INSIDE: Reader Questions Puzzle Points Volume 12 Number 6

Reader Questions
Volume 12 Number 6
INSIDE:
Puzzle Points
Reader Questions . . . . . . . . . . . . . . . . . . .1
Prostate Forum
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With a vegetarian diet you need to watch carefully for carbohydrate excess.
At AIDP, www.prostateteam.com, men with lymph node
metastases who have failed Lupron have a greater than 80%
survival at 3 years on second line hormonal therapy.
I strongly recommend the shingles vaccine to my patients. You
should also get the Pneumovax vaccine against pneumonia and
remember to get the flu vaccine yearly.
There is no evidence that BPH leads to prostate cancer or
that the prevention of BPH would prevent prostate cancer.
Based on my experience, I would guess that much of the
adverse reputation that ketoconazole has results from accidental ingestion of ketoconazole with acetaminophen.
At my clinic, the most effective treatment for rectal bleeding
after radiation has been Leukine.
Is there any hope for patients who have had non-nerve sparing surgery
and salvage external beam radiation to recover some amount of penile
function? Is there any basis for taking a drug like Levitra prior to an
injection?
It will be difficult for you to recover sexual function. Levitra,
Cialis, or Viagra are not likely to be of much benefit. While injecting the penis might work, many men find that difficult to do mentally and many also find it quite painful. The vacuum pump can
make the shots more effective. However, the most successful
approach may well be a penile implant. Perhaps the best direction
for you to take is to see a specialist in this area.
I am 46 and just had open radical prostatectomy surgery performed at
end of July. I haven’t had a PSA since my operation, but have one
scheduled for the end of October. At the time of my diagnosis in May,
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Volume 12 Number 6
my PSA was 2.7. In December 2009 it was 2.38. In
December 2007 it was 1.19. I did not get a PSA in
2008. The pathology report was overall favorable. My
Gleason was 3+3, bilateral from apex to mid portion.
No extraprostatic extension, no seminal vesicle involvement, negative surgical margins, no vascular invasion.
There was some (5%) perineural invasion (only tissue
from the right bundle was removed) although adipose
tissue, nerve, and ganglia from this bundle were negative. The bladder neck was also negative. There was a
“tiny focus” of adenocarcinoma in the tissue of the
portion anterior urethra that was removed during surgery. No lymph node dissection was performed. My
surgeon was Dr. Herbert Lepor of NYU.
I have three questions:
1. Is this truly a “good” report? I am somewhat
concerned that it wasn’t a “clean” report.
2. I am taking all the supplements and vitamins
(especially D, as it was very low at time of diagnosis)
you recommend and adhering to a healthy diet with
the idea of helping prevent a reoccurrence or to slow
down progression if by some chance any cancer did
escape. But I would like you to clarify your recommended dosage for fish oil of 4000 mg. I am taking
Nordic Naturals Ultimate Omega. The dosage on the
bottle says 1000 mg per 2 softgels (containing 650mg
EPA and 450mg DHA). Should I take 4x the amount
of the serving size, meaning 8 softgels/day?
3. Can fish oil raise my triglyceride levels? I had
blood work done at my GP’s office last week to check
on my Vitamin D levels and they told me my triglycerides were high. This really surprised me because I’ve
eaten healthier in the last 3 months than I ever have
and I have never had high levels before in my life. I
am eating VERY little animal protein—some chicken, a
little bit of goat cheese in a salad for example. I eat a
lot of vegetarian meals and some fish.
First, let me say that Dr. Lepor is one of the
best surgeons in the business. I do not usually think
of reports as good or bad, but if I must I would say
yours was good, but not perfect. By that I mean
you have some risk of recurrence, but that is hard
to quantify. I would recommend you continue to
get your PSA done every 3 months for six years.
As for fish oil, I usually recommend the Nordic
Naturals Purified fish oil, 4,000 mg a day. That
would provide just over 1,000 mg of fish omega 3
fatty acids. The Ultimate Omega is more concen-
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trated, so just take enough to get 1,000 mg of DHA
plus EPA.
