Friday, October 14, 2011

Should You Get the Test for Prostate Cancer?

Two years ago the United States Preventive Services Task Force stirred up a bit of controversy by stating, after an intensive review of the medical literature, that Mammograms don’t have a good cost/benefit analysis for women under age 50 (see blog November 2009.) Just as the dust was beginning to settle, the Task Force is at it again; it now recommends that asymptomatic men forego the famous PSA, or Prostate Specific Antigen widely used to screen for prostate cancer.

Just as I agreed with the Task’s Mammogram recommendations, I agree that the PSA should no longer be done, unless men are having symptoms in their genitourinary area. But, before you have a cow, please, keep in mind that any man who wants the test may still get it, just as any woman who wishes to have a Mammogram may do so.

I plan to recommend ambivalent asymptomatic men that they forego the PSA. Of course, some men will choose to get the PSA and then ignore a positive finding, or will welcome aggressive follow up testing and treatment if the PSA were to be elevated. Some men may also choose screening to implement the lifestyle changes outlined below. I will gladly do the test for them while I review the Task Force’s reasons for its recommendation stance. It is based on many studies, most of which I have reviewed, that have concluded that any treatment or prostate cancer is not likely to prolong life. While they may make the consequences of cancer less problematic in some cases, the incidence of problems like incontinence and impotence is high enough to question the potential benefits from aggressive therapy. In fact, conservative therapy has better survival.[1]Besides, the PSA leads to over-diagnosing or unwarranted testing and procedures on healthy men.[2]

Whence prostate cancer?

Once we determine why men get prostate cancer we may then be more effective in preventing it. At an Endocrine Society Symposium in 2005 it was posited that estrogen-like chemicals in the environment (plastics, heavy metals, pesticides, dioxins chlorinated compounds, etc) over stimulate growth of the prostate and female sex organs and breasts.[3] This problem is worsened in those who do not eat optimal amounts of plant-based foods, particularly cruciferous vegetables[4] that are redolent with antioxidants to fuel our detoxification pathways.[5] In other words, any amount of over stimulation of those sensitive tissues is “the canary in the coal mine.”[6]

Consequently, poor diets high in alcohol, fats[7] and refined sugars[8] increase the risk of any cancer. In 1931 Dr. Otto Warburg won the Nobel Prize in Medicine by demonstrating that cancers are more common in those whose glucose levels are higher. This is one of the reasons that dairy has been linked to prostate cancer:

High milk consumption has consistently not been associated with lower risk of fractures in large prospective studies, whereas increased risks of advanced or fatal prostate cancer have been observed in many studies.”[9]

How to lower your risk of prostate cancer

Obviously, avoiding estrogen-like toxins (“xenoestrogens”) is the first step. Minimizing processed foods and cutting down on alcohol and dairy products is also recommended. Eating plant based foods may reduce the risk of ANY cancer by 2/3.[10] Changing our lifestyles for only two years as above, while being more active and maintaining good relationships has been shown to significantly reduce the risk of prostate cancer.[11] It seems that the protective changes accrued involve DNA changes, specifically, lengthening the chromosomes’ telomeres,[12] a concept that won the Nobel Prize in 2008.

Details

Vegetables have more zinc[13] and selenium;[14] they help lower the risk of prostate cancer. Herbs like Milk Thistle[15] and Curcumin[16]have shown significant benefits. The following nutrients have also been shown to be helpful, in addition to the ones highlighted in the September 2011 newsletter, like pomegranate juice:

Soy isoflavones, J. Nut and Cancer 2008;60:461

Green tea, J. Nut and Cancer 2008;60:483

Walnuts, J. Clin Cancer Res 2008;14:4491

Fish, J. Nut and Cancer 2008;60:222

Tomatoes, J. Nutrition and Cancer 2008;60:145

Vitamin D J. Carcinogenesis 2005;27:32

Grape seed extract, Int J. Cancer 2004;108:733

Olive oil, Br J. Nut 2002;88:225

The best!

…. Or men would like to think so: frequency of ejaculation is not related to prostate cancer, but it might reduce its incidence![17] Guys always ask me to write that down as a prescription to show their significant others….



[1]Conservative Management on Prostate Cancer,” JAMA 2009;302:1202

[2] J. Natl. Cancer Inst. 2009 :101; 1293

[3]Endocrine-disrupting chemicals probed as potential pathways to illness,” JAMA 2005;294:291

[4] J. National Cancer Institute 2000;92:61

[5] J. National Cancer Institute January 5th 2000

[6]Prostate enlargement: the canary in the coal mine?” Am J. Clin Nut 2002;75:605

[7] American Cancer Society 2005

[8]Prostate cancer prevention [is possible] by nutritional means to alleviate metabolic syndrome,” AJCN 2007;86:889S

[9] Am J. Prev Med 2005;29:320 & British J. Nutrition 2006;95:539

[10] Apoptosis by dietary factors,” J. Carcinogenesis 2007;28:233

[11]Clinical Events in Prostate Cancer Lifestyle Trial: results from 2 years follow up,” J. Urology 2008;72:1319

[12]Increased Telomere Activity and Comprehensive Lifestyle Changes,” J. Lancet Oncology 2008;9:1048

[13]Zinc deficiency alters DNA damage response genes in normal human prostate epithelial cells,” J. Nutrition 2008;138:667

[14] J. Nut and Cancer 2008;60:171

[15] J. Carcinogenesis 2001;22:1399

[16] J. Carcinogenesis 2007;28:1188

[17] JAMA 2004;291:1578

Friday, October 7, 2011

"Salus Populi Suprema Lex" -- The health of the people is the supreme law.

