Prostate Cancer Prevention Controversy
By William Faloon
An editorial I generated for the May 2013 issue of Life Extension magazine® received quite a bit of feedback and critique.
Some Life Extension® members said it should be a mandatory part of physician education. Others raised concerns about the use of the PSA blood test as a screening tool, why I suggest Avodart® for certain men, and why drugs were mentioned since there are nutrients that function via similar mechanisms.
The most impressive critique came from Patrick C. Walsh, MD, who may be the most renowned prostate cancer expert in the world. Dr. Walsh was involved in identifying the genetic characteristic of hereditary prostate cancer and pioneered “nerve-sparing” surgery. I have urged hundreds of prostate cancer patients to travel to Johns Hopkins to have Patrick Walsh perform their surgery, as I consider him the finest in the world.
So when Dr. Walsh writes us, I pay attention, and Life Extension members should be informed that there are credentialed individuals that are against using drugs in the class of Avodart® for cancer prevention purposes.
Shortly after my 2013 editorial was published, the American Urological Association issued revised guidelines for PSA screening. They now say PSA screening should be mostly considered only for men aged 55-69 (AUA 2013). We vehemently disagree with this new recommendation and chastise this group for not emphasizing the need to devise safer and more efficient ways of performing prostate diagnostics.
To emphasize the seriousness of all this, the chart titled “A Risk of Aging” shows the spiraling incidence of prostate cancer that occurs as men age. Autopsy results reveal that 85% of men have atypical cells in their prostate glands and 1 in 4 has cancer (Billis 1986). While many men with atypical lesions or even malignant cells in their prostate do not ever progress to clinical disease, aging men cannot ignore this problem.
The public still accepts absurdly short life spans. We at Life Extension do not and that is just one reason why our position on prostate cancer differs from the mainstream.
There is something to be said about attending live lectures as opposed to staying glued to our computer/TV screens. A good speaker can make an impact that you may forever remember.
I’ll never forget a lecture I attended in 1977 at a South Florida condominium social hall. The place was packed with retirees. The lecturer was over age 80 and passionately urged all men to visit a urologist once a year for a digital rectal exam. He began by reading a long list of the names of the many members of his retirement community who had suffered agonizing deaths from metastatic prostate cancer.
The lecturer understood that a digital rectal exam would not detect all prostate cancers, but he knew it could save lives. If the PSA blood test had been available at that time, I can only imagine how feverish this benevolent speaker would have been in advocating PSA tests to his fellow men.
Move forward 35 years and the federal government and some mainstream medical groups are recommending against PSA screening, which is more reliable than digital rectal exams, though both ideally should be done annually (AUA 2013; Moyer 2012).
What Makes Prostate Cancer Different?
Prostate cancer is unusual in that it has a blood marker called prostate-specific antigen (PSA) that can facilitate early detection, thereby enabling therapies to be employed before cancer spreads to regional lymph nodes or distant metastases occur (Catalona 1994).
With the advent and widespread use of PSA screening, an argument can be made based on a large human study that huge numbers of men could be spared agonizing deaths from metastatic prostate cancer (Bokhorst 2013; USDC 2012). The earlier diagnosis of prostate cancer, however, must be put into context of the individual patient to ascertain which men need to be treated and which men are reasonable candidates for active surveillance or “watchful waiting.”
The journal European Urology published a study in 2013 conducted on nearly 35,000 men aged 55-69 (Bokhorst 2013). This data came from the European Randomized Study of Screening for Prostate Cancer, a major, robust study examining the impact of PSA screening over a median period of 13 years on prostate cancer mortality. The eye-opening conclusion was that men who underwent repeated PSA screening were 51% less likely to die from prostate cancer than men who did not undergo screening (Bokhorst 2013). If the statistics from this study are applied to the entire population of men aged 55-69 in the United States, PSA screening could potentially save over 80,000 lives in a 13-year period (USDC 2012).
The United States Preventive Services Task Force (USPSTF) published a report in 2012 recommending that men stop undergoing PSA screening (Moyer 2012).
Life Extension disagreed with the USPSTF recommendation, particularly as it relates to our members to whom we are steadfastly committed. We know that in the absence of PSA screening, prostate cancer will once again be diagnosed at an advanced stage, when there is painful bulky disease and only a small chance of curative therapy.
The widespread use of PSA testing beginning in 1987 enabled doctors to identify prostate cancer at a greatly reduced stage of disease (NCI 2012). If the dictum of the USPSTF is followed, a major advance in medicine will be erased.
The Staggering Statistics
Here is what the American Cancer Society says about prostate cancer in the United States (ACS 2013d):
More than 238,000 new cases of prostate cancer are diagnosed yearly (based on 2013 data).
Over 29,000 men die of prostate cancer yearly (based on 2013 data).
About 1 man in 6 will be diagnosed with prostate cancer during his lifetime.
