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What’s Good for the Heart; Testosterone Levels; ED and Your Health

For a gland the size of a golf ball, the prostate sure does cause a lot of trouble, and treatment can be all-consuming.  That’s why this website has so much “prostate-forward” content.  But guess what?  There are other body parts you have to think about proactively, too!  Don’t forget about the rest of your body!

            This means you still need to think about screening for other cancers, such as colon cancer and skin cancer.  You still need regular checks for blood cholesterol, liver function, kidney function, and diabetes – the lab tests doctors usually order at a routine yearly physical.  You need someone to listen to your heart and check your blood pressure.  If, like many men, you don’t have a family doctor or internist, but only go to the urologist, make sure your urologist is aware of this, and be sure to raise any health concerns at your office visit.

Be Good to Your Heart

            Right up there at the top of your health goals should be cardiovascular wellness.  Here’s one big reason why:  “If you have localized prostate cancer and are treated successfully for it, your biggest risk of dying is of a heart attack,” says Edward “Ted” Schaeffer, M.D., Ph.D., chairman of urology at Northwestern University.  He made this point in our book.

            “Even if you don’t have prostate cancer, heart disease remains the number one cause of death in men,” he continues.  “If you have advanced prostate cancer and are on androgen deprivation therapy (ADT), your risk of a heart attack goes up.  Thus, focus on being heart-healthy!”

            What’s good for your heart?  It’s pretty straightforward:  Eat a diet rich in fruits and vegetables and low in processed foods, fried foods, and sugar.

            Now, what does this actually mean?  I’m not going to tell you never to have cookies, cake, burgers, hot dogs, pizzas, etc.  Just don’t make that the vast majority of what you eat.  Think of an old-fashioned scale, like the scales of justice.  On one side is all the stuff you do eat, whatever it is.  On the other side is what you don’t eat.  It’s not eating vegetables and fruits. Not getting enough protein — your sins of omission are every bit as bad, maybe worse, than any sins of commission (eating a cinnamon roll as big as your head).  You need a lot more protein than you may think:  about 30 grams PER MEAL.  For a 185-pound man, that’s at least 90 grams a day.  There is no shame to protein shakes!  It’s a great way to get a big honking dose of protein.  Other sources:  nuts (6 grams in an ounce of almonds), eggs (a boiled egg has 6.3 grams), a meat bar such as Epic makes (7 grams in one bar), a Kind bar (7 grams in a peanut butter/dark chocolate bar).

            Back to our scale:  whatever goes into the one side should be balanced by the other.  If you eat a slice of pizza, have a salad or a vegetable side.  If you have a scoop of ice cream, make it healthier by putting raspberries or blueberries on top.  Try not to eat a lot of processed meats – but if you do eat a hotdog, or chicken apple sausage, or salami, or pepperoni, try to get the healthier kind without additives.  And know this:

The vast majority of processed food is not good for you.  It’s just convenient.  Even prepackaged food that is marketed as “healthy” actually is often full of junk!

Take, for example, the 25-ingredient veggie burger, which contains few vegetables and is packed with additives.  What the heck is carrageenan, anyway?  (It’s in a lot of prepared foods, and it is not good for you!)  I just interviewed Weill-Cornell medical oncologist David Nanus, M.D., who is Principal Investigator of a study looking at a whole-foods, plant-based diet for men on ADT.  I will report on this soon; the initial findings are exciting and hopeful.  Nanus offers this advice for anyone trying to eat a healthy diet:  “If it’s got more than five ingredients, don’t eat it.”

Or consider the chicken-teriyaki meatballs with 750 mg of sodium in one serving – and one serving is four small meatballs!  Let’s not even get started on fast food and chain restaurants, which make money by offering high-calorie, high-sodium and high-sugar food that pleases the palate but adds to the waistline.  The stakes (and steaks!) are high.

           If you drink alcohol, do it in moderation – although again, many studies show health benefits to red wine.  Aim for some moderate exercise every day.  It doesn’t have to be a heroic effort; just do something.  Anything is better than just sitting around looking at a screen.

Testosterone and Your Overall Health

            Note: If you have advanced or high/risk prostate cancer and you need ADT, then do it.  “That’s the most important issue right now,” says Schaeffer, “keeping the cancer under control.”

            But for men who are not on ADT, men who don’t have prostate cancer or men who have been treated successfully for localized prostate cancer are in a different situation.  They do need testosterone for good health.  “Male hormones play a big role in keeping your body healthy,” says Schaeffer.  “Ideally, men should have testosterone levels that are in the normal range.”

            This can be a tough concept to grasp, says Johns Hopkins neuro-urologist Arthur Burnett, M.D.   “Ever since (Nobel prize-winning scientist) Charles Huggins made the observation 70 years ago that in advanced prostate cancer, if you shut down the male hormones, that will cause a regression of the disease, there’s been widespread notion that if you have prostate cancer, you need to get the testosterone down.  The reality is, if you are cancer-free, if you have low testosterone, you should get to a normal testosterone level.” Even in men who have not been treated with ADT, testosterone can be low for other reasons, including age, obesity, and certain chronic medical conditions.

            Burnett, with investigators at Harvard, is conducting a trial of supplemental testosterone in men after prostatectomy.  The hypothesis is that restoring low testosterone to the normal range “is safe and efficacious, that it can improve cognitive function and some physical limitations that some men have when their testosterone is low, and that there might be some sexual benefit from getting testosterone back into the normal range.  For men who have radical prostatectomy or radiation therapy for localized disease who happen to be testosterone-deficient, rather than condemn them for the rest of their lives to having too little testosterone, how do you help them achieve maximal health?”

              The key is to keep testosterone in the normal range of between 300 and 800 ng/dL, says Schaeffer.  Among other things, “very low testosterone levels can raise the risk of a heart attack or stroke, decrease muscle mass, weaken bones, impair cognitive function, increase the risk of metabolic disease, frailty and depression.” If you are experiencing symptoms such as fatigue or low sex drive, speak to your urologist or primary care physician.

 “Sexual Health is a Barometer”

            Both surgery and radiation therapy for localized prostate cancer can cause temporary or longer-lasting difficulties with erectile function.  But other medical conditions can cause erectile dysfunction (ED), too.  Burnett, a pioneer in the field of men’s sexual health – whose scientific discoveries about the role of nitric oxide in erection led to development of the drug Viagra – has written about this in detail in his book, The Manhood Rx: Every Man’s Guide to Improving Sexual Health and Overall Wellness.

            For example:  “Heart disease and ED, the two entities are linked,” he says.  We have previously discussed that here.  “Erection is a matter of vascular function in the genitalia.  Heart disease affects more than the heart – the entire cardiovascular system.  It can cause cerebral vascular disease, peripheral vascular disease, and penile vascular disease.  Erection is all about blood flow and how it’s regulated.”  In fact, “ED is a marker, not only for heart disease, but for diabetes, metabolic syndrome, some autoimmune diseases, and systemic inflammation (diseases including gout, inflammatory bowel disease, gastritis, and prostatitis).”  Being overweight can affect erectile function, as well; basically, fat cells raise estrogen levels, and reduce testosterone.

            There are many ways to treat ED, including drugs such as Viagra and Cialis, penile injections, and surgery to implant a penile prosthesis.  “Sexual health after prostate cancer requires a multifaceted approach that begins with the patient,” says Burnett.  “Healthy living, preserving your best health after prostate cancer – eating a balanced diet, exercising, avoiding smoking and moderating your alcohol intake – can help maximize blood flow to the penis.  You won’t get your 25-year-old penis back, but it may help preserve the function you have.  And more proactively, talk to your urologist.  Seek out interventions.  If you don’t respond to a PDE5 inhibitor (Viagra or similar ED drug), there are nonsurgical interventions, including pumps or penile injection, and surgical intervention, implantation of a penile prosthesis.  Don’t give up!”   Seriously.  Look through this website.  There is a lot about ED, including the inspiring story of Serge Thomas.   There is always hope.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that 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 regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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DIY Home Fitness: Starting Small is Fine!

