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INTRODUCTION TO DR. STRUM'S PROSTATE CANCER UPDATE
When I was diagnosed with advanced prostate cancer in September
1991, I thought my life, as I had envisioned it, was over. Instead, I
have found a whole new universe of living and, in doing so, have come
to terms with my own mortality.
Transformation is what is possible when we are faced with a
life-threatening illness. When the unthinkable happens to us and we are
faced with our mortality, we have an opportunity to transform our lives.
Acceptance of our situation is the first milestone we must pass
before we can truly begin the process of healing. For me this
translates into doing everything I can to understand the entire process
of my illness and what I can do to become well. While I do not blame
myself for my diagnosis, it has been valuable for me to take an
introspective look at my life in relation to the kinds of stressors or
environmental exposures that may have played a role. Sometimes it is
not until we are on the reef that we realize it is there.
Fortunately for us, the cancer patient today has many more resources
available than there were just a few years ago. What follows by Dr.
Stephen Strum is an update of the treatment of prostate cancer. I have
known Steve for over 10 years. He is one of the precious few who have
brought a new and compassionate dimension to the patient/physician
relationship.
Frederick Mills
Prostate Cancer Survivor
Founding Member of Educational Council
for Prostate Cancer Patients
PROSTATE CANCER UPDATE 2003
Stephen B. Strum, M.D., F.A.C.P.
GENERAL INTRODUCTION
In this, the year 2003 edition of Disease Prevention and Treatment,
I will discuss prostate cancer (PC), using the metaphor of a military
incursion--needing to have a focused, strategic approach, deployed in a
systematic, problem-solving manner. The purpose of such a metaphor is
to bring to the student of this disease a different perspective that
will hopefully provide new insights that will lead to victories in our
battles against this disease. The reason for such a departure from the
conventional formal discussion of PC is that this latter academic
approach is not being translated into winning strategies for the man
with PC. The battle is being lost because we, the generals, are not
translating what has been published in medical journals and discussed
at national meetings into real-time preventive, diagnostic, evaluatory,
and treatment tactics. Medical pragmatism--the art of being practical
and using common sense--is not being practiced.
The battle to prevent this disease, to diagnose it earlier, and to
treat it effectively is also not occurring at the proper pace largely
because men are not taking an active role in winning this war. As we
are learning in our war against terrorism, you defeat the enemy by
recognizing their presence early (not late), preventing their buildup,
learning their location, and eradicating them with the proper weaponry.
There are too many men, already diagnosed with PC, who are not taking
an active role in their own recovery. Many believe that because they
are consulting a professional with a medical degree (who may also
command a generous salary), all or part of this equates with getting
the very best advice and treatment. Wrong. In today's world of rapid
pace, where medicine is practiced with 15-minute office visits and
where physicians are too busy to read and translate much of what is
being published, the patient and his partner must not take a passive
role and assume that all that can be done is being done.
My recommendations, therefore, either to patients with PC or to
their loved ones, will be those of a counselor or guide, offering
practical advice based on 20 years of working on the front lines of PC
management. I do not hesitate in telling you that for the vast majority
of men diagnosed with PC, a successful outcome can be realized. But the
principles you are about to learn must become part and parcel of the
strategic approach used by the patient/partner/physician (PPP) team.
The patient and his partner have the most to gain as well as the most
to lose when encountering PC. They must expend serious energy to win
this particular war. In doing so, they learn the art of battle; they
are brought closer together and evolve in their lives; and other
intertwined health issues are brought to light and healed. This is the
beauty of such an approach. Are you willing to invest in the time to
help yourself? Are you worth it?
THE 2003 DISEASE PREVENTION AND TREATMENT EDITION
The most important take-home lesson that I can relate to you within
the pages that follow relates to your ability to use concepts. It is
through the use of concepts--the structural framework of our
thinking--that we intelligently plan a strategy of success.
| Comparison of a Military Campaign with Prostate Cancer Strategy |
| |
Winning a Military Campaign |
|
Defeating Prostate Cancer (PC) |
| 1 |
Preventing War |
1 |
Preventing PC |
| 2 |
Basic Military Training |
2 |
Getting Help to Understand Biological Principles |
| 3 |
Military Information (Intel) |
3 |
The Importance of the Medical Record |
| 4 |
Early Recognition of Enemy Activity |
4 |
Early Diagnosis of PC |
| 5 |
Assessment of the Enemy |
5 |
Risk Assessment of the PC Patient |
| 6 |
Knowing Pros and Cons of Weaponry |
6 |
Understanding Pros and Cons of Treatment Options |
| 7 |
Understanding Enemy Vulnerability |
7 |
Learning Principles Underlying Tumor Growth |
| 8 |
Stopping Supply Lines to the Enemy |
8 |
Antiangiogenesis Treatments, Dietary Changes |
| 9 |
Stabilizing Key Arenas of Conflict |
9 |
Focus on Bone Integrity, Biomarkers, etc. |
| 10 |
Supporting the Troops |
10 |
Supportive Care of the Patient |
| 11 |
Boosting Morale of Troops |
11 |
Fostering a Will to Live, Empowering the Patient |
As stated in the introduction, defeating PC is a military campaign.
Winning a military campaign, or a war against PC, involves concepts
such as prevention, basic training, military intelligence (Intel),
early recognition of enemy activity, assessment of the strength of the
enemy, an understanding of the pros and cons of the weapons in our
arsenal, stabilization of key areas of conflict, stopping supply lines
to the enemy, supporting our troops, and other issues common to a
military arena (see Table 1). A strategy for success, be it in a
military war or a war against PC, simply involves adding factual
information to a sound conceptual framework.
