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Prostate cancer (PC) is the most common form of cancer and the second deadliest among men. The incidence rate varies greatly between countries. Prostate cancer is most common in Western countries, although when men migrate from non-Western countries to Europe or US, their rates of PC also rise. The reasons for the increased incidence in the West is a combination of factors: there is increased use of prostate-specific antigen (PSA) screening in the West, and the more PSA testing, the more prostate cancer that is detected. In addition, the risk of diagnosis is increased likely due to lifestyle and environmental factors.
The management of cancer is undergoing vast changes, and prostate is among those cancers most affected by this. Within the last decade, the screening, diagnosis, and treatment of PC have changed immensely. New blood serum tests can distinguish between pathologically insignificant and aggressive PC and reduce the occurrence of unnecessary biopsies (described below).
Magnetic resonance imaging (MRI) has come into its own in the diagnosis of prostate cancer. Especially with the use of the new 3-Tesla (3T) machines, MRIs can now visualize the inside of the prostate gland with amazing accuracy. MRIs have the advantage of not employing any ionizing radiation. Some patients now opt for having MRIs in advance of a biopsy, which yields information on whether or not suspicious area are in need of being physically sampled.
The new "targeted" or "fusion" biopsies fuse MRI images with real-time ultrasound to target areas that are most suspicious for cancer. The result is that at some centers, at least, prostate biopsies have become more selective, targeting the most significant questionable areas of the prostate and leaving other areas as undisturbed as possible.
Another big development has been the slow-but-steady introduction of alternatives to either radical prostatectomy (RP) or ionizing radiation therapy (RT), the two historic standby treatments of prostate cancer. Nonionizing forms of treatment that are presently available at some centers include cryoablation, radio frequency ablation (RFA), and high-intensity focused ultrasound (HIFU), which recently received FDA approval. Irreversible electroporation (NanoKnife) – which pokes tiny holes in cancer cells – is another very promising development. These ablative treatments utilize a variety of methods, including heat, cold, sound, electricity, light waves, radio waves, and so on to selectively kill PC cells, but they all avoid using ionizing radiation. They thus spare the prostate and the surrounding structures from the adverse effects of ionizing radiation.
At the same time, there is a revolution under way in deciding who really needs aggressive treatment and whose disease can be managed through dietary and lifestyle interventions. This topic is being closely studied and an "active surveillance" approach has become more accepted by the scientific community.
I also want to introduce the reader to a path-finding doctor, Geo Espinosa, ND, and his new book: Thrive – Don't Only Survive. Espinosa is a naturopathic physician who is fully integrated into an academic urology department, in this case New York University Langone Medical Center. His book on prostate cancer offers a science-based lifestyle program called the CaPLESS Method. Men – and women – who are concerned about the best treatment for PC, including natural methods, should get a copy of this very accessible book.
Who and When to Screen for Prostate Cancer
Having first-degree family members with a history of prostate cancer doubles an individual's risk of a PC diagnosis; this risk is 4 times greater when that first-degree family member has been diagnosed before age 60. African-American men are also at a much higher risk than the general population.1
Multiple genetic mutations, including BRCA 1 and BRCA 2, confer up to 7 times greater risk of PC.2
Men with an elevated risk of prostate cancer should consider screening starting at age 40. For men aged 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing death from PC for over a decade against the potential harms associated with screening and treatment.3 PSA testing has many deficiencies. But I believe that one should combine the information to be gotten from PSA with the use of other markers, such as 4K, MRIs, and an innovative blood test for 25 forms of cancer, including PC: ONCOblot (www.oncoblotlabs.com).
Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy. Screening for prostate cancer in men over 70 is a highly individualized process. If you have no family history, have never had an elevated PSA or digital rectal exam (DRE), and are in basically good health, you probably can skip any further PSA tests. But any sign of elevation of PSA over 4.0, a progressive increase in the score, or abnormality on DRE, and so on, should trigger the decision to have an MRI and possibly a biopsy as well.3
How to Screen for Prostate Cancer
The screening process for prostate cancer starts with a DRE, wherein the physician manually palpates the gland, looking for hard or nodular areas. This misses many cancers but it is still useful. The physical exam is preceded by a PSA test. Although the use of PSA for screening is controversial, the American Urological Association (AUA) still finds it useful, at least until other more reliable screening tools become more generally available.
Prostate Cancer Antigen 3 (PCA3). PCA3 is a molecule found via a urine test to determine if PC is present. It is more specific to PC than PSA. Studies with PCA3 have been mixed about its ability to determine the grade or stage of PC. For instance, a PCA3 score higher than 35 suggests that PC may be present, but it does not indicate whether it is low grade (and likely insignificant) or aggressive (and very significant).4
PSA Density (PSAD) measures the amount of PSA relative to the overall prostate size in cubic centimeters as determined by ultrasound or MRI. Sometimes a man produces more PSA because his prostate is larger, not because he has cancer in the gland. Again, as with PSA, you can have high value and not have prostate cancer. PSAD also does not tell the difference between aggressive and nonaggressive cancer.5
Percent Free PSA. This test analyzes how much free PSA is traveling in the blood and how much of that is bound to a companion protein. If more than 25% of the PSA is free, chances are that it is being produced by a noncancerous but enlarged prostate. If the free PSA is lower than 15% to 25%, it is more likely that cancer is the cause.
