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Charred Food Bad, Veggies Good for the Prostate

grilled meatGood news for people who love barbecue, hot dogs, burgers, and steak cooked on the grill: It pays to eat your veggies.

The key to this story is something called “PhIP.” A few years ago, noted Johns Hopkins scientist Bill Nelson, M.D., Ph.D., director of the Sidney Kimmel
Comprehensive Cancer Center, began investigating its role in cancer. PhIP is a funny little word. (Pronounced “fipp,” it’s a short name for a long chemical
compound.) It sounds so harmless: “Hey, let’s get PhIP and go over to the club for some tennis,” or “I don’t give a PhIP what you do,” or “Let’s do some
PhIP shots!” But it’s not.

PhIP is found in meats cooked at high temperatures. It is a “pro-carcinogen,” a chemical that turns into something that can attack and mutate DNA, and is
known to cause prostate, breast, and colorectal cancer in rats. Unfortunately, we create carcinogens, or cancer-causing agents, with every steak we grill
or piece of chicken we fry, and PhIP is one of them. In 2007, Nelson and pathologist Angelo De Marzo, M.D., Ph.D., reported in Cancer Research
that when rats are exposed to PhIP, DNA mutations occur in the prostate. Since then, they have learned much more about this little sucker’s role as a
dietary contributor to cancer. I recently wrote about Nelson’s work for Discovery, the research magazine for the Brady Urological Institute at Johns
Hopkins.

The scientists have discovered that veggies help counteract the effects of PhIP. “When we fed rats tomato and broccoli along
with PhIP, the animals lived longer and showed reduced incidence and severity of prostate neoplasms (new, abnormal cell growth; particularly of PIN,
prostatic intraepithelial neoplasia – funny-looking cells that are linked to prostate cancer), intestinal cancers and skin cancers as compared to rats fed
PhIP alone,” says Nelson. “This provides even more evidence that eating vegetables may protect against cancer-causing agents like those in overcooked
meats.”

grilled veggiesThere is a twist to the story: Food safety pays off, too.
Nelson, along with De Marzo and scientist Karen Sfanos, Ph.D., has also explored the idea that prostate cancer may involve a combination of “environmental insults” – bad things in the diet, plus something else that weakens the body, like an infection. They wondered whether chronic inflammation, caused by bacterial infection, would make a difference in rats that had consumed PhIP. Using a specific strain of E.coli isolated from a patient with chronic prostatitis/chronic pelvic pain syndrome, they found to their surprise that the charred food plus the nasty bug seemed to have a systemic effect.

Together, E.coli and PhIP caused an increase in the development and progression of cancer in the skin and digestive tract. (Note: many people have E.coli in their gut and it is harmless, but some strains can get into meat when it’s processed and can survive if the meat is undercooked.) The rats that received the double punch of E.coli plus PhIP fared worse than rats that ate the PhIP alone. In one study, the bacteria- and PhIP-consuming rats developed more precancerous lesions within the prostate and might have developed even more problems – except they also died sooner.

In further experiments, they found that “when we inoculated PhIP-fed rats with E.coli in the prostate, the animals developed acute and chronic
prostate inflammation out of proportion to that seen with PhIP ingestion or E.coli inoculation alone, and had more prostate neoplasms, intestinal
cancers, and skin cancers,” says Nelson. “This hints that prostate infections and dietary carcinogens might interact to promote chronic prostate
inflammation and prostate cancers, and that prostate infections might augment carcinogen effects on other tissues, as well.”

What does this mean for you? One, that if these things cause changes in the prostate, it’s a pretty good bet that they are hurting you elsewhere, as well,
so take precautions: eat a veggie in addition to a potato. Potatoes are delicious, but they don’t help fight cancer the way green, leafy vegetables and
tomatoes do. Two, tomatoes and broccoli probably aren’t the only vegetables that can help diffuse the bad effects of charred meat; these are just the ones
that were studied in this particular investigation. Three, don’t eat undercooked meat. You’re not just risking food poisoning, which comes in like a
freight train and goes away quickly; you may be adding to your risk of developing cancer.

Nelson, along with De Marzo, Sfanos, and Hopkins colleagues recently published two papers on these striking new findings in the journals PLoS ONE
and Cancer Prevention Research.

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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Prostate Cancer Screening and You

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

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

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

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

Start When You’re 40

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

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

Get the Test

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

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

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

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

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

What if You Don’t Have a Baseline? 

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

When Can You Stop Screening? 

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

In the Case of PSA, Numbers Really Matter

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

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

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

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

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

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

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

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

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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Prostate Biopsy Fun Facts! Also, Why Cancer Can be Missed in African American Men, and a Word about the Bacteria in your Rear End

I lied in the headline.

strawberriesA prostate biopsy is not actually fun. But if you need one – if your PSA has gone up more than 0.4 ng/ml a year, or if your doctor has felt something suspicious, like a hard spot on the prostate during the rectal exam – then you need one, so here are a few things you should know.