Can’t get to a gym?  No problem! You can do a lot with your own 30-second circuit stations at home!

It can be intimidating to walk into a gym.  There’s a fair amount of peacocking (at least at the YMCA in my hometown), and there’s always at least one guy  lifting huge weights loudly, with big grunts, like you might see in an Olympic-level clean and jerk.  You’re not there to compete with Mr. Grunt, but gosh, that can be off-putting!

Or, maybe you are all set to start your own exercise program with the idea, “Go big or go home.”  Maybe it’s not the first, or the fifth, time you have done this: with the best intentions in the world, you try to do too much, too fast, quit after a few weeks, and feel discouraged.

Overambitious goals can set you up for failure.  But here’s great news:  It doesn’t have to be this way! says Harvard scientist Christina Dieli-Conwright, Ph.D., M.P.H., who recently talked about exercise at a Facebook live event for the Prostate Cancer Foundation.  What she has to say applies not only to prostate cancer patients, but to anyone who would like to become more fit:  Starting small is fine.  In fact, it’s good!

Even better: You don’t need a lot of money, or even a lot of time, to make a difference in your health.  

Note: First, talk to your doctor about what you can and can’t do.  For example, in the world of prostate cancer, men are advised to avoid heavy lifting too soon after prostatectomy, because of the risk of developing an inguinal hernia.  And men on long-term androgen deprivation therapy (ADT), who have a greater risk of fracture, should seek medical approval before lifting heavier weights.  When in doubt, start with light weights.  

“When it comes to exercise, something is better than nothing,” Dieli-Conwright says.  “Pick something you enjoy – or something that you hate the least,” if exercise is not your thing.  And stick with it.  Just do something: fit something into your day.”  You don’t have to be like the people in the home exercise equipment or athletic shoe commercials, and you don’t need to push yourself like Rocky Balboa.  You can improve your health, and your body’s cancer-fighting capabilities, with even moderate exercise.

“It’s worth it,” says Dieli-Conwright, whose research is focused on finding out why and how exercise slows or prevents cancer recurrence, and how it can reduce the risk of death from other health conditions – diabetes, obesity, cardiovascular disease – in cancer patients and survivors.  Specifically, she is tracking biomarkers in the blood, muscle and fat related to obesity, lean mass, inflammation, and metabolism to help understand the underlying physiologic mechanisms by which exercise and obesity/sedentary lifestyle make cancer more or less likely to recur.  “Exercise is a one-stop shop.”  As my friend, medical oncologist Jonathan Simons, M.D., often says, if pharmaceutical companies could make a drug that offers all the benefits that you get just from simple exercise, they would make billions.  (Well, they make billions anyway, but still.)

Exercise makes you sleep better.  It also makes you feel less tired during the day, Dieli-Conwright says.  “It makes you feel better, and lowers depression, stress, and anxiety.  It reduces the risk of diabetes, which is especially important for men on ADT.”  Men on ADT tend to gain weight more easily and also to lose muscle mass.  Exercise burns calories, and even light weights or resistance bands can maintain and build muscle strength.

Moreover, improving your cardiovascular fitness also improves your ability to do “activities of daily living,” starting with sitting down and getting up.  Exercise prevents deconditioning (loss of strength), which can affect the circulatory and respiratory systems as well as muscles and bones.

Walking:  You don’t need to join a gym or even buy any equipment (except for some comfortable walking shoes).  You can walk for free!  The first step is, literally, a step:  “Walking is a great way to start!” says Dieli-Conwright.  “It can be done outside if it’s safe, but you can even do it inside, just walking around your home.  You can walk with friends or loved ones, or your dog.”  When people are sick, she adds, “or hospitalized even for a day or two, the first thing they stop doing is walking.” Deconditioning can happen very quickly.  “Just walking from room to room, back and forth, can help prevent this.”  Over time, even if you don’t increase your distance, try to improve your gait speed.  “People who have a higher gait speed tend to live longer.”

 Note:  If you have balance issues or other conditions, your doctor can help you modify exercise to fit your needs.  The solution might be as simple as a cane! 

Circuit training:  You can do a lot in 30 seconds.  “Circuit training is faster-paced and time-efficient,” says Dieli-Conwright.  “One of the main barriers to exercise is that people feel they don’t have time.  In circuit training, you set up little exercise stations and move through each station in a systematic way (for example, alternating between upper and lower body exercises), at a good pace.”  Do 30 seconds at one station and move to the next one.  Then repeat the whole circuit.  It may be less than five minutes total, but that’s fine!  You can do this once or several times a day.  Some DIY stations you can set up: 

“Couch squats.”  Stand up and sit down, using the sofa or a sturdy chair, over and over for 30 seconds.

Push-ups.  You don’t have to do the full-body push-up with straight legs; you can do it with your knees on the ground.

Wall sits:  Back to the wall, bend your knees and slide down, hold five seconds, then push back up.  Be sure your feet are positioned far enough away from the wall so when you “sit,” your knees form a 90-degree angle.

Walk in place.  Talk about a low-budget station!  Just pick a spot, go there, and walk in place for 30 seconds.

Stairs:  Not the whole staircase!  Just one or two steps, up and down, over and over for 30 seconds.

Weights:  If you don’t have actual weights, use what’s available.  Water bottles, food cans – anything you can lift safely and easily.

“You can get in better shape without any workout equipment,” says Dieli-Conwright.  “Use what you have at hand.  The biggest thing is to make sure you have a safe space where you won’t bump into anything.”

Another thing that’s good about exercise: it’s not sedentary!  “There is a lot of evidence that sedentary behavior has an impact on mortality.  Even taking a 20-second break from sitting every half-hour or hour to take a lap around the kitchen table goes a long way.”

So, instead of “Go big or go home,” think: “Start small at home.”  Says Dieli-Conwright:  “Don’t be intimidated by unattainable goals, like an ultramarathon.  Start small, find things that are going to motivate you, and be consistent.  Just keep at it!  Consistency is the key.”

 

In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

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Matters of Prostate Cancer Survivorship

Who’s a survivor?  You are, if you are trying to get your life back after a diagnosis of prostate cancer.

 

            Survivor.  What does that word bring to mind?  (Besides, of course, the name of the rock band whose song, “Eye of the Tiger,” went double-platinum in 1982 and was the theme of “Rocky III.”)

            There are more prostate cancer survivors now than ever before.  More men are being cured of localized disease, and more men are living longer with advanced cancer than ever before.  This is great news!  It also means that, as men live longer after treatment for prostate cancer, they have new things to deal with – which brings us to the evolving area of cancer survivorship.

             Survivorship is basically the day-to-day effort to live your best life during or after treatment for localized cancer, or between and in the midst of treatments for more complicated disease.  It’s such a big part of cancer treatment now, in fact, that medical centers are devoting significant resources to it.  One of them is Dana Farber, where medical oncologist Alicia Morgans, M.D., will soon become the new Medical Director of Cancer Survivorship.

The criteria for survivorship used to be a lot more strict, she notes.  “The old-fashioned definition would say that patients living with cancer are not survivors” – that a true survivor could only be someone whose cancer has been cured.  That has changed.  “Now, anybody living after a diagnosis of cancer is a survivor and deserves to have the best quality of life possible.”

Good news: for many men recovering from treatment or living with prostate cancer, help is available.  But it may be up to you to ask for it, if your doctor doesn’t address it specifically.

Note:  Here is where your spouse, partner, family or friends can help.  Those who love you may be aware of some things that you might not have noticed, and their insights can help your doctor take better care of you – if you say it’s okay for them to talk about it.

