1. Thanks Dalene for bringing this pilot study to the attention of those battling prostate cancer or trying to prevent it. Information about the role of diet and stress reduction in preventing and combatting prostate cancer needs to reach a wider audience, and this blog helps.

The study is further evidence that a supportive program involving diet, nutrition, supplements, stress reduction and exercise can help combat prostate cancer. While the study did not address exercise, there is a growing body of evidence that all these elements increase our chances of success. (I write this as my sore muscles are recovering from a workout this afternoon.)Dr. Charles Myers, Jr., MD, a medical oncologist specializing in prostate cancer who is very well known in the PC survivor community, has strongly advocated a program of nutrition, stress reduction and exercise for many years now. Dr. Mark Moyad, MD, another well-known communicator to the prostate cancer community, also advocates such a program. So, while the news is not new to some of us, it is most welcome as a further favorable indication that we are on the right track. For those interested, you can get an abundance of information from the National Library of Medicine's site, www.pubmed.gov, by searching for "prostate cancer AND ____", filling in the topic of your specific search, such as "emotional stress" (91 hits on that particular search); check them out by clicking on the authors' list, which will give you the abstract of the study for free).

This study used a "plant based diet" in their experiment, so it was a diet low in saturated fat (but perhaps not low in monounsaturated and polyunsaturated fat). Dr. Myers and others have urged us to eat a diet that is predominantly plant based, but not low in mono and polyunsaturated fat. (More details of his recommendations are at www.prostateforum.com, including, I think, references to two books for PC patients involving nutrition that Dr. Myers has authored or co-authored, and at www.cancer-foundation.org, another site that he and his team sponsor. There are other good books on PC and nutrition as well, such as Dr. Bob Arnot's oldie but goodie (about 2000), "The Prostate Cancer Prevention Plan."

However, the abstract of the study contains one egregiously erroneous, misleading statement about the efficacy and safety of hormonal blockade therapy for prostate cancer. I'm addressing that in a second reply.

Jim Waldenfels (web site: http://www.mycancerplace.com/profile.php?id=147)

Posted at 5:46PM on Dec 23rd 2006 by Jim Waldenfels

2. While Dalene's blog was excellent in my opinion, as I mentioned, the abstract of the study itself contains an egregiously erroneous and misleading statement about the effectiveness and safety of hormonal blockade. I'll give the authors half a pass, as they have swallowed one of the myths about hormonal blockade. Those of us following developments in hormonal blockade closely know it is a myth and we think we understand its basis. The real, unfortunate consequence is that many men do not consider advanced hormonal blockade as an option, which is proving surprisingly effective, tolerable (though hardly a cake walk) and safe.

Here's the problem. The abstract includes the following misleading statement: "While hormonal therapy may slightly extend survival in a minority of patients, it is not curative and produces side effects including hot flashes, decreased libido, and loss of bone mass."

Hormonal therapy, specifically the advanced triple hormonal blockade form of that therapy, has been my therapy for an advanced, challenging case of prostate cancer for the past seven years; I have had no other therapy (no surgery, no radiation, etc.), though I have supported hormonal blockade with diet/nutrition/supplements, exercise and stess reduction. My case was challenging, with an initial PSA of 113.6 (very high and rare) and a biopsy/staging indicating aggressiveness and adverse features. Yet I'm alive and thriving at the seven year point and expect to continue for years to come. I had two respected urologists from respected institutions (The City of Hope, Johns Hopkins) give me a prognosis in early 2000 of three to five years, with three good and two declining years. They were reading the same sheet of wrong music in 2000 that the authors of the current study were influenced by.

In fact, there seem to be three groups of responses to advanced hormonal blockade. The first group, nowdays a small minority thanks to early screening with the PSA test, or better, PSA plus Digital Rectal Exam, seems to typically have at diagnosis widespread cancer that has metastasized to the bone, or other signs of a highly aggressive cancer (more so than mine). While they do typically benefit from advanced hormonal blockade, it often needs to be combined with a short course of chemo at the outset, and even that combination does not stop the progression of cancer in a substantial proportion of cases. This is the group that most nearly matches the pessimistic forecast in the study abstract. Fortunately, with recent advances, such as zoledronic acid (Zometa) to help protect bone density and combat bone metastases, to name just one such advance, this group of patients has a significantly improved prognosis, though their situation is still challenging.

The middle group responds like I have: we are capable of achieving repeated complete remissions and going "off-therapy" under an intermittent program, with usually a satisfactory quality of life while on therapy and often an excellent to outstanding quality of life off-therapy, and many of us are capable of doing this for an extended period, such as at least a decade or two. In effect, it appears we may have turned the disease into a chronic and controllable disease, like diabetes, rather than a lethal disease. The outer limit really is not established yet, as significant numbers of patients began using triple hormonal blockade only in the early 1990s. Speaking personally, I confidently expect to be off-therapy for at least a year and a half, and then I confidently expect to be successful with another round of full therapy, lasting at least a year, followed by subsequent rounds. If those like me eventually need additional therapy, there is more powerful hormonal therapy available, but it involves more side effects and drug interactions (such as high dose ketoconazole with hydrocortizone). If all that fails, modern chemotherapy for prostate cancer is steadily improving. All of this adds many years of successful control of the cancer. I would be happy to provide citations to medical research. The Scholz, Lam, Strum and others research published this year in the Journal of Urology is one prime instance.

