Focus on Men’s Health Dr. Philip Rouchotas 1 July 2013 Focus on Men’s Health - What You Need to Know About Prostate Cancer By: Philip Rouchotas MSc, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca email@example.com Jump to: Part 1 Part 2 Part 3Part 4 Part I: What is Prostate Cancer? Though not popularly discussed, prostate health or lack thereof impacts most men as they approach the age of 50 or older. It is hard to believe that this little organ, about the size of a walnut, can be so important. Nonetheless, prostate disease falls into two general categories: benign prostate disease and prostate cancer. Prostate Disease Benign prostatic hypertrophy (BPH or enlarged prostate) is a common but non-cancerous condition among men over 50 years of age. Symptoms include urinary frequency, difficulty urinating, or having to get up at night to urinate. These symptoms arise due to the enlarged prostate compressing on the urethra. Although this has long been attributed to actions of the hormone testosterone, newer research suggests that excess estrogen, which can be converted from testosterone in men especially in fat tissue, may also play a role.(1) Prostate cancer on the other handis a malignant condition characterized by uncontrolled cellular proliferation. Prostate cancer is the second leading cause of cancer in men, following lung cancer, with over 238,000 new cases expected in 2013.(2) Prostate cancer growth is also driven by testosterone. These two conditions may be easily confused, since both may present with similar symptoms; therefore, getting appropriate testing is crucial. Diagnosis There are two essential parts to prostate cancer screening and diagnosis. The first is theblood test called PSA (Prostate Specific Antigen). PSA is used to screen for prostate disease, but it is not specific for prostate cancer, since it will also be elevated in men with BPH.(3) Higher PSA predicts higher risk, however, it needs to be interpreted in light of the relative amounts of free and total PSA. Therefore, the ratio of free-to-total PSA is even more predictive of prostate cancer risk than total PSA alone.(4,5) While elevated total PSA predicts higher risk, lower free-to-total PSA correlates with higher risk. In some cases, PSA may decrease, but free PSA may decrease more, leading to an overall worsening in risk. It is crucial to have a healthcare provider with expertise in this area assist you in getting appropriate testing and interpretation of results. The second step in diagnosis is having a prostate biopsy with an assessment of the tumor sample for appearance of the cells and aggressiveness of the tumor. This system of tumor grading is called the Gleason score; depending on what the Gleason score is for a particular patient, either a “wait and watch” approach, or active anticancer therapy such as surgery and chemotherapy will be recommended.(6) Early stage, non-aggressive forms of prostate cancer do not usually warrant aggressive anticancer treatment. Instead,a “wait and watch” approach also known asactive surveillance is advised for slow changing tumors. Receiving a diagnosis at this time is actually important because this is the ideal time to implement diet and lifestyle changes that can slow the progression of an early-stage cancer. In Part II we will discuss diet and lifestyle strategies that can prevent the development of prostate cancer and improve prognosis of existing cancer. References 1. Nicholson TM, Ricke WA. Androgens and estrogens in benign prostatic hyperplasia: past, present and future. Differentiation. 2011;82(4-5):184-99. 2. American Cancer Society. Cancer facts & figures 2013. URL: http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/ca…. Accessed 29 April 2013. 3. Bantis A, Grammaticos P. Prostatic specific antigen and bone scan in the diagnosis and follow-up of prostate cancer. Can diagnostic significance of PSA be increased? Hell J Nucl Med. 2012;15(3):241-6. 4. Toubert ME, Guillet J, Chiron M, Meria P, Role C, Schlageter MH, et al. Percentage of free serum prostate-specific antigen: a new tool in the early diagnosis of prostatic cancer. Eur J Cancer. 1996;32A(12):2088-93. 