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High-Risk Localized Prostate Cancer:  Changing the Rules

A full-on assault of high-risk prostate cancer with intensive neoadjuvant hormonal therapy before surgery marks a huge shift in medical thinking.  Instead of doing things in a well-ordered sequence, oncologists like UCSD’s Rana McKay are launching many weapons earlier than ever, when cancer is less prepared for battle, and they’re going for a cure.

Why the No-Holds-Barred Approach Now?

Which scenario would you prefer:  “I’ve got high-risk prostate cancer.  I sure hope it doesn’t come back after surgery or radiation!  Fingers crossed!  My doctor and I are really hoping for the best!” or,

“I’ve got high-risk prostate cancer that has a chance of coming back after initial treatment.  So, my doctor is going after it relentlessly, like Inspector Javert hunting Jean Valjean in Les Mis.”

High-risk prostate cancer is formidable: it will spread if not treated and is more likely to recur after initial treatment.  That’s why doctors like Rana McKay, M.D., medical oncologist and PCF-funded Young Investigator at the University of California San Diego (UCSD) are now throwing the proverbial kitchen sink at high-risk prostate cancer as soon as it is diagnosed.

This marks a huge shift in medical thinking.  Advanced prostate cancer treatment in the past has been like a methodical series of “if: then” statements in math, like, “If A, then B,” or “C if and only if B.”  If cancer spreads beyond the prostate, then the traditional next step has been androgen deprivation therapy (ADT), shutting down testosterone and other male hormones that drive prostate cancer’s growth.  If the cancer becomes resistant to ADT, then other medications are added: chemotherapy and/or androgen receptor (AR)-targeting drugs (also called androgen-directed therapies, or AR-signaling inhibitors).

Over the last few years, doctors have been compressing this time frame, giving these AR-targeting drugs at the time that ADT is initiated – based on studies such as STAMPEDE, LATITUDE, suggesting that the cancer, which evolves and mutates as it spreads, is more vulnerable to treatment sooner rather than later.   Although these treatments can extend survival, they are not a cure.

What’s different about this new, full-on, kitchen-sink approach?  First, a high-intensity burst of hormonal suppression (ADT plus an androgen-directed drug, such as enzalutamide or abiraterone) is finite, given as neoadjuvant therapy for a few months before surgery and for up to a year afterward.  Then it’s over, and within a year, testosterone comes back.

Second:  “We are going for a cure,” says McKay.  This is worth repeating:  Going for a cure!

Early results of exciting clinical trials, with more on the way, are highly encouraging.  One Phase II trial still in progress, led at UCSD by McKay in collaboration with Mary-Ellen Taplin, M.D., of the Dana-Farber Cancer Institute, grew out of a 2014 PCF Challenge Award study, led by Taplin.  The investigators tested two combinations of drugs given for six months before surgery:  abiraterone and prednisone plus leuprolide (Lupron), vs. abiraterone and prednisone, Lupron, and apalutamide.  After surgery, “men were randomized to continue therapy for one year, or simply to be monitored.”  The initial results of this trial were presented at the American Society of Clinical Oncology meeting in 2020.

“We showed that about one out of five men who received intensive hormonal therapy up front demonstrated very residual amounts of tumor, or no tumor at all, in their prostatectomy specimen” when the surgically-removed tumor was thoroughly examined by a pathologist under the microscope.   This “pathologic response,” seen in the surgically removed tissue, “hasn’t yet been proven in prostate cancer to be associated with long-term outcome,” notes McKay.  “But in several other tumor types – breast, bladder, rectal cancer, and others – evidence demonstrates that the pathologic response is associated with overall survival.”  In follow-up data from this and two other neoadjuvant studies, recently published in the Journal of Urology, McKay and colleagues showed that “of those patients who had no tumor or very little tumor left behind in their prostate, the rate of recurrence (the average follow-up time so far is 3.6 years)  was significantly lower.  In our cohort of 117 patients, only two patients who had a pathologic response and minimally residual disease had a recurrence, and no man died of prostate cancer.  Our hope is that we will develop data to prove that a pathologic response is associated with long-term outcomes in prostate cancer.”

 In Some Responders at Prostatectomy, Cancer’s Already Dead!