The third and most favorable group, a very large group these days, essentially features low-risk prostate cancer patients who need only one round of triple blockade (no surgery, no radiation, no cryo, etc.) for about a year before going on an easy maintenance program for many, many years, apparently for the rest of their lives. That's not a cure, but it is a maintained, durable complete remission. Their quality of life off-therapy is excellent, highly similar to the quality prior to therapy. While there have been no published studies in peer-reviewed, respected journals (disregarding a a short follow-up study published in the Oncologist by Leibowitz and Tucker in 2001), there is a growing body of clinical observation that indicates that just one round is all it takes for a stunningly high percentage of low-risk men - virtually 100%. The best evidence I know of is available at www.doctorleibowitz.com on the home page via the button for the Orlando presentation to the special meeting on prostate cancer of the American Society for Clinical Oncology (ASCO). Follow-up for the earliest patients is around fifteen years, and the presentation reported amazing success for the first 100 who reached the median 75 month point since first therapy, including an on-therapy period of just thirteen months.

I think there's little doubt among those following intermittent triple therapy that it does far more than "slightly extend survival," as stated in the study abstract. While it is not considered curative for most men, it is considered curative for a small proportion, a point made by the eminent PC physician Dr. E. David Crawford, both in his published papers and in his presentations to patients at this October's "International Conference on Prostate Cancer, 2006." Drs. Stephen Strum and Mark Scholz, partners before Dr. Strum's semi-retirement, also have observed that there appears to be a small percentage of cures, an observation also made by Dr. Robert Leibowitz and Dr. Charles Myers, Jr. Estimates I have heard are that the cure rates range from a few percent to ten percent. These would be true cures, not maintained complete remissions. Therefore, the study abstract's statement that hormonal blockade is not curative is close to the mark but not right on target.

The study abstract draws attention to side effects of hormonal blockade: "produces side effects including hot flashes, decreased libido, and loss of bone mass". All that can be true for many of us, not to mention such fairly common effects, IF NOT ALSO COUNTERED, as atrophy of muscle (particularly upper body), anemia, fatigue, depression, weight gain, and an increase in cholesterol. However, virtually all of these side effects can be fairly effectively countered for most men with a reasonable investment of time, energy and money, at least reducing these effects to a tolerable level, especially considering that the on-full-therapy period is only about a year for each round, after which testosterone is recovered, these effects reverse and the patient regains an excellent quality of life in a very high percentage of cases. There is no incontinence and virtually no permanent impotence, which are fairly common side effects of surgery and radiation, at least to some extent.

Why are these authors and so many other researchers making these misleading statements? (Trust me, they are. I have heard such statements from at least three of the doctors I consulted, and, as a member of the AACR's Scientist-Survivor Program, exchanging information between the two communities, I have met quite a few researchers who did not realize they had accepted the myth.)

Dr. Myers has stated he thinks acceptance of the myth stems from an old study published in the highly respected New England Journal of Medicine (vol. 321, p. 419 etc.) in 1989 and led by Dr. Crawford, the expert I mentioned earlier. His team found that, for patients treated with hormonal therapy THEN available, hormonal therapy tended to work for these lengths of time:

- for men with widespread bone mets and pain, just 8 months;

- for men with wide spread bone mets without pain, 18 months;

- for men with few bone mets in the hip and spine, 4 to 5 YEARS, with 30-40% still responding to blockade at 9 years.

Back then the typical presentation of disease when a patient was diagnosed was the second category: wide spread bone mets but without pain. The forecast of the effectiveness of hormonal therapy for them was only 18 months, a fairly short time. Unfortunately, many physicians and researchers today have translated the short time frames to today's typical patients, but today patients typically are low-risk with no mets of any kind, either in the bone or soft tissue. They don't fall in any of the categories in the Crawford study. As noted above, such patients are doing extremely well in a couple of clinical series. Also remember that hormonal therapy options are greatly improved over what they were when the Crawford team was conducting its study.

One final note, a related myth that has been busted is that survival is fairly short after hormonal therapy fails, which usually takes many years, as discussed above. The numbers I've heard in uninformed circles range from 18 months to 2 years. An excellent study by respected experts debunking this myth is "Oefelein MG, Agarwal PK, Resnick MI (Case Western) "Survival of Patients with Hormone Refractory Prostate Cancer in the PSA Era," Journal of Urology, 2004 April, 171 (4) 1525-8. Looking at 254 men treated in the PSA era (but before many recent advances) for whom hormonal therapy no longer controlled the cancer, they found that on average they lived 68 more months if their bone scans for cancer were negative at the point that hormonal therapy no longer worked, and 40 more months if their bone scans were positive.

For anyone who has read to this line, thanks for bearing with me and letting me stand on one of my favorite soap boxes for a while. It's important that this information also get out. I would be happy to provide additional detail.

Jim Waldenfels (web page: http://www.mycancerplace.com/profile.php?id=147)

Posted at 8:28PM on Dec 23rd 2006 by Jim Waldenfels