“Men are stoic, and may not feel comfortable admitting a weakness or vulnerability, or they may not have the words to describe what they’re going through,” says Morgans.  “Or, they may not perceive a problem, but their caregivers or loved ones may.  Raising their concerns – with the permission of the patient – to the doctor can be very helpful.”  This is especially true, she adds, in cases where the patient is experiencing “psychological distress, depression, anxiety, and may not recognize it.  Sometimes the caregiver can say, ‘You don’t realize it, but you’ve had a really short temper.’ Or, ‘You may not recognize it, but you’re sleeping all day, and you’re not eating.’Or, ‘Your cancer is controlled, but your behavior is very different, and you seem really down.’  We may not perceive these changes as being different or outside our norm, but if they’re empowered to speak (with your permission!), your caregiver or family members can really help reflect back to us more accurately what’s happening with you.”

While visiting the doctor, phone a friend!  If it’s not possible for a family member to be there at the appointment, no problem!  “We can often call or conference a loved one in,” with Zoom, FaceTime, or through the medical center.  There are also “electronic ways,” Morgans adds, for loved ones to communicate with the doctor.  You can write an email to the doctor, using the patient’s portal – or even your own.  “In many systems, caregivers can have an account that’s connected to the patient.  I have many patients whose spouse has an adjacent account.  Others just use the patient’s account.”

Be sure to identify yourself, that this is the patient’s daughter, spouse, or friend.  “Don’t represent yourself as the patient if you’re not the patient.”  This does happen, Morgans says.  “Sometimes wives will get on there as the patient, and you know it’s the wife: women tend to talk a lot more than men!  I’ll see a long description, and write back, ‘Is this John’s wife?’”  The information is still appreciated, she adds.

“If there’s something they think the doctor needs to know, and if they’re empowered by the patient to speak to us, the caregiver or spouse can intervene in a meaningful way.”

Sexual Health

Sexual health is “one of the most underrecognized issues” for prostate cancer patients and their partners.  One big reason why is that men just don’t want to talk about it, either because they keep hoping it will get better, or they just decide to be stoic and carry on.  “Even though we have a roadmap for how to address these issues after surgery or radiation, we often lack the support system,” says Morgans.  “There are way too few sexual health counselors specifically dedicated to helping men recovering from prostate cancer.”  And yet: “This is an area of high interest to many patients.  Sexual health affects their personal experience, their mood, energy, everything they do.”  It also affects the health of their partners.

Although this is the issue many men wish would just go away, what they need to do is just the opposite of hoping for the best:  be proactive.  If you had surgery and you haven’t already had this discussion with your urologist, find out what you can do for penile rehabilitation.  This may include pills such as Viagra, Cialis, or other PDE5 inhibitors; vacuum devices for stretching the penis to protect against scar tissue formation; in-office or at-home treatment with a small TENS unit to stimulate nerve regeneration and help with return of urinary control; penile injection; or a penile implant.

Don’t suffer in silence!  Don’t listen to anyone, yourself included, who thinks, “Your cancer has been cured. Just be happy with that.”  There are many steps you can take to recover your sexual health – but they won’t happen if you don’t ask for help.

Intimacy: This is not the same as sexual health, but men on ADT and their partners still need intimacy.  If your oncologist or medical center does not provide counseling in this area, ask for a referral to a sexual health counselor, and keep this in mind: you are not alone, whether you’re the patient or his partner.  There are thousands of couples dealing with this issue, as well.  Your doctor also may be able to recommend support groups, online and affiliated with local medical centers.

Fighting Back on ADT

ADT will try to affect your overall health, but here’s the good news:  you can fight back, Morgans.  Arm yourself with what it might do, and you will be better able to protect yourself against its tactics.  So here, in no particular order, are some of the things ADT might affect, and countermeasures you can take:

Bone health:  Prostate cancer can affect your bones, and so can ADT, in different ways.  Treating prostate cancer in the bones not only protects them, it can improve survival!  ADT raises your risk of osteoporosis – but not only is this treatable, it’s not a “done deal” that every man on ADT will develop it!  “Avoiding fractures is so important,” says Morgans.  “Men who have fragility fractures (due to osteoporosis) can lose their mobility and independence, and can have some major changes in their lives until those fractures are repaired.  If we simply follow the guidelines we already have on how to care for bone and prevent osteoporosis, we can improve those outcomes pretty dramatically.

“A lot of the complications associated with ADT are absolutely things that we can address head on, try to prevent and to reverse; for instance, we have effective therapies to counteract bone thinning and lower the risk of fracture and complications from weak bones.  Many of the known side effects of ADT are not necessarily inevitable.”

Your risk of cardiovascular disease:  Here’s some good news:  A new drug, Orgovyx (relugolix), was approved in December 2020 by the FDA for men with advanced prostate cancer, based on results of the Phase 3 HERO study.  It lowers testosterone, but it works in a different way.  It’s also administered differently – a once-daily pill instead of a shot – and it has a significantly lower risk of major adverse cardiovascular events compared to Lupron (leuprolide).  If you have cardiovascular risk factors, such as high blood pressure, high cholesterol, a family history of cardiovascular disease, diabetes or pre-diabetes, if you’re overweight or if you smoke: heart disease needs to be on your radar, because ADT can make it worse. “Multiple studies have shown that men who have cardiovascular risk factors, particularly if they are not addressed, have higher rates of complications and even death on ADT,” says Morgans.  But treating these risk factors with diet, exercise, and medication if needed, can “improve overall survival and also quality of life.  When your body is healthier, you feel better.”

Note:  For just about every category on this list, exercise is one of the answers.  Men on ADT who exercise lower their risk of having cardiovascular and cognitive effects, developing insulin resistance, diabetes or pre-diabetes, obesity, and high blood pressure.  “All of these are modifiable risk factors,” says Morgans.

Depression:  “Depression is highly treatable,” says Morgans.  “This is important, because evidence suggests that men treated with ADT do have higher rates of depression than men who have prostate cancer but are not receiving ADT.”  But depression is underdiagnosed and undertreated in men on ADT, she adds, “perhaps because of reticence to ask for help, or a perceived stigma with mental illness,” or perhaps because it has crept up, and the patient hasn’t recognized that there’s a problem.  This is where friends, family and caregivers can help.  Depression can affect sleep, appetite, and memory, as well.

Cognitive changes:  ADT can cause cognitive decline and dementia.  However, this is more complicated than it sounds, Morgans notes.  For one thing, symptoms of depression can be mistaken for cognitive decline, and can improve with antidepressants and exercise.  For another, there are multiple forms of dementia, including vascular dementia.  “If that risk is increased because of ADT, then a medicine that reduces the risk of major adverse vascular events could feasibly lower the risk of dementia, as well,” although this remains to be proven in large-scale studies. In general, “what’s good for the heart is good for the brain,” and taking steps to improve your cardiovascular health will help protect your cognitive function, too.  “We also have strategies and mental tricks to help improve memory, and even medicines that may slow the progress of Alzheimer’s.”  The key is to tell your doctor, and get further evaluation and help if needed.  “The choice of therapies may help, as well,” Morgans notes. “In multiple ongoing studies, some really interesting MRI data suggests that there may be differences in some distribution of blood flow in the brain” between androgen-targeted medicines, “including one study with darolutamide that has just launched.”

Hot flashes:  “At its basic level, ADT is lowering testosterone, which keeps men’s bodies functioning in a way they’re used to,” says Morgans.  “Just as we see when women go through menopause, there are widespread changes.  The constellation of symptoms is much broader than just the effects of ADT on the prostate cancer cells themselves.”

Among the most annoying and persistent – and undertreated – are hot flashes, which “can affect mood, sleep, and cognition,” says Morgans.  A novel approach on the horizon is a “wearable,” she adds.  It’s like an Apple watch, and can be linked to your phone.  The basic idea is to stimulate the autonomic nerves on the wrist, with a cool sensation.  “PCF is actively engaged in supporting work that can potentially improve quality of life and reduce hot flashes in men on ADT.  This is an area with much room for improvement, where attention is needed, and pharmacologic therapies aren’t as effective as we wish.”