Over time, prostate cancer acquires genomic alterations that help it to be more aggressive.  Each tiny mutation gives the cancer extra protection, maybe starting out with the genetic equivalent of a bullet-proof vest or stronger helmet, then becoming much more sophisticated – imagine a fighter jet deploying decoy flares or chaff as missile countermeasures.

Is it more vulnerable, and easier to kill, early on?  McKay and colleagues believe the answer is yes, and they’re testing this idea in several clinical trials.  One phase II study at UCSD still in progress, in collaboration with Taplin, involved 119 men with “unfavorable intermediate or high-risk disease.  “More than 90 percent of the patients had high-risk disease, and all of them, from the get-go, had very aggressive tumors,” says McKay.  “Over one-third of patients had Gleason 9 or 10 disease, and about 60 percent of patients had stage 3 cancer,” that had spread slightly beyond the prostate but with no evidence of distant metastases.  Men in the trial received either neoadjuvant abiraterone and prednisone plus leuprolide (Lupron), vs. abiraterone and prednisone, Lupron, and apalutamide.

One major reason why McKay and colleagues are testing this approach with surgery rather than radiation is to study the pathologic response: looking at how much residual tumor is present in the surgical specimen that has been removed after treatment.  Have they seen any changes?  Not in all men, but in about 20 percent, there’s a remarkable change:  “The primary tumor was dead and necrotic.”  The pathologists “looked at every little sliver of the prostate,” and found that these exceptional responders had either “less than 5 mm of tumor left behind, or no tumor left behind.”

Just think about that for a minute:  the surgeon removes the prostate, gives the tissue to the pathologist, who starts looking at it under the microscope and sees only corpses of cancer cells!

One patient who participated in this study is Pat Sheffler, who was diagnosed at age 53 with stage 3 prostate cancer and a PSA of 37.  He received abiraterone and prednisone, Lupron, and apalutamide for six months before prostatectomy, and started to see results right away.  In monthly blood tests before his surgery, his PSA levels dropped:  “34, 27, 21, 10, 4, 2, and 0.2.”  At surgery, he had “very minimal remaining tumor,” says McKay.  Then he underwent one more year of hormone therapy after surgery.  Two months after he stopped taking the trial medications, not only was his PSA undetectable, but his testosterone levels were coming back to normal.  “My hope for Pat is that he’s cured, that he can go on just being an amazing dad, husband, and advocate for prostate cancer awareness.”

In another phase II study led by Taplin, published in the Journal of Clinical Oncology, McKay and colleagues at UCSD, Dana-Farber, Beth Israel Deaconess Medical Center, Johns Hopkins, and the University of Washington reported a complete pathologic response (no remaining live cancer cells in the prostate) or minimal residual disease in 30 percent of patients treated with neoadjuvant enzalutamide, Lupron, abiraterone and prednisone before prostatectomy.

But what about the men who were not exceptional responders to big-gun hormone therapy?  The scientists have identified some key genetic changes in men who were non-responders, and they have some ideas about how to help these men, as well.

In several clinical trials, including this one, an intense blast of neoadjuvant androgen deprivation therapy (ADT) and androgen-directed treatment (drugs such as abiraterone and enzalutamide) has shown promising results in some men – but not all men.  Why is this?

McKay, Taplin, and colleagues have found an explanation:  Men who have not responded (who had a significant amount of tumor remaining after neoaduvant treatment) in these clinical trials have certain genetic differences in their prostate cancer – loss of PTEN (a tumor suppressor gene, which is knocked out in as many as 70 percent of men with prostate cancer) or alterations in ERG (an oncogene that fuses with another gene, called TMPRSS2, in as many as half of all men with prostate cancer).

“Very few of the men who responded had PTEN loss,” says McKay, “and ERG positivity was also associated with lack of response.”  But these men also seem to have something else that might render AR-blocking drugs unhelpful: lower AR expression, compared to other men.  Basically, if a tumor does not seem to have a lot of androgen receptor activity, then a medicine that targets these receptors won’t have much to work with.

This information is not discouraging, McKay hastens to add:  it’s helpful!  It has taught the scientists that “the responders have a certain tumor profile, and non-responders have a certain profile.  Similarly, responders had mutations in a gene called SPOP” (which is mutated in about 10 percent of primary prostate tumors).

Knowing this, McKay adds, could be an opportunity:  a springboard for additional or different therapy – perhaps neoadjuvant chemotherapy, for example.  Remember:  you’re still ahead of the game here.  You don’t have metastatic cancer, and many scientists believe that high-risk cancer, when it’s localized, is still vulnerable enough to be cured, if it’s hit hard with multiple weapons.