The 4Kscore Test. The 4Kscore is a blood test that incorporates a panel of four kallikrein protein (enzyme) biomarkers: total PSA, free PSA, intact PSA, and human kallikrein-related peptidase. It provides a percentage risk for high-grade (Gleason score 7 or higher) cancer on biopsy. In 10 studies, the kallikrein biomarkers of the 4Kscore Test have improved the prediction not only of biopsy accuracy but also surgical pathology and occurrence of aggressive, metastatic disease. The 4Kscore gives you the odds of having an aggressive cancer with a Gleason score of 7 or above.6
To Biopsy or Not to Biopsy
While MRI imaging is continuously being improved, a biopsy is still the only way that a physician can conclusively make a diagnosis of prostate cancer. Biopsies have drawbacks: they can raise the risk of potential infection, cause some discomfort, and lead to temporary blood in the urine It may also lead to temporary erectile dysfunction.7
There are two main types of biopsies: random and targeted. Random means a transrectal ultrasound (TRUS) guided biopsy. The urologist inserts a probe into the rectum while identifying the prostate area of interest on a monitor. Then a thin needle is shot through the rectal tissue in a fraction of a second, to take a small sample of prostate tissue, called a core. The number of cores can vary, but the average is 12. Targeted biopsies, also known as MRI-ultrasound fusion biopsies, are done with a TRUS along with the utilization of the MRI images, in order to target suspicious areas. This has become the biopsy of choice, although it is not yet available everywhere.8
Does the patient have the type of PC that can progress and kill him, or does he have the indolent type that will never grow, spread, and lead to an early death?
Genomic testing can reduce the chances of missing an aggressive cancer. And it can help the patient make an informed decision as to the best treatment.9
Four labs presently offer genomic testing to help patients and physicians make a more informed decision: Decipher from GenomeDx (San Diego, California), Oncotype from Genomic Health (Redwood City, California), Prolaris from Myriad Genetics (Salt Lake City, Utah), and ConfirmMDx from MDx Health (Irvine, California).
Table 1 gives a quick summary of the difference.
Active Surveillance vs. Watchful Waiting
For many men with PC, the best approach may be no aggressive treatment at all. Their cancers may be indolent enough to postpone or avoid immediate treatment. In "active surveillance," you don't have any destructive treatment until your doctor detects signs that the cancer is growing or becoming more aggressive. In the meantime you will have to return to the doctor regularly for blood tests, digital rectal exams and, possibly, periodic biopsies to keep close tabs on disease progression.10 You also will have to pay close attention to any symptoms.
As Dr. Geo Espinosa makes clear in his new book, Thrive, there is a big difference between "watchful waiting" and "active surveillance." The latter involves comprehensive lifestyle modifications, Dr. Geo's CaPLESS method (explained below).
Active surveillance is an option for those who have a cancer that is not likely to progress rapidly and have a relatively low Gleason score, PSA level, and clinical stage. However, some evidence suggests that it also might be suitable for certain men with intermediate-risk prostate cancer (such as some Gleason 3 + 4 = 7 tumors).
The biggest drawback to active surveillance is a psychological one – the ongoing stress or even panic that patients may experience, knowing they have a form of cancer and are not doing anything about it. Many men cannot handle what feels like a passive approach and have a tough time following this option. An aggressive lifestyle approach like "Dr. Geo's" CaPLESS method helps with this problem, since the patient takes action in changing eating habits, improve fitness and lifestyle, and create a inhospitable body for cancer.11
Boosting Immunity. When it comes to fighting PC, the body's first defense is the immune system. This begins with your cytotoxic lymphocytes known as natural killer (NK) cells. These seek out and destroy cancer cells. NK cells ultimately hold the key to the growth and spread of prostate cancer.
NK cells are recognized as the immune system's front-line defense against cancer, viruses, and other pathogens such as bacteria and parasites.
Interrupt Cancer Formation. Antitumor compounds work by directly and indirectly interfering with cancer cells. Yet cancer cells are also resourceful. For them to survive, they need a blood supply. As a result, they go through a process of creating their own blood vessels (called angiogenesis), primarily by producing a substance called vascular endothelial growth factor (VEGF).
Certain natural substances block the action of VEGF, preventing the formation of blood vessels that surround and feed cancerous tumors, and therefore deprive them of nutrients that they need to grow, thrive, and spread. In nature these agents interfere with the natural progression of cancer, and when taken in proper amounts can be one part of the anticancer arsenal. In fact, two of the most powerful chemotherapy drugs, paclitaxel (Taxol) and docetaxel (Taxotere), have natural roots and are ultimately derived from the Pacific yew tree.
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