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The PSA screening debate was growing stale. Here are a few landmarks over nearly 50 years:

  • Early 1970s – Richard Ablin, MD and others identify prostate specific antigen (PSA) as a biomarker for disease or disturbance in the prostate.
  • 1987 – Thomas Stamey, MD notes that PSA is useful to monitor PCa patients for changes
  • Early 1990s – The PSA blood test is promoted as a screening tool for PCa
  • After 1993, the prostate cancer death rate begins declining about 17% per year
  • 2008 – U.S. Preventive Services Task Force (USPSTF) recommends against screening for men ages 75+, says evidence is inconclusive whether benefits outweigh harms of overtreatment for younger men
  • 2012 – USPSTF recommends against PSA screening for all men. Professional societies and patient advocacy groups disagree but screening rates start to decline.
  • 2014 – Data from the National Cancer Institute shows a 51% decrease in PCa deaths since 1993, attributable to PSA screening but possibly also to other factors.
  • 2016 – Studies suggest that while rates of PCa diagnosis are lower, there are higher rates of diagnosing aggressive PCa
  • 2018 – USPSTF recommends that doctors and patients make case-by-case decisions after informed conversations about the merits vs. risks of PSA screening.

Today’s status quo

Does PSA screening reduce PCa mortality, or doesn’t it? We know that PSA is not specific for cancer, since many prostate conditions can cause a rise in PSA blood levels. We also know that an elevated PSA can lead to a conventional TRUS-guided biopsy, and that such biopsies can either miss PCa (30% rate of false negatives), or overdetect insignificant PCa, or underdetect significant PCa. Finally, we know that the detection of insignificant PCa can lead to whole-gland overtreatment with risks of short- and long-term urinary and sexual side effects.

Thus, the 2018 USPSTF counsel that PSA testing is an individual decision seems to be the prevailing practice in the U.S., with occasional “screening events” still offered by patient programs. But the core question remains: Does PSA testing save lives?

2018 published study based on 400,000 patient records

Paul Alpert, a urologist with UC/San Francisco School of Medicine and the Kaiser Permanente Medical Center published a 2018 paper on the lifesaving benefits of PSA screening. The cohort included the records of “400,887 men under age 80, with no history of prostate cancer, who had PSA testing at Kaiser Permanente Northern California.[i]

The study design afforded maximum data harvesting and interpretation:

The 5-year study period 1998-2002 was selected because there were prior PSA data going back to 1992, allowing for 6-11 years of prior data to examine screening intervals. This study period also provided 12-16 years of follow-up on patients diagnosed with prostate cancer, an amount of time deemed reasonable to calculate mortality rates.[ii]

The men were sorted into 6 groups according to screening interval (how far apart they received regular PSA tests) and 7 groups according to age. The objective of the analysis was to determine whether PSA screening reduced prostate cancer mortality, and if there is an optimum interval for greatest lifesaving benefit. The size of the database helps offset the lack of randomization, but the database itself had built-in limitations. For instance, if the first record of a man having a PSA test is October, 1999, the file might not indicate if it was simply a screening PSA (no reason to suspect PCa) or a “PSA for cause” (a symptom or risk factor that triggers a PSA blood test).

What the study found

After adjusting for various artifacts, based on the data the author concluded that

…yearly PSA screening is highly beneficial, reducing prostate cancer deaths by 64% for men aged 55-74 years, and reducing all-cause mortality in this group by 24%. Yearly screening is the interval of choice. No benefit was found for men under age 55. When combined with active surveillance to prevent overtreatment, these data lend support for yearly population-based PSA screening for prostate cancer for men aged 55-74 who are in good health.[iii]

Alternatives to overtreatment

The USPSTF recommendations barely avoided throwing the baby out with the bath. Why give up PSA screening, which Alpert’s study shows to be lifesaving, when multiparametric MRI (mpMRI) resolves biopsy and treatment dilemmas? Imaging using mpMRI a) eliminates unnecessary biopsies, b) guides real-time targeted biopsies that are efficient and diagnostically productive, and c) guides real-time focal therapies that control cancer while avoiding side effects. Until science produces a highly accurate and specific biomarker screening tool, the PSA blood test coupled with mpMRI offers the best means to save men’s lives from prostate cancer deaths.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Alpert, P. New evidenced for the benefit of prostate-specific antigen screening: data from 400,887 Kaiser Permanente patients. Urology. 2018 Aug;118:119-26. https://www.sciencedirect.com/science/article/pii/S0090429518303765

[ii] Ibid.

[iii] Ibid.

The post Lifesaving PSA – Does It or Doesn’t It? appeared first on Sperling Prostate Center.

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The 18th century French writer and philosopher Voltaire was known for his wit. One remark is especially apt for this blog: “In the case of news, we should always wait for the sacrament of confirmation.”

In January, 2018 the Nymox Pharmaceutical Corporation made a big urology news splash with the announcement that the World Journal of Urology (WJU) would be publishing the results of a Phase III clinical study of BPH treatment using injectable fexapotide triflutate (FT). The May, 2018 WJU carried the full article by 17 urologists from U.S. study sites that enrolled 995 BPH patients between 2009-2016.[i] The study was a placebo-controlled double-bind randomized trial. For every 3 patients who received FT, 2 patients received placebo. Follow-up, defined as long term, ranged from 2-6.75 years.