The average age at diagnosis is 67.
Prostate cancer is the second leading cause of cancer death among American men.
About 1 man in 36 will die from prostate cancer.
If prostate cancer were an infectious illness, there would be widespread panic. To put this in perspective, HIV infected less than 50,000 Americans in 2011 (CDC 2013a).
In 2013, the United States Preventive Services Task Force urged all Americans to undergo routine HIV screening (USPSTF 2013).
There are valid reasons for HIV screening, but almost five times more Americans are diagnosed with prostate cancer each year compared to HIV (ACS 2013d; CDC 2013a). The same government-funded Task Force that suggests universal HIV screening does not want aging men to benefit from early detection of prostate cancer. They maintain that the treatment is worse than the disease. They confuse the message conveyed by the PSA with the judgment and actions of physicians who too often are programmed toward invasive and expensive therapies.
Do we toss out the baby with the bath water, so to speak, because physicians are not taking the time, or possibly do not have the expertise to advise patients soundly? The actions of the USPSTF and the American Urological Association should be to fix the deficiency of the physician with strict guidelines, just as was done in the 1980s to alter the routine use of the radical mastectomy performed in almost every woman diagnosed with breast cancer (Ghossain 2009).
The United States Preventive Services Task Force (USPSTF) prefers aging men wallow in ignorance concerning their prostate health, which within the next decade will send death rates spiraling upwards. The USPSTF clearly wants aging men to bury their heads in the sand and not concern themselves about prostate cancer.
The hard statistics showing more than 238,000 newly-diagnosed prostate cancer cases annually proves otherwise (ACS 2013d). While the USPSTF recommendations will save government health programs billions of dollars in the short term, there will be catastrophic long term costs to pay when record numbers of men who could have been cured instead develop metastatic disease.
Why Life Extension Members Are Different
There are factors that influence mainstream recommendations that do not pertain to Life Extension members. The typical American male over age 60 is remarkably unhealthy, often suffering multiple underlying maladies relating to metabolic syndrome and other pathologies called “co-morbidities” (Ervin 2009). This is indicative of a state of disease in the biologic environment of the patient.
A frank diagnosis (or indication) of prostate cancer should act as an early warning that something is amiss in the patient’s overall health and that further attention is warranted to various systems. Thus a diagnosis of prostate cancer need not be equated with invasive procedures such as radical prostatectomy, radiation therapy, cryosurgery, high-intensity focused ultrasound, or androgen deprivation therapy, but with a call to the patient and physician to be alert to pathologic states that if corrected can stabilize or repair some or all of the systems that are amiss.
One reason the USPSTF believes that PSA screening should be halted is that so many men are already in such poor health they are likely to die of some other cause before prostate cancer becomes clinically relevant (Moyer 2012).
Huge Decline in Prostate Cancer Deaths Since Advent of PSA Screening
This is the opposite of Life Extension members, who go to extraordinary efforts to slow aging and protect against degenerative disease. It would be irrational for healthy Life Extension members to stop PSA screening merely because their age group on average is in such poor overall health.
Few doctors today have comprehensive programs designed to reverse multiple underlying factors that lead to clinically-diagnosed prostate cancer. The typical aging person does not know about lifestyle changes, drugs, and nutrients that may keep an indolent cancer confined to the prostate gland.
Life Extension members have long been armed with this information and have access to health advisors to help guide them to more effective ways of working with their physician to improve their odds of keeping low-grade prostate cancer, or indications of low-grade prostate cancer (such as rising PSA), under control. This protocol is dedicated to reminding members and alerting the public about these novel approaches to disease prevention.
Most urologists believe when PSA reaches a certain level that their only choice is to perform needle biopsies. They often overlook existing tests, such as testing and properly analyzing blood results of free PSA percentage, PSA density, and PSA velocity, along with other diagnostics such as PCA3 urinary test and advanced non-invasive techniques that can provide additional insight that may reduce the need for invasive procedures (Vessella 2000; Lieberman 1999; Stephan 2005; Loeb, Carter 2013; Hessels 2009). Urology patients are not always made aware of these non-invasive choices, and especially of the importance of measuring the PSA rise over time (PSA velocity) to help ascertain if prostate biopsy is warranted.
What clearly separates Life Extension members from the general public, however, are the aggressive steps we take to achieve meaningful extensions of our healthy life spans. Those advising against PSA screening are largely “writing-off” men over age 70.
Life Extension male members need to ensure their prostate health is assessed and maintained at an optimal level for the many decades of extended life they expect.
American Urological Association Capitulates
When the United States Preventive Services Task Force suggested that aging men stop PSA screening altogether, the American Urological Association disagreed. About a year later, the American Urological Association issued revised guidelines that will sharply reduce the number of PSA screenings performed (AUA 2013; Pollack 2012; Allard 2012). And other professional groups have issued similar opinions (Qaseem 2013).