Fish oil decreases the serum triglyceride concentration; it does not increase it. The most common cause of high triglycerides would be too many
carbohydrates: this is a common problem of a low
fat diet and one of the reasons I never recommend
such a diet. From your note, it does sound like that
is what you have done. With a vegetarian diet in
particular, you will need to watch carefully for carbohydrate excess. One major problem is the common American breakfast of cereal, milk, and fruit:
this breakfast is largely just sugar and carbohydrate
with inadequate protein and no healthy fats. A better breakfast might be 3/4 cup of Eggbeaters, 8
almonds, an apple and a glass of Concord grape
juice. Alternatively, you could add almonds to the
cereal along with 20 - 30 grams of soy protein isolate. Ironically, your triglycerides would be lower if
you replaced some carbohydrate with chicken, fish
or egg whites as well as heart healthy fats like olive
oil, almonds, pistachios, avocados or hazelnuts.
In a recent log post
(http://askdrmyers.wordpress.com/2010/08/25/bpaplastics-prostate-cancer/) you mentioned staying away
from plastic containers that were labeled with a #7. I
noticed on the bottom of my bottle of POM Wonderful
Pomegranate Juice that it is marked with a #1 and a
#7. Can I assume that the benefits derived from the
pomegranate juice outweigh the negatives involved in
the #7 plastic used in the container?
I think the better question would be why drink
any pomegranate juice in such a plastic container.
Either find a brand bottled in glass or consider one
of the many pomegranate extract capsules. As an
added benefit, the capsules have much less sugar.
In fact, I have long recommended that my patients
take the capsules because of the tendency for
pomegranate juice to increase blood sugar. I have
most commonly used the capsules from Life
Extension, but the new capsule from POM
Wonderful also now looks quite good.
I was diagnosed with stage 3-4 prostate cancer one
year ago. I have been on Lupron and Casodex and
have received 44 radiation treatments. My PSA is at
0.0 with no bone intrusion although all three doctors I
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Volume 12 Number 6
consulted tell me it is metastatic and cannot be
removed. My question is: How long does the hormone
treatment usually keep the PSA down? I have been
told anywhere from 12 -24 months.
First, you really need to learn more about your
disease. It was either stage 3 or 4, not 3-4. That is
almost like being partially pregnant. You also
always need to provide your Gleason and your
PSA at diagnosis.
What you have been told about the duration of
hormonal response appears to be way, way off
base. For example, if you had bone metastases limited to your pelvis and lower spine, median time to
hormone-resistance is 4-5 years. You really need to
read my book on hormonal therapy Beating
Prostate Cancer, which you can order online at
http://www.prostateforum.com/bookstore.html. If
you have no bone metastases, then the median time
to hormonal therapy may be closer to 10 years than
5 years. The combination of radiation therapy and
hormonal therapy would usually be applied to
patients with cancer that penetrated the prostate
capsule or had invaded the seminal vesicles or had
spread to the pelvic lymph nodes. In that case,
properly done radiation will cure many patients.
You need to completely master the details of your
disease as I outline above. You then need to read
Beating Prostate Cancer to get a better understanding of how best to control your disease.
I am looking for help for my husband’s advanced
prostate cancer. He was diagnosed in February 2008
with a Gleason 9 cancer. He had a prostatectomy in
March 2008. He had 39 radiation treatments in
January 2009 and has been on Zoladex every since.
His PSA began rising again in April 2010 and 2 lymph
nodes showed on CT scan in August 2010, disqualifying him from a clinical trial at Duke. They say nothing
else can be done until the cancer progresses to his
bones and then they’ll start chemotherapy next. The
doctor said this would be in 2011. Is there anything
we can do to slow the progression of the disease
before it goes to his bones?
This is pretty crazy. Reading this, I almost feel
I have been transported back in time to 1999. In
February of that year, I was diagnosed with
prostate cancer that had invaded the seminal vesi-
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cles on both sides and spread to the lymph nodes in
the pelvis along the common iliac artery as well as
one in the back of my abdomen. At the time, I was
told that I would have advanced disease by five
years and be dead by 10 years. It is now 11 years 7
months later and my PSA is less than 0.01 ng/ml.
In 1999, that prediction was reasonable, though
subsequent events proved otherwise. Today, it just
makes me angry to hear such nonsense.
In my case, one critical move that saved my
life was to have the pelvic lymph nodes treated
with radiation. I would ask why, eleven years later,
it couldn’t be done for your husband? Second, we
now have very effective second line hormonal therapy programs. At AIDP, www.prostateteam.com,
men with lymph node metastases who have failed
Lupron have a greater than 80% survival at 3 years
on second line hormonal therapy. You need to get
your husband into the hands of physicians who are
more aggressive in the treatment of metastatic
prostate cancer.