“This is an opportunity for us to develop and design a personalized treatment strategy for these men,” says McKay.  “It would be awesome if we could use somebody’s own genomics to help design the best treatment for him – similar to what’s being done in the breast cancer I-SPY trials, neoadjuvant studies with multiple treatment arms, some determined by biomarkers (specific genetic alterations that show up in a blood or tissue test).

Some men with high-risk prostate cancer might respond better to a PARP-inhibiting drug, such as olaparib and rucaparib.  This is the focus of another study that will be starting soon, McKay says.  “In men who have germline (inherited) alterations, such as a BRCA1 or BRCA2 mutation, we hypothesize that giving a PARP inhibitor in a neoadjvant setting before prostatectomy might significantly improve pathologic response.  We are finalizing the protocol for NEPTUNE, a biomarker-focused neoadjuvant trial testing PARP inhibitors in localized prostate cancer.”

“It is really exciting to be part of this paradigm shift,” says McKay.  “We have the opportunity to improve outcomes for men with high-risk localized disease, and we’re in the midst of trying to prove that through well-organized, thoughtful clinical trials.

“At the end of the day, the question is, how can we help our patients live longer and live better?  That’s really the big driver.  The good thing about localized disease is that we can try to cure more men of prostate cancer – not just extend life for metastatic disease, but can we develop a pathway so they don’t ever develop metastatic disease, and so they can be cured?  That’s what we’re aiming to do.”  And, bonus:  after the big blast of intense hormonal treatment, most men get their testosterone back.  “Most patients actually recovered their testosterone fully within the first year of discontinuation of treatment.”

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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Metastatic Prostate Cancer: Don’t Accept Complacency!

You have metastatic prostate cancer, and your doctor has said you’re doing all you can do.  How can you be sure?  This is a post that’s very close to my heart, because I have met many men over the years who hear this from their doctors and they just accept it.  Maybe you truly are doing all you can do.  But maybe you aren’t.  With the hope of fighting the spirit of complacency or worse, despair, that can overtake anyone with an illness so easily, I recently interviewed Duke oncologist Andrew Armstrong for the Prostate Cancer Foundation (PCF).  He proved to be a kindred spirit, who wants to encourage men not to give up.

“This is all we can do” is a phrase no cancer patient wants to hear, especially someone with metastatic disease.  Medical oncologist and PCF-funded investigator Andrew Armstrong, M.D., M.Sc., hears those six words a lot – from patients who have come to see him at Duke University’s Cancer Center, a comprehensive cancer and clinical trial center.  The patients are hoping their local doctor was wrong – that this is, in fact, not all that can be done.

And here’s some good news:  Often, there is something more, and the list of options is growing even as we speak.  “The FDA has approved many new therapies for advanced prostate cancer,” says Armstrong.  The challenge, he adds, is in knowing which of these might be helpful for you – and which are likely a waste of your time and money.

Why don’t all of these drugs work for everyone?  Because underneath the umbrella diagnosis of metastatic prostate cancer are many factors that make the response to treatment different in each man.  Understanding whether or not you have some of these factors could not only save you thousands of dollars, but could point you away from treatment that is not going to work, and toward better, more promising options.

Do you need a “liquid biopsy?”  Armstrong and investigators at five centers recently completed the PROPHECY trial, funded by a Movember-PCF Global Challenge Award.  The study’s goal was to use a “liquid biopsy” – a blood test that can detect circulating tumor cells (CTCs) shed by prostate cancer – to evaluate a biomarker called AR-V7 as a predictor of response to androgen receptor-blocking drugs such as abiraterone (Zytiga) and enzalutamide (Xtandi).  AR-V7 is a variant androgen receptor that some men develop over time.  “AR-V7 does not show up when you’re first diagnosed with prostate cancer,” says Armstrong, “and it generally does not show up before you start hormonal therapy.  It only shows up when a patient has developed resistance to commonly used hormonal therapies like leuprolide or degarelix, and more commonly after he has been taking an androgen receptor pathway inhibitor like enzalutamide or abiraterone.”