5. Luboldt HJ, Swoboda A, Börgermann C, Fornara P, Rübben H; Early Detection Project Group of the German Society of Urology. Clinical usefulness of free PSA in early detection of prostate cancer.Onkologie. 2001;24(1):33-7. 6. Epstein JI. An update of the Gleason grading system. J Urol. 2010;183(2):433-40. Focus on Men’s Health - What You Need to Know About Prostate Cancer Part II: Diet and Lifestyle Influences on Prostate Cancer Risk and Prognosis by: Philip Rouchotas MSc, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca firstname.lastname@example.org In Part I we reviewed the diagnosis and usual treatment of prostate cancer. In this section we discuss importantdiet and lifestyle factors that play a role in the risk of both developing prostate cancer as well as in the progression of prostate cancer: fruits & vegetables and dietary fiber reduce risk, while intake of saturated fat, refined carbohydrates, and being overweight result in increased risk of prostate cancer. Fruit and vegetable consumption A large study conducted by Harvard University followed 1,560 men diagnosed with non-metastatic prostate cancer for several years.(1) Men were categorized into four groups according to their intake of vegetables: the top group consumed 5.7 servings of vegetables per day, while the bottom group consumed only 1.4 servings per day. With respect to cruciferous vegetables like broccoli and cauliflower, the highest group consumed almost one serving per day, while the lowest group consumed almost none. Men in the highest group of cruciferous vegetable intake had an almost 60% lower risk of progression of their prostate cancer. At least 5 servings each of fruits and vegetables per day are recommended for cancer prevention. Dietary fiber Fiber in the diet assists in the elimination of hormones and hormone metabolites from the body.(2) An American study of dietary fiber, intake over 20g per day was associated with approximately 50% decreased risk of prostate cancer compared to fiber intake under 13g per day.(3) Saturated fat The large NIH-American Association of Retired Persons (AARP) Diet and Health Study followed 288,268 men for nine years. Saturated fat intake was associated with an over 20% increased risk of advanced prostate cancer, and 47% increased risk of fatal prostate cancer. On the other hand, intake of the omega-3 fatty acid EPA was associated with an almost 20% decreased risk of fatal prostate cancer.(4) Refined carbohydrates A high intake of refined carbohydrates has been associated with increased risk of prostate cancer. A 15 year study following 8128 healthy men aged 45-73 yearsfound that a high intake compared with zero intake of sugar-sweetened beverages was associated with a trend toward 38% increased risk of prostate cancer.(5) In addition, among men with high blood sugar at the time of diagnosis had a 50% greater increased risk of cancer recurrence within approximately 3.5 years, compared to men with normal blood sugar.(6) Body mass index Maintaining a healthy body weight is crucial in preventing cancer. Carrying excess fat tissue results in fat cells producing hormones and growth factors that drive cancer growth. When prostate cancer patients are being assessed to determine whether they qualify for active surveillance or whether they need more aggressive therapies, overweight and obese men have up to a four-fold increased risk of having more aggressive tumors than testing would otherwise indicate.(7) Among men undergoing surgery for prostate cancer, those who gained even 2.5kg (5lb) had increased risk of recurrence, while those who lost the equal amount of weight did not.(8) Part III will discuss supplements that can complement the effect of a healthy dietary pattern for prostate cancer. References 1. Richman EL, Carroll PR, Chan JM. Vegetable and fruit intake after diagnosis and risk of prostate cancer progression.Int J Cancer. 2012;131(1):201-10. 2. Li Z, Aronson WJ, Arteaga JR, Hong K, Thames G, Henning SM, et al. Feasibility of a low-fat/high-fiber diet intervention withsoy supplementation in prostate cancer patients after prostatectomy. Eur J ClinNutr. 2008;62(4):526-36. 