 10-centimeter (about four inches) increase in waist circumference. 

Having fat right around the waistline is already linked to Type 2 diabetes, high blood pressure, and heart disease; now, apparently, it is linked to cancer.  That’s because, unfortunately, fat in this particular location happens to surround organs, and it stresses them out.

walkingThe good news is, the risks go down as you shape up.  With every pound you lose, every bit of fat that you turn into muscle, your odds of being healthier go up.

Irwin has found that brisk walking lowered levels of two major biomarkers, insulin and “insulin-like growth factors” (IGF), in postmenopausal women who had survived breast cancer.  Both are linked to a higher risk of breast cancer.   She also has noted that breast cancer survivors who are obese have a 33 percent higher risk of having cancer return, or of dying from breast cancer, than other survivors do.

However, women who lost 6 percent of their weight through exercise and diet had a 30-percent decrease in levels of a protein associated with breast cancer, and women who exercised after being diagnosed with breast cancer had as much as a 40-percent lower risk of having the breast cancer return, and of dying.

To sum up, people who lose weight and exercise can improve their odds of not dying from cancer significantly. 

©Janet Farrar Worthington

Regular disclaimer: This is a blog. It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional.

Don’t Shun the Sun

sand_sun_beachIn 2002, when I ghostwrote the first edition of The Paleo Diet for Loren Cordain, I thought we were writing sacrilege when he said people need sunlight.  That’s because our view of what’s normal and natural has gotten skewed.  “Oh, no!” I thought.  “Must have sunscreen.  Sunscreen good, sun bad!”  Just a few steps away from Frankenstein being terrified of fire.

I’ve lightened up, so to speak, since then.  Cordain was right:  Yes, excessive sunlight exposure is linked to skin cancers, including squamous cell cancers, which form on the top layers of the skin; basal cell cancers, which form on the bottom layers of the skin; and melanomas, which form within the skin’s pigment-producing cells, the melanocytes.  However, avoiding sunlight is not the way to prevent disease.

“The experience of our hunter-gatherer ancestors proves helpful,” Cordain wrote.  “Many studies have shown that people with high lifetime sunlight exposure, similar to that of hunter-gatherers, have lower rates of melanoma than those with low sunlight exposure.  Also, indoor workers have a greater risk of melanoma than outdoor workers.  Even more puzzling, melanomas often arise in body areas that are infrequently or intermittently exposed to sun.”  Many scientists believe that severe sunburn during childhood — like that time where you went to the beach and came home red as a lobster, and maybe your mom (as mine did) treated it with baking soda and/or aloe, apple cider vinegar, or other home remedies — or intense burns in areas that usually don’t see the sun are bigger risk factors for the development of melanoma.

“When your exposure to sunlight is gradual, moderate and continuous,” Cordain explained, your body responds “in a manner guided by evolutionary wisdom.”  Your skin begins to get tan, because your body is ramping up its production of melanin.  The darkened skin helps protect you from the sunlight’s most damaging ultraviolet rays.  Also important: Vitamin D levels in the blood start to increase, too, as the UV light hits the skin and your body starts to convert cholesterol into Vitamin D.

Vitamin D is a really good thing.  It’s actually a hormone, which is mostly formed in the skin.  As an aside, jumping to other books I’ve co-written: In Dr. Patrick Walsh’s Guide to Preventing Prostate Cancer, Walsh, the noted Johns Hopkins urologist, points out that “over the last 25 years, the death rates from prostate cancer in America have been the highest in the regions of the country that get the least sunshine” (north of 40 degrees latitude).  However, Walsh cautions, taking too much Vitamin D is not a great approach, either.  If you’re going to take a Vitamin D supplement, he advises not taking more than 4000 IU per day.

Cordain cited evidence from population studies confirming that people with the greatest lifetime sun exposures have the lowest rates of prostate, breast, and colon cancers.  But most important to Cordain, from years of study of our Stone Age ancestors, is this: “Exposure to sunlight is natural for humans.  It is part of our evolutionary heritage.  Without sunlight, it is virtually impossible to achieve an adequate intake of vitamin D from the natural foods that were available to our hunter-gatherer ancestors.  Our food supply has been a significant source of vitamin D for a very short time — less than a century, when dairy producers began adding it to the milk and later, to margarine.  Sunlight exposure is healthy as long as it occurs in a slow, gradual, and limited dose over the course of a lifetime.”

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional. 