The way doctors look for cancer in the prostate is much like looking with a needle in a haystack. The needle in this case is a spring-loaded biopsy gun, a tiny device that’s attached to an ultrasound machine. It’s not like a sewing needle; this one has a hollow center, so that it can capture at least 10 to 12 tiny cores of tissue, each one about a millimeter thick. Those cores go to a pathologist, who studies them under the microscope.

The Seeds in the Strawberry

What are they looking for? Johns Hopkins urologist Patrick Walsh, my co-author of Dr. Patrick Walsh‘s Guide to Surviving Prostate Cancer, uses this image with his patients: Imagine the prostate as a large strawberry.

Prostate cancer is multifocal. It causes what scientists call a field change. Multiple tumors pop up like dandelions, all at about the same time.

These seeds are tumors, and three to seven is the average number of separate cancers found in a radical prostatectomy (the operation to remove the entire prostate) specimen. How can a man develop several different spots of cancer? Prostate cancer is multifocal. It causes what scientists call a “field change” – basically, the entire prostate undergoes a transformation. Multiple tumors pop up like dandelions, all at about the same time. Each spot can be millimeters in size.

So this is what the urologist is looking for with the biopsy needle. But it’s not easy to hit a tiny seed inside a strawberry, especially one you can’t always see.

Why Cancer Can be Missed in African American Men

In another post, I mentioned the important work that another urologist, Ted Schaeffer, M.D., Ph.D., chairman of urology at Northwestern, is doing in understanding how prostate cancer is different in African American men. One reason it may be more aggressive when it’s diagnosed is that black men with prostate cancer make less PSA per gram of cancerous tissue, “So their PSA score could be misleading,” says Schaeffer. “There are fewer early warning signs.”

But even when an African American man does get a biopsy, his cancer can be missed. This is because his cancer, for some ornery reason, picks the hardest-to-get-to, easiest-to-miss-on-a-biopsy region of the prostate. “The way I explain it to patients,” says Schaeffer, “is, think about your prostate like a house.

“You have a basement. Just under that basement, the sub-basement, is the rectum, where we do the biopsies. You have a first floor, and an attic. Tumors in most Caucasians occur in the basement. If you’re taking tissue samples of the prostate from the sub-basement, you can get a good sampling of that area and are more likely to pick up a cancer. But if you’re African American, you have a high chance of having what we call an anterior tumor, in the attic of the house. It’s just harder, frankly, to be able to sample that area on a standard biopsy.”

This is why Schaeffer and colleagues get MRI images of their patients at highest risk, including African American men. “If we see something suspicious, we do an MRI-guided biopsy. We’re not the only place in the world doing this, but we’re doing it for reasons that were discovered at Hopkins.”

So, this is what I hope will be the take-home message:

If you are a black man, you need to be checked for prostate cancer starting at age 40. Get a baseline PSA test and have a rectal exam. If your PSA goes up more than 0.4 ng/ml a year – even if the number itself is low – you need a biopsy. Ideally, you need an MRI-guided biopsy. If no cancer is found, and that PSA keeps going up, you need another biopsy. If your doctor does not feel this way, find another one – a doctor who understands that prostate cancer is different in African American men in several important ways.

And Now, a Word About the Bacteria in Your Rear End

No offense, but you have bacteria in your bottom. We all do, so it’s nothing personal here. But it becomes an issue, so to speak, when you need a prostate biopsy. You’ve probably heard of nasty bugs known as multi-drug-resistant bacteria. When the biopsy needle goes into the prostate, it goes “transrectally” – through the rectum. To minimize the risk of infection, the standard protocol is for men to have an enema and to take antibiotics.

But this is not always enough. It turns out that one out of every five men has this multi-drug-resistant bacteria. If you have it, and you get an infection, “you can get very sick,” says Ted Schaeffer. The men most at risk? “Diabetics and health care providers.“ He made this observation in a study of a huge Medicare database of patients. His father, noted urologist Anthony J. Schaeffer, Urologist-in-Chief at Northwestern, is an expert on infection. Together, they came up with a protocol to lower the risk of a bad infection. “Before any biopsy, we sample the rectal flora” – the butt bacteria, if you will – with a simple swab test. “If we detect resistant bacteria, we then appropriately modify the antibiotic we give before the biopsy. That’s very important, because we’re preventing infectious complications that could be life-threatening.”

Before your biopsy, talk to your doctor about the risk of infection, and whether it would be possible to get a simple swab test ahead of time.

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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Prostate Cancer is More Aggressive in African American Men

self portaitIf you are a man of African American descent – or a woman who loves him — I hope you read this. You are in the group that is hit the hardest by prostate cancer of all men in the world.