Do you recommend the Shingles Vaccine for your
patients who are actively on intermittent hormonal
therapy and those who are in prostate cancer remission? My internist recommended that I be vaccinated
since I turned 60 this summer and am considered by
him to be “high risk”. I am not on any treatment at
this time, but have seen a steady increase in my PSA
in 2010 and will be treated again with Casodex and
Avodart if my PSA reaches 2.0.
Yes, I strongly recommend the shingles vaccine
to my patients. I also made sure I got this vaccine
myself. You should also get the Pneumovax vaccine against pneumonia and remember to get the
flu vaccine yearly.
If you are in the off phase of hormonal therapy,
you should do what you can to slow the re-growth
of the prostate cancer. I would strongly recommend
you at least adopt a Mediterranean heart healthy
diet free of red meat, cold cuts, and bacon. I also
recommend you take enough vitamin D to make
sure you are not deficient: this is best done with a
blood test measuring the 25-hydroxyvitamin D3. At
AIDP we have a much more comprehensive program that requires close monitoring of our patients,
but then we try to keep our patients off hormonal
therapy for as long as possible.
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Volume 12 Number 6
I am 68 years old and have been recently diagnosed
with prostate cancer: (2 cores: 20% & 5%, T1C, both
Gleason 3+3). My PSAs have increased .8 each of the
last 3 years from 2.2 to 3.0 to 3.8. My urologist has
suggested Active Surveillance with PSAs and DRE every
6 months as well as a yearly biopsy. I have researched
surgery and radiation treatment, as well as surveillance, but I haven’t determined how my current health
situation is relevant to my choice. I have had Type II
diabetes for over 10 years, with occasional hypoglycemia, which makes control difficult. I have had 2
TURPS (the most recent in 2008, resulting in an emergency cystoscopy). I have ED, with some function
remaining. In your opinion, what effect should these
factors have on my treatment choice?
I think your urologist makes a lot of sense.
First, the facts available would seem to make you
eligible for active surveillance. Second, with poorly
controlled type II diabetes, you have a very significant illness that has a much poorer long-term survival than does a small Gleason 6 prostate cancer.
For example, one recent British study involved
patients with diabetes at your age range and with
diabetes of similar duration and found median survival of 16 years. Over the next ten to twenty
years, you are much more likely to die of your diabetes than you are of the prostate cancer.
Gat and Gornish in Israel have published on a novel
treatment for BPH that does not involve the prostate.
I’m curious what you might know about the procedure. My Dad and Granddad each developed prostate
cancer when they were my age. If the treatment can
remedy BPH, can it also prevent eventual prostate cancer? My PSA is 0.3.
Gat and Gornish propose that BPH progression
is fueled by impaired drainage of venous blood
from the testes. I would just note that there is no
evidence that BPH leads to prostate cancer or that
the prevention of BPH would prevent prostate cancer. Nor is there any reason to think that impaired
testicular venous drainage causes progression of
prostate cancer.
Recent German studies based on the Heidelberg
cohort of the European Prospective Investigation into
Cancer and Nutrition have focused on vitamin K2 as
Prostate Forum
potentially important in reducing the risk of advanced
prostate cancer; the studies also identified cheese as a
good source of vitamin K2. Many of us have avoided
cheese for years due to the apparent added risk posed
by dairy products for prostate cancer. In view of the
recent partial easing of concern over consuming dairy
products by prostate cancer patients and men at risk,
do you consider vitamin K2 an emerging important
nutrient for us, and how safe, on balance, is cheese for
us? What is your opinion of cottage cheese for us?
This is a great question for illustrating many of
the issues I have been talking about over the years
on how to look at scientific and medical data. The
study in question gave a food-frequency questionnaire to 11, 319 men. This was used to estimate the
intake of vitamin K1 and K2. I quote directly from
the paper: “We observed a nonsignificant inverse
association between total prostate cancer and total
menaquinone (vitamin K2) intake.” First, I would
note that the association was not statistically significant. Second, I would point out that using a foodfrequency questionnaire is not the same thing as
actually measuring the amount in the food consumed nor the same thing as measuring the amount
in the blood of the subjects. Each year, there are
more than 5,000 papers published on prostate cancer. I would simply, as a matter of course, ignore
studies this weak in design and ambiguous in the
results generated.