The results of the PROPHECY study, published in the Journal of Clinical Oncology and updated this past year in JCO-Precision Oncology, showed that AR-V7 is a “negative predictive biomarker” for response and outcomes to abiraterone or enzalutamide.  In other words, if a blood test shows that your cancer cells have detectable AR-V7, these drugs are not likely going to be helpful for you.  There are two blood tests for AR-V7:  one is an mRNA assay developed at, and offered by, Johns Hopkins, and the other is a more widely available CTC protein-based assay made by Epic Sciences.  Both tests are good, says Armstrong.  “It’s common practice,” he explains, “that if a man has been on enzalutamide and his cancer has progressed, to try another hormonal agent such as abiraterone, and vice versa.  But that strategy can lead to cross-resistance,” where neither drug is effective in this patient.  “These drugs are very expensive.”  Abiraterone is now available in a much less expensive generic form, but enzalutamide can cost more than $10,000 – per month!   That’s a lot of money, particularly if it’s not going to help you.

New Strategy:  Shotgun and Sniper Rifle! 

If you have AR-V7, what should you do instead?  Think shotgun – many pellets aimed at the disease – and sniper rifle – a highly focused, precision medicine approach.  “The answer is not to give up, but also not to give therapies that don’t work,” says Armstrong.  “Right now, drugs that are more effective would be chemotherapy: docetaxel and cabazitaxel, and radium-223,” a drug that mimics calcium – and, like calcium, gets absorbed into areas of bone with a lot of cell turnover, particularly areas where bone metastases are forming.”  Treating cancer in the bones not only improves quality of life, but has been shown to increase survival.   Another experimental way to treat areas of metastasis is with stereotactic ablative radiotherapy (SABR, or SBRT), an intense, focused dose of radiation directly to a metastatic site.

Gene-targeted treatment is another option for some men.  “I look at AR-V7 as not the only blood test you’re going to do, but as part of a broader plan to find a therapy that fits the patient,” says Armstrong.  A small percentage of men have microsatellite unstable (MSI-high) prostate cancer – defects in one or more “spell-checker” genes involved in DNA mismatch repair.  This can be identified by tumor genomic sequencing biomarker tests.  “About 5 percent of men have microsatellite unstable prostate cancer, and those patients can do very well on immunotherapy such as pembrolizumab– and may even get complete remission of their cancer!”

Another small percentage of men – those who have a defective BRCA1 or BRCA2 gene – may have an excellent response to a PARP inhibitor drug like olaparib or rucaparib and to off label platinum-based chemotherapy.   “Ongoing trials are exploring a range of combination approaches of both immune therapies and these targeted agents, as well.”

Armstrong is an investigator in clinical trials for still other treatments: newer immunotherapies, targeted molecular agents, newer AR degraders and other inhibitors of hormone signaling, and PSMA-targeted radionuclides, which can detect and attack areas of prostate cancer throughout the body.  “A negative test (such as a blood test finding AR-V7) doesn’t mean you close all doors.  It just means that other doors may open to you, and if those doors are more likely to help, those are the doors you should open.  But the first step is going to see an expert who can open those doors for you.” Look for a Comprehensive Cancer Center or a PCF-VA Center of Excellence (for Veterans).

And don’t forget:  you can help your body fight prostate cancer, as well!  As we’ve discussed previously, exercise can help minimize side effects and maximize the effectiveness of treatment.  The stress hormone, cortisol, plays a role in some forms of prostate cancer, and lowering stress can help slow down cancer’s growth.  Diet can do a lot:  foods that lower inflammation and insulin resistance can also slow cancer’s growth, and new evidence suggests that caloric restriction can decrease metastasis and increase overall survival.

To sum up:  Don’t accept complacency.  “I see it all the time,” says Armstrong, “and I’ve heard stories you wouldn’t believe,” of patients who have been told there is nothing more that can help them.  “Sometimes, if you just do some of these tests, you can find really actionable results.”  There is almost always something else you can do.  There are clinical trials under way and entirely new avenues of treatment, such as PSMA-targeting radionuclides, that offer tremendous promise.

“Andy Armstrong and his team are making tremendous strides towards precision medicine for men with advanced prostate cancer,” says medical oncologist and molecular biologist Jonathan Simons, M.D., CEO of PCF.  “If your doctor doesn’t mention new tests or experimental treatments – or even different uses for existing treatments that might be helpful for you, then it’s up to you to start this conversation.  And even during the pandemic, some clinical trials are still enrolling patients.”