Prostate Cancer Screening and You

Prostate Exam“Hey, buddy!  It’s me, your prostate.  How’s it going?  I know you’re busy, but … I’m just going to put it out there.  You’re ignoring me.  You never call, you don’t even text — and you don’t get me checked.”

Okay, that wasn’t actually your prostate, but let’s face it, for most men the prostate is not a top health priority.  It falls in the category of “obscure body parts” that includes the spleen, the medulla oblongata, and the little thing that hangs at the back of your throat.

Most men reckon that the prostate is best dealt with on a need-to-know basis.  Unfortunately, you will need to know about the prostate sometime, because this troublesome gland is the source of three of the major health problems that affect men:  Prostate cancer, the most common major cancer in men; benign enlargement of the prostate (BPH, for benign prostatic hyperplasia), one of the most common benign tumors and a source of urinary symptoms for most men as they age; and prostatitis, painful inflammation of the prostate, the most common cause of urinary tract infections in men.  Some men are unlucky enough to deal with more than one of these over the course of their lifetime.

Today, I want to talk to you about prostate cancer.  Because when it’s caught early, it is usually curable.  Equally important:  In its earliest, most curable stages, prostate cancer produces no symptoms and you feel perfectly fine.  The best way to not die of prostate cancer is to find it when it’s still curable.  As Patrick Walsh, M.D., the great Johns Hopkins urologist and my longtime co-author, puts it, “If you can expect to live at least 10 to 20 more years and don’t want to die from prostate cancer, you should be screened.” 

Start When You’re 40

Screening involves two things:  A blood test for PSA (prostate-specific antigen) and a digital rectal exam that takes about a minute.  You should start when you’re 40, and depending on your results, you may not even need to get screened every year.  The PSA test is like a barometer for the prostate – but it’s best served up as a continuum, not a cut-and-dried, one-shot reading.  Another Johns Hopkins urologist, H. Ballentine (Bal) Carter, M.D., came up with a concept called PSA velocity.   Years ago, using an excellent database called the Baltimore Longitudinal Study of Aging (BLSA), he was able to look at the blood of men over a period of many years.  He looked at their PSA levels, and watched as they changed, or didn’t change, over time.   He has published many articles on this, and Patrick Walsh and I have written about it in several books (most recently, the Third Edition of Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer, which has everything you could possibly want to know about PSA and the many ways to test it.)

Here’s the most basic information you need to know:

Get the Test

If you are in your forties, and you have a PSA level greater than 0.6 ng/ml (nanograms per milliliter), you should get your PSA measured every year. 

If you are in your fifties, and your PSA is greater than 0.7, you should get your PSA measured every year.  (These numbers come from Carter’s research. In another study, urologists Stacy Loeb, now at New York University, and William Catalona of Northwestern University, found the numbers to be slightly higher; 0.7 for men in their forties and 0.9 for men in their fifties.) 

This first PSA test is your baseline.  From this, your doctor will watch your PSA to see if it changes.  If you have a low PSA level (between 1 and 4 ng/ml), any increase is alarming.  In a study using data from the BLSA, Bal Carter and colleagues found that if PSA climbs more than 0.2-0.4 ng/ml per year, this is a predictor of death from prostate cancer.  This is really important:  No matter what your number is, if it keeps going up, you need to have it checked out.  Especially if you are in a high-risk group for prostate cancer — if you have a family history of the disease, or if you are an African American.  The number shouldn’t be changing very much.  If it is changing, and you don’t have a good reason for it (like a urinary tract or prostate infection; see below) you need to get a biopsy.  If no cancer is found and it’s still going up, you need to get a repeat biopsy in several months.  (There are other reasons why PSA can go up, including BPH, but this is more common in men in their sixties and older.  For men with a PSA greater than 4, an average, consistent increase of more than 0.75 ng/ml over the course of three tests is significant.)

Now, as I write this, I have a friend with a family history of prostate cancer; his father, uncle, and grandfather have all had it.  He is 51.  His PSA has gone up more than 0.2 ng/ml each year over the last two years.  His urologist has not recommended a biopsy.  In my opinion, his urologist is an idiot.  A lot of doctors are still lulled by low numbers; it used to be that any PSA below 4 was considered “safe.”  That’s not true. 

[Tweet “The key is, is your PSA going up, and if so, how fast? #prostatecancer”]

What if You Don’t Have a Baseline? 

What if this is your first PSA test?  Says Walsh:  “If you are in your 40s, 50s, or 60s and you have never had a PSA test, if you get one and your level is greater than 2.5 ng/ml and you can expect to live at least another 15 to 20 years, you should have a biopsy.  If your biopsy finds no cancer, you should continue to have your PSA level rechecked at regular intervals, using both the total PSA level and the speed at which it rises over time to determine whether and when you need to have a repeat biopsy.” 