But even if you wanted to get vitamin K2 into
your diet, cottage cheese would make a terrible
source. Vitamin K2 is found, for the most part,
only in cheeses fermented with propionibacteria,
like Jarlsberg or Emmental. Cottage cheese is not
fermented and contains no vitamin K2. You actually make K2 in your large intestines as part of the
fermentation that takes place there. You will likely
make more vitamin K2 in your large intestines in
one day than you would find in several pounds of
cottage cheese.
In summary, this vitamin K paper does not alter
my recommendations on cheese intake.
I have read your comments to the fact that sugar does
not feed prostate cancer in your newsletter (Prostate
Forum Vol. 11 # 11
http://www.prostateforum.com/backissues.aspx?id=3011#11) and saw your vlog post on
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Prostate Forum
Volume 12 Number 6
this subject http://askdrmyers.
wordpress.com/2010/02/24/does-sugar-feed-cancer/.
At the recent PCRI meeting last month, it was clear
that Dr. Strum thinks that excess sugar will feed
prostate cancer progression. Can you comment on the
differences between two experts in the field?
Dr. Strum is a real student of this disease and I
always listen carefully to his ideas. I continue to
stand by the position I took in the newsletter and
vlog. However, I talked to Steve at the meeting and
I think in actual practice we end up with our
patients doing the same thing. We both agree that
excess sugar and carbohydrate are very dangerous.
We agree that in America today, excess sugar and
carbohydrate intake plays a large role in the epidemic of obesity, diabetes, hypertension and heart
disease. We also agree that men who are on hormonal therapy are at high risk for insulin resistance
leading to obesity, diabetes, hypertension and heart
disease. I start by telling my patients that no more
than 40% of the calories at any meal should be
from carbohydrate and that high glycemic index
foods should be avoided (see
www.glycemicindex.com for more information on
the gylcemic load of most food items). I recommend 8 almonds or a tablespoon of nuts like pistachios or hazelnuts, half an avocado or tablespoon
of olive, avocado, almond or avocado oil with each
meal.
It is important to realize that people vary dramatically in how well they can use fat versus carbohydrate as energy sources. Gene profiling will
soon give us a way to tailor diets to the genetics of
each patient. For now, we need to use fairly primitive tools. Barry Sears, in his early Zone Diet books
advocated using the serum triglyceride divided by
the HDL cholesterol as a rough index of insulin
resistance and carbohydrate excess. This is based
on the observation that carbohydrate excess and the
resulting insulin resistance will increase the serum
triglycerides and decrease the HDL or good cholesterol. I discussed this phenomenon in an earlier
question on page : the patient went on a low fat
vegetarian diet and subsequently saw a large jump
in his triglycerides. The optimal ratio of triglyceride to HDL is 1 or 2. Diabetics often have ratios
above 5. We follow this ratio and use it to tailor
carbohydrate intake to fit each patient’s genetics.
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While far from perfect, this is the most practical
tool available today. At the PCRI meeting in early
September, I was gratified to hear that Dr. Strum
also uses the triglyceride to HDL ratio and has the
same goals for this number. The end result is that
our patients most likely end up with the same carbohydrate intake even though our views on sugar
and prostate cancer differ.
I have painful bone metastases and my doctor has put
me on ketoconazole to treat the cancer. I have been
given Vicodin and the label says that it contains acetaminophen. Since acetaminophen is also in Tylenol,
does this mean that it is as dangerous to take Vicodin
with ketoconazole as it would be to take Tylenol?
First, let me congratulate you on reading labels
so carefully. Yes, Vicodin is dangerous to take with
ketoconazole because it has acetaminophen in it.
While marketing would lead you to believe that
Tylenol is a safe alternative for pain relief, this is
not the case. Recent articles have pointed out that
the active ingredient in Tylenol, acetaminophen, is
probably the major cause of liver failure and liver
transplant in America. As ketoconazole is also a
liver toxin, the combination of Tylenol and ketoconazole is particularly dangerous.
However, acetaminophen is not only found in
Tylenol, but is added to a wide range of medicines
used for pain, symptoms of viral infections and
even sleep medicines. There are more than 600
over-the-counter preparations with acetaminophen
added. Table 1 on the next page lists some of these
medicines. Because many Prostate Forum readers
are from outside the United States, I have included
some of the more common medicines containing
acetaminophen from Europe and Asia. Because this
list is incomplete, please look at the label of any
new drug you plan to take if you are on ketoconazole. Based on my experience, I would guess that
much of the adverse reputation that ketoconazole
has results from accidental ingestion of ketoconazole with acetaminophen.
I had radiation therapy and now I have rectal bleeding. What can be done about this?
This question takes me back to the fall of 2000
when I had to go on medical leave from work
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Volume 12 Number 6
Table 1.
Medications With Added Acetaminophen
Percocet
Vicodin
Darvocet
Syndol
Mersondol
Paracetamol
Panadol
Anacin-3
Tempra
Datril
Acamol
Efferalgan
Doliprane
Excedrin
Alka-Selzer Plus
Various Benadryl combinatinos
Contac
Midol
Various Robitussin combinations
Sinutab
Sudafed
Tavist
TheraFlu
Triaminic
Vicks NyQuil
because of rectal bleeding. I quickly had to become
an expert in this problem! The severity can range
from occasional spotting to massive bleeding and
the treatments must vary to accommodate the
severity.
First, you need to be sure that this is due to
radiation. Many men with this complaint have
internal hemorrhoids as the cause of bleeding. If
this is the case, then treatment should be aimed at
treating that problem. Your family doctor can
advise you on this matter. If radiation damage to
the rectum or sigmoid colon is causing the bleeding, this is usually from a network of fragile blood
vessels on the bowel surface. The medical term for
this network of fragile blood vessels is telangectasia. If your symptoms are mild, there are some simple things you can do to protect those fragile blood
vessels. First, keep your stool soft by eating
enough fiber. If fiber alone will not do the trick,
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simply add magnesium to your diet. Somewhere
between 300-500 mg with each meal is enough for
most patients. (You know the magnesium dose is
too high if you get diarrhea.) The lining of the
bowel is coated with mucus that allows the stool to
slip by without abrading the bowels surface. This
mucus is made up of glucosamine molecules linked
like beads on a chain. Radiation damage causes
less mucus to be produced, making it more likely
that stool will abrade the telangectasia. I have
found that 1,000-2,000 mg of glucosamine sulfate
with each meal and at bedtime can often lessen
mild bleeding. If this is going to help, it does so
within 72 hours. Similarly, if you stop it, you will
return to your previous state within 72 hours or so.
The point is that this is not a cure, but merely putting a band-aid on the problem.
For more severe bleeding, laser coagulation of
the telangectasia will reduce or stop it. However, in
many men the telangectasia will return and they
will resume bleeding after a period of time. I have
had men undergo laser coagulation multiple times
before the bleeding was under durable control.
Hyperbaric oxygen treatments work for some
patients. This involves entering a hyperbaric chamber—which is impossible if you fear closed spaces.
There the pressure is increased to twice atmospheric pressure. This typically will be done once a day
for at least 45 days. The high pressure delivers
oxygen to the tissues and this aids healing. Again,
many men will relapse and need to be treated several times.
At my clinic, the most effective treatment has
been Leukine. We have found that thirty days of
Leukine treatment will dramatically decrease
bleeding in nearly all patients. Again, it is fairly
common for bleeding to resume after a period of
time and re-treatment is usually effective. In my
own case, it was Leukine that finally solved my
problem.
Please comment on the effect of marijuana on fatigue.
I got this question at the recent PCRI conference. As background, Medical marijuana is now
legal in California. After the meeting, my wife Rose
and I went for a walk along the beach in Venice. If
you do not know Venice, California, it has a distinct
counterculture aura. As you might expect, legaliza-
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Volume 7 Number 1
tion of marijuana appears to have hit this town like
a tornado. Along the beach there were multiple
shops where you could purchase marijuana if you
had a prescription. Many of these shops had a doctor available to write the prescriptions and a list of
complaints for which the doctor could write the prescription. The implication was that you had only to
manufacture the right complaint and you would
legally obtain marijuana. In this atmosphere, it
appears that this drug can solve most of life’s problems. Well, it is a good general rule that if something seems to good to be true, it probably is. Many
of the supposed benefits of marijuana are bogus.
The use of marijuana for fatigue is one of the bogus
uses of this drug. The best I can say about this is
that you will likely be mellow enough that you will
not mind the fatigue.