It never hurts to ask.  Don’t give 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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PSMA-PET Imaging:  Finding the Needles in the Haystack

We’ve talked about PSMA-PET before, but now it has gotten FDA approval for use in imaging prostate cancer.  This is just the start: more approvals are expected.  PSMA-targeting is also being used in Europe and Australia, and in clinical trials in the U.S., as a means of treating prostate cancer, not just showing where it’s hiding in the body.  For the Prostate Cancer Foundation (PCF), I recently interviewed Thomas Hope, M.D., part of a team of scientists at UCSF and UCLA whose PCF-funded research led to the FDA approval for PSMA-PET imaging.  The possibilities here are truly exciting:

“If we can see it on PSMA-PET, we can treat it, right?”

 “My PSA is no longer undetectable after surgery, but cancer didn’t show up on a PSMA-PET scan.  Do I still need radiation therapy?”

 “I’m at high risk of cancer recurrence.  A bone scan was negative, but the PSMA-PET scan shows a few spots of cancer outside the prostate.  Do I have metastatic prostate cancer?”

 These are just some of many new questions that men with prostate cancer and their doctors are starting to deal with after recent FDA approval of PSMA-PET, a new kind of scan that can show, for the first time, the needles in the haystack – tiny spots of prostate cancer hiding in the body that are too small to be picked up by standard imaging.

PSMA stands for prostate-specific membrane antigen, a molecule identified in the late 1980s that sits on the surface of prostate cancer cells.  Supported by many years of PCF funding, scientists have managed to link PSMA to radioactive tracers that can home in on this very specific molecule wherever it happens to be:  think of heat-seeking missiles locking onto a target.  Depending on the radioactive molecule linked to PSMA, it can either detect prostate cancer by shining a virtual spotlight on areas as small as a BB – the imaging technique the FDA has just approved – or detonate it with chemotherapy or tiny doses of radiation delivered by radionuclides at the cellular level.  In Europe and Australia, and in clinical trials in the U.S., PSMA-PET is being used to target and kill cancer in just those tiny outposts, leaving nearby cells unscathed.

“The PCF saw the potential of PSMA targeting way back in 1993,” says medical oncologist and molecular biologist Jonathan Simons, M.D., CEO of PCF.  “Over nearly 30 years, we have invested more than $26 million in research on PSMA, with the goal of finding cancer that has escaped the prostate when it is very early and at a very small volume, because we believe that the sooner we can target it, the sooner we will be able to treat it and change the course of metastatic prostate cancer.”

The particular PSMA-targeted contrast agent that just got approved – a remarkable achievement in itself, based on five years of research by investigators Thomas Hope, M.D., at the University of California-San Francisco, and Johannes Czernin, M.D., and Jeremie Calais, M.D., MSc., at the University of California-Los Angeles – is called 68Ga-PSMA-11.  (The “Ga” stands for gallium; other PSMA agents are in various stages of getting FDA approval.)  And this particular FDA approval, for now, is for use on a very small scale:  only in California, at UCSF and UCLA.  But it’s a start – and it marks an important milestone in prostate cancer detection and treatment.  

This FDA approval is for use of PSMA-PET imaging in two main groups of patients (for now), says Hope, who is Director of Molecular Therapy in the Department of Radiology and Biomedical Imaging at UCSF: “in high-risk men before treatment with prostatectomy or radiation therapy, and in men who have already been treated for localized prostate cancer who have a rising PSA.”

The strong collaboration among the PCF-funded scientists at UCLA and UCSF undoubtedly helped secure the FDA’s approval – itself a bit of a milestone.  “This is really unusual,” Hope notes.  “The FDA has never approved a drug at two manufacturing centers before, and both centers were approved on the same day.”

Achieving a PSMA-PET scan is more labor-intensive and expensive than patients might realize, Hope adds.  “We have to make the imaging agent ourselves in small batches,” a high-tech process that requires a gallium generator, and the solution can’t be stockpiled for long-term storage, because gallium has a half-life of a little more than an hour.  “For now, there is no commercially available PSMA-PET contrast agent,” but Hope believes this will change soon; two new drug applications for PSMA agents are under review by the FDA, and more are expected.