For now, treatment with antidepressants may help; so can exercise.  Many men seek relief of symptoms with holistic treatments, including relaxation therapy, hypnosis, cognitive-behavioral therapy, and acupuncture.

In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

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Enough Dismay! Rewriting the Prostate Cancer Story for Black Men

Just hear me out here.   Look:  I get it.  I come from a high-risk prostate cancer family, with five beloved men, including my husband, my dad, his dad, his grandfather, and my grandfather affected so far.  So you know I am not ever going to downplay the risk.  But enough!  Let’s stop being afraid of prostate cancer, or feeling that it’s just inevitable, or that there’s nothing you can do, or worse, pretending like the risk isn’t there.  Dismay doesn’t help; action does!

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Why do I worry so much about black men and prostate cancer?  Well, I’ve met a lot of men with prostate cancer over the years, and two who hold permanent places in my heart are both black, both U.S. Veterans, the toughest guys you could ever meet (one, Les, was a USMC drill sergeant!), both devout in their faith, both devoted family men, both not screened for prostate cancer when they needed to be, starting at age 40.  Both were diagnosed with metastatic prostate cancer, and for both, cancer proved an enemy they couldn’t beat.  Their deaths devastated me.  Which is why you may think I’m crazy when I say this now:  Enough with the Dismay!  

Just hear me out.  Look:  I get it.  I come from a high-risk prostate cancer family, with five beloved men, including my husband, my dad, his dad, his grandfather, and my grandfather affected so far.  Two of them, my husband and my dad, got screened, were diagnosed early, and their cancer was cured.  I worry about our two sons, and you can believe I will be on them like the proverbial duck on a June bug to make sure they get screened!  So you know I am not ever going to downplay the risk.  But enough!  Let’s stop being afraid of prostate cancer, or feeling that it’s just inevitable, or that there’s nothing you can do, or worse, pretending like the risk isn’t there.  

Dismay doesn’t help; action does!  Yes, if you are of African descent, you are at higher risk of getting prostate cancer.  However, says physician-scientist Kosj Yamoah, M.D., Ph.D., radiation oncologist and cancer epidemiologist at Moffitt Cancer Center in Tampa, Florida, who is also black, this news should not make you feel defeated. Instead, use this knowledge as advance warning!  Here, then, are some facts and encouraging advice about how you can take action:

Fact: If you’re a black man, you are more likely to get prostate cancer.  Your odds are one out of six, as opposed to one out of eight for men of other races. “In other words,” says Yamoah, “you are 74 percent more likely to get the disease than non-black men.”

How can you act on this?  “Get your first PSA by age 40.”  Note: you might have to ask your doctor for this, because many doctors don’t start prostate cancer screening until patients are in their mid-forties or even early fifties.  But research currently under way at Moffitt and elsewhere  suggests that for some black men, the early fifties may be too late to catch cancer while it is still confined to the prostate.  For whatever reasons – genetic, environmental, or both – in black men, cancer can take less time to develop, and to spread outside the prostate.  So, if you are in your forties and have not been screened, Yamoah advises, ask your doctor for a PSA test and physical exam to check for prostate cancer.  “This is something you can do.  Make it happen.” 

Fact:  Treatments for localized prostate cancer work equally well in men of all races.  But that’s a limited-time offer; it only holds true if cancer is caught and treated early.  “If you or a loved one are African American and have prostate cancer, get treatment in a timely manner!” says Yamoah.  “Particularly for localized prostate cancer, whether you get surgery or radiation, if you are diagnosed and are treated adequately, know that African American men survive the disease exactly the same as non-black men – as long as these two caveats are met.  In equal-access environments, there is no difference in survival.”  However – perhaps because they may be younger, and otherwise may be feeling strong and healthy – if men delay treatment, because “I feel fine,” their cancer may become much more difficult to cure.  Ladies, if you are reading these words, know that you may have to do what my mom and I did with my dad, and what I did with my husband:  make him get regular screening.

Fact:  Unfortunately, treatment is variable.  Success of prostate cancer treatment is operator-dependent; so is quality of life. 

What does this mean for you?  “Seek the best care; don’t settle for less,” says Yamoah.  “It may require a bit of researching, but it makes a difference.”  Making the effort now to do your due diligence and find the best surgeon or radiation oncologist will pay off for years to come.  “In many states across the U.S., we have the best of the best in cancer care, but sometimes patients don’t seek the best care from centers with the appropriate expertise.”  Important note:  “It is also okay to get a second opinion if you are unsure about your treatment plan.”  Unfortunately, patient support groups and online chat rooms abound in stories of regret, anger, or sadness from patients who did not receive excellent care.  Yamoah tells his patients: “Look at it this way.  You would not want to take your car to a bad mechanic; you want to take your car to the best shop.  Why not your body?  It should be no different for health care.  We should be looking for the best.  Being your own advocate for getting the best care could change your life.”

That said, “Don’t fear treatment.”  For every possible side effect you might have, there are effective treatments.  You can get your life back.  The main thing is to be cancer-free.  Also, there are exciting new treatments being investigated now that don’t involve removing or treating the whole prostate; because of advances in imaging (MRI and PSMA-PET), it is now possible to get a pretty accurate idea of the extent of cancer.  On the horizon are treatments that may be able to cure prostate cancer when it is caught very early that have few to no side effects!  

You Need Personalized Care!

      Not only does prostate cancer tend to start at a younger age, and to be more aggressive, in some black men: it also tends to start in a different part of the prostate!  And not only is it often in a different part (the anterior region of the prostate, behind the urethra): it’s a part that’s more difficult to reach, and easier to miss, with a tiny biopsy needle.

What can you do about this?  Yamoah offers this advice: “An MRI and perhaps an additional blood or urine test, to discover or rule out aggressive cancer, will help even the playing field for black men – even for black men who are thought to have lower-risk disease, who may want to be on active surveillance.”  Is it truly safe to be on active surveillance?  Do you truly have low-risk disease – or was there more intermediate- or even high-risk disease hidden in the prostate that was not captured by the biopsy needle?  “Active surveillance works well – as long as patients are staged correctly.”

Here’s another difference:  Black men seem to respond better to some treatments than other men!  Research by Yamoah and colleagues has shown that Provenge (Sipuleucel-T), an immunotherapy drug currently approved for men with metastatic prostate cancer, is more effective in African American men than in other men.  Many black men “seem to have an immune microenvironment enriched for immunosuppressive biomarkers,” says Yamoah.  “Also, in these men, prostate cancer tumors may be a bit more sensitive to radiation.   We are seeing something in clinical trials: that medications like Provenge, and in some instances radiation and ADT, seem to benefit black men more than white men, as measured by longer disease-free intervals and longer survival.”  This suggests, he adds, that “maybe there is some component of a distinct biological subtype that favors certain treatments in black men; it’s a paradigm shift!”

Encouraging results from several studies now under way will help oncologists “tailor treatments appropriately with personalized medicine, based on individual patients’ biology.  This may be leading to a change in the way we see metastatic disease, that will convert it into a chronic disease.  This is all emerging; it’s all new stuff.”

What You Can Learn from Eastern European Jewish Women

“It might seem racist to say that cancer is different in black men than it is in other men,” says Yamoah.  “But that couldn’t be further from the truth: it’s not about race.  It’s about subtypes of cancer.  It is incorrect to say that you have a different type of cancer because of your skin color; the message is that, in order to treat all men equitably, we have to study all populations.”

What are subtypes?  They are specific varieties of a disease – based on differences in mutated genes, or differences in the immune system, or maybe even differences in the microbiome.  Each subtype may respond slightly differently to treatments and also to biomarker tests.  “We know that the cookie-cutter approach, treating all patients the same, does not work with prostate cancer,” says Yamoah.  “So, we need to fine-tune our diagnosis and treatment.”  Unfortunately, much of what scientists have learned about prostate cancer has come from studying predominantly white patient populations.  “We have not had enough African American participation in studies and in scientific exploration.”