The latest recommendation from the American Urological Association (AUA) is for men over age 70 to avoid PSA screening (AUA 2013). The AUA is essentially saying that once you move past age 70, your life span is too short to bother with.
The American Urological Association is also writing off men aged 40-54 for prostate screening because of the relative low incidence of cancer in this group compared to men over 54 (AUA 2013). This is a tragedy as it condemns younger men who do develop prostate cancer to probable death. Earlier diagnosis provides a huge advantage when attempting curative therapy. Just ask Prostate Cancer Foundation Chairman Michael Milken, who insisted on a PSA test at age 46 and discovered he had prostate cancer in time to benefit from curative therapy (Moore 2005).
On the flip side are famous people like Frank Zappa, Telly Savalas, Bill Bixby, and other younger men who likely could have identified their prostate cancer earlier had they undergone PSA screening (PCCNC 2013). These men probably had rising PSA levels long before metastatic disease manifested.
Overlooking More Efficient Procedures
In recommending more limited PSA-screening, the American Urological Association is tacitly admitting that conventional diagnostic and early treatment of prostate cancer is so inadequate, or performed so incompetently, that it’s better to wait for full-blown metastatic disease to manifest. Once advanced stage prostate cancer develops, however, treatments are seldom curative.
Instead of looking at physicians who are diagnosing and treating early stage prostate cancer using less invasive procedures and then emulating these skilled artists, the American Urological Association has apparently caved in to accepting and promoting mediocrity within their profession.
A big problem is that most urologists are not properly assessing PSA results, nor are they efficiently implementing further diagnostic and treatment protocols. And on the other end of the spectrum are the many men who are promptly sent for ultrasound-guided biopsies after one PSA elevation. And again, to add insult to injury, the biopsies are often not ones targeted to abnormalities within the prostate but merely targeting the prostate as a gland.
It is one issue to biopsy an ultrasound lesion that may represent the needle in the haystack, but it’s another issue, and a sad one at that, when it is the haystack that is the target. You know that this is the case when a man has had 2, 3, or 4 prostate biopsies showing no cancer cells, and then he is referred, finally, to a competent physician who uses excellent ultrasound equipment to directly target suspicious lesions within the prostate gland.
In these cases, it seems the diagnosis is magically made; but it’s not magic, it is just an issue of a far higher degree of competence. All men are not equal in talent and all equipment is not of the same quality. The unfortunate outcome is that too many aging men are being subjected to needless and incompetently administered invasive procedures that sometimes result in unnecessary suffering and premature death.
Instead of recommending that medical professionals upgrade their evaluation and treatment protocols to deliver state-of-the-art technology, the United States Preventive Services Task Force suggests that aging men not undergo PSA screening at all, while the American Urological Association limits its recommendation for PSA screening mostly to men aged 55-69 (AUA 2013).
The media treats these authoritarian groups as being virtually infallible.
Prostate Cancer Not an Isolated Disease
A common mistake made by doctors and patients is thinking that prostate cancer manifests in isolation from other pathological events occurring as a person ages. This is not the case.
Research shows that other serious pathological conditions are frequently seen in prostate cancer patients (Post 1999). These factors involved in prostate malignancy can adversely impact other parts of the body (Howcroft 2013).
For example, Life Extension has shown one way prostate cancer and coronary atherosclerosis are related is that they are both influenced by the breakdown of bone (Faloon 2009). As an aging man develops osteoporosis, excess calcium released into the blood contributes to arterial calcification (Faloon 2009). What’s lost in the bone ends up in the coronary arteries and other major vessels of the body (Faloon 2009; Demer 2004).
These atherosclerotic lesions are not vascular “calcifications” but bone growth or osteogenesis (Demer 2004; Demer 2009; Abedin 2004). Bone breakdown also releases growth factors into the blood that promote the proliferation of what may have been indolent prostate cancer cells (Patterson 2010). Therefore, it should come as no surprise that nutrients that prevent bone loss such as vitamin K2 also inhibit vascular calcification (Beulens 2009; Fodor 2010).
PSA screening thus provides an important clue of a man’s overall health, with the advantage of identifying problems early enough to take effective corrective actions. That’s a LOT of benefit for assessing one’s prostate gland once a year utilizing PSA blood testing.
What Makes Cancer Cells Propagate?
When designing prevention and treatment strategies, Life Extension focuses on underlying mechanisms of disease that are fueled by specific biological factors in the body. This is not perfect science however because you can block one factor involved in tumor development, and cancer cells will use other growth-promoting vehicles to progress.