3. Lewis JE, Soler-Vilá H, Clark PE, Kresty LA, Allen GO, Hu JJ. Intake of plant foods and associated nutrients in prostate cancer risk.Nutr Cancer.2009;61(2):216-24. 4. Pelser C, Mondul AM, Hollenbeck AR, Park Y. Dietary Fat, Fatty Acids, and Risk of Prostate Cancer in the NIH-AARP Diet and Health Study. Cancer EpidemiolBiomarkers Prev. 2013;22(4):697-707. 5. Drake I, Sonestedt E, Gullberg B, Ahlgren G, Bjartell A, Wallström P, et al. Dietary intakes of carbohydrates in relation to prostate cancer risk: a prospective study in the Malmö Diet and Cancer cohort. Am J ClinNutr. 2012;96(6):1409-18. 6. Wright JL, Plymate SR, Porter MP, Gore JL, Lin DW, Hu E, et al. Hyperglycemia and prostate cancer recurrence in men treated for localized prostate cancer. Prostate Cancer Prostatic Dis. 2013 Mar 5. 7. Ploussard G, de la Taille A, Bayoud Y, Durand X, Terry S, Xylinas E, et al. The risk of upstaged disease increases with bodymass index in low-risk prostate cancer patients eligible for active surveillance.Eur Urol. 2012;61(2):356-62. 8. Whitley BM, Moreira DM, Thomas JA, Aronson WJ, Terris MK, Presti JC Jr, et al; SEARCH Database Study Group. Preoperative weightchange and risk of adverse outcome following radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital database. Prostate CancerProstatic Dis. 2011;14(4):361-6. Focus on Men’s Health - What You Need to Know About Prostate Cancer Part III: Natural Strategies for Early Stage Prostate Cancer by: Philip Rouchotas MSc, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca email@example.com In Part I we reviewed two common courses of treatment for prostate cancer; active surveillance for early-stage non-aggressive prostate cancer, or a combination of surgery, chemotherapy, and radiation followed by hormonal therapy for aggressive or recurrent cancers. For those with non-aggressive tumors on active surveillance, a selection of natural agents may help decrease PSA and slow tumor growth. Lycopene An exciting dietary agent for the prevention and treatment of prostate cancer is the tomato-based flavonoid, lycopene.(1) Lycopene consumption (approximately 1 cup cooked tomatoes or 2 tbsp tomato paste per day) has been shown to predict a low rate of prostate cancer.(1) Among men with prostate cancer, lycopene supplementation (tomato extract standardized to 5-10% lycopene content) has been shown to reduce PSA levels and reduce tumor size.(2-4) Lycopene intake has been associated with approximately 20% reduced risk of prostate cancer.(1) In studies of prostate cancer patients, lycopene supplementation was found to slow the rate of disease progression as well as reduce symptoms such as pain and urinary symptoms.(5) The target dose of lycopene is 30mg lycopene per day, equivalent to~2 tbsp of tomato paste per day, or 1 serving of cooked tomato 5 days per week. Selenium In men with low selenium levels, supplementation can help lower risk of prostate cancer.(6) Selenium supplementation has been shown to reduce incidence of prostate cancer by ~50%.(7) Selenium has been associated with possible increased cancer and diabetes risk in people with higher levels, so a low dose of selenium only is recommended: 50mcg per day, which can easily be obtained from Brazil nuts. Only 1 Brazil nut delivers 50mcg.(8) Green tea Green tea is thought to act on the tumor cells to cause death and prevent further proliferation. One study examined the use of green tea extract in prostate cancer patients awaiting surgery. The tumor samples taken at surgery showed significant reductions in PSA and growth factors such as insulin-like growth factor and vascular endothelial growth factor compared to baseline.(9) Soy Soy is thought to block the stimulating effect of hormones on tumor cells. In prostate cancer patients who have undergone surgery and are at risk of recurrence, a combined dietary intervention of low fat (15%), high fiber (21g/d), and soy supplementation (40g soy protein isolate) has been shown to lower blood levels of hormones and growth factors that stimulate tumor growth. When prostate cancer cells were exposed to blood from these patients, in a lab setting, the cancer cells growth was significantly inhibited.