Beating Prostate Cancer

Today, we bring you new research about prostate cancer, and we start with the sometimes problematic results of PSA testing.

While 64 percent of men develop hidden prostate cancers by their 60s, the lifetime risk of being diagnosed with prostate cancer is only about 11 percent (and the risk of dying from prostate cancer is 2.5 percent at the average age of 80). So, most men develop prostate cancer, but they die with their tumors rather than from their tumors. Most men with prostate cancer live their whole lives never knowing they even had it. That’s one of the problems with screening for it. Many prostate cancers that are detected may never have led to harm even if they’d gone undiscovered. Nonetheless, not all men are so lucky. About thirty thousand Americans die each year from prostate cancer. So, should you get a PSA prostate screening test or not?

PSA stands for prostate specific antigen, an enzyme secreted by cells of the prostate to liquify semen and cervical mucus to facilitate fertilization. Elevated levels in the blood can be a sign of prostate cancer, which led to FDA approval as a screening test for the early detection of prostate cancer in the 1990s. If it comes back high, the test is usually repeated. If it’s still high, the next step is typically an ultrasound-guided biopsy of the prostate through the rectum. If there’s cancer, then options include surgery, radiation, and chemotherapy, or a delayal of treatment.

However, the USPSTF, the U.S. Preventive Services Task Force, the main independent scientific panel that sets evidence-based clinical prevention guidelines, recommended against routine PSA screening, as does the American College of Preventive Medicine, the American Academy of Family Physicians, and the vast majority—85 percent—of professional medical societies in developed countries around the world opposed.

In 2018, though, the USPSTF shifted from a summary judgement against to “the decision about to be screened for prostate cancer should be an individual one,” which is more in line with the “shared decision-making” stance of the American Urological Association, the American College of Physicians, and the American Cancer Society. In other words, men should be informed about the risks and benefits, and decide for themselves. However, men who are on the fence and don’t express a clear preference in favor of screening should not be screened, according to the latest USPSTF recommendations.

More recently, an international panel of experts concluded that clinicians need not feel obligated to systematically bring it up, judging that most men would decide to decline PSA testing, given the clear harms and small and uncertain benefits. That, however, is up to you. I personally declined, but let’s run the numbers.

Similar to the 92 percent of women who didn’t know or overestimated the mortality reduction from mammograms by tenfold or more, 89 percent of men vastly overestimated the benefits of prostate cancer screening, or simply had no idea. Most thought 50 prostate cancer deaths could be prevented out of 1,000 men regularly screened, when in reality, it’s more like one. But doesn’t even a one in 1,000 chance of not dying from cancer make a few blood tests worth it? The downsides are more than inconvenience, though.

About one in seven men who undergo PSA screening will test positive, yet in two-thirds of the cases, the biopsy results will be normal. So, out of the 1,000 men regularly screened, about 150 will have a false alarm and be biopsied unnecessarily, which can cause minor complications like pain and bloody ejaculate, or in approximately 1 percent of cases, more serious complications like blood-borne infections that require hospitalization. The greatest harm, though, is overdiagnosis. Unnecessary biopsies are bad enough, but nothing compared to unnecessary cancer treatment.

Large-scale randomized trials suggest that 20 to 50 percent of men diagnosed with prostate cancer would have never become symptomatic in their lifetime. They never would have been any wiser had they not been screened, but now they may be needlessly heading to the operating table. About three in 1,000 men die during or soon after radical prostatectomy. That may help explain why there appears to be no overall mortality benefit to prostate cancer screening. For every life that is saved, another may be extinguished for a cancer they never would have even known about.

Another 50 in 1,000 men end up with serious surgical complications. Even if the surgery goes smoothly, about one in five men develop long-term urinary incontinence requiring the use of pads, and most men—two out of three—will experience long-term erectile dysfunction. Most men who receive radiation therapy also experience long-term sexual erectile dysfunction, and up to one in six experience long-term bowel issues, such as fecal incontinence. If this was saving your life, it would be worth it; but over 16 years, rather than being saved from a prostate cancer death by screening, it may be 25 times more likely that you were instead over-diagnosed with a cancer that wouldn’t have bothered you. Yet, you come away after treatment thinking the PSA test saved your life. It’s like with the mammograms; The people who have been harmed the most—unnecessary cancer treatment—feel as though they’ve been helped the most.

In our next story, we look at a novel approach to help men change their diet after a prostate cancer diagnosis.

A cancer diagnosis is seen as a teachable moment in medicine where we can try to get people to eat healthier, but research suggests that male cancer patients in particular may be reluctant to introduce dietary modification. This has been attributed to dietary modifications often being viewed as mimicking “feminine” eating behaviors, such as emphasizing an increase in fruit and vegetables. 

Although healthy eating might enhance long-term survival, few men with prostate cancer make diet changes to advance their well-being. Many of the cancer survival trials, for example, require adherence to strict, plant-based diets, and though researchers tried providing extensive nutrition education and counseling programs, dietary adherence was still a challenge.

The way Dean Ornish was apparently able to reverse the progression of prostate cancer with a plant-based diet was home delivering prepared meals to their door, figuring men are so lazy they’ll just eat whatever’s put in front of them. After all, male culture tends to encourage men to eat convenience food, meat, and beer.