When Can You Stop Screening? 

That’s a good question.  Again, your PSA track record determines a lot.  In his research, Bal Carter showed that if PSA testing were discontinued at age 65 in men who had PSA levels below 0.5-1.0 ng/ml, it would be unlikely that prostate cancer would be missed later in life.  A more recent study suggested that it is safe to discontinue PSA testing for men aged 75-80 with PSA levels lower than 3 ng/ml.  However, the men aged 75-80 who had PSA levels greater than 3 remained at risk of developing life-threatening disease.   This also depends on your general health.  If you are in your seventies, you don’t have any other health problems and can expect to live a good long life, for your own peace of mind you may prefer to keep on getting tested.  

In the Case of PSA, Numbers Really Matter

If PSA is so important, why do you need the rectal exam?  Because the PSA test is not foolproof.  About 25 percent of men who turn out to have prostate cancer have a low PSA level — say it’s 1.2, and it goes up a little over time, maybe to 1.8 — one that, despite an increase, doesn’t get flagged as suspicious.  For several reasons, including the way some tumors make PSA, you need a “back-up” plan (I admit, pun intended).   Conversely, the rectal exam is not perfect, either.  In many men with prostate cancer, the tumor may be in an inopportune spot, just out of finger’s reach, where it simply can’t be felt by a doctor.  In other men, cancer is “multifocal”– there are several patches of cancer, not just one – and the prostate feels uniform in consistency.  It’s deceptive, but the doctor’s finger doesn’t have a microscope on it and doesn’t always know when it’s being fooled.  Most normal prostates feel soft.  Cancer feels hard.  But if it’s in several places, or too small to feel yet – even though it’s growing and dangerous – a doctor could touch it and not know. 

This is why you need both tests, instead of an either-or approach for early detection.  It’s like using the breast exam and mammogram together to find breast cancer in women.  In one study of 2,634 men, investigators found that the PSA test and the digital rectal exam were nearly equal in cancer-detecting ability – but they didn’t always find the same tumors.  So if only one technique had been used, some cancers would have been missed.  Together, these two tests make a formidable team.

Really Important Things You Need to Know Before the PSA Test That Your Doctor Might Not Tell You

Don’t ejaculate for at least two days before you have your blood drawn.  This can raise your PSA level, throw off the test, and scare everyone unnecessarily.

Whatever you do, make sure to have the test before the rectal exam.  (The rectal exam can stimulate the prostate and cause more PSA to show up in the bloodstream and again, make your PSA level seem higher.)  I tell you this because my husband once had the test before the exam, it made his PSA number higher, and we got scared.  His doctor should have known better.

If you are taking Proscar or Avodart for BPH, or Propecia for hair loss, all of these drugs lower PSA.   They can make it seem artificially low, and if you have cancer, it might be missed.  (To correct for this, if you have recently started taking one of these drugs, your PSA level should be multiplied by 2.0.  If you have been taking it for five years or longer, your level should be multiplied by 2.5.)

If you have had surgery or a laser procedure to treat BPH, this can make your PSA much lower.  Don’t focus on the number; watch what it does.  If your PSA begins to increase steadily, you should see a urologist.

If your PSA test shows a significant increase, repeat the test in the same lab.  In 25 percent of these cases, the reading will be back down to its former level.  Says Walsh:  “If there is a clear-cut elevation, ask your doctor about prescribing antibiotics to rule out a possible infection.  Often, men receive ciprofloxacin or levofloxacin for three to four weeks and have the PSA measured again.  If it is elevated again, you should have a biopsy, using a different antibiotic when you have this procedure, to avoid infection from resistant bacteria.”

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional. 

Smokeless Tobacco: Move Your Chaw to Save Your Jaw

antique spittoon on floorIf you use smokeless tobacco, or know a guy who does and want to help him, this is for you.  Obviously, the best thing you can do is quit.  But if you can’t do that, these three words may save your life:  Move your chaw!

I’ll explain, with help from Jason Campbell, D.D.S., a Prescott, Arizona, dental surgeon who specializes in complex reconstructions.  (Note: Campbell is also a very nice guy, and he says if you have any questions about what we’re talking about in this story, contact him at frontoffice@myprescottdentist.com and he will answer them.)