How can you help change this?  “Get involved in research.  Become active participants in discoveries for treating prostate cancer.”  Particularly, different biomarkers may work better in black men.  “Whether it’s helping to determine the polygenic risk score – are you at risk, or do you have a family member at risk – or whether it’s helping to find out through biomarker discovery what subtype of prostate cancer you have, and how best to treat that, we could really use your help.”  Many academic medical centers have “biobanks,” collections of patients’ blood, biopsy and tissue samples that can be used for research.  If your doctor asks you to participate, consider saying yes.

Consider the case of Ashkenazi Jewish women – descendants of a very small group of about 350 people who lived in Eastern Europe about 700 years ago.  Around one in 40 people with Ashkenazi Jewish ancestry has a mutation in the BRCA gene, which is linked to breast and ovarian cancer, and also other cancers, including prostate cancer.  “Through studying a sub-population, we discovered that gene,” says Yamoah.  But the implications of this gene are widespread:  “Recently, BRCA mutations have been linked to triple-negative breast cancer, which is more predominant among African women.  If we hadn’t studied it in the Ashkenazi population, we never would have identified it.  Now it has become a biomarker,” and scientists have identified a class of drugs – PARP inhibitors – that work well in cancers with this genetic mutation, including prostate cancer.  “It is no different from studying black men.  What we learn from identifying subtypes is going to benefit the globe.”  The message is “not treating you different; it’s treating you right.”

Each of us has a certain predisposition to disease, Yamoah adds.  “For example, some people smoke for 30 years and never get lung cancer.  Others smoke for 10 years and get it.  We all have a different threshold, based on our genetic predisposition.”  Prostate cancer develops because a gene is mutated.  “regardless of how it occurred,” whether through decades of eating a bad diet (environmental factors), or through inheriting a bad gene (direct genetic predisposition).

The idea of “one size fits all” medicine sounds nice and egalitarian, but in reality, one size does not fit all.  Take, for example, tattoos used in radiation oncology to help pinpoint the areas of treatment.  “We had some patients come through, and the technicians called me into the clinic and said, ‘We can’t find the spot; we can’t tell where the tattoo is.’  I said, ‘That’s because the ink in these localization tattoos was developed for the lighter skin and not for the darker skin!”  Yamoah found a company that has developed fluorescent tattoos (which show up on any skin color), to be available for his patients with dark skin.  “We have made a lot of our discoveries in prostate cancer only looking at one patient population,” but that is changing.  “We are now in an era of moving towards more personalized care, regardless of race.”

Another way you can help is to become an advocate.  “If you are a black man and you don’t have prostate cancer, you have a voice.  You have a sphere of influence; use your influence to encourage others to take heed,” to get tested starting at age 40, and to get prompt treatment from the best doctors you can find.  “If you’ve had prostate cancer and you’re a survivor, please be an advocate.  We need your voice.  Whether you have it or whether you don’t, please help change prostate cancer for this population!”

How Diet, Exercise, and Lifestyle Can Help Lower Your Risk of Fatal Prostate Cancer

If you are overweight, if you smoke, are sedentary, or if you eat a high-fat, high-carb, low-vegetable diet, you are doing prostate cancer a favor:  you’re making sure it has a very hospitable environment.

“Cancer is also a chronic disease,” explains Yamoah.  “Men with prostate cancer who also have high blood pressure, hypertension, diabetes, and coronary disease – many American men of all races who are affected by one or more of these conditions – do worse with their prostate cancer.  If your body mass index (BMI) is high, if you have cardiovascular disease or diabetes, these are conditions that can be made worse by androgen deprivation therapy (ADT).  If we have a man who might benefit from ADT, but who has chronic conditions that are detrimental to his overall well-being, we may have to give suboptimal care to decrease the risk of severe side effects because of these co-morbid conditions.”

What can you do about it?  Exercise has so many beneficial effects on men with prostate cancer, that it might as well be considered a medicine.  “The most effective  avenue for combating the side effects of ADT is exercise,” says Yamoah.  Similarly, “if you are being treated for localized cancer, if you follow a few simple guidelines for wellness, you are going to do better, recover sooner, and have fewer side effects.”

Exercise doesn’t necessarily mean vigorous activity.  Just walking is a great start!  You don’t have to pump serious iron, either; even light weights can help strengthen your muscles and protect your bone density.

If you smoke, there’s never been a better time or reason to quit.  Men who quit smoking immediately begin to lower their risk of dying of prostate cancer.  For more, see this discussion.

Look for foods that fight inflammation and that help prevent insulin resistance – both of which can make cancer grow faster.  Caloric restriction – eating fewer calories a day – is also proving to help slow prostate cancer.

“We wish we had medicine to prescribe that had as many beneficial effects as exercise, weight loss, not smoking, and eating an anti-inflammatory diet,” says medical oncologist and molecular biologist Jonathan Simons, M.D., CEO of the Prostate Cancer Foundation.  “What’s good for the heart is good for fighting prostate cancer.  What’s good for the blood pressure is good for fighting prostate cancer.  It’s all connected.”

Finally, one easy-to-fix problem that is common in black men is not getting enough Vitamin D.  “Most black men are Vitamin D-deficient,” says Yamoah, “especially in the U.S.”  Just spending time outside in the sunshine may not be enough, he adds.  But good news:  an inexpensive, over-the-counter supplement can restore your body’s Vitamin D levels.  Note:  2000 IU is the recommended safe dose of Vitamin D.  It’s not a case of, “if some is good, mega doses are better,” because you can get too much.  Just stick with 2000 IU per day.  What does vitamin D do?  “It’s like flame retardant on cancer,” says Simons.  “It helps cool the inflammatory environment that cancer loves so well.”

In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

 

 

 

 

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A Power Outage for Prostate Cancer

Limiting Prostate Cancer’s Fuel by Restricting Calories and Changing the Diet:  Just when it seems like the picture of diet and prostate cancer is finally coming into focus, Nicole Simone, M.D., a radiation oncologist at Thomas Jefferson University, has added a new dimension.  It may not be just a question of the good foods you do eat, and the bad foods you don’t eat:  It also appears to matter, very strongly, how much you eat at all.

Simone’s research in prostate cancer and also in breast cancer suggests that restricting calories has many anti-cancer effects in the body – including, in mice, decreasing the likelihood of metastasis.  Early research in humans has shown, so far, that it lowers inflammation, changes the gut microbiome, may decrease the side effects of systemic therapy and generally seems to slow down cancer.  In effect, caloric restriction gives cancer a “brown-out,” limiting its energy.  “We’re just beginning to understand the promise and the power of caloric restriction,” says medical oncologist and molecular biologist Jonathan Simons, M.D., CEO of the Prostate Cancer Foundation (PCF), which funded this research.  “If there were a drug that could do all these things, we’d prescribe it in a heartbeat.”

Wait… aren’t people with cancer supposed to keep their calories up?  If you’re thinking that limiting calories when someone’s fighting cancer seems like the opposite of the common wisdom – well, you’re right!  “This is not what we were all taught in medical school,” says Simone.  And she’s not entirely sure why this approach produces as many good effects as it does – but here’s a clue:  One way to look for various forms of cancer is with a PET scan, which involves injecting a radioactive dye.  “That dye is actually a radio-labeled glucose,” which is eagerly taken up by tumor cells because “cancer loves to eat.  Cancer is metabolically active, and sugar is one of its favorite foods!”

Simone’s laboratory has been investigating caloric restriction for several years.  “Initially, we were looking for a way to increase the effectiveness of radiation and chemotherapy in tumors that have a poor response to standard therapies.”  In mouse models of hormone-sensitive breast cancer, Simone found that simply restricting the mice’s daily caloric intake made a big difference:  it not only altered cell metabolism and made cancer cells more vulnerable to radiation and chemotherapy.  It also “decreased metastasis and increased overall survival.”