What we seek to do is stay two steps ahead of the cancer by cutting off its many growth promoters and pathways used to escape eradication. For instance, we know that dihydrotestosterone (DHT) promotes prostate cell growth (proliferation) (Wen 2013). This growth affects both benign prostate cells as well as cancerous ones. In the context of a man with prostate cancer, a serial rise in PSA is circumstantial evidence that the tumor cell population is increasing. Such an increase in PSA is not only of importance insofar as prompting investigations to rule out prostate cancer. We have evidence that PSA breaks down natural barriers that keep isolated tumor cells confined to regions within the prostate gland. Remember that PSA is a serine protease, an enzyme that breaks down proteins (Pezzato 2004). One such containment protein degraded by PSA is the extra-cellular matrix, i.e., the natural barrier that may confine cancer cells within the prostate gland.
But suppressing DHT alone is not a total solution. There are other prostate tumor growth promoters such as insulin, estrogen, prolactin, transforming growth factor beta (TGF-1 and TGF-2), and vascular endothelial growth factor (VEGF) that also should be brought under control (Cox 2009; Singh PB 2008; Giton 2008; Dagvadorj 2007; Tu 2003; Ling 2005; Häggström 2000). Fortunately, many of the nutrients Foundation members already take can help suppress growth factors used by prostate cancer cells (and other cancers) to proliferate (Meyer 2005; Ripple 1999; Yan 2009; Hussain 2003; Giovannucci 1995; McLarty 2009; Liang 1999; Singh RP 2008; Smith 2008; Xing 2001).
There are other mechanisms involved in the evolution of a prostate tumor such as 5-lipooxygenase (5-LOX) (Gupta S 2001; Matsuyama 2004; Ghosh 1997) and cyclooxygenase-2 (COX-2) (Xu 2008) that can be markedly improved by dietary changes, along with curcumin (Bengmark 2006; Lantz 2005), fish oil (Taccone-Gallucci 2006; Calder 2003; Norrish 1999), boswellia (Safayhi 1995), aspirin (Salinas 2010), Zyflamend® (Bemis 2005; Yang P 2007; Capodice 2009; Huang 2012; Sandur 2007), and prescription COX-2 inhibitors like Celebrex® (Harris 2009; Pruthi 2006).
Genetic factors involved in prostate cancer initiation and promotion may be favorably modulated by taking relatively high doses of vitamin D (Chen L 2009; Flanagan 2006). Hormonal influences like prolactin and insulin can benefit from using prolactin-suppressing drugs like cabergoline (Dostinex®) (Webster 1992) or Lisuride (Bohnet 1979) and the insulin-suppressing drug metformin (Clements 2011; Hitron 2012; Wright 2009).
The overriding goal in reversing any cancer is to induce favorable changes in the genes that regulate cell proliferation and apoptosis (cell destruction). We know that nutrients like curcumin (Teiten 2010; Shishodia, Singh 2007; Reuter 2011), genistein (Chen 2011; Lakshman 2008; Davis 1998; Davis 1999), fish oil (Berquin 2007; Deckelbaum 2006), and vitamin D (Krishnan 2003; Mantell 2000) favorably affect genes involved in carcinogenesis, as do drugs like aspirin (Yoo 2007; Kim 2005), metformin (Jalving 2010; Avci 2013; Isakovic 2007), finasteride (Proscar®) (Luo 2003), and dutasteride (Avodart®) (Schmidt 2009).
THE WHOLISTIC NATURE OF HEALTH IN RELATION TO PROSTATE CANCER
As we learn more about specific health issues we see evidence of the interconnectivity of all key processes involved in mind and body functions. This should come as no surprise since this phenomenon characterizes all living entities, from the atom to the universe.
Importance of Food Choices
What one eats (and doesn’t eat) makes a huge impact on whether prostate cancer ever develops (Miano 2003; Itsiopoulos 2009).
Healthier eating patterns also improve the odds of treatment success (Ornish 2008; Kenfield 2007).
A rising PSA level or prostate cancer diagnosis can be the signal that it’s time to switch what you eat more towards a Mediterranean diet that focuses on fish instead of red meat, whole vegetables instead of glucose-spiking starches/sugars, foods cooked at lower temperatures, and reduced intake of omega-6 fats (Ferris-Tortajada 2012; Kenfield 2013; Sofi 2008).
Those who pioneered aggressive dietary changes to help treat cancer were decades ahead of their time. While it’s unlikely that aggressive dietary alterations will cure clinically diagnosed prostate cancer, there are strong mechanistic values to consuming foods/beverages that suppress prostate cancer proliferation (like cruciferous vegetables [Xiao 2003; Garikapaty 2005; Srivastava 2003] and green tea [Chuu 2009; Thakur 2012]) as opposed to continuing to eat foods that have been related to higher prostate cancer risk such as red meat (Punnen 2011; Michaud 2001; Richman 2011), starches and sugars (Bidoli 2005; Freedland 2009), excess dairy (Michaud 2001; Song 2013; Chan 2001; Gao 2005), and excess omega-6 fats that contribute to a high omega-6:omega-3 ratio (Williams 2011; Masko 2013).
The section of this protocol titled, “Impact of Diet on Prostate Cancer Risk and Mortality” describes foods that promote prostate cancer and which ones protect against it. We explain how consuming the wrong foods can fuel prostate cancer growth, while following healthy dietary choices can reduce the risk that you will develop clinically diagnosed prostate cancer.
Some men instinctively start eating healthier as they mature, but it took a higher PSA reading (1.4 ng/mL) ten years ago for me to alter my diet in a healthier direction. My diet is not perfect, but it’s a huge improvement over what I consumed in my younger years. My last PSA test came in at 0.4 ng/mL…a 71% decrease in a ten-year period (PSA levels normally rise with age).
If I had not had my PSA checked annually, I may have continued making poor dietary choices and may have developed prostate cancer by now. My father was diagnosed with it around age 75. He consumed a typical diet for his era, with a daily intake of red meat and high glycemic starches like potatoes, while never touching a vegetable or fruit. He set himself up perfectly to encourage prostate cancer growth and mutation.
Even for those who aren’t sure if they are making the proper food choices, laboratory tests like the Omega Score® test (a fatty acid profile) enable one to evaluate their diet and supplement program and make changes to optimize health. You are what you eat and what you assimilate does have a bearing on your health.
Five Stages of Prostate Cancer Progression
As prostate cancer progresses from Stage I to Stage IV, the cancer cells grow within the prostate, through the outer layer of the prostate into nearby tissue, and then to lymph nodes or other parts of the body.
A More Rational Approach
Most prostate tumors are very sensitive to their internal environment or what we prefer to call their “biological milieu.” We know this because when androgen-deprivation therapy is properly administered, PSA levels can drop to near zero and prostate cancer cells die through the process of programmed cell death, a.k.a. apoptosis (Grossmann 2001; Nishiyama 2011).
However, it is not uncommon for prostate cancers to eventually find other growth factors to fuel their continued proliferation and the anti-proliferative and pro-apoptotic effects of androgen-deprivation therapy wear off, as evidenced by a continuously rising PSA that was once brought down to below 0.05 ng/mL by adequately suppressing testosterone (Cox 2009; Singh PB 2008; Giton 2008; Dagvadorj 2007; Tu 2003; Ling 2005; Häggström 2000; Nishiyama 2011).
When a diagnosis of prostate cancer occurs in the setting of a rising PSA in the lower range (below 4 ng/dL ideally), Life Extension views this as an opportunity for early intervention that might result in one’s body regaining control over tumor expansion.
We know that the drug Avodart® (dutasteride) lowers PSA levels by inhibiting the formation of dihydrotestosterone (DHT) (Arena 2013). Avodart® and its less potent cousin Proscar® (finasteride) are 5ARIs (5-alpha reductase inhibitors) (Knezevich 2013). 5-alpha reductase is the enzyme that converts testosterone to DHT (Knezevich 2013). The effect of DHT on prostate cancer cell growth is five times greater than that of testosterone (UCF 2013). By blocking DHT, drugs like Avodart® and Proscar® provide a unique opportunity to suppress tumor growth. At the same time, comprehensive adjunct protocols can be initiated that are designed to deprive tumor cells of growth factors or fuels, further inhibiting cancer growth and/or invasion.
For example, a recent study found that men taking finasteride for prostate cancer prevention were far more likely to benefit if they had lower estrogen levels prior to initiation of treatment with finasteride (Kristal 2012). This study clearly showed high concentrations of estrogen to be associated with increased cancer risk. So much so that the elevated estrogen neutralized the prostate cancer prevention impact of finasteride. Life Extension has repeatedly warned aging men about the critical need of achieving estrogen balance. One reason was our continued observation of high estrogen levels in newly diagnosed prostate cancer patients. Men can easily suppress elevated estrogen levels with aromatase-inhibiting therapies (Ta 2007).
So in response to a rising PSA and/or other indicators of prostate disease, men have a range of diagnostic options to assess whether there is underlying malignancy and if there is, what may be helping to fuel it (such as elevated DHT or estrogen).
If non-invasive diagnostics indicate malignancy, a color Doppler ultrasound-guided biopsy can indicate whether it may be high-grade (Gleason score over 7 that requires treatment) or low-grade (Gleason score under 7 that may be controlled with comprehensive surveillance/intervention).
Some Life Extension members choose to attack a rising PSA as if there is already low-grade prostate cancer present, especially if they suffer urinary symptoms relating to benign prostatic hyperplasia (enlargement). In consultation with their doctor, they may choose to take 0.5 mg of Avodart® daily (though it may not need to be taken every day) and simultaneously introduce an arsenal of mechanistic approaches to restrain benign and/or tumor cell propagation and induce benign and/or tumor cell apoptosis.
The use of Avodart® or finasteride can shrink prostate gland volume by 25% thus relieving benign symptoms, improve the accuracy of a needle biopsy if this diagnostic procedure is needed, and deprive tumor cells of one growth promoter, i.e. DHT (Cohen 2007; Nickel 2004).
A comprehensive arsenal of mechanistic approaches might involve healthy eating, high doses of specific nutrients (at least temporarily), hormone adjustment aimed at reducing DHT, insulin, prolactin and estrogen (but maintaining free testosterone [Yavuz 2008] in youthful ranges), and drugs like metformin and aspirin. If prolactin levels are elevated, the drug Dostinex® (carbergoline) can be used to suppress this cancer stimulating pituitary hormone.
I know this paradox has troubled aging men for decades, but according to a number of observations and some published studies, low levels of testosterone seem to predispose men to prostate cancer, including more high-grade Gleason score tumors. One explanation is that only low levels of testosterone are needed to convert into excess dihydrotestosterone (DHT) (Nishiyama 2011). When prostate cells are deprived of their free testosterone, they may mutate to over-respond to other growth vehicles such as estrogen, insulin-like-growth factor, and DHT (Kristal 2012).
How Life Extension Differs From the Mainstream
A common approach to dealing with biopsied-confirmed low-grade prostate cancer is called “watchful waiting.” Under this scenario, PSA tests are performed at reasonable intervals and treatment decisions based on indicators of disease progression (or regression).
In the presence of persistently rising PSA and other markers, the patient and their doctor discuss wide ranges of treatment options ranging from surgical removal of the prostate gland, different forms of radiation, cryoablation, and/or androgen ablation to temporarily reduce PSA and buy more time. All of these treatment modalities have side effects to consider.
Instead of merely “watching” a PSA rise until risky therapies are required, we at Life Extension view a low-grade prostate cancer (or even a biopsy that reveals no cancer) as an opportunity to intervene aggressively with a multitude of non-toxic approaches that benefit one’s overall health. Success or failure is measured by monthly PSA testing, along with other tests to ensure that other growth factors like insulin, estrogen, DHT, and prolactin are being adequately suppressed.
To clarify the point about a no cancer diagnosis, the accuracy of typical initial needle biopsies today is only around 75% (Taira 2010). So if your urologist tells you he has good news, i.e., the biopsy showed no tumor cells in your prostate gland, there may be a 25% chance you do have tumor cells, thus making the kinds of comprehensive intervention that benefits your entire body a rational choice.
So rather than “watchfully wait,” as your underlying disease may progress, we suggest comprehensive intervention. The objective is to take away every route that enables tumor cells to propagate and escape confinement within the prostate gland.
For those who require a prostate biopsy, there are new (and expensive) genetic tests that may more accurately predict which tumors are aggressive and likely to metastasize and those that are so indolent that only minimal changes may be needed to keep control over them. If these genetic tests prove themselves in the clinical setting (outside the bias of company-sponsored clinical trials), intelligently using the results of these tests can spare many men from needless treatments and provide information about genetic mutations to target in prostate cells that may enable better long-term control.
Our Enlarging Prostate Glands
Aging results in a proliferation of prostate cells that is technically referred to as benign prostatic hyperplasia (BPH) (Gharaee-Kermani 2013). The graphic titled “The Development of Benign Prostatic Hyperplasia” depicts an advanced case of BPH with a constricted urethra that would impede or block urine flow.
Symptoms associated with BPH include frequent urination and urinary hesitancy that can be especially troublesome at night (Gharaee-Kermani 2013). In severe cases obstruction of urine flow requires insertion of a catheter into the bladder via the penile urethra.
A major culprit involved in the benign over-proliferation of prostate cells is dihydrotestosterone (DHT) (Clark 2004). Drugs such as Avodart® (dutasteride) or Proscar® (finasteride) reduce DHT levels and shrink the size of an enlarged prostate gland, which reduces BPH symptoms (Schmidt 2011). These drugs also lower PSA levels by almost 50%, which may reflect the mechanism(s) that explain why men taking these drugs have reduced overall prostate cancer risk (Kaplan 2002; Handel 2006; Nelson 2010). In two large studies, men taking Avodart® or Proscar® had about a 24% reduced risk of prostate cancer (Thompson 2003; Andriole 2010).
Men should know that testosterone is not the culprit behind prostate problems. Numerous studies suggest that youthful levels of testosterone do not increase prostate cancer risk (Tan 2004; Agarwal 2005; Gooren 2003; Morgentaler 2007; Rhoden 2008; Raynaud 2006). What happens in the aging man’s body, however, is that testosterone converts to estrogen and DHT, and these two testosterone metabolites have been shown to be involved in benign and malignant prostate disease. Fortunately, there are low-cost methods available to suppress DHT and estrogen in aging men, while maintaining youthful ranges of free testosterone.
Recall that PSA is not just a marker of prostate cancer, but functions as a tumor promoter by degrading barrier structures in the prostate gland that may contain isolated tumor cells.