When you stick a plug of tobacco in your mouth, it begins to break down, or denature, the tissue it touches.  It doesn’t just alter the tissue but the genetic code, as well, and this can lead to cancer.  By habit, says Campbell, “guys typically tend to keep the tobacco in the same spot all the time. “ The repeated chemical attack, of denaturant leaking out of a chaw of tobacco day after day, causes the body’s immune system to launch defensive countermeasures.   “The body’s way of protecting the tissue is, it toughens it up and thickens it, like when you get callouses on your hands from shoveling or lifting weights.  We see that wherever that tobacco goes.”  The official diagnosis of this phenomenon is called “tobacco pouch keratosis.”  (It’s gross.  Google it.)

Tobacco pouch keratosis is a precancerous condition.  “When the body starts laying excessive tissue down in order to protect itself, when those immune system cells get turned on, the body is automatically activating a system for cell formation.”  Cancer, Campbell points out, “is the continuous growth of tissue.  If the chemicals in tobacco alter the normal process, this system can get turned on and never turned off, and that’s when cancer can form.”  Usually, Campbell sees this keratosis on the lip and gum, but it’s kind of a tip-of-the-iceberg situation.  “Some of the fallout is, it creates inflammation in the area.  Periodontal bone loss is a process of inflammation, and that inflammation can cause a receding gum line, because it damages the bone, and then the gum follows the bone.  So periodontal defects are also very common in people who hold their tobacco in the same place over and over. “

If you smoke instead of chew, don’t feel too smug: The heat from a cigarette or cigar damages tissue, as well, and hampers the immune system in that area.  “So the heat is a problem, but the chemicals in smoked tobacco also inhibit the immune system,” says Campbell.  “Consider that the mouth is a pretty dirty environment.  A lot of different bacteria live there, and if the immune system is suppressed, it’s going to increase someone’s risk for bacteria-induced gum disease, as well as bacteria-caused tooth decay.”  (Another downside of smoking tobacco is that it messes up the taste buds; food doesn’t taste as good, and this suppresses the appetite – which is why you might see super-thin models and actresses puffing on cigarettes.  When people quit smoking, food starts to taste better.)

[Tweet “The damage to your lip and gum are reversible when you quit smokeless tobacco”]

Good news: the damage to the lip and gum is “100 percent reversible when tobacco products are discontinued.”  In the mouth, there is “a constant turnover rate of tissue replacement,” Campbell says.  “When the tissue detects that it doesn’t need to protect itself, that over-reactive thickening stops.  Usually that tissue can rebound.”  Periodontal damage, and damage from bone loss, can be corrected with surgery.

If you can’t quit chewing tobacco, there is still good news:  “I encourage our patients, if they are unwilling to quit, to move it.  My job as their dentist is to help them avoid big problems.  I’d much rather have them move it than increase their risk for cancer.”  For example:  If you generally keep your chaw tucked away on the right side of your mouth, put it on the left.

Campbell knows that for a lot of people, this means, “I just reduced my risk for cancer.  It’s okay for me to continue to chew!”  So, just because you can minimize your risk of cancer by moving your chaw, don’t think that’s one more reason why you shouldn’t quit.  “But one upside is, seeing that tissue heal does bring peace of mind for people.” It doesn’t happen right away, but “in six to eight months, we usually see that kind of leathery tissue start to dissipate.  In the tissue where there is receding of the gum, almost instantly we see the inflammation go down.  The gum is usually red and inflamed there, and that will heal very quickly.”

Keep in mind, Campbell notes, that tooth decay and gum disease are bigger oral health worries than the risks of cancer when it comes to smoking or chewing tobacco – and quitting reduces your risk for having to get cavities fixed, having your teeth go bad and needing crowns, or needing to have gum surgery.  “People need to understand that their risk of developing oral cancer is low.  But their chance of survival is very low.”  The mouth has a lot of blood flow – blood that can take cancer elsewhere, allowing it to metastasize.  People who get oral cancer from tobacco may need to have part of their face removed, or may risk having that cancer spread to other parts of the body.   I wouldn’t wish that on anyone.

Rinse Tests for Oral Cancer:  “We’re getting better at detecting oral cancer,” says Campbell.  Most dentists now check your mouth and throat very carefully for tissue changes, and at many practices, you can request a diagnostic test for oral cancer – a fluorescent rinse that bonds with precancerous cells, causing them to glow or stand out when the dentist shines a light on them.  These tests look for abnormal tissue, and aren’t just limited to changes caused by tobacco.  They can also detect other oral cancers, such as those caused by HPV.

©Janet Farrar Worthington

Regular disclaimer:  This is a blog.  It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional.