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Carbohydrates + Prostate Cancer

Dr. Stephen Freedland is a urologist at Cedars-Sinai in Los Angeles, California, and the Director of the Center for Integrated Research in Cancer and Lifestyle, Co-Director of the Cancer Genetics and Prevention Program and Associate Director for Faculty Development at the Samuel Oschin Comprehensive Cancer Institute.

Dr. Freedland treats the whole patient and not just a man’s prostate cancer.

Prostatepedia spoke with him about diet and prostate cancer.

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What do you tell your patients about prostate cancer and diet?

Dr. Freedland: Given the link between obesity and prostate cancer, I focus on getting my patients to lose weight. The easiest way to lose weight is to cut out all the extra sugar in your diet: cookies, cake, candy, all of that. A meta-analysis published in the Journal of the American Medical Association of all the popular diets found that the best diet for weight loss was a low-carb diet. That was the best diet. They’re all decent, but low carb is the best.

Is that true primarily for American patients or for everyone?

Dr. Freedland: I think it’s true for everyone. A recent study published in the Lancet followed over 135,000 people in 18 different countries on over five continents. They found that the more carbs you eat, the more likely you are to die earlier. Eat fewer carbs, live longer. Fewer carbs and more fat make you live longer.

This is a landmark study that supports what an increasingly loud minority of us has been saying. Fat is not the problem. Carbs are the problem.

I focus my patients on their carb intake. Let’s focus on the carbohydrates in the diet and see which of those we can get rid of. If you’re having whole-grain oatmeal for breakfast, maybe that can stay. But most people are having pancakes with butter and syrup. We can get rid of that.

While you’re giving up the sugars, cakes, and candies, we focus on what we can put in their place: fruits and vegetables.

Yes, fruits have sugar, but it’s a natural source. As long as patients aren’t juicing, natural fruits contain a lot of fiber that will slow the absorption of sugar in the intestine. Nuts, beans, and those types of things are also good replacements.

I worry that because we’ve been advocating that people cut out fat and tell them to eat lots of fruits and vegetables, people are going to go to the store, buy fat-free ice cream and say, “I had a salad with my dinner so I can eat all the ice cream I want now. I’m being healthy!”

Remember the old food pyramid from the 1980s? Carbs were at the bottom of the pyramid, the largest food group.

Dr. Freedland: Right. Lots of bread. Our entire way of thinking has been very carb-centric. Let’s eat carbs and avoid fat. And the result has been that the obesity rates have almost tripled in the United States in the last 30 years.

What do you say to people who argue that you should have carbs in balance with fat and protein?

Dr. Freedland: Your body doesn’t need carbs. There are animals and people raised without eating a single carb. You can’t survive without eating fat. You can’t survive without eating protein. You can survive without eating carbs.

What protein sources do you recommend?

Dr. Freedland: People get in this mindset that red meat is bad and fish is good. Fish (we think) is good because it contains fish oil, an omega-3 fatty acid. But I found an article that looked at tilapia. It turns out that tilapia doesn’t have much fish oil. If you want fish oil, you know what are better sources than tilapia? Doughnuts and bacon.

Bacon?!

Dr. Freedland: Doughnuts and bacon have more fish oil than tilapia per gram.

I guess not all fish are created equal.

Dr. Freedland: Correct. And not all meat is created equal. A nice grass-fed steak probably has as much omega-3 fatty acid as many kinds of fish. The worst protein for prostate cancer is charred meat. Those black lines you get on your steak in charring form heterocyclic amines that can cause cancer. This is true mostly for meat because that’s what you tend to char, but it’s also true for chicken and potentially fish.

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Dr. Mark Moyad: Diet, Lifestyle + Prostate Cancer

Moyad Headshot-2Dr. Mark A. Moyad, the Jenkins/Pokempner Director of Complementary and Alternative Medicine in the Department of Urology at the University of Michigan Medical Center, has published over 150 medical journal articles and 12 books, including The Supplement Handbook: A Trusted Expert’s Guide to What Works & What’s Worthless For More Than 100 Conditions.

Dr. Moyad frames this month’s conversations on diet and lifestyle for prostate cancer.

Join us to read the entire issue.

First, I’d like to say that I find it incredibly wonderful that we’re now talking about diet and exercise for prostate cancer. In the old days, it was unusual to even talk about it, but now you stick out if your institution doesn’t cover diet and exercise. What a wonderful and diverse collection of experts in this issue—such a pleasure to read and learn from some of the best in this field now and in the future.

I always say that heart-healthy is prostate-healthy. Heart-healthy is all healthy. Reducing your cardiac risk as close to zero as possible is the smartest thing you can do as a prostate patient. That’s the top of the pyramid when it comes to diet and exercise for prostate cancer. Maintaining a health weight is the first step in becoming heart-healthy.

Every few years, we realize that more and more cancers are associated with obesity. Now we know that obesity is associated with up to at least 13 types of cancer, not to mention the ongoing, ravaging obesity epidemic.

That said, I don’t believe that we have neither the power nor the right to tell people what diet to follow. It doesn’t matter if you want to go vegan, high fat, or low carb: there’s nothing more important than maintaining a healthy weight and having the heart-healthy numbers to support that healthy weight loss.

The new elephant in the room is alcohol. Alcohol often becomes self-medication in elderly people, but it is one of the largest sabotages to a heart-healthy and prostate-healthy lifestyle.

First, the caloric content of alcohol is high: seven calories per gram. Second, the data clearly show a relationship between excessive insulin production and excessive alcohol exposure. This makes it so easy to gain weight when you drink alcohol. Some of the greatest weight loss I’ve seen in the past 12-months has come when a patient eliminates alcohol. There is also a correlation between alcohol and potentially aggressive prostate cancer. So alcohol makes you gain weight, encourages prostate tumor growth, encourages cardiac risk, and encourages risk of other cancers.

Exercise is important, but we have to be careful as we age. We become very delicate machines. That’s why I agree with Dr. Rob Newton that finding an exercise physiologist is a great idea. We have to be smart about exercise: if you don’t preserve yourself, you won’t be able to stay active and get the benefits of exercise for your prostate cancer.

I’ll also add that the biggest benefit to exercise is a mental health benefit. I love the cardio/metabolic effects of exercise in men on hormonal therapy, but I don’t give a damn if exercise ends up being physically beneficial to cancer patients. What excites me is the impact on the quality of life of a man. Patients are completely different on hormonal therapy when they are regular exercisers. Mentally, they’re still in the game. They’re beautiful to be around.

Socialized exercise also gives you a boost. When you work out in your basement, you’re not getting all the benefits of exercise. When you have a trainer, go to a gym, or work out with support group members, you get an added mental health boost. You can become isolated in exercise.

Finally, I’d like to add that we lose credibility if we don’t follow probability with supplements. The results from the VITAL trial, which looks at vitamin D and cancer in about 26,000 people, will be published next year. I’m going to wait for those results before I recommend higher vitamin D intakes to patients.

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Women + Movember

Heather Mott is one of the Movember Foundation’s top fundraisers.

Prostatepedia spoke with her about raising money for men’s health.

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How did you become involved with Movember?

Ms. Mott: This is my sixth year participating as a Mo Sista and raising funds for the cause. I don’t remember exactly how I heard about it, but I think it was through social media. It sounded interesting and fun and it benefits men’s health, so I started doing it.

When I started, Movember was more focused on prostate and testicular cancers, but now they’ve branched out into mental health awareness and healthy lifestyle activities.

How can a woman participate?

Ms. Mott: It is easy to get involved – all you have to do is sign up on their website. I try to do a different photo every day of the month. Since I am genetically-challenged to grow my own mustache, I usually order fake moustaches and take some selfies. Sometimes friends help me.

I’ve tried doing themes with some common factor across the different photos. For example, my theme for this year’s Movember campaign is photos of individuals in a role that serves the community. Today, I posted a photo with a Navy backdrop, thanking all those who serve or have served in the Navy. I’ve posted backgrounds with other public servants like teachers, those in the justice system, or first responders.

What kind of themes have you used in the past?

Ms. Mott: One year I had the different individuals from the Village People who sing the YMCA song. I had a cop, a construction worker, and all that. There hasn’t been a real rhyme or reason to the themes, just whatever strikes me that year.

How do you get people to join your team?

Ms. Mott: When I started, I didn’t join a team. Then the next year my company, Johnson & Johnson (I’m at the Los Angeles Neutrogena facility) started a team. I joined them and this is our fifth year. We have new people each year and some reoccurring partners. We do a lot of recruiting onsite and there is some friendly competition. We have all kinds of events over the course of the month.

Has your involvement in Movember had an impact on your community?

I started with Movember because I thought it was an interesting way to raise awareness and help fund research. Then, about three years ago, my father was diagnosed with prostate cancer. Thanks in part to Movember awareness, he caught it so early that he was able to do active monitoring for a year. There wasn’t enough cancer to treat.

Last year, he went through treatment. Because he caught it so early, he went through a program called CyberKnife. He has had hardly any side effects, no pain, nausea, nothing that people tend to associate with cancer treatment.

My involvement in Movember impacted me personally and made a big difference in my father’s life.

Would he have waited to be screened if you hadn’t been involved with Movember?

Ms. Mott: He’s been a pretty healthy and health-conscious individual throughout his life, so he is pretty diligent about getting his annual checkups. Once he got to a certain age and was a little bit more aware, it definitely helped him. It helped him network, understand treatment options, and talk to others about it. I know that that’s something Movember is big on, raising awareness. There are networks out there to help you when you find out you have cancer. He was nervous at first, so it definitely helped him get through all of it. It helped him be conscious that it’s important to get these checkups, especially at a certain age.

Does he participate in Movember along with you?

Ms. Mott: He is a very active supporter, but he doesn’t have his own Mo Space or anything like that.

You should set him up.

Ms. Mott: [laughs] I know. He’s always had facial hair.

He was already growing the moustache?

Ms. Mott: Yes. He was growing long before.

Do you have any thoughts for men or women who want to fundraise for Movember?

Ms. Mott: I would love to see even more Mo Sistas, because we all have men we love in our lives. I became aware of Movember through social media, so I’m always posting through my social media platforms.

But I’ve also done some bake sales at a community brewery and I worked with local businesses to get the word out.

Is it worth trying to get your company or place of work to organize a team?

Ms. Mott: Yes. I work at a large company, so a lot of individuals here care about health. That has made it easier for us to have a team each year.

Last year, our goal was to raise $10,000; we raised about $13,750. It does help partially that I work with a large company, but this is something anybody can get behind.

We all know at least one man who’s at least had a scare, right?

Ms. Mott: Yes.

Does your team have events throughout the month, or is it mainly just about getting together and raising as much money as you can?

Ms. Mott: We have events. I’m co-leading our team here onsite this year. We have a Shave Off kick-off each year where all of the guys signed up come, and since we make men’s care products, they do a shave off together.

We then host different fundraising activities. This year we have a lot of healthy activity initiatives at Johnson & Johnson. We’re doing some yoga and a Ping-Pong competition. People can buy-in to donate to the team; there will be some prizes at the end of the tournament.

We do different activities each year to keep it fun, engaging, and to generate funds. Johnson & Johnson has a culture of supporting these types activities and there are other ways for companies to help. Companies often match donations.

Any last thoughts for men who might want to participate?

Ms. Mott: It’s so easy to sign up and get involved. It’s such a fun activity. Movember is a very engaging group. Their United States headquarters is in Culver City, CA—right next to us.

It’s a great way for men to touch base in a less formal environment, and it definitely builds a network, so that should you get diagnosed, you have others who understand, can offer support, and who have maybe been through it themselves.

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Patients Speak: Choosing Focal Therapy

Mr. David Fitch talks to Prostatepedia about choosing focal therapy for prostate cancer.

Join us to read our November issue on focal therapy.

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What was your life like before prostate cancer?

Mr. David Fitch: I live by myself. I’m 74. I’m retired. Ever since I quit working, I found it is a lot better to interact with my friends. I bicycle and swim. I’m more of a cyclist than a swimmer. I cycle almost every day. I’m probably riding 200 to 300 miles a week. I started doing that initially for the social part of it—all my friends are bicycle folks.

Then I got into the VA Palo Alto swimming pool a few years ago and so I’ve got a lot of VA pals as well. All my exercise basically started as more of a social thing. That’s what was happening before the diagnosis of prostate cancer.

How did you find out that you had prostate cancer?

Mr. Fitch: That was through the VA. The VA in Palo Alto, California, is really good. I’ve been going there for over 10 years. I found out through my endocrinologist. I can’t say enough nice things about her. She has literally saved my life at least twice and this was one of those times. She was looking at my PSA over the years. She said: “It’s gently rising. It doesn’t really rise to the threshold of being something to worry about.” It was around 2.5 for several years before rising to around 3.5 over a period of about four to five years. She said, “Would you like to go talk to the urology department?” I said, “Sure, I’m always happy to talk to people.” She sent me to the head of the urology department. I had no clue about what a urologist did. I went to see the guy, and he did a digital rectal exam (DRE) and said he could feel a lump. My previous DRE was 18 months earlier with my primary care physician and she said everything was fine.

The urologist sent me for an MRI— I had no idea what an MRI was. This started my research: What’s an MRI? With the MRI he said, “It looks to me like there’s something wrong, so I need to do a biopsy.” He told me that the protocol for the VA is a blind biopsy, not using the MRI, just poking 12 holes or so into my prostate and taking samples. Very hit-or-miss. My research indicated that using the MRI fused to a picture of my prostate gave the radiologist a better chance of seeing the suspicious areas to sample, but the VA doesn’t do that. There is a program, Veteran’s Choice, that allows patients to be sent outside the VA if a procedure cannot be performed within the VA. I was sent to Stanford for an MRI-ultrasound fusion biopsy. The Stanford radiologist, Dr. Sonn, found lesions on both sides of my prostate. The right side had more suspicious areas than the left. The pathologist’s report confirmed the presence of intermediate prostate cancer. On the right side were two areas: Gleason 4+3 and 3+4. On the left side, it was Gleason 3+4.

What was your reaction? How did you feel when you found this out?

Mr. Fitch: I was very concerned of course but not distraught. The VA Urology Department did not inform me of the difference between blind biopsy and directed biopsy or of the availability of the Veteran’s Choice Program until I asked. I was now suspicious: What else hadn’t I been told? The only solution was my own research. I went down this rabbit hole trying to answer: What is prostate cancer? What does it mean? What do all these numbers mean? Who can do what, and how do I go about finding out? I joined a support group at the VA Palo Alto, which was worthless. Then I went to two other local support groups, one in Los Gatos, and another at Mountain View—both of them pretty good.

I found out from talking to a lot of guys that doctors generally prescribe their own methods of taking care of this stuff, whether or not it fits. Urologists want to cut and radiologists want to radiate. Then I found an online support group, Inspire.com, a partner of Us TOO. It’s fairly comprehensive. You can get a lot of questions answered, and you can spend literally hundreds or thousands of hours digging through—it’s like trying to take a drink out of a fire hydrant.

I was willing to educate myself. I was looking for people who could help me educate myself to find out what needed to be done. The best way I can characterize this is the problem that I had didn’t seem to me to be life-threatening at the moment. It seemed to me like I had plenty of time to figure out what to do next, but I was going to have to do something.

I didn’t like the fact that the head of the VA Urology Department told me he could only offer me surgery or radiation—nothing else. I thought both of those things were like amputating my arm because I got a scratch. I told him that. I said, “You’re not helping me a whole lot.” I had a 20-minute appointment at most. He just seemed too busy to have any sort of a long conversation. I went in there with all this reference material, a ton of it. I didn’t exactly know where I wanted to go with it, but I wanted to have a conversation with the man. His bedside manner was terrible. He gave me 20 minutes and said, “Okay, well, do whatever you want.” I wasn’t getting anywhere.

At that point, I felt that the VA Urology Department was not very helpful. I began to realize that there is a huge difference in doctors’ expertise as far as prostate cancer was concerned. I realized that I had to take this into my own hands. I had to educate myself in order to be able to go forward: What is a urologist? A radiologist? An oncologist? Do they specialize in prostate cancer?