Salus Populi Suprema Lex.” The health of the people is the supreme law[1]

The responsibilities of the physician extend not only to the individual but also to society and demand his cooperation and participation in activities which have as their objective the improvement of the health and welfare of the individual and the community... As good citizens it is the duty of physicians to be ever vigilant for the welfare of the community.”[2]

Doctor Rudolph Virchow, considered to be the father of Cell Pathology, was a contemporary of Otto Bismarck. Virchow was very involved in public health, which irritated Bismarck to no end. When Virchow opposed him on the issue of Employer-Based Health Insurance, Bismarck challenged the good doctor to a duel. As tradition would have it, Virchow had the questionable honor of choosing the weapons: sausages. At that time, and perhaps to this day, sausages were widely felt to be the reason many fell ill, no doubt due to the conditions under which they were made. Bismarck, on viewing the “weapons” relented, amused, and perhaps fearful that handling the wieners could make him ill. He famously declared that “Laws are like sausages; it is better not to see them
being made
.”

Today, doctors face the same dilemma: community involvement versus politics that would absolve physicians of that noble obligation as described in the AMA code of ethics.

Virchow was a man ahead of his time. He determined over 150 years ago that practically all diseases are inflammatory conditions, a fact not fully understood until the 21st century. But, in my opinion, his skills as an Anthropologist sealed his place in medicine by stating that “Medicine is a social science, and politics nothing but medicine on a large scale. Physicians are the natural attorneys of the poor.” Many doctors have followed his example and thus laid the foundations of modern Public Health and Medicine. By taking care of community issues such as clean water and food, garbage disposal, sewage, etc. illnesses were dramatically reduced and in many cases prevented. Leaps forward in longevity were thus achieved.

Much of the subsequent spectacular progress in public health in the 19th and early 20th centuries was due to a better understanding of microbiology and the transmission of infectious diseases, together with the recognition of the importance of clean water, hygiene and sanitation.”

But what are public health physicians and government policy makers doing about this state of affairs? There is no coordinated strategy, and there is a very poor information base on effectiveness and cost-effectiveness... Properly thought out prevention, especially targeting young adults and children will save the resources necessary for treatment of chronic diseases later. But where are the zealous physicians and public health advocates of the 19th and 20th centuries?”[3]

Doctors like Virchow are struggling to be heard over the chorus of voices who feels physicians should not be involved in the community.[4] No doubt economic pressures and the inherent arduous nature of practicing medicine make community involvement difficult if not impossible. After all, attending to patients in our clinics is our main obligation. By maximizing effectiveness, quality and savings in our clinics we also benefit the patients we serve.

One group of doctors in Salt Lake City (IHC) has made national news by computerizing practice protocols for maximum efficiency in their pharmaceutical/surgical approach. Why not do the same with community/environmental issues?

If doctors were to study similar protocols designed to track public health issues like polluted air, processed foods, and other community issues that impact our patients’ health, how much more efficiently could we serve our patients? These protocols already exist, but they tend to be ignored as not “hard” enough evidence[5] or as “a socialist agenda.”

The new baseball movie “MoneyBall” chronicles how teams are now using the same computerized approach; by crunching player stats teams rank the best players available. Mr. Beane struggled to convince baseball higher ups to adopt this approach for years. He finally succeeded with the Boston RedSox who went on to win the World Series in 2004 and 2007. There is no argument that money and profits are powerful motivators. Even the most idealistic physicians would agree. In a sense we now have “MoneyHealth.”If ALL issues pertaining to our patients’ health were plugged into the computer, we would certainly save a lot of money[6] and keep our communities healthier.[7]

Capitalist innovators like Schumacher[8] have pleaded for years that the bottom line of Capitalism be expanded beyond profits to include social and environmental responsibility.[9]

It is tempting to retreat away from public health issues in today’s present economic/political situation. But, strong ideologies may not be conducive to putting patients’ welfare first, which is bound to deteriorate, especially for the poor.[10] If physicians do not live up to Virchow’s legacy, our communities may be at a higher risk of “Collapse.”[11]

Should medicine ever fulfill its great ends it must enter into the larger political and social life of our times. It must indicate the barriers which obstruct the normal completion of the life cycle and remove them. Should this ever come to pass, medicine whatever it may then be will become the good of all.”[12] Virchow



[1] American J. Public Health 2001;91:689

[2] AMA statement quoted in “Social and Political Responsibilities of Physicians,” J. Med Philos 1977;2: 376

[3]The Catastrophic Failures of Public Health,” J. Lancet 2004;363:745

[4]Medicine Is a Social Science in Its Very Bone and Marrow,” J. Mayo Clin Proc October 2011;86(10):930

[5]Medicine Is a Social Science in Its Very Bone and Marrow,” J. Mayo Clin Proc October 2011;86(10):930

[6]The future of Public Health,” Special issue, J. Managed Care, September 2005;14#9

[7] Structural Interventions for Addressing Chronic Health Problems,” JAMA 2009;302(6):683

[8] Book “Small is Beautiful: economics as if people mattered,” E.F. Shumacker; Hartley & Marks 1973

[9] Book “The Politics of Fortune; a new agenda for business leaders,” Jeffrey Garten; Harvard Business School Press, 2002

[10]Facing the New Reality: preparing poor America for harder times.” Report by Community Action Agencies, 2011

[11] Book “Collapse: how societies choose to fail or succeed” by award-winning anthropologist Jared Diamond; Viking Press, 2005

[12]Rudolf Virchow, Public Health and the Built Environment,” J. of Urban Health 2003;80:523