The approaches used in a winning strategy, whether for a military
campaign or a medical battle, are superimposable. That which occurs in
the life of a cell is reflected in society as well.1 Cellular battles
are but a microcosm of what takes place on a more macromolecular level
within the individual, his community, his country, the planet, and the
universe. This is reflected repeatedly throughout the entire history of
man.
1. PREVENTING WAR: PREVENTING PC
Most students of either campaign will maintain that
prevention is the key to being truly victorious. There is no argument
there. However, the desire to understand the principles and importance
of preventive tactics does not appear to be a top priority for most
people until the harsh reality of war or cancer is present. For
example, the appreciation of terrorism in America was not brought home
until September 11, 2001. This appreciation of the enemy may take the
form of seeing the reality of cancer up close and personal when a
father, brother, or other family member is diagnosed with PC or another
malignancy. Otherwise, the motivation to learn and utilize prevention
tactics does not seem to be part of human reality for the vast majority
of us. What can we do to foster an appreciation of the value of
preventing PC?
Hereditary PC: Risk Factors
Out
of every 100 men diagnosed with PC, approximately 5 will have
hereditary PC (HPC).2 HPC is presently defined by any one of the
following three criteria:
- Three successive generations with members having PC
- Three first-degree relatives, for example, a father and two brothers, three brothers, or a father and two sons with PC
- Two relatives with PC diagnosed before age 55(3)
It is not surprising that the incidence of hereditary breast cancer
is also about 5% of the total population of breast cancer patients--the
same incidence as that of HPC.4
Genetic Transmission from Father to Son and Father to Daughter
HPC
is transmitted by a gene from father to son and from father to daughter
and then to her son. When HPC is present, nearly half the male
offspring will have PC, and many of these will develop PC before age
55. In fact, HPC accounts for approximately 43% of PC diagnosed before
the age of 55 years.3,5,6
Since the transmission of the gene may also occur from father to
daughter and then to her son, a sound medical history includes
information about the health of the maternal grandfather as well as
maternal uncles and maternal cousins regarding any history of PC.
Studies of PC within families show a stronger familial inheritance
pattern than colon or breast cancer.
Value of Intensified Surveillance in High-Risk Situations
Most
importantly, procedures to routinely test the first-degree relatives of
those having HPC have yielded an eightfold higher detection of PC than
that found in the general population.7 Soon, genetic testing for
chromosomal abnormalities found in HPC may become commercially
available. Patients' interest in testing HPC similar to that available
for breast cancer, appears great when there exists a family history of
such disease.8,9
Increased Risk of Male Breast Cancer and Colon Cancer in Male Offspring and Breast Cancer in Female Offspring
It
should also be emphasized that men with a history of breast cancer (BC)
in their family are also at greater risk for developing PC, just as
women with a family history of PC are at greater risk for developing
BC.10 Since both PC and BC share common genes, it is not surprising
that men who are carriers of the gene associated with BC (BRCA1 or
BRCA2) are at a greater risk for developing male BC in addition to PC
and colon cancer.4,11-13
Therefore, greater vigilance is suggested when a history of PC or BC is present.
What Are the Tests for High-Risk Persons?
Currently,
most physicians who focus on PC as their main specialty will recommend
routine prostate-specific antigen (PSA) testing starting at age 40.
This is important to establish objective findings that indicate a
healthy prostate. In subsequent paragraphs, this will be shown to
equate with a baseline PSA of less than 2.0 and often less than 1.0
ng/mL. In a population in which there is a family history of PC, such
as has been described, PSA testing should be commenced at age 35 with
yearly testing for a few years to establish a trend or profile. Then,
if the PSA remains below 1.0 ng/mL, consideration for testing every 2-3
years can be considered. Vigilance on the part of the empowered
patient, partner, and physician will also involve digital rectal
examination (DRE) at reasonable intervals and tracking of the PSA over
time. If any persistent PSA increase is noted, determinations of PSA
velocity, PSA doubling times, free PSA percentage, and additional
testing that will be discussed in subsequent sections must be done.
Moreover, a baseline colonoscopy and stool testing for microscopic
blood (Hemoccult) would be a reasonable consideration in such men
starting at age 40 rather than at age 50.
General Preventive Measures
Besides laboratory testing, physical examination, and investigative
procedures to rule out the presence of PC and other diseases, an action
plan to prevent their development should be considered. These types of
preventive measures are preemptive, or defensive, measures. The most
apparent of these relates to what we eat and drink.
There is no doubt that what we put into our bodies relates to the
health of our cells. It is obvious that food intake is associated with
delights to our senses of sight, smell, and taste. However, on a
survival level, food is the necessary fuel source for all the cells of
the human body. The quality and quantity of the food, water, and air we
put into our bodies clearly have serious ramifications. There are major
parallels between human nutrition and a high-performance engine:
- The kind of fuel we add to high-performance engines
- The fuel-to-air ratios that occur within the combustion chambers
- The metabolic breakdown products resulting from internal combustion
- The wear and tear on the engine due to driving habits
- The preventive measures used to increase engine life
The human body is certainly no less of a high-performance engine
than that of an airplane or car. Yet, although we appreciate the
preventive maintenance that is part of the strategy of engine survival,
we are inconsistent when we too often ignore the needs of our own
bodies--that is, until we have signs of engine breakdown. As many of us
love our cars and care for them, we must do the same with our bodies. |
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