If this worked in breast cancer, would it work in prostate cancer?  Yes!  “In several models of hormone-sensitive prostate cancer, we found the same,” she says.  “We were able to decrease tumor growth, decrease metastasis, and increase survival.”  Then Simone’s lab tested caloric restriction in mice with castrate-resistant prostate cancer (CRPC), cancer that is no longer controlled by androgen deprivation therapy (ADT).  Again, caloric restriction affected how tumors responded to radiation.  “We saw some really interesting systemic, molecular changes,” Simone says.  “We wanted to take it a step further, and use that preliminary data as a launching pad to see what would happen in patients with prostate cancer if we put them on a caloric restriction diet.”

Eating 25 percent less:  In a pilot study, 20 patients – men diagnosed with localized prostate cancer who were scheduled to have prostatectomy – underwent caloric restriction for 21 days.  Simone individually tailored each man’s daily calorie total, based on what he had reported eating for several days ahead of time.  “We figured out their average caloric intake and then decreased that by 25 percent.”  Simone’s team also gave the men some dietary guidelines, encouraging (but not requiring) an anti-inflammatory diet with less refined sugar and processed food, more fruits, vegetables and complex carbohydrates.  “The men were able to stick to the diets really nicely,” she says.  “We went over their diet logs and calculated their dietary inflammatory index.   They did increase their anti-inflammatory foods!  They also lost an average of 12 pounds each.”

Could just three weeks of restricted-calorie, pretty much anti-inflammatory diet make a difference?  Yes, in several ways:

A decrease in systemic inflammation.  Men had changes in inflammatory markers in the blood, including a lower sedimentation rate (a blood test that measures inflammation).

Changes in the gut microbiome.  Rectal swabs, taken before the men started the diet and three weeks later, were sent to PCF-funded investigator Karen Sfanos, Ph.D., at Johns Hopkins, who performed in-depth analysis.  In the swabs taken at three weeks, Sfanos found a significant change in what the gut microbes were producing:  more butyrate!  Butyrate is an important fatty acid that helps control inflammation and is made by beneficial bacteria.  The fact that butyrate increased suggests that the population of bacteria in the gut changed for the better, simply with caloric restriction and an anti-inflammatory diet.

Less inflammation in the gut wall, as measured by lipopolysaccharides (LPS) in the blood.  “When there is inflammation in the gut, it creates spaces between the epithelial cells in the gut wall.”  Inflammatory cells can “leak” out of the gut into the blood, and increase inflammation elsewhere.

Less inflammation in the tumor.  “We saw a decrease in inflammatory markers such as NF-κB (an inflammatory pathway) in the tumor itself, and in MIR21.”  MIR21 is a microRNA gene (which makes RNA instead of proteins) that is believed to drive cancer development, growth, metastasis, and resistance to treatments.  Simone is discussing this aspect with another scientist she met at PCF’s Scientific Retreat, Shawn Lupold, Ph.D., of Johns Hopkins, who is a pioneer in the study of MIR21.

Ultimately, Simone believes, caloric restriction can play an important role for men with all stages of prostate cancer – but to make it even more effective will also require precision nutrition, based on precision oncology.  In this case, that means figuring out whether someone’s cancer prefers a diet that is sweet or savory.  “Prostate cancer can metabolize through the glucose pathway, or through lipid pathways,” says Simone.  Understanding which pathway really appeals to a particular cancer – some prefer sugar, some really go for fat– “can tell us how your cancer is driving its own energy.”

Thus, “if the tumor’s feeding on lipids, we change the dial on fat content in the diet.”  And if the tumor prefers sugar, then a diet aimed at keeping sweets and simple carbohydrates to a minimum will foil the cancer’s gustatory pleasure.

One of the biggest challenges with chemotherapy, ADT, or even radiation therapy, is resistance to treatment:  the cancer evolves to minimize the damage of attempts to kill it.  “Diet can almost be a more powerful tool,” says Simone.  “Cancers get smarter; a drug will work well for a while, then all of a sudden, cancer will figure out a way around it.  The power of restricting food is that it provides less energy for the cancer to use up.”

In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

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Worried About Prostate Cancer?  Be Proactive! Part 2: Exercise and Key Foods

Recently for the Prostate Cancer Foundation (PCF), I interviewed two scientists who study lifestyle factors and their effect on prostate cancer:  Epidemiologist June Chan, Sc.D., of UCSF, and epidemiologist Lorelei Mucci, M.P.H., Sc.D., of Harvard.  In the last post, we talked about diet.  Now let’s look at exercise, and we’ll wrap up with some quick takes on various foods.

Here’s some good news:  By launching your proactive strike against prostate cancer, you’re not just helping your prostate (or helping to keep cancer from coming back, if your prostate is long gone):  You’re helping your heart, and you’re also helping to lower the risk of diabetes and insulin resistance.  Go, you!

A sedentary life is not good for the heart.  Diet is important, but it’s not the whole story here.  The research team of June Chan at UCSF has shown in multiple studies that exercise can help delay or prevent prostate cancer progression.  “Aerobic exercise after prostate cancer diagnosis may reduce the risk of prostate cancer recurrence or death by 60 percent.”  Chan’s earlier studies in this field, funded by PCF nearly a decade ago, showed a benefit to an hour of jogging six days a week – the level of exercise most of us can’t or don’t want to sustain.  But don’t get discouraged!  In more recent studies, she and colleagues have been looking at more doable levels of exercise – walking 30 minutes a day, or three or more hours a week, at a brisk pace (3 mph or faster).  The brisk pace is important:  One study found that men who walked three or more hours a week after diagnosis had a 57-percent lower risk of having prostate cancer recur than men who walked at a slower pace, for less than three hours a week.

“Just walking, not running!  Walking is so common.  During these Covid times, when we’re confined to small spaces, people might find it difficult to walk the way they would prefer,” says Chan.  “But I would say, just use it as a break to get fresh air – even if you’re just going up and down the same block.  Any little bit of walking, as opposed to sitting.  Movement is good for your overall bone health.  Don’t push yourself to injury; just get in a good habit.  It’s something you can do when you’re doing something else;” for example, “when I’m walking, often I’ll grab my phone, and use it as a chance to catch up with somebody.”  Don’t focus on the number of steps, or the time.  “If you’re always looking at your watch, you’re not enjoying the walk as much.”  And don’t overdo it:  “If you get injured, you might lose all interest in continuing.”

Note:  the key here is giving the cardiovascular system a good workout, not necessarily the act of walking itself.  So, apply this to your own needs:  if walking that much is not a good option for you, swimming and riding an exercise bike – whatever you are able to do – are good, too.  Studies by Chan and others have provided so much proof of the benefit of aerobic activity, in fact, that “we’re actually at the stage now that the updated Physical Activity Guidelines put out by the American College of Sports Medicine specifically note that exercise is recommended for men with prostate cancer to avoid the risk of dying from prostate cancer.  We’re really excited that we got to contribute to that work.”

What is it about exercise?  Chan and colleagues are still tapping the surface of all the ways exercise is good for the body.  “It improves energy metabolism, lowers inflammation and oxidative stress, helps boost immunity, and is beneficial for androgen signaling pathways.”  It is good for the heart and lungs, improves muscle strength and muscle mass, burns fat, lowers fatigue, anxiety, stress, and depression.  “It just improves your overall quality of life,” says Chan.  Bonus:  exercise also may help slow down prostate cancer’s growth.

