- DRE and PSA screening along with surgery and radiation for PC did not reduce the incidence of PC mortality.
- There is insufficient evidence to recommend routine prostate cancer screening with PSA and DRE for all men.
- Treatments of PC often causes moderate to substantial harm including erectile dysfunction, bladder and bowel problems.
- Routine prostate screening in men over 75 should be discontinued due to more harm then good as a result of this screening.
When men reach the age of 40 their prostate glands begin to enlarge. Some say that this is normal. I suspect that it is not normal, but due to a lifestyle of pervasive sedentary habits and lifetime of overexposure to synthetic hormone-like chemicals including plastic (See Plastic newsletter). About 1/3 of the male population will experience benign prostatic hypertrophy (BPH), ½ the male population will experience prostatitis and 1 in 10 males will experience prostate cancer (PC), the most common cancer in men. The US and Canada have the highest incidence of PC around the world.
Due to these findings many men and their loved ones are reasonably concerned, and are seeking an alternative approach for prostate screening, monitoring and intervention. This month’s newsletter is intended to address these concerns.
A minority of PC’s are aggressive tending to metastasis and death. The majority are considered indolent and non-aggressive. The trend at this time suggests that indolent PC is quite common in low-risk young males. So common that in time we may consider the existence of some types of prostate cancer a natural occurrence.
Until recently men who were diagnosed with PC and chose to postpone treatment were counseled to engage in watchful waiting (WW). WW essentially means that a man waits until PSA values rise to a point where surgery and or radiation are dictated. The passive nature of WW is not a viable approach to address PC and is being replaced by active surveillance (AS). Even conventional urologists are realizing that a majority of men with PC will benefit from (AS).
At this time, biopsies are the only legal way to diagnose prostate cancer; however biopsies pose several concerns including:
- Pain, prostatitis relapse and heavy antibiotic use after biopsy.
- May miss a cancer and thus give a false negative finding.
- Cancer may be seeded or spread into other tissues when a biopsy is performed.
Active Surveillance Program Outline
The goal of AS is to monitor the aggressiveness of PC and to assess for the risk associated with metastasis. AS allows men to pursue a number of natural therapies to reduce the likelihood of invasive interventions down the line. AS is also applicable for men who want a non-invasive methodology to screen for possible PC. A British study of interest has shown that men choosing AS did not experience significant psychological stress as compared to men who sought immediate invasive treatments.
First, it is important to consider your basic risk factors for all types of cancer:
- High stress markers (high stress personality, high adrenal cortisol)
- High carbohydrate (sugar) diet and high commercial animal protein diet
- Heavy metal exposure
Second, consider these additional risk factors for PC:
- African-Americans are at increased risk.
- PC in patient’s immediate family (a brother with PC poses a higher risk then father or Grandfather with PC)
- Grandfather or father with PC
- American Urological Association (AUA) Symptom Score: If you have prostate problems a high score is good and more indicative of BPH (see appendix for this test). While PC can block urine it is usually the case in a male who has not been evaluated for many years and has a PSA of 20ng/ml or more, on up into the hundreds.
Third, assess for PC based on lab findings. The lab tests I’m referencing in this article are common to urologists, but are not typically used to assess for PC risk due to expense, time involved and lack of insurance reimbursement. Generally, urologists just want to do the quick and less expensive biopsy to assess for PC.
Prostate cancer of low risk includes the following parameters (explanations to follow):
- Diagnosed PC with biopsy, yet the minority of biopsy cores are positive and of those cores only partially positive.
- Gleason score less then 6-7.
-No PSA velocity (increasing PSA readings over a period of time) over 2.0ng/ml/year or over
- 0.75ng/ml/year consecutively over two to three years and PSA values capped at 8-12ng/ml (PSA in excess of 12ng/ml is suspicious of more aggressive PC)
Some urologists still advise yearly biopsy with AS, but this trend is changing. A non-invasive alternative protocol to biopsy would be: TRUSP with color doppler imaging, PSA dynamics analysis and genetic marker testing.
Prostate Lab Value Interpretation Guide
Elevated PSA is generally an indicator of prostatitis or BPH. PSA, despite many reports of its unreliability for assessing for PC risk, still has some value to: track residual PC after removal of the prostate, mark the severity of BPH, and to be used as a PC assessment when monitoring PSA rate of change over time known as the PSA velocity (PSAv).
A single PSA reading which, again, is of limited value when taken out of context from other prostate markers and risk factors, may indicate the following:
- 0.0-2.0 ng/ml: relatively low risk for PC
- 2.0-10ng/ml: requires further work-up
- 10.0ng and up: likely PC or severe BPH
PSA velocity values should not increase more than 0.75ng/ml/year. If they do, then PC is suspect. A rate greater then 2.0ng/ml/year is suggestive of an aggressive tumor. A reverse velocity can be indicative of tumor regression.
Percent Free PSA (PSA-f or FPSA)
This is a qualitative test which suggests whether the PSA is coming from cancer or non-cancer (BPH) prostate tumor cells. PSA-f of 25% or higher is indicative of BPH, and below 15% is indicative of PC.
If a biopsy has been done, then a Gleason score is given. Values below 7 are preferable and appropriate for AS.
The Transrectal Ultrasound of the Prostate (TRUSP) with color Doppler and subsequent analysis can help determine PC risk. Radiation centers can run the TRUSP without doing a needle biopsy, but this is not a common practice. Never the less, this test will provide useful visual guidance in marking a patient’s progress. Suspicious lesions can be identified with TRUSP and Doppler then monitored over time for changes.