Note:  Many men won’t ever need PSMA-PET.  If you have a small amount of Gleason 6 prostate cancer and you are enrolled in active surveillance, or you were diagnosed with low- or intermediate-risk cancer that was treated with surgery or radiation and your PSA is undetectable, then PSMA-PET is probably not something you will need to consider.  But for other men – those with a rising PSA after treatment, for instance; men at high risk of cancer recurrence; or some men with metastatic prostate cancer – PSMA-PET can help determine what to do next.  As Hope says, “Now we know where it is.  The question then becomes, what’s the best way to treat it?”

Smarter Treatment

Having this extra insight shouldn’t be a scary prospect, he adds.  “It’s never bad to know; instead, what can we do with this knowledge?” One exciting thing is to treat men with oligometastasis, as oncologist Phuoc Tran, M.D., Ph.D., is doing at Johns Hopkins: and he’s going after a cure!   Another thing is to actually put the treatment where the cancer is, instead of where it is not.  Hope explains:  Many men who have a rising PSA after prostatectomy “get radiation therapy blindly to the prostate bed; 30 percent of those patients have a recurrence of cancer after about two years.  But with PSMA-PET, we know that about 30 percent of these patients have disease outside the radiation field.  Those are the patients who are recurring!  Now we can expand the radiation field to include known sites of cancer.  We assume the patient will benefit – we just haven’t proven it yet.  Do we not want to know where the disease is, and treat them blindly?” No! And this could be a game-changer for some men.

It’s also important to note that PSMA-PET is not the perfect crystal ball; it can’t detect areas of cancer that are really tiny.  Hope says that “some patients take a negative PSMA-PET to mean they don’t need any treatment,” and that’s not always correct.  “If you have biochemical recurrence (a rising PSA), and PSMA-PET doesn’t show any evidence of disease, the cancer is going to continue to progress.  Don’t think you don’t need treatment, particularly if you’re a candidate for salvage radiation therapy.”

These and other issues will become increasingly clear as PSMA-PET becomes incorporated into the standard of care.  As Hope notes, “It’s early days yet.”

In addition to the book, I have written about this story and 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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More Fuel for the 2020 Dumpster Fire: The Fallout of Not Screening for Prostate Cancer

The dumpster fire that is 2020 just keeps on burning, and the latest fuel for this crappy fire is a study, published in the Centers for Disease Control’s Morbidity and Mortality Weekly Report, showing that the incidence of men being diagnosed with metastatic prostate cancer doubled between 2003 and 2017. 

It doesn’t take a genius to figure out why:  Many men are not getting screened for prostate cancer.  It’s not just because of Covid.  (By the way, the coronavirus fallout is massive:  neglected routine medical maintenance – mammograms, colonoscopy, dental visits, yearly bloodwork, delayed care.  I am also extremely worried about the mental health ramifications of isolation, particularly on the elderly, which I will be addressing in other posts.)

No, this failure to screen for prostate cancer has been going on for a while.  It upsets me greatly, because I have known too many men over the years who have died from metastatic prostate cancer.  Wonderful men, like this one.  If these men had been screened regularly, with a simple PSA blood test even if they didn’t get a physical exam, they might have been diagnosed with cancer that was still confined to the prostate, cancer that’s much easier to treat, cancer that can be cured.

But no.  They didn’t get screened because their family doctor told them they didn’t need to.  And this is because, often, family doctors don’t know all the ins and outs of screening for particular cancers; they simply can’t be specialists in everything, so they rely heavily on the government guidelines.  They don’t consider that maybe the guidelines were written by people who might have an axe to grind, people who might want to ration care, people who might think that every single man diagnosed with prostate cancer gets unnecessary treatment and suffers terrible side effects, as if there hasn’t been any improvement in prostate cancer screening and treatment since the 1990s, or people who might believe, mistakenly, that prostate cancer is very slow-growing and doesn’t need to be treated at all – or all of the above.

In 2012, the brain trust of the U.S. Preventive Services Task Force (USPSTF) – speaking of dumpster fires– published guidelines discouraging routine screening for prostate cancer, concluding that the benefits do not outweigh the harms of treatment.  Urologists and medical oncologists protested this from the get-go.

How’d that work out for us?  Not great.  This was a disastrous ruling, and in 2018, the USPSTF walked it back, lamely, saying that prostate cancer screening for men aged 55-69 should be “an individualized decision based on personal preferences when weighing the benefits and harms of screening.”

