Progress On Prostate Cancer

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Having an aging prostate gland myself, I do follow the trends in preventing, diagnosing, and treating prostate cancer, an extremely common but fortunately not highly lethal disease. It’s been said, for example, that every man, if he lives long enough, will eventually develop prostate cancer but will most likely die of something utterly unrelated.

In fact, of the 2.5 million men in the US currently diagnosed with prostate cancer (average age at diagnosis, 67) only about 30,000 will actually die per year from the disease. This makes it the second most lethal cancer for men, well below lung cancer, which kills about 90,000 men each year, both small potatoes when compared to heart disease, which kills 350,000 men annually.

“Catch it early” is the buzz phrase of virtually all cancer screenings (in contrast to the “prevent it altogether” philosophy of WholeHealth Chicago). With early diagnosis in mind, there was a great deal of excitement generated when the PSA (prostate specific antigen) test was developed as a simple screening blood test for prostate cancer. PSA is a protein produced by the prostate. When high levels are detected, there’s suspicion (but not likelihood) that prostate cancer might be present. Other causes of an elevated PSA are simply having a large prostate or a mild urinary tract infection.

PSA recent history

Until recently, when a man had an elevated PSA, he’d be advised to undergo needle biopsies of his prostate to look for cancer cells. Fortunately, the vast majority of prostate biopsies were negative (like breast biopsies), but the procedure itself is definitely an uncomfortable one and no man has ever stepped up and exclaimed, “Let me have another one of those!” In fact, these biopsies were showing positive results so rarely that a couple of years ago physicians began to suspect they might have been jumping the gun when it came to recommending standard PSA screenings for men over 50, even younger if there was a family history of prostate cancer.

But what cooled everyone’s PSA enthusiasm were the disappointing long-term results of gung-ho treatment when a biopsy came back positive for cancer. Three treatments were offered: surgical removal of the prostate, hormone manipulation to turn off testosterone production, and seeding of the prostate with tiny radioactive pellets. Since all urologists are surgeons, you can guess what topped the Recommended List.

Hearing “Let’s just get that cancer out of you and we won’t have to worry about it in the future” sounded so right. Too bad it was wrong.

Every hospital ached to be a prostate “center of excellence” and to do so needed to lease a Da Vinci Robotic Surgery system from the multi-billion-dollar Intuitive Surgical. Since the leasing contracts mandated that hospitals would perform a certain number of procedures each year in order to keep the machine, I began to think the main indication for having a total removal of the prostate (prostatectomy) was having a prostate gland. In fact, some hospitals developed such a reputation for speedily scheduled surgeries that I was thinking of warning patients to keep their knees close together and their gluteals tightly compressed if they happened to be in the neighborhood.

What no one ever heard was “Let’s go slow here and keep an eye on your PSA.”

Two significant problems surfaced with surgical prostatectomies

First, of 1000 procedures performed, 5 men would die within weeks due to surgical complications. And second, of the 995 surgical survivors, another 300 would suffer long-term effects from bowel and bladder incontinence and/or sexual dysfunction. That’s a lot of misery for a cancer that kills relatively few men.

What finally ended the PSA as a screening test dawned on investigators after years of tracking numbers. Read carefully: whether or not men had the 1-2-3 combo of PSA-biopsy-prostatectomy or did absolutely nothing at all (no PSA in the first place), the overall death rate from prostate cancer in each group was precisely the same. In three months, Intuitive Surgical stock fell by a third. Sputtering, blustering urologists argued the data and urged doctors not to abandon the PSA even as referrals from primary care doctors ground to a halt. There went the yacht.

Why was this? How could having no PSA screening at all be equivalent to having your cancerous prostate plucked? Here’s what they figured. By the time the elevated PSA was discovered, the biopsy completed, and the prostate removed, the cancer had already spread, but its microscopically small metastases had been missed during the routine pre-operative x rays and scans. Don’t be too alarmed at this. Remember, most men with biopsy-proven prostate cancer die of something else.

My professional association, the American College of Physicians (whose members are internists), advised us to mention the PSA and immediately warn of its risks since patients would likely question your competence if you didn’t say anything. Let the patient make his choice.

Instead of all this screening, how about some prevention?

We now have some really good evidence for these factors.

Lifestyle  Regular masturbation “housecleans” the prostate of potential carcinogens.

Diet  Eat more onions and garlic. Add spices like ginger, oregano, and rosemary to your food. Drink green tea. Eat more tomato sauces, rich in lycopene, one of the carotenoid vitamins that significantly reduces prostate cancer risk. Drink red wine, or use the supplement Resveratrol Ultra.

Supplements  Lycopene and vitamin D (at least 2,000 IU daily), definitely. Saw palmetto and zinc, very possibly.

And finally, here’s the latest news in prostate cancer prevention

The results of the finasteride study (Propecia/Proscar) were released last week. The difference between the two is tablet size. Propecia contains 1 mg of finasteride, Proscar 5 mg (note: more may not be better.) Finasteride works by blocking the conversion of testosterone, made in the testicles, to its hormone-active form DHT (dihydrotestosterone). Since high levels of DHT are responsible for prostate enlargement and some forms of hair loss, reducing DHT should help both, and it does.

But investigators had suspected that prostate cancer was linked to DHT and this week the New England Journal of Medicine reported that after ten years, regular users of finasteride had reduced their prostate cancer risk by a full one-third, an impressive drop.

However, like most drugs, side effects can occur, mainly emotional depression and lowering of sex drive, fortunately both rare. These usually appeared with Proscar taken for prostate enlargement, because of its larger size. However, there’s good evidence that 1 mg is as effective as 5 mg for your prostate, so if you’re considering the finasteride route, get the lower dose.

Who really should consider finasteride for prostate cancer prevention? If we have a cancer that every male will eventually get but very few will die from, I’d personally stick with the natural products and the diet and lifestyle add-ons. However, there are some especially high-risk groups.

Black Americans have a significantly higher prostate cancer rate (including a higher death rate) than whites, and this is one group that might consider taking long-term finasteride. Blacks also have much lower vitamin D levels than whites, so there’s likely a significant tie-in there.

Also, in certain families of all races prostate cancer is quite prevalent, some men dying from it, most not. For these men, too, a low daily dose of finasteride might be a good preventive step in. Finasteride 1 mg is inexpensive, but requires a prescription. A bottle of 100 tablets is $162 at Costco and about half that in Canada.

Be well,
David Edelberg, MD