I should also point out that THC, the active
ingredient in marijuana, is available everywhere in
the US as Marinol. In the USA, Marinol is a
Schedule III drug, available by prescription. As a
Schedule III drug, it is considered non-narcotic and
by definition to have a low risk of addiction, either
physical or mental. It is approved for the anorexia
of AIDS. It is also approved for nausea and vomiting caused by cancer chemotherapy. I have used it
for cachexia (wasting) in patents with advanced
cancer and for nausea and vomiting from
chemotherapy. While it has proved useful for
cachexia, I think there are much better prescription
drugs for chemotherapy-induced nausea and vomiting. Even strong ginger tea seems more effective for
nausea and vomiting.
I have received quite a few questions on how to do
intermittent hormonal therapy. When should this
treatment be started? Should Casodex be started
first? How long should hormonal therapy continue?
How do you manage the period of time off hormonal
therapy?
It is important to understand that intermittent
hormonal therapy has been done in several different ways. There are no randomized controlled trials
comparing these different methods. As a result, I
have tried to make the best decisions on incomplete
information. If you want a more complete discussion my book, Beating Prostate Cancer goes into
great detail on hormonal therapy.
Prostate Forum
When we do hormonal therapy at AIDP, we
usually do triple blockade, which means combining
Eligard, Lupron, Trelstar or Zoladex with Casodex
and Avodart. I like this combination because it
results in the most rapid and complete decline in
PSA and shrinkage of the prostate gland. Also, the
best reported results from intermittent hormonal
therapy are from Drs Leibowitz and Strum, both of
whom used triple blockade. If given once a day, it
can take up to a week for Casodex blood levels to
reach the therapeutic range. However, a loading
dose of three Casodex should give a therapeutic
blood level within 24 hours. Depending on the clinical situation, we will do Casodex daily for a week
or more or use the loading dose. In patients with
hormone-sensitive cancer, it is common to see a
very dramatic drop in PSA so that many newly
diagnosed patients will have a PSA less than 0.01
ng/ml in 3-4 months. If the PSA stops falling, we
will either increase the Casodex dose to two or
three per day or go to second line hormonal therapy. In any case, we do not regard hormonal therapy
as successful unless the PSA drops below 0.01
ng/ml. More recently, we have also asked that bone
metastatic disease and lymph node enlargement
normalize. For example, if at 6 months the PSA is
less than 0.01 ng/ml, but bone metastasis show no
healing, we will consider the switch to second line
hormonal therapy. If the patient has five or fewer
bone metastases, we will consider referring the
patient for radiation therapy to the bone lesions, but
will ask that the dose be 45-50 Gy, not a palliative
dose of 20-30 Gy.
If everything has gone well, the patient will be
in remission by the end of one year. At that point,
we would stop Lupron or related injections and the
Casodex pill. Off hormonal therapy, we aim to
slow the cancer re-growth. In practice, this means
slowing the PSA doubling time. We would keep the
patient on Avodart because it will speed the return
of a normal testosterone level and, in our hands,
slows the PSA doubling time. We also emphasize a
Mediterranean heart healthy diet. First, this diet has
been shown to reverse insulin resistance and hypertension that are such a problem in men during hormonal therapy. Thus, this diet aids patients’ recovery from treatment. Second, one phase II clinical
trial showed this diet slowed the PSA doubling
time. We also emphasis exercise: both aerobic exer-
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Volume 7 Number 1
cise to lose weight and resistance exercise to
rebuild muscle strength. If the patient has excellent
cardiovascular health and blood pressure, we will
consider Celebrex at 200 mg twice a day to further
slow the growth of prostate cancer. We also monitor vitamin D blood levels and make sure the
patient takes in enough vitamin D not to be deficient. We also use a panel of supplements, but I am
reluctant to be too specific because my recommendations can change from month to month.
Pomegranate capsules appear likely to be a durable
member of our team, though. We also use antioxidants, but have recently dropped selenium and vitamin E and added resveratrol and curcumin.
However, the choice of antioxidant may very well
change as a result of some very interesting clinical
trials currently in progress. In some patients, this
program arrests prostate cancer progression and in
those patients, they never need return to hormonal
therapy. I have one patient who came off hormonal
therapy in April 1997 and his PSA has remained
undetectable ever since while his testosterone was
normal by the end of 1998. However, the average
time off hormonal therapy is 2 to 4 years.
Our guidelines at AIDP for restarting hormonal
therapy are based on the PSA doubling time. If the
PSA doubling time is slower than one year, we will
let the PSA go up to 5-10 ng/ml. If the PSA doubling time is faster than 3 months, we will often
restart treatment when the PSA hits 1-2 ng/ml. As
hormonal therapy can markedly worsen diabetes
and heart disease, we will often delay hormonal
therapy in order to gain better control over cholesterol, blood pressure or blood sugar. After all, it is
not a success if the patient dies of a heart attack
with an undetectable PSA!