Later, after my focal laser ablation (FLA) procedure, I met Dr. John Leppert, a VA urologist who has been very helpful and supportive in my quest to understand prostate cancer.

Did you turn to the online groups? Is that where you went first for education?

Mr. Fitch: I started online, yes. I did a lot of reading. I just worked for a long time until I had the answers that I wanted. Additionally, I began to hear the names of certain doctors mentioned over and over again: Dr. Snuffy Myers, Dr. Mark Scholz, Dr. Mark Moyad, Dr. Fabio Almeida, Dr. Dan Sperling, Dr. Pete Carroll, Dr. Joe Busch, and many others.

In many cases, Google was where my investigation began and I watched many YouTube videos. I concluded that many doctors want to cut something out of me or to radiate me, and both those things have serious consequences. I didn’t like either one.

It was about that time that I stumbled onto FLA. It probably had more to do with side effects than it did with whether it worked or not, quite frankly. I found that the biggest side effect from FLA was financial. It would cost me $20,000.

I decided not to buy a new car that year and use the money to take care f my body instead. I’m being a little facetious here. If it didn’t work, I could always do anything I wanted to the second time around. That’s what led me to FLA.

Once you found out about focal therapy as an option, how did you figure out which form of focal therapy was best?

Mr. Fitch: My FLA was done in 2016. There are more types of focal therapies now than in 2015 when I made the decision. Additionally, there are very few doctors who do this particular FLA. I went to Dr. Eric Walser at the University of Texas Medical Branch in Galveston, who I think I found out about on Inspire.com. Initially, I was going to Dr. John Feller at Desert Medical Imaging in Indian Wells, California. He had a clinical trial that I was eligible for, but I changed my mind at the last minute because Dr. Feller’s clinical trial would cost more than Dr. Walser’s commercial practice and would require two trips. And Dr. Feller uses an MRI machine that is 1.5 Tesla. I know it works just fine in the right hands, but it is not a 3.0 Tesla machine.

What was the actual procedure like for you?

Mr. Fitch: The procedure was outpatient. It lasted maybe an hour. I was never knocked out. It was just local anesthetic. I spent a few days in Galveston recovering. They did two overlapping ablations on the right side and one on the left. They took larger margins to preclude missing some hard-to-see cancerous spots. Prior to this time, FLA procedures had recurrence rate in the 10-15% range. Taking a little larger margin around the tumor would reduce the recurrence rate. And in my case, they ablated twice, overlapping, on the right and once on the left side. The tumor on the left side was rather small and hard to see. The two tumors on the right side were fairly close to the urethra, which meant that when my poor old prostate swelled up from the ablation, it closed off the urethra. Without a catheter in place, I wouldn’t have been able to pee.

The only painful part of the procedure was reinsertion of the catheter for the blocked urethra. I ended up staying in Galveston from Monday to Friday waiting for the urethra to open. I was told this problem was not typical and was probably due to the ablation near the urethra.

Any side effects after the treatment?

Mr. Fitch: My ejaculations are dry. I’m told that’s pretty typical. I’m 74 years old and not having kids is really not a problem for me. Otherwise, there don’t seem to be any aftereffects.

How are you monitoring now for potential recurrence after treatment?

Mr. Fitch: Active surveillance. The protocol is to have a PSA test every three months and an MRI at six months and 12 months. If everything is clean at the end of 12 months, then maybe an MRI once a year. It varies a little bit after that. The PSAs typically go on at three-month intervals. They’re just part of my normal blood work that I have done at the VA.

To put the PSA in perspective, before the FLA, it was about 3.5. Three months after FLA, it dropped to 2.3. Then at six months, it dropped to 0.25. I was so surprised by that number that I had it confirmed with a second test a few days later. It was 0.28.

At nine months, it jumped back to 0.55. That could have been partly due to riding my bike a lot. That does have an impact on PSA. At one year post-FLA, it is 0.43. I’ve had a one-year MRI as well which shows some scarring but no other problems.

Do you have any advice for men who are in a similar situation?

Mr. Fitch: I would do it again for intermediate prostate cancer (i.e., Gleason 7) which has not metastasized. It’s expensive, not covered by insurance, and I had to travel, but it was well worth it. No pain, no leaking, and sex works. If the cancer reappears in the gland it can be re-ablated or any other procedure used. There are many available therapies for organ-contained prostate cancer that has not metastasized: cryotherapy, CyberKnife, MR-guided focused ultrasound, NanoKnife, proton beam, photodynamic therapy with TOOKAD, stereotactic body radiation therapy (SBRT), brachytherapy (seeds), and more. Technological improvements are happening quickly. I suspect we’re headed down the road of some new, permanent therapies that will eradicate prostate cancer forever. Immunotherapy comes to mind. Until then, FLA seems like a good interim measure.

Any other thoughts for other men struggling with prostate cancer?

Mr. Fitch: Listen to the doctors. If you like what they say, and if you want to follow their advice, that’s fine. If you think there might be something else out there that works better, at least take a look at other options and see how they stack up against what you’re being told. Prostate cancer probably hasn’t changed a heck of a lot in a long time, but the ways that we approach it are changing rapidly. Active surveillance for low-risk cancer (Gleason 6) is increasing dramatically, and scanning techniques make this possible. If it weren’t for the new technologies in scanning, we wouldn’t be doing focal anything. Scanning helps find the tumors. I was a fighter pilot. If somebody was shooting at me, I could combat that by seeing the threat and defeating it. The same goes here. If you can see it, you can probably defeat it.

There are a lot of scanning techniques including MRI. PET/CT scanning techniques use different imaging agents (injected during the scan) and can help to see both inside and outside the prostate. These agents include C 11-acetate, PSMA, Axumin (fluciclovine F 18), and many others. It’s worthwhile investigating those to make sure that a guy knows exactly what he’s got and exactly what he has to deal with before he goes down any road. He’s got lots of time, especially if it’s low or intermediate risk. Take the time to educate yourself, to understand what needs to be done.

The last point I’d make is to attend the Prostate Cancer Research Institute (PCRI) conferences in the fall. It’s designed for patients, given by world class doctors, lasts three days for $50 or so. The education is remarkable.

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Robotic Prostate Cancer Surgery After Focal Therapy

Dr. Paul Cathcart is a consultant urological surgeon at Guy’s Hospital and St. Thomas’ Hospital in London.

Prostatepedia spoke with him about a clinical trial he’s running that looks at robotic surgery in men whose prostate cancers have come back after focal therapy.

Why did you become a doctor?

Dr. Paul Cathcart: I always liked science; that was my favorite subject. I was thinking about whether to become a vet or a doctor and did lots of school visits. During one of those visits, I met an inspirational character, a surgeon. I spent some time with him, following him around hospital wards and clinics. I thought that he was the sort of person I would like to be: he does the job I’d like to do. I think that’s often the case in life: you meet some inspirational figure who pushes you along one line.

Later on, another inspirational figure who came into my life was a urologist. I was originally going to be a colorectal surgeon. Everything was set for that. Then I met this urologist who showed me the different mix there is in urology, which I found interesting. Then I met Dr. Mark Emberton; I was his research fellow for many years. He’s quite an inspirational person as well. I’ve been working with him for 17 years now on various things.

What is the thinking behind your trial on robotic surgery after focal ablation?

Dr. Cathcart: Focal therapy is a new concept, which Dr. Emberton and one or two other people have pioneered to reduce the side effects and morbidity of prostate cancer treatment. Unfortunately, a proportion of these patients will experience recurrent disease after focal therapy. No cancer treatment is 100% effective. A couple of these focal therapy patients were recurring three or four years after starting the focal therapy program.

No urologist wanted to operate on these patients because they felt that it would be an extremely difficult surgery. In fact, urologists were only offering exenterations to remove the patients’ prostate, bladder, etc.

I got to know quite a few of these patients. (I do a lot of post-radiotherapy surgery, as well.) I decided that this procedure called salvage surgery interested me. We thought that we could do this salvage surgery and maintain good outcomes for our patients because only part of their prostate had been treated during focal therapy. We thought that the side effects of the surgery after focal therapy would actually be a lot less than after radiation, but we needed evidence to prove it. That is why we set up the trial.

We’re also interested in learning why some patients may fail focal therapy. What is it about their disease that leads it to recur? If we can understand why some patients may fail focal therapy, this can help us select up front which patients should have focal therapy and which should not.

What can patients expect to happen during the trial?

Dr. Cathcart: We are halfway through the study at the moment.

Of course, patients undergo a salvage prostatectomy. We take the tissue to be analyzed and look for various genetic markers to see why their cancer may have returned.

This is also a toxicity and side effect study. We have patient-reported outcome measures at baseline and sequentially thereafter. There are a number of blood tests looking at hormone profiles before and after the surgery.

We follow patients for about 12 months after those sequential patient-reported outcome measures; we’re looking to chart that toxicity.

I’ve taken out more prostates after focal therapy than most because of my link with Dr. Emberton. We’re now demonstrating the feasibility and toxicity of salvage focal surgery and trying to understand why these tumors have recurred.

Are you still recruiting patients?

Dr. Cathcart: About 20 patients have undergone the surgery. We’re recruiting 20 more. We haven’t had any adverse events. We were worried about things like rectal injuries, because the rectum can stick to the prostate after focal therapy. We haven’t had any of those.

We’ve actually had a fantastic continence outcome. The prostate cancer community said everyone would be incontinent and impotent, but all our patients so far have been continent.

We’ve got the patient-reported outcome measures to demonstrate it.

The potency rates are taking a little bit longer to return to baseline. The outcomes from potency won’t be as good as the continence outcomes. We haven’t had any side effects at the time of surgery. No complications or anything, so we’re delighted with the way things have gone.

Does the fact that the man has had focal therapy make the potency issues worse?

Dr. Cathcart: It depends on the location of their focal treatment. In those with anterior tumors (tumors away from the neurovascular bundles), we’ve noticed potency returns faster. If they’ve had an ablation on the peripheral zone, near where one of the nerve bundles is located, potency returns more slowly.

We’re also noticing a difference between different treatments. You can give focal therapy with high-intensity focused ultrasound (HIFU), cryotherapy, or something called electroporation. The different energy sources have different effects on the structures surrounding the prostate and a different impact on the chance of potency returning. Electroporation seems to be very precise and leaves the least amount of collateral damage. In those patients, potency returns faster. Cryotherapy creates more periprostatic fibrosis and scarring; potency takes slightly longer for those patients to return. Potency return for HIFU patients falls somewhere in the middle of the modalities.

I’ve also taken out prostates after photodynamic therapy. Photodynamic therapy is better relative to preserving the tissue planes, but it does depend on which part of the prostate has been ablated in the first place.

Is there anything else you think patients should know about your trial?