(10) Patients currently receiving chemotherapy or radiation should consult with a licensed healthcare provider prior to taking natural health products. This will ensure most effective use of supplements as well as minimize the potential for negative interactions with chemo or radiation. References 1. Giovannucci E, Rimm EB, Liu Y, Stampfer MJ, Willett WC. A prospective study of tomato products, lycopene, and prostate cancer risk. J Natl Cancer Inst. 2002;94(5):391-8. 2. Zhang X, Wang Q, Neil B, Chen X. Effect of lycopene on androgen receptor andprostate-specific antigen velocity. Chin Med J (Engl). 2010;123(16):2231-6. 3. Grainger EM, Schwartz SJ, Wang S, Unlu NZ, Boileau TW, Ferketich AK, et al. A combination of tomato and soyproducts for men with recurring prostate cancer and rising prostate specific antigen.Nutr Cancer. 2008;60(2):145-54. 4. Vaishampayan U, Hussain M, Banerjee M, SerenS, Sarkar FH, Fontana J, et al. Lycopene and soy isoflavones in the treatment of prostate cancer. Nutr Cancer. 2007;59(1):1-7. 5. Haseen F, Cantwell MM, O'Sullivan JM, Murray LJ. Is there a benefit from lycopene supplementation in men with prostate cancer? A systematic review. Prostate Cancer Prostatic Dis. 2009;12(4):325-32. 6. Marshall JR, Tangen CM, Sakr WA, Wood DP Jr, Berry DL, Klein EA, et al. Phase III trial of selenium to preventprostate cancer in men with high-grade prostatic intraepithelial neoplasia: SWOG S9917. Cancer Prev Res (Phila). 2011;4(11):1761-9. 7. Duffield-Lillico AJ, Dalkin BL, Reid ME, Turnbull BW, Slate EH, Jacobs ET, et al; Nutritional Prevention of Cancer Study Group. Selenium supplementation, baseline plasma selenium status and incidence of prostate cancer: an analysis of the complete treatment period of the Nutritional Prevention of Cancer Trial. BJU Int. 2003;91(7):608-12. 8. Thomson CD, Chisholm A, McLachlan SK, Campbell JM. Brazil nuts: an effective way to improve selenium status. Am J ClinNutr. 2008;87(2):379-84. 9. McLarty J, Bigelow RL, Smith M, Elmajian D, Ankem M, Cardelli JA. Tea polyphenols decrease serum levels of prostate-specific antigen, hepatocyte growthfactor, and vascular endothelial growth factor in prostate cancer patients andinhibit production of hepatocyte growth factor and vascular endothelial growthfactor in vitro. Cancer Prev Res (Phila). 2009;2(7):673-82. 10. Li Z, Aronson WJ, Arteaga JR, Hong K, Thames G, Henning SM, et al. Feasibility of a low-fat/high-fiber diet intervention withsoy supplementation in prostate cancer patients after prostatectomy. Eur J ClinNutr. 2008;62(4):526-36. Focus on Men’s Health - What You Need to Know About Prostate Cancer Part IV: Natural Strategies to Support Hormonal Therapy of Advanced Prostate Cancer by: Philip Rouchotas MSc, ND Bolton Naturopathic Clinic 64 King St W, Bolton, ON L7E1C7 www.boltonnaturopathic.ca firstname.lastname@example.org In Part III we discussed the use of natural agents to slow progression in patients on active surveillance. Patients with aggressive tumors or cancer recurrence are treated with a combination of surgery, radiation, and chemotherapy, which may be followed by an anti-testosterone drug regimen called androgen-deprivation therapy in patients with metastatic disease. The side effects of androgen-deprivation therapy (ADT) can be considerable, including feminization, hot flashes, depression, blood sugar and cholesterol problems, loss of muscle mass, and osteoporosis.(1,2) Nonetheless, studies have shown that its use does improve survival.(3) At this stage of disease, focus shifts to supporting the body through therapy. Specific natural agents can help offset the side effects of ADT. It is highly advisable to seek the care of a licensed naturopathic doctor to help guide the process of diet and supplemental strategies for a person at this stage of illness. Certain dietary inclusions and exclusions are key in helping manage negative metabolic consequences of ADT: cholesterol, blood sugar, loss of muscle mass, osteoporosis, and possibly mood. These include: One handful of raw nuts (almonds, walnuts, pistachios) per day;(4) Two tbsp. of raw extra virgin olive oil per day;(5) Avoid coffee which has not been paper filtered (most deluxe home brewing machines, espresso, cappuccino, French press, latte, etc). Coffee which has been paper filtered is permissible. Maintain a healthy body weight; if possible, engage in 30min of moderate intensity physical activity five days per week(6) Select nutritional supplements have proven very useful for individuals undergoing ADT. The below is a very brief list of some key agents to consider: Creatine is an important agent for maintaining muscle mass.