What troubles Dr. Walsh and some other experts is that some of the men taking Avodart® or finasteride who do contract prostate cancer have been shown in two studies to develop more aggressive forms of the disease. They are so concerned that they warn men not to use these drugs for the purpose of prostate cancer prevention, as does the FDA.
On the flip side are proponents of these drugs who point out that Avodart® as well as Proscar® (finasteride) reduce prostate gland volume by such a degree that the ability to identify high-grade tumors via prostate biopsy is improved. So it does not appear that Avodart® or Proscar® causes more high-grade tumors. Instead, these drugs facilitate earlier detection of such cancers, which is another reason to consider taking them.
A frustration with needle biopsies is that they miss as many as 20-30% of prostate cancers (Taira 2010; Rabbani 1998; Numao 2012). The larger one’s prostate gland, the easier it is to have the biopsy miss those sites that are malignant. The illustration titled “12-core Prostate Needle Biopsy” depicts a 12-core biopsy to show why a larger prostate gland makes it more difficult to detect malignant cells. So an advantage of shrinking one’s prostate gland using drugs like Avodart® or Proscar® is that if a needle biopsy is required, it may more accurately detect underlying malignancy (Kulkarni 2006).
In the December 2013 Life Extension magazine article titled The Avodart®-Proscar® Debate, there is compelling evidence that these drugs may reduce high-grade prostate cancer risk.
Another virtue to using 5-alpha reductase inhibitors (like Avodart® or Proscar®) is that in the presence of prostate cancer, PSA levels don’t decrease as much after these drugs are initiated (Kaplan 2002; Handel 2006; Nelson 2010).
Physicians using 5-alpha reductase inhibitors should take into account the PSA-lowering effect of these agents by doubling the PSA lab value (Andriole 2006). Given that PSA decreases less in the presence of prostate cancer, the doubling of PSA will result in a higher value of PSA and will trigger the need for diagnostic investigations sooner.
What doctors have observed is that drugs like Avodart® or finasteride suppress PSA levels more effectively in men with benign prostate enlargement or low-grade prostate cancer. When PSA levels drop then start raising again, this indicates that the 5-alpha reductase inhibitor is reducing low-grade cells of questionable clinical significance but is not affecting higher grade malignancies (Cohen 2007). This finding is another plus for using a 5-alpha reductase inhibitor as it can increase the sensitivity of the PSA test to reveal which men need aggressive diagnostics such as needle biopsies.
12-core Prostate Needle Biopsy
This diagram depicts a 12-core needle biopsy of a prostate gland. Note how many areas of the prostate are missed during biopsy. In the PCPT (Prostate Cancer Prevention Trial) where only 6 core biopsies from 6 regions of the gland were obtained, the effect of Proscar® in reducing gland volume was to increase the ability to detect high-grade prostate cancer (Yavuz 2008; Redman 2008).
Why We Suggest Certain Drugs
When it comes to combatting cancer, Life Extension long ago learned that the initial treatment regimen should be aggressive enough to deprive tumor cells of an opportunity to mutate into forms that are resistant to future therapies. If we know of a relatively side effect-free drug that works via a single or multiple mechanisms to impede tumor survival, we’re going to include it in our comprehensive surveillance program.
Let’s talk first about metformin. It was used in England in 1958 but did not make it into the United States until 1995—37 years later (Dowling 2011)! I am familiar with metformin because the FDA tried to have me incarcerated for recommending it as an anti-aging drug long before it was “approved” to treat type II diabetes.
What’s been happening over the last ten years is an explosion of published studies that consistently show that metformin reduces the risks of certain tumors and may be an effective cancer treatment (Hirsch 2009; Anisimov 2005; Vazquez-Martin 2011; Tomimoto 2008; Gotlieb 2008; Cantrell 2010; Libby 2009; Memmott 2010).
People ask me all the time, how can an anti-diabetic drug work so well against cancer? The encouraging news is that metformin functions via multiple mechanisms to create a less favorable environment for tumor progression (Evans 2005; Currie 2009; Nagi 1993; Choi 2013; Luo 2010; Ben Sahra 2011; Loubière 2013; Zakikhani 2008; Ben Sahara 2008; Ersoy 2008). We know that insulin (and glucose) increase the risk of many tumors (Parekh 2013). This is of particular concern to obese men with prostate tumors. Metformin lowers blood glucose and insulin levels. The sidebar titled “Anti-Cancer Actions of Metformin” reveals the multiple anti-cancer mechanism of metformin.
There are nutrients that can have similar effects such as standardized green coffee extract (Ong 2013). We nonetheless suggest that a man with an elevated or rising PSA should ask his doctor to consider prescribing metformin. The starting dose can be 500 mg of extended release (Metformin ER) taken with breakfast each day. Under the supervision of the patient’s local medical doctor, the dose can be increased to 500 mg ER taken at breakfast and at dinner. (Dose ranges for non-extended release metformin are 250-850 mg taken before no more than three meals a day.) Metformin is an inexpensive generic drug and can be taken along with nutrients (like green coffee extract) that similarly function to reduce glucose/insulin.