Dr. Cathcart: We’re going to get a great understanding of why these patients in particular failed focal therapy. The genetic markers and the locations of the tumors will inform which patients are suitable for focal therapy from the beginning. There may be parts of the prostate, or particular types of tumors or genetic markers, which will identify patients best suited to a whole-gland approach such as a radical prostatectomy up front.

It’s not just about the location and grade of the tumor, but also about the tumor’s genetic signature, which may predispose a particular tumor to being better suited for focal therapy.

It’s interesting, in some patients you knock out one tumor say on the right-hand side and that’s it, the tumor never comes back. Other patients’ prostates seem somewhat unstable and have multiple tumors that keep appearing throughout the prostate. I’m sure there is a genetic basis to it.

Because we’re taking out these patients’ prostates, we can analyze all the different tumors. Some people even think that by treating part of the prostate we may be changing the genetics of that tumor—i.e., it gets angrier. I don’t think that’s the case. This study will help prove that point. We’re also going to open up a comparative arm of the study very soon for patients who have had whole-gland radiation or ablation techniques—open to anyone who has had the whole of their prostate treated with brachytherapy, radiotherapy, HIFU, or cryotherapy. We’ve been finding that patients who have had surgery following focal therapy have better outcomes than those who have had whole-gland therapy up front. We’re going to recruit into that second arm to demonstrate that surgery after focal therapy has a better outcome.

Can non-UK residents come to you for surgery?

I’ve got a clinic called the Recurrent Prostate Cancer Clinic. I have a reasonable number of patients who come from the United States. They normally come to Dr. Emberton for focal therapy, then if they develop recurrent disease, I operate on them. A lot of urologists wouldn’t operate on these patients. Certainly, in the United States, hardly anyone operates on post HIFU patients simply because HIFU has not been available until very recently.

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The Moustache: A Fun Approach To A Serious Problem

Sandy Goodman is one of Movember’s top fundraisers. Prostatepedia spoke to him about their annual moustache-growing campaign.

Goodman

What is Movember?

Sandy Goodman: Movember is a fun approach to a serious problem. A bunch of guys sat down over some beers and dreamed up this way to follow the lead of breast cancer awareness advocates, who had been doing such a great job talking to women about early detection. These guys talked about what could be done for men. It’s grown into something much larger. The bottom line: guys don’t talk and men are dying too young (6 years earlier than women, on average).

Men are dying too young, and, for Movember, the simple solution is the moustache. The moustache is just our ribbon—it’s our banner. I don’t grow a moustache normally. Because I do it once a year, everyone asks why I’m growing one. It sparks the conversation.

Movember has been very innovative. They’ve made all the fundraising and gift-giving tools available online to everybody. An incredible amount of partnership and research has been funded through Movember. The back end—what the money is going towards—has real outcomes.

I’m happy to be a part of something that’s fun, and I’m proud to be part of something that’s truly making a difference.

image003Sounds like the annual campaign isn’t just about fundraising, but is also a way to start talking about some of these issues.

Sandy Goodman: Yeah, that’s right. It’s definitely all about sparking conversation. Men are terrible at making doctor appointments. Men are terrible at following up on doctor appointments. Men are terrible about checking themselves and being aware of what’s going on. To the extent that we can just spark conversation is a big impact.

Movember used to say that one moustache reaches an average of 100 people in a month. The number of emails you send out and share, Facebook posts, blog posts, the pictures—the reach is large and it just multiplies.

I’d be surprised to find anyone on the globe now who doesn’t understand what a moustache during the month of November means.

For me, it’s just about being involved with something. We all need to give back. I’m a huge believer in lifting with your pinkies as a group. It’s such a powerful thing when we all just lift together.

How did you get involved with Movember?

Sandy Goodman: I got involved 10 years ago because my father-in-law was diagnosed with prostate cancer. He had been doing all the right things. He went to his doctor for PSA and DRE exams every year. When his doctor saw something he didn’t like, he said, “You have an elevated PSA score and need to come back.”

At the time, he was getting remarried. His brother had had some complications after a prostatectomy, so my father-in-law was afraid to go back. He didn’t go back until a year later when he was doubled over in pain and they said it was too late. He was terminally ill with prostate cancer. It had spread. They gave him three years to live; he made it eight years, but it was not a very good eight years.

Early detection is so important, but beyond early detection is early action. My father-in-law did the right things, but then didn’t follow through… he didn’t take action. It was sad to watch this whole process. It was especially terrible, because it was completely avoidable.

At the time, I knew nothing about my prostate. I didn’t know what it did. I didn’t really know where it was and I never checked it. I was 45 years old. None of my friends knew anything about their prostates, either. We never checked our testicles or any of that stuff.

At the same time, a work friend’s dad had cancer. He was getting involved with Movember. He started a team and I joined him. Movember had only been in the United States for a year at the time.

It was a fun approach to a serious problem, which was right up my alley. I grew a moustache, got hooked, and I’ve been growing for 10 years now. I’ve been talking to everyone I can, all my bros.

Movember has had the viral social media aspect going for it.

Sandy Goodman: Completely. I started a golf tournament for our team 5 years ago. It’s grown. My goal was to bring the Movember message to my local community. I was walking around the South Bay and people would recognize that I had grown a moustache, but I think they saw me as a novelty. I wanted to do more. The golf tournament brings in local businesses. They set up on every other hole, so it’s an interactive experience. It’s a fun day. One of them sponsors the team photos of everyone holding up the tournament banner.

This year, instead of having a professional photographer there to take the picture, we’re asking the players to take the pictures with their own cameras and phones, so they’ll have it immediately. Then they can share and post their photos with hash tags. It’s just another way to keep the message growing virally.