Chan is investigating the underlying biological mechanisms for “why exercise has these benefits for prostate cancer and overall health.  Is it a systemic effect, or an anti-androgenic effect?  Is it acting on oxidative stress pathways?”  Her group is looking for insight from blood and tissue samples taken from men with prostate cancer before and after exercise interventions.  In another large, phase 3 clinical trial funded by Movember, Chan and epidemiologists Stacey Kenfield and Lorelei Mucci, with principal investigators Rob Newton and Fred Saad, are studying high-intensity exercise in men with metastatic prostate cancer, at more than a dozen sites worldwide. “It’s a two-year, tailored intervention, with both strength and aerobic components,” to see if exercise can help men with metastatic prostate cancer live longer and better.  What else lowers stress?  Meditation.  Stress may play a role in the growth of prostate cancer, so lowering stress is a strategy worth pursuing.

Speaking of strength training:  We all lose muscle mass as we get older.  Strength training (lifting weights or using resistance bands, and doing muscle-building exercises) fights this loss.  Strength training can be especially helpful in men on androgen deprivation therapy (ADT) for advanced prostate cancer, who are at higher risk of loss of muscle mass, osteoporosis, and also of weight gain, metabolic syndrome, and diabetes.  Note:  If you have advanced prostate cancer, check with your doctor to make sure strength training is safe, and also for some guidance about the weights you should be lifting.

Final note on exercise:  Start out slow.  “If you have not exercised regularly for a long time, consult with a physician or personal trainer, to get a program tailored to fit you,” says Chan.  “Start small, and go up by five- or ten-minute increments.  Then see if you can pick up the intensity.  Just make little changes.”

Look to the long haul:  “Thank goodness I ate that broccoli on Thursday.  Now I won’t get prostate cancer,” said no one ever.  It’s not just one good food choice, but many years of erring on the side of healthy.  The other side of that, however, is reassuring:  It’s not just one bad food choice, or being a couch potato last weekend, but many years of not eating things that can help your body fight prostate cancer, many years of not exercising.  “Diet is something you have to do every day,” says Chan.  So is exercise.  That said, “we’re all balancing so many things with food.  Food is part of our culture, taste, our family habits, celebrations.  I feel like the recommendations should just be like filters.”  In other words: many good decisions, over time, will help fight prostate cancer more than the occasional lapse will help promote it.

 

Thumbs Up, Thumbs Down:  Quick Takes on Food

            I asked Lorelei Mucci for her expert opinion on some foods you may be wondering about for their cancer-fighting powers.  Here’s the rundown, in no particular order:

Extra virgin olive oil (EVOO):  Yes!  More than 2 tablespoons a day.  Among other things, EVOO contains hydroxytyrosol, which scientists now recognize as a natural means of cancer chemoprevention.  It is a powerful antioxidant, and it has been shown to protect against cancer by slowing proliferation of tumor cells and increasing apoptosis – “suicide” – of cancer cells.

Tomatoes:  Yes!  Especially when cooked in, or drizzled with, olive oil, which helps you absorb a key component of tomatoes, lycopene.  “The prostate accumulates a lot of things,” including cholesterol.  “It accumulates lycopene.  When a man eats a diet high in lycopene, for some reason, lycopene levels in the prostate go up.  Lycopene makes sense biologically, because it does accumulate in the prostate.  It is an antioxidant.  This is one of the individual dietary components that seems pretty promising.”

Don’t like tomatoes?  Good news:  Lycopene is in watermelon and grapefruit, too!

Coffee:  “Coffee is looking more and more promising .  There are now a number of studies that suggest drinking coffee regularly, one to two cups a day, can help prevent aggressive forms of prostate cancer.  Some studies say three to four cups offer even more of a benefit, but there’s an initial benefit with one to two cups.  Coffee may also lower the risk of diabetes, liver cancer, and Parkinson’s disease.”

Tea:  Sure, what the heck.  There are far fewer studies on tea than on coffee, but tea has antioxidants.  People in Asia, which has less prostate cancer than the U.S., drink a lot of green tea.  “Tea lowers inflammation, but has not been shown to have an effect on insulin levels.”  However, and this is important:  it doesn’t seem to raise your risk of getting prostate cancer.

Note:  If you go to a fancy coffee shop and get a 1,500-calorie coffee with not only cream but whipped cream, and loads of sugar, or if you drink a super-sweet tea loaded with sugar or high fructose corn syrup, the effects on insulin resistance and risk of weight gain will probably cancel out the antioxidants.

Fish:  Yes.  “We published a meta-analysis of epidemiologic studies that looked at fish and prostate cancer death, and there was a pretty good benefit with regular consumption of fish.”  Particularly “dark-meat” fish rich in omega-3 fatty acids, like salmon and red snapper.

Devil’s advocate:  Are men healthier because they eat fish, or because if they choose fish, they’re not eating a big old ribeye steak cooked in butter?  Talk amongst yourselves, but fish is not nearly as pro-inflammatory as red meat.

Nuts:  Sure.  “There’s not much evidence one way or another with prostate cancer death, but they really seem to lower the risk of cardiovascular disease and overall mortality.”  Also, if you’re eating a handful of nuts as a snack, maybe you won’t be eating a bag of chips.  “In one of our studies,” says June Chan, “we observed that substituting 10 percent of calories from carbohydrates for calories from healthy, plant-based fat (nuts) was associated with a 29-percent lower risk of prostate cancer death, and a 26-percent lower risk of all-cause death.”

Pasta:  In moderation.  However, non-traditional pastas, made from cauliflower or chick peas, are another way to sneak in vegetables.  They may also help you manage your weight.  “Excess body weight, particularly the visceral fat around the abdomen, is associated with worse outcomes from prostate cancer.  Anything men can do to help reduce their weight – limiting bread and pasta, and increasing things like cauliflower pasta and vegetable intake – is beneficial.”

Charred meat:  Try to limit it.  When food is charred, it makes a chemical compound called PhIP, that is a known carcinogen.   Even worse: those beautiful (charred) grill marks combined with a pro-inflammatory food, like red or processed meat.

Soy:  sure.  “Consumption of soy is much higher in Asia, where the incidence of prostate cancer death is lower.  Soy is probably part of a strategy for maintaining healthy weight, and it’s a way of replacing red meat.  Does it lower prostate cancer death?  I don’t know that we have that evidence.”  Another complicating factor:  “Men who eat more healthy diets tend to get screened for prostate cancer.  If you get regular PSA testing, you’re five times more likely to get diagnosed with prostate cancer.”  And, if you get diagnosed early, you are more likely to get early treatment while the disease is confined to the prostate.  It’s like the children’s book, If You Give a Mouse a Cookie, a domino effect.

Vitamin D:  Yes.  “There’s really promising data on vitamin D and prostate cancer mortality.”  One randomized trial, the VITAL study, showed “specifically in black men who have low levels of vitamin D, there’s a reduction in prostate cancer mortality.  Evidence from many studies suggests that this makes sense; there’s a lot of genetic data on inherited vitamin D pathways; this pathway seems to be very important for prostate cancer.”  Vitamin D is found in some foods, such as fatty fish and egg yolks, and your body makes vitamin D when you get out in the sunlight.  However, most people don’t have sufficient levels of vitamin D.  Thus, your best strategy is to take a vitamin D3 supplement:  2,000 IU daily.  It’s not a case of “more is better.”  2,000 IU is what you need.

Final thought on food:  In the words of the title song on Al Jarreau’s 1977 breakthrough album:  Look to the Rainbow.  Build your diet around an array of colorful, plant-based fruits and vegetables: green, red, yellow, orange and purple.  Those colors reflect the good nutrients in them.  Eat less red meat, and have restraint with sugar and carbs, and go for EVOO instead of butter.

In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

 

 

 

 

 

 

 

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Worried About Prostate Cancer?  Be Proactive! Part One

Part One:  Live Your Best Life!

What can you do to live your best life?  You might say, quite reasonably, that your best life does not include prostate cancer.  True.  But no matter where you are in your journey – prevention, treatment, recovery, or survivorship – what can you do to maximize the good, to help your physical and mental wellbeing?  There’s actually quite a lot!