What’s wrong with this?  So much.  For one thing, men need to start getting screened in their 40s.  If you have a family history of prostate cancer, you need to start getting screened at age 40.  For another, why is there a cutoff at age 69?  Healthy older men can still be diagnosed with prostate cancer, and can still be cured of it – or, conversely, still die from metastatic prostate cancer – so this, too, is just misguided.  I’ve written about that here.  For another, what are the personal preferences?  Not wanting to die of prostate cancer?

There are also lifestyle factors that put you at higher risk; do they mention those?  No.  If you are obese, or if you smoke, and you get prostate cancer, you are more likely to die of it.  (Good news:  if you lose weight and/or stop smoking, your risk of dying starts to drop right away.  You can read more about that here.)

And finally:  a lot of men don’t know their family history.  Or, their family history is happening in real time, as an uncle, father, brother, or grandfather is diagnosed with prostate cancer.  If you have prostate cancer in your family, that puts you at a higher risk of getting it, and you need to be screened regularly.

But what about the risks of treatment – namely, the risk of incontinence and impotence?  Fair question.  First, here’s something else very important you need to know:  Three-fourths of men in the U.S. are diagnosed with localized prostate cancer, and many of those men don’t have to do anything at all!  If you are diagnosed with Gleason 6 cancer, you can simply monitor it closely with active surveillance.  It may well be that the cancer will just sit there, not grow fast, and not spread.  You may never need treatment, and after many years, you can just die with it, not of it.   Or, you can get the cancer treated with surgery or radiation.

But about those risks:  Yes, there are side effects to surgery.  This is why you do your best to minimize those side effects by finding the best surgeon possible.  Here are some ways to do that.  Those side effects are treatable.  There are much worse side effects to treatment for metastatic prostate cancer, which includes androgen deprivation therapy (ADT).  ADT’s side effects include the loss of testosterone, loss of sexual desire, weight gain, loss of muscle mass, breast enlargement, and a higher risk of other health problems including diabetes, heart attack, stroke, metabolic syndrome, osteoporosis, and cognitive impairment.

I know men with metastatic prostate cancer who would give anything to be dealing with the aftereffects of surgery for localized prostate cancer if it meant they could be cancer-free.  

Hear this:  I am confident the survival rates for men with metastatic prostate cancer are rising and will go up even higher with the use of second-line hormonal therapy (androgen receptor blockers like abiraterone, enzalutamide, and others); with smarter use of SBRT radiation to treat isolated spots of cancer before widespread metastasis; with immunotherapy and gene-targeted therapy, which are both still in their early days in prostate cancer; and with PSMA-targeted radionuclides.  There are many exciting treatments in the works, and some of them have the potential to be game-changers.

That said, for the years this study covered (between 2003-2017), fewer than one-third of men diagnosed with metastatic prostate cancer survived five years.  The five-year survival rate actually rose during the study’s time period, from nearly 29 percent between 2001 and 2005 to more than 32 percent between 2011 and 2016.  Again, don’t let these numbers discourage you:  they are going to get better with the new treatments on the horizon.

In contrast, for men diagnosed with localized prostate cancer, the 10-year relative survival rate was 100 percent.

Between 2003 and 2017, about 3.1 million men were diagnosed with prostate cancer.  In 2003, 78 percent of these men were diagnosed with localized cancer; in 2017, this had dropped to 70 percent.  In 2003, 4 percent of men were diagnosed with metastatic prostate cancer.  By 2017, this percentage had doubled to 8 percent.

If you’ve read this blog for a while, you may remember that I wrote about this disturbing trend in 2018.  You can read more about it here.  I interviewed Edward “Ted” Schaeffer, M.D., Ph.D., Chairman of Urology at Northwestern University.  Here’s some of what he said:  “Hindsight is 20/20, and there’s no question that when PSA screening first became available, many men were overdiagnosed.”  Back in the 1990s, doctors hadn’t figured out who needs to be treated and who can safely do active surveillance.  They know a lot more now.  In 2018, Schaeffer had already noticed this disturbing trend – declining rates in the diagnosis of low-grade, localized prostate cancer, and a sharp increase in the number of men newly diagnosed with metastatic prostate cancer.  “We need nationwide refinements in prostate cancer screening and treatment, to prevent men from being diagnosed with metastatic prostate cancer.

“We don’t want to diagnose low-grade cancers,” which may never need to be treated.  “But we really need to pick up the disease before it becomes metastatic.”

 

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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