There are new ideas every year.

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What has been your own approach to Movember?

Sandy Goodman: It’s changed over the years. At first, it was about getting people on the team. We’ve had as many as 80 people on a team and we’ve had as few as 20. I haven’t even really started building a team yet for this year. I used to start up on September 15, the day the website goes up, but it was a bit early. I just sent my first email for recruiting.

Originally, we just had a get-together with the guys. Then, we connected with some local bars and existing local events. Now we help promote. Bars and restaurants are happy for us to bring our crew, so we’ve had a lot of success with that. If there’s too much happening on the calendar, though, people can get burnt out, so we take that into consideration.

Movember has made it easier to host an event. Once you’re signed up, you can send invites to your friends or you can post events publicly. It’s fantastic. You could post a keg party if you wanted and ask for donations as admission.

When they were in college, I helped my sons set up their own team, The Buffalo Mo Bros. I encouraged them to use those tools to set up keg parties and things like that. It was super easy. It’s about getting together, having fun, and raising awareness and some money.

How do you motivate people to donate to a cause like this?

Sandy Goodman: In the beginning, I fundraised almost exclusively through email. I would send out about eight emails throughout the campaign. I started with the kickoff, maybe something for Halloween, then Veterans Day, and halfway there’s the golf tournament and then the wrap-up.

I would always attach a personal message. I would cut my group into subgroups, such as work friends or high school friends, and then cater the messages to them. Movember allows you to upload pictures to the site, so I do that, and they can see my progress.

Now, I focus exclusively on the golf tournament, because it’s just a big event. It raises about $50,000. I organize everything.

For whatever reason, I am fortunate to have some very generous friends. Everyone understood that I was passionate about it and that resonated. I was passionate because of my father-in-law. I was passionate because I have three sons who have a history to be concerned with because they’re two and a half times more likely to get it than I am.

What works for my fundraising is email campaigns and being thoughtful about how I word the emails and who I send them to.

I’ve been doing this for 10 years. I’ve been the top United States fundraiser for the past 8 years. The individual who has raised the MOst MOney is called the MoMo. It’s a title I love. I would love to retain it.

I imagine if you’ve been doing this for eight years, you must have a core group of people who campaign with you every year?

Sandy Goodman: I do, but people come in and out. It’s hard to maintain the passion. There are many charities that compete for our attention and our dollars. People have other things in their lives. Sometimes life throws you a curve ball, and your focus and priorities just change.

For example, one of the guys who has been with me all these years just told me: “My mother-in-law has breast cancer. So I’ve decided to focus on the breast cancer walk this year.” I think that’s great. There’s nothing wrong with that. I miss him, but he’s still doing great things.

For me, it’s just about being involved with something. It’s such a powerful thing when we all lift together. It’s about numbers.

It’s about having a clear message and a clear path for success. You have to make it frictionless for people so that they can just click and be done. If people don’t see a hyperlink and they don’t understand your methods, you’re not going to win. Movember has been fantastic at that. They get that need for ease. That’s why they were trailblazers and why they were able to have such success and to grow so quickly.

They made it frictionless. They made it easy for people to understand the message, to follow somebody who’s passionate and having fun and to see your progress. Pictures and emails are template-driven, so they allow you to spin to your group, update, and customize your message. “Just click here.” It’s that simple.

What are your tips for men who want to start their own group?

Sandy Goodman: Have fun. Be passionate. And do the work. There’s a full spectrum of Mo Bros and Mo Sisters. There are people out there who sign up and they’ve raised zero dollars, but they have fun and they have an excuse to spark conversations. That’s great. They’re doing something and making a difference. If one moustache saves one life, even if you haven’t raised any dollars, that’s fantastic.

On the other end of the spectrum, some people just get really into it. They get passionate, organized, do the hard work, and they raise a lot of money and awareness. It’s a balance between both.

Do you have any advice for patients or their loved ones who want to participate?

Sandy Goodman: I watched my father-in-law suffer. It was a very difficult experience for everybody—obviously for him—but also for all his family members. Once he had prostate cancer, we learned that it was so confusing to find and understand the resources available, the best course of action, or the best treatments.

Movember had resources that were really comforting and helpful and focused on care (LIVESTRONG at the time). Knowing that they’re doing the research and the work is comforting also.

Under “About Us,” they have information on the work that they’re doing. There are over 1,200 projects funded by Movember in all areas of men’s health: prostate cancer, testicular cancer, and mental health and suicide prevention.

They also provide links to other resources. They have hotlines for people to call for more information and support.

Resources for mental health have really grown in prominence at Movember over the past few years, mostly in response to the mental anguish that you go through when faced with any cancer and not knowing who to talk to. When you consider that three out of four suicides are men, it’s a huge issue at all ages.

I never want to get a message from someone saying they’re glad I’m doing this because they’ve just been diagnosed with prostate cancer. That’s terrible. But the fact that they were diagnosed and they’re taking action is fantastic, because they’re reaching out. They’ve seen me, my passion, and they’ve seen my moustache every year.

I always pick up the phone. I try to help however I can. If I can provide a resource through Movember, I always do that, but it’s a tough journey.

Most people with prostate cancer will die of something else.

Sandy Goodman: That’s true. For those who already have prostate cancer, it’s the treatment and it’s the side effects that are difficult.

I have several friends that have gone through complete prostatectomies and several going through active surveillance. It’s not an easy journey, even if it’s super successful. It just takes time.

Do you still feel men don’t want to talk about prostate cancer?