The summary of study results included the following points:

  • There were no significant safety differences between FT and placebo
  • Urinary symptom scores were more favorable in the FT group than the placebo group
  • Long-term follow up revealed less incidence of acute urinary retention in the FT group
  • Long-term follow up showed less incidence of prostate cancer in the FT group
  • At 12 months, FT patients chose no further treatment, oral medications, BPH interventional treatment, or another FT treatment.
BPH background

Some background on benign prostatic hyperplasia (BPH) will explain why FT is so promising. BPH is a non-cancerous enlarging of the prostate as men age. It is not a disease. Most men don’t know it’s there until urinary symptoms appear (more frequent night urination, sense of urgency more often, difficulty starting urination, weaker stream, incomplete bladder emptying, etc.) These symptoms can lead to complications like urinary tract infections, or retaining so much urine that a trip to the emergency room is necessary (acute urinary retention). These are due to the growing prostate bulk compressing the passageway (urethra) through the gland that carries urine from the bladder out to the penis.

When symptoms become aggravated, treatment is necessary. Conventional BPH treatments include oral medication, widening the urethra using surgery or ablation (tissue destruction), implanting a device to widen the urethra, and reducing prostate bulk using Focal Laser Ablation (FLA). Depending on the side effects of any of these, their success and durability, researchers have long been looking for a “silver bullet” that would be quick, economical, safe, and effective for everyone. In the words of Ralph Waldo Emerson, “Build a better mousetrap and the world will beat a path to your door.

FT – a better mousetrap?

By now, you’re wondering what FT treatment consists of. It’s a 3-5 minute process of injecting the drug fexapotide triflutate directly into the prostate, through the rectal wall. The injection is guided by ultrasound. One half of the dose is placed in the left transition zone of the prostate, and the other in the right. The procedure is done in the doctor’s office, and “does not require a urethral catheter, intravenous or general anesthetic, and apart from a standard transrectal ultrasound (TRUS) requires no specialized equipment or instrumentation.”[ii]

The drug FT works by causing cell destruction and death – but it is selective. It only works against prostate glandular tissue, and does not affect nerves or blood vessels. As Shore, et al. (2019) describe it, “The architecture of the injected glands becomes distorted as cells die and eventually the majority of cells in the injected areas have been depleted.”[iii] It also does not appear to circulate outside of the prostate nor can it be detected in the blood. Because it is delivered transrectally, an antibiotic must be administered, but it is considered to have less infection risk due to the small needle size and only two punctures, as compared with the larger needles used to capture 12-16 tissue samples in a prostate biopsy. In the clinical studies, there were no serious infections reported.

Of note, there were also no reported adverse effects on sexual function, no doubt because FT does not affect the nerves. As for the reduced incidence of prostate cancer, the authors theorize that FT may disperse somewhat from the targeted transition zone into the peripheral zone where most prostate cancers arise. They theorize that FT has “…an inhibitory effect on clinically undetected low-grade PCa microfoci or precursor cells and lesions…”[iv] 

A word of caution

There is considerable excitement about FT. Nymox is applying for U.S. FDA approval as well as other agencies in Europe. However, the authors remind everyone of the need for more investigation:

The efficacy and safety of FT combination treatments, of FT used in different patient study populations, comparative studies versus other treatments, and the variability of dosing schedules remain to be answered by future investigations. Patients who have intractable severe LUTS but are poor surgical candidates are another important group where investigation may be warranted. Further studies will be needed to determine the impact of FT in relation to the gold standard of TURP.[v]

At our Center, we will be eagerly watching in hopes that the “sacrament of confirmation” will bless FT with proof of its safety and effectiveness. It certainly may offer a rosy future to men with BPH!

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Shore N, Tutrone R, Efros M, Bidair M, Wachs B et al. Fexapotide triflutate: results of long-term safety and efficacy trials of a novel injectable therapy for symptomatic prostate enlargement. World J Urol. 2018 May;36(5):801-809.

[ii] Shore N, Tutrone R, Roehrbom CG. Efficacy and safety of faxapotide trifulutate in outpatient medical treatment of male lower urinary tract symptoms associated with benign prostatic hyperplasia. Ther Adv Urol. 2019 Jan-Dec; 11:1756287218820807.

[iii] Ibid.

[iv] Ibid.

[v] Ibid.

The post The Biggest BPH Treatment Breakthrough Yet? appeared first on Sperling Prostate Center.

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Finding out that you have prostate cancer (PCa) is never good news. However, the blow is softened when your doctor assures you that it is early, slow-growing, and confined to the gland (localized). In such cases, statistics show a 15-year survival rate of 96%.[i]  However, there is no treatment that comes with a 100% guarantee of freedom from recurrence. There is always a chance—however small—that the disease will come back, even for men with low risk PCa. Unfortunately, greater risk comes with higher recurrence rates.

Prostate specific antigen (PSA)

Prostate cancer comes with a built-in biochemical “communication device” called the PSA blood test. PSA stands for Prostate Specific Antigen, a surface protein on all prostate cells that is released into the blood stream in measurable amounts. As long as the prostate gland remains in the body, it will continue to release PSA. In fact, any activity that stimulates the gland can raise the amount of PSA in the blood. Here are just a few things that can elevate the PSA:

  • Infection or inflammation in the gland
  • Benign prostatis hyperplasia (BPH, a normal aging-related gland enlargement)
  • Prostate cancer
  • Digital rectal exam (DRE)
  • Sexual activity
  • Even something as ordinary as riding a bike

As you can see, a higher-than-usual PSA can mean a lot of different things, not just prostate cancer. But it’s important to remember that just as healthy prostate cells have PSA, so do prostate cancer cells. Why? Because they are still prostate cells, only mutated.

PSA can indicate prostate cancer recurrence

However, there is one situation in which a rising PSA can only mean that prostate cancer is back after treatment. When the prostate gland is completely removed (radical prostatectomy), radiated or ablated, it’s called radical treatment (radical = total). When radical treatment is successful, there are no more functional prostate cells. Therefore, it is expected that within a short time after radical treatment, a man’s PSA will be undetectable. No prostate cells, no PSA. No prostate cancer cells, no PSA. This is why a man must have an annual PSA test after PCa treatment. It’s a safety check to make sure that the “communication device” is on “radio silence.”

However, a detectable PSA after radical treatment is the first blip on the PCa radar screen. Before setting off an alarm, it’s normal to repeat the PSA test within a few weeks or months. If it is still detectable, or even a little higher, there is a suspicion that PCa is back. This is called biochemical recurrence because PSA is a “biomarker” for PCa recurrence. But the most important question is, Where is it? Before sending in a SWAT team, the medical detectives have to pin down the location.

PSMA-PET scan

There is a powerful new tool for identifying even very early, tiny PCa recurrence called PSMA-PET scan. PSMA, or Prostate Specific Membrane Antigen, is different from PSA, and is more indicative of prostate cancer cells. In fact, PSMA helps the cancer cells get the nutrients they need to fuel their growth. Learn more details about this at my looking for a needle in a haystack blog.

The new type of imaging called PSMA-PET uses radioactive tracers that are “tagged” onto molecules that trick PSMA into binding these molecules onto individual cancer cells. This makes the cells “light up” during the scan. Even a very small cluster (pre-tumor) of PCa cells will show up, whether they are in the prostate bed, nearby lymph nodes or bone, or even remote locations such as another organ or different part of the skeleton. The sooner a recurrence is detected and identified, the more quickly a potentially curative plan can be put into place.

The future for PSMA-PET

PSMA-PET has been more available in Europe, but the number of U.S. centers is growing. I invite you to watch a good 12-minute video interview with an Italian expert, Stefano Fani, who offers encouraging news about PSMA-PET and how it applies to locating biochemical recurrence. He assures us that it is “simple, fast, patient-friendly…and very accurate.” There are other imaging uses as well, such as staging metastatic disease.

Even more exciting is what is called theranostic medicine. In an age of increasingly personalized medicine, the ability to use a technology like PSMA-PET to deliver a cancer-killing agent directly to the cell by disguising it as a desirable nutrient for PSMA to bind to the cell (think of the Trojan Horse) offers hope for developing treatments for recurrent PCa that were unheard of until only recently.

While the future is incredibly promising, it’s important to keep in mind that, as with all imaging technologies, there is a learning curve. Dr. Fani points out that certain body conditions such as inflammation in the lungs from chronic smoking may also attract the tagged molecules and be mistaken for recurrent PCa on the scan. Thus, experience matters, as does being trained by an expert.

Similarly, multiparametric MRI (mpMRI) of the prostate has become more widely available in the U.S. but here too experience matters. The Sperling Prostate Center is proud to be a globally recognized leader in using our powerful 3 Tesla (3T) magnet in the hands of our expert team. Whether it’s mpMRI for detection of suspected PCa, or PSMA-PET for identifying recurrence, entrusting your prostate health to top authorities is a wise investment.

[i] https://www.webmd.com/prostate-cancer/prostate-cancer-survival-rates-what-they-mean#1

The post Patient-Friendly Scan Accurately Detects Prostate Cancer Recurrence appeared first on Sperling Prostate Center.

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How would you rate yourself in terms of healthy eating habits? In a 2016 survey of 3,000 Americans, 75% of respondents said their diets were good, very good, or excellent. And yet, “…more than 80 percent of Americans fail to eat the recommended amounts of fruits and vegetables. At the same time, many Americans overeat refined grains and sugar.”[i] What’s up with this apparent contradiction?

Part of the problem may be our perception of what’s presented to us in the media and on store shelves as “all natural” or “vitamin-enriched” or any of numerous other labels. I’m not accusing food manufacturers of deliberately deceiving us. However, the way healthy foods are processed and packaged may be compromising them.

Ultra-processed foods

There will always be a demand for food because, well, we all have to eat. And there are roughly 7.6 billion mouths to feed. In the U.S., we lead fast-paced lives filled with multi-tasking, and families that bear no resemblance to those in 1950s TV shows. In most two-parent households, both mom and dad are working full time outside of the home. In single-parent households, one frazzled person is busy being both mom and dad while also working full time. Who has time to shop for fresh foods, come home, prepare them, cook them, and clean up?

There is not only a need to generate enough food to feed the planet, but to do so in a way that makes eating convenient for busy households. This means the food industry is kept well-occupied doing the work of processing, packaging, marketing, distributing, stocking and selling what ends up on our plates.

We’ve all heard of processed foods. Now, a new French study of 105,000 people suggests we add a new term to our gastronomic vocabulary: ultra-processed foods.

What counts as ultra-processed? Here’s the list from a Feb. 15, 2018 news article[ii] about the study:

  • Mass-produced packaged breads and buns
  • Sweet or savory packaged snacks including potato chips
  • Chocolate bars and sweets
  • Sodas and sweetened drinks
  • Meatballs, poultry such as chicken nuggets or tenders, and fish sticks or nuggets
  • Instant noodles and soups
  • Frozen or shelf-life ready meals
  • Foods made mostly or entirely from sugar, oils and fats

The study, by Fiolet, et al. (2018)[iii] was published by the authoritative British Medical Journal. The authors cite the theory of the World Cancer Research Fund/American Institute for Cancer Research, that about a third of the most common cancers could be avoided by changing lifestyle and dietary habits in developed countries. They describe what amounts to an illusion of food safety: “After undergoing multiple physical, biological, and/or chemical processes, these food products are conceived to be microbiologically safe, convenient, highly palatable, and affordable.” These foods are estimated to constitute 25-50% of our daily energy intake.

Hold it right there! Do we fully understand what ultra-processing does to food? I will quote key points from the study:

  1. “Ultra-processed foods often have a higher content of total fat, saturated fat, and added sugar and salt, along with a lower fibre and vitamin density…Beyond nutritional composition, neoformed contaminants, some of which have carcinogenic properties (such as acrylamide, heterocyclic amines, and polycyclic aromatic hydrocarbons), are present in heat treated processed food products.” 
  2. “The packaging of ultra-processed foods may contain some materials in contact with food for which carcinogenic and endocrine disruptor properties have been postulated, such as bisphenol A.”
  3. “Finally, ultra-processed foods contain authorised,22 but controversial, food additives such as sodium nitrite in processed meat or titanium dioxide (TiO2, white food pigment), for which carcinogenicity has been suggested in animal or cellular models.”

Perhaps you think this study is overstated, overblown, and downright alarmist – like some sort of foodie propaganda. However, its research and findings are backed up with 59 respectable papers.

Implications for overall cancer risk

The bottom line is a sobering calculation:  For every 10% increment of ultra-processed foods in your total diet, your overall cancer risk goes up by at least 10%. In addition, “These results remained statistically significant after adjustment for several markers of the nutritional quality of the diet (lipid, sodium, and carbohydrate intakes and/or a Western pattern derived by principal component analysis).”

Now that you know what not to eat, do you know what you should eat? My guess is, yes – so just do it!

[i] Allison Aubrey. “75 Percent of Americans Say They Eat Healthy — Despite Evidence To The Contrary.” NPR online. Aug. 13, 2016. https://www.npr.org/sections/thesalt/2016/08/03/487640479/75-percent-of-americans-say-they-eat-healthy-despite-evidence-to-the-contrary

[ii] James Gallagher. “Ultra-processed Foods ‘Linked to Cancer.’” BBC News online. Feb. 15, 2018. http://www.bbc.com/news/health-43064290

[iii] Fiolet T, Srour B, Sellem L, Kesse-Guyot E, Allès B et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort. BMJ. 2018 Feb 14;360:k322. doi: 10.1136/bmj.k322.

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Thanks to PSA screening and early detection, most prostate cancer (PCa) is diagnosed while it is still contained in the prostate gland. This implies favorable odds that any whole-gland treatment is potentially curative: radical prostatectomy, beam radiation, brachytherapy (seed implants), cryotherapy (freezing), or HIFU. For patients whose PCa exists as an unifocal disease—that is, an isolated tumor of small size—focal therapy carries the same odds.

Before any treatment decision is made, however, it’s essential to get the most complete cancer profile to determine that true level of risk. Other risk factors include:

  • Age and family history
  • Diagnosis of aggression and disease volume based on mpMRI and biopsy
  • Tumor volume and stage
  • Genomic analysis to rule out gene variants that characterize more lethal cell lines
  • Life expectancy based on overall health and any coexisting conditions.
What if the prostate cancer is high risk?

Unfortunately, not every case of prostate cancer is detected and diagnosed within the most likely window for successful localized treatment. Patients with Gleason score 8-10 PCa (or any primary score of Gleason 5) are at significantly greater risk for PCa spread into the pelvic and groin lymph nodes, and potential remote metastasis which is incurable. This is alarming, but high risk PCa does not rule out an aggressive localized treatment by radical prostatectomy (RP) or radiation therapy (RT). The question then becomes how to boost the probability of successfully vanquishing the cancer—especially using radiation, since no repeat radiation can be done if cancer comes back.

The problem with aggressive radiation therapy (RT)

Traditional external beam radiation has a scatter effect that can lead to early and even late-onset urinary, sexual and bowel toxicity (side effects). The greater the radiation dose, the more toxicity risk. Radiation technology has improved, and a method increasingly used for PCa is called Intensity Modulated Radiation Therapy (IMRT). IMRT is more precise and able to be more focused on the target:

IMRT allows for the radiation dose to conform more precisely to the three-dimensional (3-D) shape of the tumor by modulating—or controlling—the intensity of the radiation beam in multiple small volumes. IMRT also allows higher radiation doses to be focused to regions within the tumor while minimizing the dose to surrounding normal critical structures.[i]

This sounds encouraging, but when it comes to high risk PCa, the question is raised as to how much anatomy (how big an area) can be safely treated in an effort to prevent recurrence? Since the pelvic lymph nodes are a preferred location for early spread of PCa, it makes logical sense to radiate them as well as the prostate. However, traditional EBRT to such an extent could not avoid affecting bladder, rectum, and bowel. Damage to these last two structures, in particular, would have a negative effect on gastrointestinal function (intestinal digestion and excretion).

PIVOTAL trial demonstrates IMRT safety

Therefore, a clinical trial was designed to compare radiating just the prostate gland with IMRT vs. radiating the prostate plus the lymph nodes to evaluate the rate of side effects of each approach. It’s called the PIVOTAL Trial (Prostate and Pelvic Lymph Node Versus Prostate Only Radiotherapy in Advanced Localised Prostate Cancer). [ii]

The International Journal of Radiation Oncology, Biology, Physics (March, 2019) has now published the results of this Phase II randomized multicenter trial. For the PIVOTAL trial, 124 PCa patients who had received no prior treatment were enrolled, and randomly assigned to have IMRT either just to the gland, or to the gland and the lymph nodes. Both groups received the same radiation dose to the prostate and seminal vesicles, while the lymph node group also received radiation to the nodes.

What did the study find?

The average follow-up was just over three years, more than enough time to track short-, medium- and long-term side effects. At week 6, a larger proportion of the prostate-plus-nodes group had more gastrointestinal distress symptoms such as rectal bleeding or diarrhea than the prostate only group (26% vs. 7%). By week 18, both groups had similar low scores on a questionnaire regarding inflammatory bowel disease; the prostate only group reported 96.7% freedom from side effects, whereas the prostate-plus-nodes group reported 95.2% freedom from side effects.

Based on these and other results, the authors concluded “…that high-dose pelvic lymph node IMRT can be delivered at multiple centers with a modest side effect profile.” This is good news for men with high-risk disease who undergo IMRT to the prostate gland plus lymph nodes as their primary treatment. The broader treatment area gives added insurance against future advancing PCa.

One note of caution: the research team notes that although the PIVOTAL trial demonstrated a favorable safety profile for more extensive IMRT treatment, how well it ultimately controls PCa was not established over three years’ follow-up. Still, the trial report should hearten men with high-risk PCa.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] https://www.radiologyinfo.org/en/info.cfm?pg=imrt

[ii] Int J Radiation Oncol Biol Phys. 2019 Mar; 103(3):605-17.

The post The PIVOTAL Trial: The Safety of Aggressive Radiation for Prostate Cancer appeared first on Sperling Prostate Center.

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If you have an enlarged prostate due to benign prostatic hyperplasia (BPH), you may have several reasons to be unhappy:

  • Interrupted sleep from having to get up to pee
  • Difficulty starting to pee
  • More frequent urges during the day
  • Slow stream or dribbling when you pee, etc.

None of this is any fun. You wonder, how much worse can it get? When should you seek medical help? Why is it even happening?

BPH restricts urine flow             

BPH is the result of a natural change in the composition of prostate tissue that can occur with aging. The gradually enlarging prostate you have at age 55 is not the same one you had at age 20. Most men develop BPH, though not everyone is troubled by it. For those who are, the explanation is fairly simple: the tube (urethra) that carries urine out of the bladder passes directly through the middle of the prostate; since the prostate is nestled in a very confined space, as it grows it meets outer resistance, creating more pressure within the gland. This internal pressure squeezes and constricts the urethra, making it more difficult to pass urine. You know how your arm feels when a blood pressure cuff inflates and presses all around your arm? Think of a similar effect on the urethra as prostate tissue grows. In short, for men troubled by urinary symptoms, BPH is not their friend.

BPH may also restrict prostate cancer growth

While BPH may not be a man’s friend, a new study suggests it’s not cancer’s friend either. It has been noted in research studies that there is a correlation between prostate enlargement and slower growing prostate cancer (PCa), but no one knew exactly why. Now, a multinational team of researchers has demonstrated a plausible explanation. Using data from actual cases of men with BPH and PCa, the team used their imaging records (MRI) to generate a 3-D prostate simulation showing tumor locations.[i]

According to a story out of Purdue University, “At the end of a one-year period, the simulations showed that the tumor of a patient with history of an enlarged prostate barely grew at all. When the researchers removed history of an enlarged prostate in the program, the tumor had grown to be over six times larger at the end of the same time period.”[ii]

Thus, over time the enlarging prostate exerts intense mechanical force not only on the urethra—to the chagrin of its owner—but could also restrict tumor growth by slowing the cancer’s own tumor formation.  In other words, BPH may act like a natural obstacle, becoming an enemy of PCa activity and growth.

Treatment implications

Returning to the story from Purdue, if the above hypothesis holds up in future studies, “The findings suggest that it might be a bad idea to downsize an enlarged prostate through surgery or drugs, because doing so could lead to faster growth of prostate cancer.” What a dilemma this might create. For instance, a man whose BPH impairs his quality of life sees a doctor for relief, but in the process finds out he has prostate cancer. His cancer appears to be small and not aggressive, but if he takes medication or has a procedure to reduce the size of his gland in order to have better urinary function, will the cancer become larger or more aggressive, necessitating an aggressive treatment with a risk of incontinence? Is this a trade-off between problems?

And what about the problems of leaving an enlarged gland untreated? Continued enlargement is not predictable, but simply ignoring BPH can lead to other problems. Restricted or blocked urinary function may increase pressure in the bladder; urine retention (inability to pee) has been linked with urinary tract infections (UTI’s). Other complications include bleeding, kidney infection or kidney damage—all of which require treatment.

If ongoing research strengthens the theory that BPH suppresses prostate cancer growth, or if BPH alone is creating uncomfortable symptoms, the Sperling Prostate Center offers a three-pronged treatment approach that can resolve the dilemma for appropriate patients:

  1. Detection – Multiparametric MRI captures sophisticated, high resolution images of prostate anatomy as well as characterizing tissue differences. Using imaging alone, our expert team can deliver detailed information about the anatomy and location of both BPH and cancer tumors.
  2. Diagnosis – If any area is suspicious for PCa, we can do a real-time, in-bore prostate biopsy using a minimum number of needles targeted to the region of suspicion. The resulting tissue samples tell us the nature of any PCa picked up by the needles. At this point, we have all the information we need to develop a plan for MRI-guided treatment using Focal Laser Ablation (FLA).
  3. Treatment – MRI-guided FLA offers the perfect middle ground between undertreatment (don’t shrink the gland in order to restrict PCa growth) and overtreatment (surgically remove or radiate the whole gland to get rid of the BPH along with the cancer, but increase the risk of post-treatment urinary and sexual dysfunction). FLA is so precise that it can be targeted and shaped to destroy the PCa tumor, and also strategically reduce BPH without damaging the urethra or the neurovascular bundles that control sexual function.

There’s a saying: If the only tool you have is a hammer, you see every problem as a nail. Surgical procedures for BPH or PCa tend to clobber the whole gland, like hitting a thumb tack with a sledge hammer. The Sperling Prostate Center has a more adaptable tool kit, thanks to advanced MRI technology and the use of outpatient FLA.

I personally welcome further developments in the theory that BPH is a natural enemy of prostate cancer. Should this prove to be the case, we are already demonstrating that FLA is a safe and effective, yet flexible, treatment for both conditions—so our patients don’t have to put up with either. In this way, they can enjoy the high quality of life they have worked hard to attain.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Lorenzo G, Hughes T, Dominguez-Frojan P, Reali A, Gomez H. Computer simulations suggest that prostate enlargement due to benign prostatic hyperplasia mechanically impedes prostate cancer growth. PNAS January 22, 2019 116 (4) 1152-1161. https://www.pnas.org/content/116/4/1152.short?rss=1  

[ii]Purdue University. “Enlarged prostate could actually be slowing tumor growth, simulations show.” MedicalXpress. Feb. 4, 2019. https://medicalxpress.com/news/2019-02-enlarged-prostate-tumor-growth-simulations.html

The post Could BPH be Prostate Cancer’s Natural Enemy? appeared first on Sperling Prostate Center.

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There was a time when proton beam therapy seemed to be the “Holy Grail” of prostate cancer (PCa) treatments. In 1990, the Loma Linda University Medical Center became the world’s first hospital-based proton beam treatment center, making this treatment available to all cancer patients. A decade later, the New York Times reported that proton beam had now joined the ranks of other standard PCa treatment options. Patients everywhere were heartened at the news.

What’s so special about proton beam radiation? Well, protons are subatomic particles that have a positive charge. They have about 1,835 times the mass of electrons, and because of this they have less “scatter” effect. This means more accurate delivery, with less radiation emission on exiting the tumor. Also, proton radiation is very short-lived. Because of these features, patients report fewer side effects from treatment, and it is believed that there is less risk of organ damage or secondary cancers in neighboring areas. For prostate cancer patients, this translates to great expectations of higher success rates and lower side effect rates. However, in some respects proton beam is not totally special.

Radiation is not an instant treatment

Radiation is radiation. It does not kill cancer immediately, but rather interferes with the cancer cell’s ability to reproduce itself. While healthy cells are hardier and less prone to radiation’s effect, the mutated cancer cells gradually die off. Radiation can only do its job when there is prolonged exposure. It must keep the pressure on. If there’s not enough radiation, or the cancer is particularly aggressive, there’s a chance some cells will survive and “come back angry.” For this reason, beam radiation treatments must continue daily over several weeks.

This principle applies equally to proton beam treatment. It does not destroy the cancer right away. However, as I mentioned above, it has an advantage over other kinds of radiation by reducing collateral damage, thanks to less scatter.

A treatment struggling to survive?

If a PCa patient’s disease and lifestyle mean he’s not a good candidate for surgery or ablation, radiation may be the most appropriate choice. In this case, proton beam may be most appealing. However, he may have a hard time locating a center close to him, because proton beam centers are losing ground.

The initial enthusiasm for treating PCa with proton beam has cooled, largely for economic—not clinical—reasons. Proton beam radiation requires a huge investment in terms of buildings and equipment. This means many people must be treated in order to help meet costs. Many of the tumors for which proton beam is a great choice, such as pediatric tumors where less radiation scatter is extremely important, are actually relatively rare. So proton centers need all the prostate cases they can get.

However, from the standpoint of medical insurers, this is not such a good deal. Why should they cover the extra cost—up to tens of thousands of dollars—if proton results are no better? There’s little published evidence that the success rate for proton beam is superior to IMRT or SBRT—nor is there a compelling body of evidence that there are significantly fewer short- and long-term side effects. If this is the case, it makes sense that insurers are increasingly resistant to reimbursing for it. This poses a big financial hurdle for proton centers.

Another problem is scarcity. There are fewer patients than originally planned for. According to one news story, “Patient demand for the technology has been much lower than anticipated in some centers, and several centers have been grappling with financial losses or have missed financial targets…” The story goes on to cite centers in California, Indiana, and Virginia that have either closed or are deeply in debt.

I think the issue of shrinking patient demand is particularly interesting. Why is this happening?  For one thing, there’s always something a little scary about undergoing radiation, almost like a psychological fear that was perhaps implanted during the Cold War that has never quite gone away. Also, the use of Active Surveillance for low risk PCa patients has risen steeply for many reasons—though it too can cause an undercurrent of anxiety (see my blog on the subject). Finally, the idea of focal therapy like our Focal Laser Ablation continues to gain traction; PCa patients like the ability to control cancer with minimal-to-no side effects, knowing future treatment options are available.

Proton beam radiation is undoubtedly a great choice for certain cancers, such as brain, lung, central nervous system, and cancers that can’t be surgically removed. It is also a good choice for localized prostate cancers for which surgery or ablation is not recommended or feasible. However, if insurance won’t cover it for PCa, or centers aren’t available, hopefully it won’t have lost so much ground that those who truly need it will lose access to it altogether.

The post To Beam or Not to Beam? That is the Proton Question appeared first on Sperling Prostate Center.

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The late physicist Stephen Hawking was one of the most brilliant minds of his time. He believed that Artificial Intelligence (AI) could serve the good of the world. He also got the world’s attention when he warned about the danger that AI could eventually outsmart humanity. He urged that its creators exercise responsibility with best practice and effective management.

AI is a reality that touches all of us throughout our day. Common examples include easier rush hour commutes; sorting incoming email as useful (e.g. primary, social, promotion) while filtering out SPAM; connecting you to others through social media; and much, much more.

AI is the process of creating machines with their own intelligence. One component of AI is Machine Learning (ML) which includes specific scientific statistical methods that enable computers to learn on their own, progressively building on their “knowledge” without having to be repeatedly programmed by humans. In turn, a component of ML is Deep Learning (DL) which uses biological models like the brain’s neuron networks that operate bodily systems. With DL, computers can literally teach themselves to accomplish “human-like tasks, such as recognizing speech, identifying images or making predictions.”[i]

Artificial intelligence and radiology

With the advent of self-driving cars or airplane autopilots, we entrust our lives to the minds of those who create AI. A medical area in which AI is responsible for human life is radiology. This field began with medical imaging (X-rays, ultrasound, CT and PET/CT scans, MRI) to detect and diagnose abnormalities. The ability to “see” inside the body led to minimal-to-noninvasive image-guided procedures (interventional radiology) as an alternative to major surgery.

AI offers tremendous potential within radiology to improve patient outcomes. Thanks to the digitizing of diagnostic imaging, literally millions of images from all over the globe are available for computerized recognition and classification in milliseconds. AI systems, both ML and DL, are already in place to improve diagnostic accuracy and efficiency, and help radiologists make procedural decisions. With AI, a correct diagnosis based on advanced imaging may mean that correct treatment can begin the same day.

ML and DL techniques that support radiology diagnosis and decision-making

There are many techniques by which ML and DL enhance radiologic practice. Here are three types:

  1. Rule-based reasoning takes advantage of human expertise to develop “if-then” logic. For instance, let’s say there is software programmed with knowledge about clinical bone problems. When the radiologist presents it with specific information and images from a patient’s case, the software applies appropriate rules to make an educated inference: IF imaging reveals a porous bone area, THEN the problem may be either osteoporosis or bone cancer.” Of course, this is a simplistic example. In actual clinical use, very sophisticated software is presented with complex, ambiguous cases and applies the rules in nanoseconds, helping a radiologist identify a condition and rule out other possibilities. 
  2. Artificial neural networks are modeled on how the brain’s nerve cells (neurons) are structured into communication and learning networks. They use a large number of interconnected elements with statistically weighted “decision trees” to learn directly from observations. These can be used for perceptual tasks such as identifying tumor patterns in, say, a CT scan of the liver. (See my blog on computer diagnosis of prostate cancer.)
  3. Hypertext and hypermedia allow nonsequential access of related materials from the “cloud.” If you clicked on the above link to my blog, you “hopped off” of this page to a related page that was out of this sequence, and then hopped back to pick up where you left off. Thanks to AI, a radiologist facing an ambiguous clinical case may not be certain if it’s condition A or B. With a simple “Tell me everything about condition A” command, a wealth of pertinent articles, radiologic images, charts, graphs, etc. can be quickly accessed and filtered to help the radiologist determine that it is or is not condition A and move on from there.
Developer responsibility

There are other ML/DL types as well, but I hope the above categories give you some idea of the kinds of software that are helping radiologists – and there are more in development every day. With human life and well-being is on the line, the burden falls to software programmers make AI safe by designing ML and DL using best practice and effective management. Over 20 years ago, a visionary radiologist from the University of Pennsylvania, Charles E. Kahn, Jr. foresaw the task ahead:

Builders of expert systems must choose the most appropriate artificial intelligence techniques for a particular application… In addition, developers must address organizational and operational aspects of a decision support system… Validation and evaluation are crucial. Validation assures that a medical decision support system’s advice is ‘accurate, complete, and consistent’; evaluation addresses the system’s applicability, speed, acceptability, and utility to physicians in clinical practice… Developers must establish an ongoing means to monitor and update a decision support system’s knowledge to prevent its gradual obsolescence.[ii]

While AI can never replace the personal doctor-patient relationship, it can equip the radiologist in a way that allows greater authority and expertise than the individual alone can have. It can accelerate information gathering and decision-making. It can increase the radiologist’s confidence in diagnosis and treatment planning. In short, responsible AI enlarges the mind of each radiologist with the brilliance of experts for the good of each patient.

[i] https://research.googleblog.com/2018/04/an-augmented-reality-microscope.html

[ii] Kahn, Jr, Charles. (1997). Artificial Intelligence in Radiology: Decision Support Systems. https://www.researchgate.net/publication/2665196_Artificial_Intelligence_in_Radiology_Decision_Support_Systems?enrichId=rgreq-c6b7508a7d86c6f1cb5c4345276df256-XXX&enrichSource=Y292ZXJQYWdlOzI2NjUxOTY7QVM6MjgzNzI4OTI5NjczMjE5QDE0NDQ2NTc2NTY5NTI%3D&el=1_x_3&_esc=publicationCoverPdf

[accessed July 18, 2018]

The post Artificial Intelligence: Enlarging the Mind of Radiology appeared first on Sperling Prostate Center.

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Senator Angus King (Independent, Maine) is no stranger to cancer. As he was approaching his 30th birthday in 1973, he was diagnosed with melanoma, a very aggressive skin cancer. He was treated, and survived. He went on to become Governor of Maine. Later, he changed his political direction: in 2012, he ran for a seat in the U.S. Senate as a political independent, and was elected.

At age 71, four decades after his melanoma was cured, Sen. King was diagnosed with prostate cancer. At the time, he was told it was caught early. He chose to have radical prostatectomy to surgically remove the gland. In his statement to the press about his decision, King declared, “I’m looking forward to a full recovery and to continuing my service in the Senate… And no, this does not affect my intention to run for re-election, except my poor little prostate won’t be along for the ride.”[i]

Since his pre-surgery scans showed no evidence of cancer outside the gland, it must have been a shock when he was diagnosed with recurrent prostate cancer in 2018. He began eight weeks of beam radiation to treat “some small, localized, residual prostate cancer.”[ii] We wish him 100% success!

Putting aside politics

Regardless of one’s political views, anyone who has ever had cancer, or is in treatment for cancer, or has a loved one dealing with the disease should have compassion for a fellow human confronted with it. Research shows time and again that the emotional responses to a diagnosis of cancer are practically universal. Prostate cancer—any cancer—goes ignores political views, religion, economic status, gender, ethnicity or any other way of categorizing individuals. In that sense, it is a “great equalizer” because no one is 100% immune to it.

In dealing with his prostate cancer, Sen. King occupies a unique position because he is a public servant. In fact, his willingness to be open with the press about his cancer serves the needs not only of his constituents, but all of us. Helping to bring prostate cancer out of the shadows of ignorance and misinformation overcomes the historic hush-hush norm of not talking about cancer.