Using TRUSP, data measurements can be made to determine the size of the prostate in cubic centimeters. This allows calculation of the PSAD and gives more meaning to the AUA score.
PSA Density (PSAD)
If you divide the PSA by the volume in cubic centimeters of the prostate as determined by the TRUSP you can use reference tables to determine if the proper amount of PSA is being secreted by prostate cells or is suggestive of tumor cells.
PC located deep within the gland poses less of a risk then PC at the edge of the gland. Location must be considered in light of PSA readings. A low PSA is more of a concern if the tumor is near the surface of the prostate.
Identification and Risk
BPH, prostatic stones (which may be felt with DRE) and prostatitis are fairly easily recognized with TRUSP.
Natural testosterone, unlike synthetic testosterone or methyltestosterone, does not cause PC. While some say that testosterone may fuel an established prostate cancer, there is no scientific basis for this assertion. Common sense would say that if testosterone were the problem then by age 35-40 all men would have PC, before testosterone levels begin to fall with andropause (see Male Menopause newsletter).
A shift from PSA testing to the more reliable genetic marker testing is in motion, with Prostate Cancer Antigen 3 or PCA3 showing the most promise of the molecular gene tests; however this test is only available in Europe at this time.
Brief Healthy Prostate Treatment Overview
Since all prostate problems are inflammatory in nature it is important to reduce inflammation for both prevention and treatment of prostate problems.
•Exercise: leads to a 25% lower incidence of prostate problems. •Bio-identical progesterone supplementation based on saliva hormone test results. •Zyflamend: herbal anti-inflammatory oil blend •Sitz baths: see appendix •Kegel exercises: see appendix •Saw palmetto, pygeum, herbal mixes •Beta sitosterol •Diindolemethane (DIM) to reduce unhealthy estrogen metabolites.
(The above products and directions are available at health food stores)
PC is difficult to assess without resorting to frequent biopsies which pose potential risk. The use of combined non-invasive testing as described in this text to help assess risk of PC without side effects is a legitimate consideration. AS serves to educate and empower men while combining principles of both naturopathic and conventional medicine. It is important to be assertive and well informed when dealing with and working with a urologist in order to make the best decision possible regarding your health or the health of your loved one(s).
I hope you have found this month’s newsletter to be of value. Comments are welcome.
Please remember that healthy lifestyle habits (including the attitude you foster: see Positive Thinking newsletter) is the best medicine of all.
Jon Dunn, ND
AUA Symptom Score Questionnaire
This is not a test to diagnose BPH but is a tool to characterize the severity of BPH. Please answer the following 6 questions using the following responses, and then total the number of points accorded to each response.
Answers and points for each answer ranging from 0 -5 are:
Not at all (0)
Less then 1 in 5 times (1)
Less then half the time (2)
About half the time (3)
More then half the time (4)
Almost always (5)
Over the past month how often have you had a sensation of not emptying your bladder completely after you finished urinating?
Over the past month how often have you had to urinate again less then 2 hours after you last urinated?
Over the past month how often have you stopped and started again several times when you urinated?
Over the past months how often have you found it difficult to postpone urination?
Over the past months how often have you had a weak urinary stream?
Over the past months how often have you had to push or strain to begin urination?
For this last question: None is 0 points, once is 1 point, twice is 2 points, thrice is 3 points, four times is 4 points and five or more times per night is 5 points.
Over the past month how many times did you most typically get up to urinate from the time you went to bed to the time you got up in the morning?
Now add up all your points. If your score is:
1-7: Your symptoms of BPH are mild
8-19: Your symptoms of BPH are moderate
20-35: Your symptoms of BPH are severe
Sitz baths involve submersion of the pelvic region (rear end, pelvis, nearly up to the navel and first third of the thigh region) in a tube of water. Begin with 3 minutes in a tub of hot water (as hot as you can tolerate: don’t burn yourself) then shift that part of your body into a tub of cold water for 1 minute. Always do at least 3 cycles beginning with hot and ending finally with cold. This is one of the best treatments I know of for BPH and prostatitis which works by increasing circulation in the pelvic region. If you aren’t able to do the sitz bath replicate as best as possible with a removable shower head: 1 minute fairly hot to 20 seconds quite cold. Put one leg up on side of tube to get full exposure. Remember, do three or more cycles once daily.
These exercises will help improve circulation and reduce inflammation in the prostate.
First find the muscles you need to exercise. This can be accomplished by:
Stopping your urine mid-flow while at the toilet. The muscles you use to do this are the ones you want to exercise. Don’t do the exercises while urinating; this part is only a test.
If you are still unsure, the muscles you use to prevent passing gas are the same ones you want to use when exercising. It is a sort of pulling contraction of the pelvic muscles I want you to identify.
When doing the exercise, use only the pelvic area muscles, do not tighten leg, stomach or other muscles, and please don’t hold your breath.
You can do this exercise anywhere; yet initially find a quiet spot to become familiar with this exercise.
-- Pull the pelvic muscles in and hold for a count of 3.
-- Relax for a count of 3.
-- Work up to 10 - 15 repetitions each time you exercise. You should be doing 80 - 100 contractions a day, every day.
-- When you can do 10 - 15 repetitions without tiring, gradually increase the time you hold up to 10 and relax for 10.
-- Do these exercises at different times, throughout the day, while sitting, standing and lying down on an on-going basis.