Sandy Goodman: That’s changing a little. I have two good friends who have had prostatectomies and they’ve had some very serious side effects. They are extremely open about wearing diapers and the other issues. That conversation wouldn’t have happened 10 years ago. I would have waived them off like: “I don’t want to hear that.” Now, I’m open to it, everyone around me is open to it, and it’s not taboo anymore. It’s more about being there for them than anything else. The message is being heard.

Do you think that this change is due to efforts like Movember’s annual campaign, or do you think society is evolving?

Sandy Goodman: I think it’s a combination. It’s not one or the other. People are coming of age in a more communicative era. We have Facebook and social media and charities out there are promoting and discussing these issues.

We’re more accustomed to sharing our emotions as a culture?

Sandy Goodman: Yes. We share a lot. We share everything on the worldwide web. There it’s frictionless, and the messages are bouncing around at hyper speed all the time. Sometimes more than you want. But that’s for the best when you’re talking about things that in the past were not discussed and should be.

Depression and suicide?

Sandy Goodman: One hundred percent. People suffer on their own for many reasons, including cancer. That’s the main message of Movember: talk, listen, and be there. I’ve picked up the phone to check on people many times over the last couple years, and we just have a conversation. Other times people have reached out to me when I wasn’t feeling great about things. I would just be honest and say: “I just need to talk to someone right now.”

For me, that support is completely thanks to Movember and their message. I try to practice what they preach, but it’s not always easy. We’re guys. We still grew up being guys. We don’t cry. We say, put a Band-Aid on it, you’ll be fine. But that’s not as powerful as reaching out.

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Focal Therapy + Imaging

Dr. Mark Emberton is a Professor of Interventional Oncology at University College London.

Prostatepedia spoke with him about focal therapy for prostate cancer.

What is focal therapy for prostate cancer?

IMG_0571Dr. Emberton: Focal therapy is an attempt to improve the therapeutic ratio. It addresses the harms and benefits of treatment. In prostate cancer treatment, the harms are too great for the benefit to accrue.

We can’t improve the benefit very much, but we can certainly reduce the harms that we inflict on our patients. Nearly every patient who has been treated for prostate cancer will experience a reduction in quality of life because of the impact on his sexual function, continence, or rectal function.

Focal therapy attempts to address that by preserving tissue. We’ve managed to preserve tissue in all other cancer management: breast through lumpectomy, kidney through partial nephrectomy, liver through partial hepatectomy, and penile cancer through partial penectomy. Prostate is the last bastion. Until recently, all men had the prostatic equivalent of bilateral mastectomy. In other words, their whole prostate tissue was removed irrespective of tumor volume, location, or number. Everyone was treated the same. With focal therapy, we attempt to preserve tissue, which preserves function.

How do doctors determine if focal therapy is appropriate for a man?

Dr. Emberton: It’s not for everybody. At the moment, we do surveillance so that men with very low-risk disease have no treatment. We offer surgery to men with high-risk disease who’ve got extensive, high-burden tumors in the same way we manage, say, breast cancer. We might choose to watch an elderly woman with a small breast lump. We might choose to do a mastectomy on a young woman with very aggressive breast cancer. But the majority of women—currently 80%—can get away with a lumpectomy. This is enabled by the ability to identify tumors and determine location and volume.

That’s a very recent development in prostate cancer. Until very recently, we were treating all men blindly. Since Hugh Hampton Young did his first prostatectomy at Johns Hopkins about 100 years ago, we’ve been treating prostate cancer without knowledge of tumor location.

What is the role of imaging?

Dr. Emberton: The new trick in town is that we can see the prostate cancer with MRI. If we can see it, we can direct needles at it. If we can direct needles at it, we can direct energy at it. We can zap the tumor rather than having to remove the whole prostate. We can have a much more nuanced approach now. Instead of treating all men the same, we can now stratify men by risk with great precision by biopsying them differently depending on where the tumor is and then allocating treatment depending on the risk stratification that has been assessed. If a man has one millimeter of Gleason 4+3, most of us would not treat. I certainly wouldn’t. If he has extensive bilateral disease, I would offer whole-gland treatment in the form of surgery or radiation therapy. If he has got a 0.5 cc tumor in the right peripheral zone of the prostate, I see no reason why we shouldn’t offer a selective destruction of that tumor that preserves erections, ejaculation, and continence. We’re doing that today. We’re having conversations with men today that we couldn’t have had three to four years ago because we didn’t have the tools.

What about other advances in imaging?

Dr. Emberton: PSMA is very useful in staging men. It’s concordant with MRI and the prostate, but it doesn’t give us the spatial resolution that we would require to decide which part of the prostate to treat. The PSMA PET/CT will be positive on the left or the right side of the prostate, but will not give us any more information. It’s really useful in the high-risk man with whom you’re trying to rule out metastatic disease.

There are a variety of forms of focal therapy, correct?

Dr. Emberton: I think conceptually, it’s very clear. We offer men focal therapy when we can treat the tumor plus a margin and we think we can do so faithfully. But there are lots of ways to do it. Just like surgery, you can have an open, transperineal, laparoscopic, or robotic prostatectomy. In brachytherapy, high-dose rate (HDR), low-dose rate (LDR), CyberKnife, TrueBeam, protons, external beam, the principle is the same.

Yes, we have a few options with focal therapy, though not as many as surgeons and radiation therapists. We’re often accused of having a cornucopia of ways of treating. Actually, we don’t. We have heat (hot or cold) and we have electricity in the form of radio frequency or electroporation.