When you look at the men at highest risk of getting prostate cancer, one risk factor that stands out is having a family history of the disease – a father,brother, grandfather, or uncle, on either your mother’s or your father’s side of the family.

The other one is being black.

There are a bunch of reasons for this, including genetic differences in the androgen receptor, and lower levels of vitamin D, and diet, and socioeconomic differences in medical care, and some other things in the book I co-wrote with the great Johns Hopkins surgeon/scientist Patrick Walsh, called Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer. But those things – while certainly important, and of potential help for researchers trying to treat or prevent the disease in the future — don’t even really matter to you right now.

[Tweet “When African American men are diagnosed with prostate cancer, it is likely to be a more aggressive form of cancer.”]

What you need to know is that when African American (AA) men are diagnosed with prostate cancer, it is likely to be a more aggressive form of cancer. You are more likely to need to go after that cancer – if I were your relative, I would tell you not even to think about watchful waiting, or active surveillance, or whatever a doctor might call getting a repeat biopsy 6 months to a year later, and continuing to watch that PSA. You can’t do that, because prostate cancer is most likely different in you, and you need to take it very seriously.

I recently interviewed Ted Schaeffer, M.D., Ph.D., Director of the Johns Hopkins Brady Urological Institute’s Prostate Cancer Program, for a publication called Johns Hopkins Urology. (Note: Schaeffer is now chairman of urology at Northwestern.) A few years ago, Schaeffer made some important observations about the differences in cancer between men of African ancestry and other men. He followed up on them with research, he is the leader in this field, still actively researching this, and his findings are saving lives in the AA community.

“African American men often present with more aggressive cancers than other men,” says Schaeffer. For example, if you are an African American man who has been diagnosed with Gleason 6 (a stage of cancer that is often treated successfully and cured) disease, you have “a one-third higher chance of having more aggressive cancer than the biopsy suggests.” Also, “we found that when these men have surgery, they have a higher likelihood of needing additional adjuvant treatment.” These findings, published in the journal, Urology, were based on the outcomes of more than 17,000 men who underwent radical prostatectomy at Johns Hopkins; 1,650 of them were of African ancestry and were not only more likely to have a higher-grade cancer and larger tumors, but to experience recurrence of cancer compared to Caucasian men.

This is particularly worrisome in a time of confusing medical information, when many men and their doctors worry about overtreatment of prostate cancer, about side effects from surgery or radiation that didn’t need to happen, because maybe that disease would never have progressed, and a man could have lived his whole life without the cancer ever causing a problem. Yes, there are lucky men like this, and in a future post we’ll talk about what the criteria are for safely watching cancer, instead of taking it out or blasting the crap out of it with radiation. If you are a black man, you are most likely not one of these lucky men. I’m sorry, but you just aren’t, and I want you to know that so you can do something about it.

Schaeffer initially found that AA men who could be candidates for active surveillance turned out to have a much higher chance of having aggressive disease if they later needed surgery. He and colleagues later proved in the surveillance group that “the chance of failing surveillance or being reclassified
(determining that the cancer is a different stage or grade than initially thought) is 30 percent higher for black men compared to white men. We also found that even after surgery, if you control for the grade and stage of the cancer,men of African ancestry are more likely to have their cancers come back. It
means that biologically, they’re probably different.”

Cancer tends to develop in a harder-to-biopsy, easier-to-miss part of the prostate in black men than in other men. I’m going to write more about this in the next post, but the take-home message here is this:

If you are a black man, and you’re age 40 and you haven’t had your PSA checked and you haven’t had a rectal exam to check for prostate cancer, you need to do it.

You don’t want to get a rectal exam? Please. Don’t tell me, or any woman who’s had kids, where it’s like a train station in the hospital exam and everyone’s looking up inside you, that you don’t want to get that exam. It’s not that bad, and it can save your life.

If you are getting regular PSA exams and your PSA is going up consistently, more than 0.4 ng/ml a year (say you have one test and it’s a 1.4. The next year, it’s 1.9, then 2.5), you should get a biopsy. Don’t look at the overall number. PSA hasn’t been around that long, and at first, doctors thought that a PSA lower than 4.0 was okay; unfortunately, they missed a lot of cancers with just a basic cutoff number, because all men are different, and many factors, such as a man’s age and the size of his prostate, can affect that number. Ted Schaeffer would tell you that you should get an MRI-guided biopsy, because the MRI can pick up cancers that the biopsy misses.

If cancer is found, you need to treat it. Not with herbs, or dietary changes, or exercise, or supplements, or watchful waiting. Seek curative, aggressive treatment.

Don’t miss my next post in this series. Subscribe by email below and be the first to receive notifications of all of my articles.

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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