Raising awareness about prostate cancer is important in the search for a cure. This is especially true for men. Unlike women, who are comfortable discussion their bodies with each other, men don’t get into sharing personal health information with each other. This puts men’s health at a disadvantage. Many of my patients over the years have commented on the difference between funding for breast cancer research vs. funding for prostate cancer research. They note the huge attendance at breast cancer events, and how many female celebrities are featured for speaking frankly about their experience. Have you ever noticed that “mastectomy” and “lumpectomy” are household words while “prostatectomy” or “focal laser ablation” are rarely heard in men’s discussions?

Personally, I have a great deal of respect for the honesty and positive attitude of prostate cancer patients who speak out like Sen. King has. In my opinion, he is doing all men a great favor by raising awareness, just as other men in U.S. and international politics, sports, entertainment, religion etc. have done: Rudy Giuliani, Arnold Palmer, Frank Zappa, Francois Mitterand, Roger Moore, Desmond Tutu, Colin Powell and others.

It’s a great start. I hope many others follow such “prostate cancer poster boys” to keep the momentum strong. 

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Brogan, Beth. “Sen. Angus King to have surgery for prostate cancer.” Bangor Daily News, June 22, 2015. https://bangordailynews.com/2015/06/22/politics/sen-angus-king-to-have-surgery-for-prostate-cancer/

[ii] Rodrigo, Chris. “Sen. Angus King begins treatment for prostate cancer.” The Hill, Jan. 18, 2019. https://thehill.com/blogs/blog-briefing-room/news/426113-sen-angus-king-begins-treatment-for-prostate-cancer

The post U.S. Senator from Maine Raises Prostate Cancer Awareness appeared first on Sperling Prostate Center.

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Yoga for prostate cancer? It all began with the side effects of radiation treatment for prostate cancer (PCa). External beam radiation may be the right treatment for certain patients, but it can have downsides because it affects healthy cells as well as the cancer cells.

Most of radiation’s side effects are not severe and patients can tolerate them. Most patients report fatigue, but other effects include:

  • Urination changes or difficulties
  • Blood in the urine
  • Urinary leakage
  • Abdominal cramping
  • Diarrhea
  • Painful bowel movements
  • Rectal bleeding or leaking
  • Fatigue
  • Sexual dysfunction, including diminished erectile function or decrease in the volume of semen

However, if side effects become less tolerable or more pronounced, immediate action is important. The first step, of course, is to communicate with the doctor because the sooner problems are managed, the better the odds that short term quality of life improves, and long term complications are avoided.

The second step is patient empowerment, and here’s where yoga comes in. A 2016 pilot study showed that it was feasible to enroll PCa patients undergoing radiation therapy to attend twice-weekly yoga classes for the purpose of evaluating the impact on treatment side effects.[i] This was followed a year later by publication of a randomized Phase II trial in which 22 radiation treatment patients were randomly assigned to a yoga class (twice weekly during their radiation treatments) and 28 to no class.[ii] The authors reported that compared with the control group, the results for those in the yoga group were associated with “…a significant reduction in pre-existing and RT-related fatigue and urinary and sexual dysfunction in PCa patients.” Thus, yoga helped patients cope with their treatment side effects.

Report from China

A news story from China confirms that yoga helps patients with prostate and other types of cancer cope with treatment effects. In fact, the benefits of yoga extend more broadly into other areas of patients’ lives as well. What’s unique about this particular story is the fact that it’s about male-only yoga classes. In China, as in many other cultures, men have shied away from yoga classes where the majority of participants are women, thereby missing out on what yoga can offer.

According to the story, three male cancer patients using support services at a center called CancerLink attended a yoga class along with 50 female patients. The men felt self-conscious and tended to try to find a corner away from the group. Finally, CancerLink began offering male-only classes led by trained leaders who themselves were cancer survivors. Instead of doing the more demanding yoga poses, the men “engaged in deep breathing techniques and gentle stretching to help them relax, raise their body awareness, and boost their balancing skills and pliability.”

Shiao-kuang Hsueh Maddox, CancerLink’s head of wellness and holistic care programs, observes, “Men have a different body structure, muscle and bone structures are different, so we thought … we can have men’s yoga classes, where they can come and relax and not feel competition with women who may be more flexible.” In fact, participants report that they have formed their own special social connection.

Besides the camaraderie and greater physical flexibility, yoga brings the men greater calm, less depression and anxiety, better handling of stress, better overall coping with treatments like chemotherapy or radiation, greater inner strength, peace of mind, and overall improved quality of life.

Worry and stress create negative effects in the body that burden the immune system. As yoga helps practitioners develop deeper serenity and become more adept at stress management, the body responds positively. Organ systems function more naturally and the immune system is liberated to perform as nature designed it to do. In turn, this can enhance the body’s ability to survive longer.

It is no wonder that cancer patients in general (and prostate cancer patients in particular) have a growing interest in alternative modalities to support conventional clinical practice. Yoga is an obvious choice because classes are readily available everywhere; cancer patients also find that practices such as meditation or tai chi complement and even boost the anti-cancer properties of surgery, radiation, chemotherapy, etc.

Since prostate cancer is a men’s disease, it makes sense that tailoring support programs just for them provides a safe environment to harness their inner desire for wellness—one of their best resources for a favorable outcome on the journey with cancer.

[i] Ben-Josef AM, Wileyto EP, Chen J, Vapiwala N. Yoga Intervention for Patients With Prostate Cancer Undergoing External Beam Radiation Therapy: A Pilot Feasibility Study. Integr Cancer Ther. 2016 Sep;15(3):272-8.

[ii] Ben-Josef AM, Chen J, Wileyto P, Doucette A et al. Effect of Eischens Yoga During Radiation Therapy on Prostate Cancer Patient Symptoms and Quality of Life: A Randomized Phase II Trial. Int J Radiat Oncol Biol Phys. 2017 Aug 1;98(5):1036-1044.

The post Yoga for Prostate Cancer? appeared first on Sperling Prostate Center.

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