(7) It is dosed at 3g per day. High EPA fish oil provides a long list of benefits which include but are not limited to improved mood, decreased loss of muscle mass (cachexia), decreased inflammation, improved cholesterol levels. The fish oil used should contain more EPA than DHA.(8-10) The appropriate dose is 1-2g EPA per day. Flaxseed is an important source of omega-3 fatty acids, and has also been shown to reduce symptoms of hot flashes (11). In other types of cancer, flaxseed has been shown to reduce tumor cell proliferation.(12) 2-4 tbsp per day. Vitamin D possesses anti-cancer effects, and is also a critical nutrient to maintain bone health.(13) Cancer patients are often deficient in vitamin D and ideally dosing should be chosen based on the results of blood testing. A conservative dose for those without testing is 2000 IU per day. References 1. Sağlam HS, Köse O, Kumsar S, Budak S, Adsan O. Fasting blood glucose and lipid profile alterations following twelve-month androgen deprivation therapy in men with prostate cancer. ScientificWorldJournal. 2012;2012:696329. 2. Haseen F, Murray LJ, Cardwell CR, O'Sullivan JM, Cantwell MM. The effect of androgen deprivation therapy on body composition in men with prostate cancer:systematic review and meta-analysis. J Cancer Surviv. 2010;4(2):128-39. 3. Loblaw DA, Virgo KS, Nam R, Somerfield MR, Ben-Josef E, Mendelson DS, et al; American Society of Clinical Oncology. Initial hormonalmanagement of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practiceguideline. J ClinOncol. 2007;25(12):1596-605. 4. Damasceno NR, Pérez-Heras A, Serra M, Cofán M, Sala-Vila A, Salas-Salvadó J, et al. Crossover study of diets enriched with virgin olive oil, walnuts oralmonds. Effects on lipids and other cardiovascular risk markers. NutrMetabCardiovasc Dis. 2011;21Suppl 1:S14-20. 5. Paniagua JA, de la Sacristana AG, Sánchez E, Romero I, Vidal-Puig A, BerralFJ, et al. AMUFA-rich diet improves posprandial glucose, lipid and GLP-1 responses ininsulin-resistant subjects. J Am CollNutr. 2007;26(5):434-44. 6. Culos-Reed SN, Robinson JW, Lau H, Stephenson L, Keats M, Norris S, et al. Physical activity for men receiving androgen deprivation therapy forprostate cancer: benefits from a 16-week intervention. Support Care Cancer. 2010;18(5):591-9. 7. Johnston AP, Burke DG, MacNeil LG, Candow DG. Effect of creatinesupplementation during cast-induced immobilization on the preservation of muscle mass, strength, and endurance. J Strength Cond Res. 2009;23(1):116-20. 8. Sublette ME, Ellis SP, Geant AL, Mann JJ. Meta-analysis of the effects ofeicosapentaenoic acid (EPA) in clinical trials in depression. J Clin Psychiatry. 2011;72(12):1577-84. 9. Murphy RA, Mourtzakis M, Chu QS, Baracos VE, Reiman T, Mazurak VC. Nutritional intervention with fish oil provides a benefit over standard of care for weightand skeletal muscle mass in patients with nonsmall cell lung cancer receivingchemotherapy. Cancer. 2011;117(8):1775-82. 10. Jacobson TA. A new pure ω-3 eicosapentaenoic acid ethyl ester (AMR101) for the management of hypertriglyceridemia: the MARINE trial. Expert Rev CardiovascTher.2012;10(6):687-95. 11. Colli MC, Bracht A, Soares AA, de Oliveira AL, Bôer CG, de Souza CG, et al. Evaluation of the efficacy of flaxseed meal and flaxseed extract in reducing menopausal symptoms. J Med Food. 2012 Sep;15(9):840-5. 12. Thompson LU, Chen JM, Li T, Strasser-Weippl K, Goss PE. Dietary flaxseed alters tumor biological markers in postmenopausal breast cancer. Clin Cancer Res. 2005;11(10):3828-35. 13. Shapses SA, Sukumar D, Schneider SH, Schlussel Y, Sherrell RM, Field MP, et al. Vitamin D supplementation and calcium absorption during caloric restriction: a randomized double-blind trial. Am J ClinNutr. 2013;97(3):637-45.