For example: Exercise not only helps you lose weight; it helps fight depression, and it even can help slow down prostate cancer!  And eating the right diet – as opposed to eating a lot of junk and chemicals – can boost your spirits, your energy level, and just generally make you feel better.  Even better:  it can help lower inflammation and insulin, and this can help your body fight prostate cancer, and can help prevent diabetes, cardiovascular disease, and other chronic illnesses.

There is growing evidence that the lifestyle choices that help prevent or fight other diseases – like, eating low sugar for diabetes, or exercising for your heart – can also help prevent or slow down prostate cancer.

Here are three basic principles:

What lowers inflammation helps fight prostate cancer.

What fights diabetes and insulin resistance helps fight prostate cancer.

What is good for the heart is good for the prostate.  We will cover all of this here and in part two.

Studying Diet is Hard

For the Prostate Cancer Foundation (PCF), I interviewed two scientists who study lifestyle factors and their effect on prostate cancer:  Epidemiologist June Chan, Sc.D., of UCSF, and epidemiologist Lorelei Mucci, M.P.H., Sc.D., of Harvard.

Right off the bat, both of these experts note that studying food is hard, and the answer to staying healthier is not one single thing.  There is no dietary magic bullet, and if you see one advertised and choose to take it, do so with a huge proverbial grain of salt!  In many studies over the years, scientists have tried to isolate specific foods to see if they promote or prevent cancer – but they did it by asking people to recall what they ate over certain periods of time.  And most people don’t have ideal memories:  “Yes, I ate that fairly regularly.  No, I didn’t eat this – wait, maybe I did.”  See the difficulty?

Okay, so what if people keep a food journal?  That’s more helpful, although these kinds of studies, done right, take many years.  Even then, if you isolate certain foods that seem promising, you still don’t know exactly what’s happening!  Let’s say you are studying what people eat and you notice a trend in those who didn’t get cancer:  they eat apples (hypothetically).  What kind of apples?  Is it all apples, or just Granny Smiths?  Were they all grown in the same type of soil?  Were they cooked, or eaten raw?  Peeled or not?  Organic or not?  How many did people eat a day?

But wait!  Did these people even have an actual benefit from eating the apple – say, one they brought to work from home – or did they benefit from not eating a bag of cheese puffs or Twinkies from the vending machine instead?

And wait some more!  Do the people who benefited have genetic or molecular differences that make them more likely to be helped by apples?  Or… are people who eat apples also more likely to exercise and take better care of their health in general – so maybe it’s not even the apples but their whole lifestyle that made the difference, and we’re back to the drawing board!

This is why science around nutrition takes time.  Remember back in 2010 when coffee was bad?  And now, here we are in 2020 and coffee is good?  This stuff evolves.  The good news is, we’ve learned a lot.

Broad Strokes are Better

Scientists don’t have a Paint-by-Number approach to food science, with every single food accounted for.  But they are able to paint with broad, but definitive, strokes.

In our interviews, June Chan and Lorelei Mucci both cited work led by Harvard scientists Fred Tabung, Ph.D., M.S.P.H., and Edward Giovannucci, M.D., Sc.D., that look at the relationship between diet and inflammation.  In one, the scientists tracked inflammatory markers in the blood and whether inflammation was raised or lowered by what people ate, based on data from thousands of participants in the Nurses’ Health Study and the Health Professionals Follow-Up Study.  The key for us is the foods they found that reduce inflammation:  dark yellow vegetables (carrots, winter squash, sweet potatoes, etc.); leafy green vegetables (like spinach, broccoli, kale, etc.), coffee, and wine.  Beer (one bottle, glass, or can) was in this category, too.  So was tea, but its effect was not very strong.

The pro-inflammatory (bad) category, included processed meats (hot dogs, bacon, pepperoni, lunch meat, etc.), red meat, refined grains, high-energy beverages (with additives and sweeteners), and “other vegetables,” like potatoes and corn.  Interestingly, not all fish is equal:  canned tuna, shrimp, lobster, scallops, and “other” fish were more inflammatory than “dark-meat” fish like salmon or red snapper.

But if you love canned tuna, and if you love a baked potato or corn on the cob, don’t freak out:  remember, broad strokes!  The key seems to be to make sure you do eat the anti-inflammatory foods.  For example, the anti-inflammatory effects of leafy green vegetables, dark yellow vegetables, wine and coffee are more powerful than the very mild, pro-inflammatory effect of “other fish” or “other vegetables.”  If you feel that you just can’t give up meat entirely, that’s okay – just aim for smaller portions of meat, surrounded by anti-inflammatory vegetables.  Example:  instead of regular fries, try sweet potato fries.  They’re really good, and they fight inflammation!  You can have your burger, but still help counteract inflammation:  it’s a win-win!

So:  what about foods that are bad for diabetes and insulin resistance?  Tabung and Giovannucci led another study, also using data from the thousands of participants in the Nurses’ Health Study and Health Professionals Follow-Up Study, to assess the “insulinemic potential” of diet and lifestyle – basically, how foods and exercise affect blood sugar and insulin resistance, as measured by certain biomarkers in the blood.  Foods that did not raise blood sugar or insulin resistance included wine, coffee, whole fruit, high-fat dairy (whole milk, sour cream, a half-cup of ice cream, a slice of cheese, etc.), nuts, and leafy green vegetables.  Physical activity was also good for lowering insulin resistance and blood sugar.

What do the experts make of this?  Benjamin Fu, a postdoctoral fellow in Lorelei Mucci’s lab at Harvard has been looking at these two different dietary patterns: “a diet associated with hyperinsulinemia, and a hyper-inflammation diet.”  The two diets have some overlaps, but are not identical.  Neither is good for men worried about prostate cancer, Mucci says, “particularly the hyper-insulinemia (blood sugar-raising) diet, which is associated with a 60-percent risk of more advanced or fatal prostate cancers.”  Let’s just let that sink in for a second:  if you eat a lot of carbs and sugar and you get prostate cancer, you’re more likely to have a serious form that could kill you.  Okay, let’s go on:

Mucci continues:  “The hyper-inflammatory diet also is associated with an increased risk of prostate cancer,” particularly in men who develop cancer at a younger age, in their forties and fifties.  “It may be that earlier-onset cancers are more susceptible to the effect of diet and lifestyle.”

What does heart health have to do with it?  A lot, for many reasons.  It turns out, says Mucci, that “cardiovascular disease and other chronic diseases are the major cause of death in many men who have prostate cancer.  If you look at men with localized prostate cancer and survival outcomes over 10 years, three-fourths of the deaths in those men will be due either to cardiovascular disease or another chronic disease.  Only one-fourth of the mortality is due to prostate cancer.”  Now, you may be thinking, we all have to die of something, right?  This is true, but “these men are dying sooner than they should, and eating a plant-based diet rich in cruciferous vegetables will help lower that risk of cardiovascular disease.”

Which brings us to the Mediterranean Diet:  Not only do people in Mediterranean countries, as compared to Americans, eat more vegetables and fruits, fewer fatty foods, less processed junk, and less red meat – “which increases insulin resistance, increases inflammation, raises cardiovascular risk and also is part of a dietary pattern that may increase obesity, as well,” as Mucci notes.  You know what else they eat a lot of?  Olive oil.  Greater than 30 ml a day, which is a little over two tablespoons.  “There’s really good evidence that extra virgin olive oil (EVOO), either on its own or as part of the Mediterranean diet, substantially lowers the risk of cardiovascular disease and lowers the risk of overall mortality.  The evidence specifically for men with prostate cancer is much more limited, but given the strong benefits for overall death and cardiovascular death in particular, not only using EVOO, but using it to replace butter or margarine, is something that is worth doing.”

 

Coming up:  Part 2:  What’s Good for the Prostate is Good for All of You!


In addition to the book, I have written much more about prostate cancer 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 regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 

 ©Janet Farrar Worthington

 

 

 

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