Take Men’s Health magazine, for example. Included in the list of things men should never apologize for: liking McDonald’s, not offering a vegetarian alternative, and laughing at people who eat trail mix.

It features articles with titles like, “Vegetables Are for Girls,” and sections like “Men and Meat: There’s Only One Kind of Flesh We Like Better, and Even Then, She’d Better Know How to Grill!”

To appeal to male sensibilities, doctors are advised to use ‘body as machine’ metaphors, framing men’s health in terms of mechanical objects, such as cars, requiring tuning. But if men are so concerned about their masculinity and manhood, maybe we should instead share a bit about what prostate cancer treatment entails. The prostate is situated at the base of the penis, and so when you core it out with a radical prostatectomy, you lose about an inch off your penis, if it gets erect at all. Only 16 percent of men undergoing the procedure will regain their pre-surgery level of erectile functioning.

Patients are typically quoted erectile dysfunction rates around 60 percent or 70 percent, but studies have generally considered erectile function recovery as just the ability to maintain an erection hard enough for penetration about 50 percent of the time; so, getting it up occasionally is considered recovery, but when a surgeon tells patients they will recover function, the patients probably assume that means the kind of function they had prior to surgery  And that only happens 16 percent of the time,  and only 4 percent of the time in men over 60. Only 1 in 25 gets their baseline sexual function back.

And it’s not just erections, but other problems like OAP (Orgasm-Associated Pain) even years later and urinary incontinence during foreplay, stimulation, or orgasm. The vast majority of couples overestimate how much function they’re going to recover. Couples reported feeling loss and grief. Having cancer is bad enough without the additional losses. You’d think that would be enough to motivate men to improve their diets, but almost a fourth of the men newly diagnosed with prostate cancer state they would prefer to have their lives cut short rather than living with a diet that prohibits beef and pork. More men would rather be impotent than improve their diet. It appears pleasures of the flesh may sometimes even trump…pleasures of the flesh.

In our final story today, cranberries and pumpkin seeds are put to the test for benign prostatic hypertrophy.

More than 50 percent of men in their 50s and 70 percent or more of men in their 60s suffer from benign prostatic hypertrophy or BPH––otherwise known as enlarged prostate. This can result in burdensome lower urinary tract symptoms, such as having to get up frequently at night to pee. Current medical treatments are clinically effective, but their efficacy is compromised by side effects and low compliance rates. Symptoms include sexual dysfunction, high-grade prostate cancer, and depression. No wonder there’s poor compliance. And when medication treatment fails, surgical procedures are considered, such as transurethral resection of the prostate. There has got to be a better way.

Population studies suggest that low intake of animal protein and high intake of fruits and vegetables may be protective, but not just cutting down on any animal protein. Eggs and poultry seem to be the worst, along with refined grains, but no association was found for red meat or dairy. Population studies aside, are there any foods that have been put to the test? There have been more than 30 randomized controlled trials on the herb saw palmetto. And it’s been found to be…totally useless.

Evidently, cranberries were used by Native Americans to treat urinary ailments, but you don’t know, until you put ‘em to the test. Now, when they say dried cranberries, they’re not talking about those sugary oily “craisins,” but rather just straight, whole cranberry powder. And, significant improvements were seen in BPH symptoms, quality of life, and all urination parameters for just about a teaspoon a day (around 3 grams) of powdered cranberries.

So, we know a teaspoon works, but what about a third of a teaspoon, or a sixth of a teaspoon? They also helped. So, you might as well buy it in bulk for much cheaper, and just add it to a smoothie or something.

What about a berry that’s a little tastier, like drinking purple grape juice? No benefit whatsoever.

In a previous video, I talked about the use of flax seeds, which may have a therapeutic efficacy comparable to that of commonly used drugs, with only good side effects. Okay, so what about other seeds? Pumpkin seeds have evidently been used in folk medicine as a remedy for prostate disorders for centuries, and in a petri dish, they can cut the growth of BPH prostate cells in half. Scientists have also injected pumpkin seed extracts into rabbits. But what about people?

Pumpkin seed oil appears to help with prostate issues. When pitted head-to-head against the drug Prazosin, it seemed to work as well as the pill. The same when it was head-to-head against the drug Terazosin. What they didn’t have, though, is a placebo group. It would have been nice to see how well the pumpkin seed oil supplement did against placebo. And look, in an ideal world, I’d love to see another group actually just given whole pumpkin seeds themselves. And, boom—there it is. More than a thousand men were randomized to either a pumpkin seed extract, a placebo, or just about a tablespoon a day of plain pumpkin seeds.

The study was funded by the drug company that made the supplement, but the supplement flopped; it was no better than placebo. But the pumpkin seeds themselves worked. The supplement appeared to reduce symptoms, but not better than placebo. However, just the plain old seeds did. So, it wasn’t just some compound extracted from the oil. And, in fact, we’ve since learned that even an oil-free extract seemed to work. Bottom line, the researchers concluded, is that pumpkin seed could be recommended for BPH patients with mild-to-moderate symptoms. This conclusion was echoed by the European equivalent of the FDA. Pumpkin seeds can be used for the relief of lower urinary tract symptoms related to an enlarged prostate after more serious conditions have been excluded by a medical doctor.