Metformin does more than slash tumor-promoting glucose/insulin levels. It also acts directly on cancer cells to induce apoptosis and/or inhibit proliferation (Jalving 2010). Metformin does this conserving the process by which food is converted to energy (Choi 2013; Luo 2010; Ben Sahra 2011; Loubière 2013). Healthy cells react to metformin by adjusting their functions to use less energy. A cancer cell, on the other hand, that is forced to minimize energy consumption is less able to exhibit aggressive metastatic or proliferative behavior (Dunlap 2012). In other scenarios, the energy stress caused by metformin is sufficient to cause cancer cell death.
The National Cancer Institute is sponsoring a clinical study where metformin will be tested to see if it can slow the progression of prostate cancer in men undergoing active surveillance (watchful waiting) with low-grade tumors (Fleshner 2013). We hope the study design includes the measurement of 2-hour post-prandial (2 hours after meals) blood glucose levels as well as glycosylated hemoglobin (HbA1c) to ascertain that optimal dosing of study subjects has been achieved.
At a cancer conference in early 2013, the results of a study were reported of 22 men (median age 64, median PSA 6 ng/mL) with confirmed prostate cancer that were given 500 mg of metformin three times a day 41 days prior to surgery (prostatectomy). In response to metformin the men showed the expected reductions in glucose and insulin growth factor-1 (IGF-1) blood levels, along with abdominal fat loss (Joshua 2012). What got the researchers excited was that compared to biopsied specimens, the surgically removed prostate glands showed a 32% reduction in a marker of cell proliferation (Ki-67) and a favorable alteration in a pathway tumor cells use to proliferate out of control (via mTOR) (Carlson 2012).
Knowledgeable members point out that curcumin interferes with these tumor growth pathways via similar mechanisms, which we at Life Extension have long been familiar with (Ravindran 2009). My argument for recommending metformin is that it should produce potent additive effects to curcumin. Moreover, we still don’t know what the upper dose limits are for metformin and/or curcumin for cancer treatment, so taking both may have some obvious advantages.
Furthermore, because metformin is a drug, it tends to get more attention from researchers, perhaps because it is easier to obtain funding for drug studies. A European study published this year showed that metformin was effective against advanced castration-resistant prostate cancer. The doctors who conducted this study concluded:
To our knowledge, our results are the first clinical data to indicate that metformin use may improve PSA-recurrence free survival, distant metastasis-free survival, prostate cancer specific mortality, overall survival and reduce the development of castration resistant prostate cancer in prostate cancer patients. Further validation of metformin’s potential benefits is warranted (Spratt 2013).
Interestingly, men who are on androgen deprivation therapy to treat prostate cancer often show rising insulin levels that can stimulate tumor growth (Currie 2009; Hvid 2013). By taking metformin, some of the side effects of androgen deprivation therapy can be mitigated, as was shown in this newly published European study.
So while nutrients like curcumin and green coffee extract and others may share functions that are similar to metformin, we cannot ignore the strong data showing specific benefits to low-cost metformin.
Another hormone that prostate tumors use to escape eradication is prolactin (Dagvadorj 2007), and this can easily be suppressed by taking 0.25 mg to 0.5 mg of cabergoline (Dosintex®) two to three times weekly (Drugs.com 2013).
Aspirin functions in multiple ways to interfere with prostate cancer propagation and metastasis and it may induce genetic changes that facilitate apoptosis (Langley 2011). There is too much data about the potential role of aspirin as an adjuvant cancer treatment for men with rising PSAs not to use it.
Treat Yourself As If You Already Have Prostate Cancer
This protocol is supposed to be about prostate cancer prevention, and here I am talking about therapies overlooked by most doctors that may facilitate enhanced treatment outcomes.
The reason we can’t ignore treatments is that aging men should accept the reality that in all likelihood there are malignant cells in their prostate glands now. This makes it easier to consistently follow prevention programs that can reduce the risk that clinically diagnosed disease will ever manifest. It also keeps one on the lookout for non-toxic treatments that may also have preventative benefits.
As I have related in the past, when my PSA reading came back at 1.4 ng/mL in year 2003, I treated it as if I had early stage prostate cancer by adopting healthier dietary choices and taking every nutrient and drug that had shown efficacy in prostate cancer prevention. Ten years later my PSA is 0.4 ng/mL.
I will remain on an aggressive prostate cancer treatment regimen and in the process reduce my risk for virtually every other age-related disease.
The protocol provides comprehensive approaches for the prevention of prostate cancer, including a comprehensive overview demonstrating the prostate cancer prevention benefits in response to Avodart® and finasteride. Men with any type of prostate malignancy may also benefit, as the programs we advocate for prevention may also facilitate better overall treatment.