Most patients can go through 4-7 cycles of
intermittent hormonal therapy before the cancer
becomes resistant to testosterone suppression.
We rarely do continuous hormonal therapy
because the risk of heart disease, hypertension and
diabetes is just unacceptable. Continuous hormonal
therapy also causes other serious problems with
long-term use, like loss of memory and cognitive
function, depression, and progressive muscle wasting. Finally, men on continuous hormonal blockade
just seem to age much more rapidly.
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I have a newly diagnosed stage T2C, Gleason 3+4=7.
I have been on replacement with testosterone and
human growth hormone. I have stopped testosterone,
should I also stop human growth hormone?
I am going to be blunt. It is crazy for men to be
taking human growth hormone. This is often used
to reverse aging. I think it does just the opposite.
We are now in a time when real science is being
done on aging. We have a group of well-characterized laboratory models of aging that have been
chosen to cover most forms of life on this planet.
The idea is that if something works across the spectrum of living things, it is also likely to work in
humans. These models include yeast for single cell
organisms, vinegar worm for invertebrates, fruit
flies for insects, a short lived fish for vertebrates
and the mouse for mammals. More recently, chimpanzee and monkey models have begun to be characterized. Across all of these models, increasing
growth hormone and its product, IGF-1, speeds
aging and shortens life span. If you artificially elevate growth hormone or IGF-1, you will get a temporary increase in muscle mass and vitality at the
cost of long-term health. I am reminded of the
cliché that the candle that burns the brightest, burns
the shortest. To make matters worse, IGF-1 is wellestablished to fuel progression of most cancers. In
the case of prostate cancer, the evidence is very
strong. For example, mutations that activate the
IGF-1 pathway play a role in the development of
resistance to hormonal therapy and chemotherapy.
Targeting the IGF-1 pathway is a hot area for new
cancer drug development. Diets like the
Mediterranean diet that slow prostate cancer progression also reduce serum IGF-1 levels.
So, yes stop taking human growth hormone.
Also, anyone who is reading this newsletter, please
stop taking human growth hormone unless your
doctor can provide a powerful reason why you
should remain on it. Also, avoid any over-thecounter supplement marketed to increase your IGF1 blood level or trigger growth hormone release.
I am on active surveillance and have been taking
Avodart as part of that program. I am experiencing a
decrease in sex drive from Avodart. What can I do?
www.prostateforum.com
Prostate Forum
Volume 12 Number 6
Avodart is used to lower the dihydrotestosterone level. The lower dihydrotestosterone is
thought, reasonably to my mind, to slow progression of low grade prostate cancer and may even
lessen the development of new prostate cancers.
Because of my background as a clinical pharmacologist, I always look for a means to monitor if a
drug is doing what it is intended to do. Thus, we
routinely measure dihydrotestosterone in men on
Avodart and try to keep the level below 5 ng/dL.
We find that after 6-12 months, it is possible to
gradually taper the dose of Avodart. We will first
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go to Monday, Wednesday and Friday. After 3-4
months, if the dihydrotestosterone remains below
5 ng/dL, we will then go to Tuesday and Thursday.
Some men can even go to one pill a week and still
keep the level below 5 ng/dL. As the Avodart dose
is decreased, the adverse impact on sex drive
lessens.
The other option is to drop Avodart as part of
your Active Surveillance program. Without knowing the details of your case, it is impossible for me
to advise you on this matter.
For An Appointment With Dr. Myers Contact
American Institute For
Diseases Of The Prostate
434-964-0212 Voice (For appointments, press option #2 or #4)
434-964-0216 Fax
Mailing Address P.O. Box 195, Earlysville, VA 22936-0195
Physical Address: 690 Bent Oaks Drive, Earlysville, VA 22936-0195
Office Hours: Tuesday - Friday 8 AM- 6 PM EST
Maxine Hey, Medical Assistant, Option #4
Sherrie Pleasants, Medical Clerk, Option #2
www.prostateteam.com
Rivanna Health Publications
P.O. Box 6696, Charlottesville, VA 22906
[email protected]
434-220-3774
www.prostateforum.com
PO Box 6696
Charlottesville, VA 22906
[email protected]
434-220-3774
FAX 434-974-6775
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