Our Greatest Wealth Is Health

Andrew Siegel MD   1/4/2020    Happy New Year!

In yesterday’s NY Times, Yoni Freedhoff, a physician at the University of Ottawa, nicely summarized in only 48 words how to be healthy: Don’t smoke. Get vaccinated. Avoid trans fats. Replace saturated fats with unsaturated if you can. Cook from whole ingredients — and minimize restaurant meals. Minimize ultra-processed foods. Cultivate relationships. Nurture sleep. Drink alcohol at most moderately. Exercise as often as you can enjoy. Drink only the calories you love. Full article.

Many New Year’s resolutions involve such healthier living habits.  Adopting this kind of  lifestyle has many benefits, including reducing one’s risk for many cancers, including prostate cancer, the leading cancer in men and the second leading cause of cancer death in men.

The advice that follows in this entry is relevant for men with prostate cancer on active surveillance; for the brothers, sons, nephews and other relatives of prostate cancer patients; and for any man who desires to minimize their risk for prostate cancer. It is equally applicable to men who have had prostate cancer actively treated and wish to maintain their health and minimize their chances of a recurrence.

If prostate cancer was preventable, my job would be much easier and my patient load much reduced. However, as of 2020 there is no vaccine available to prevent the disease.  Nonetheless, we have become more enlightened about measures to help minimize the chances of developing the disease.

Genetics (a strong family history), aging (prostate cancer is more prevalent as men get older) and race (African American men are at greater risk) are factors that contribute to prostate cancer that are beyond one’s control. However, environmental and lifestyle factors also play a role and can be positively influenced by healthy lifestyle and dietary practices. This can not only can reduce prostate cancer risk, but also can slow the growth and progression of prostate cancer.  A healthy lifestyle includes a wholesome and nutritious diet, weight management, regular exercise and the avoidance of tobacco and excessive alcohol.  This practice can lessen one’s risk for all chronic diseases, including heart disease, diabetes and a host of other cancers as well.

Consider this: When Asian men (who have very low rates of prostate cancer) emigrate to western countries, their risk of prostate cancer increases over time. Clearly, a calorie-rich, nutrient-poor, Western diet overloaded with processed foods is associated with a higher incidence of many preventable problems, including prostate and other cancers as well as diabetes and cardiovascular disease.

Not uncommonly, pre-cancer on prostate biopsy—high-grade prostate intraepithelial neoplasia (HGPIN) and/or atypical small acinar proliferation (ASAP)— predate the onset of prostate cancer by many years.  This, coupled with the increasing prevalence of prostate cancer with aging suggest that the process of developing prostate cancer takes place over a prolonged period of time. In fact, it is estimated to take many years—often more than a decade—from the initial prostate cell mutation to the time when prostate cancer manifests itself with either a PSA elevation, PSA acceleration or an abnormal digital rectal examination. In theory, this provides the opportunity for preventive measures and intervention before the establishment of a cancer.

6 Measures to Reduce Prostate Cancer Risk

(Note: These measures will also reduce progression risk for men on active surveillance, those with pre-cancerous biopsies, and those treated with conventional means.)

1. Stay svelte. Obesity has been correlated with an increased risk for prostate cancer occurrence, recurrence, progression and death.  Research suggests a link between a high-fat diet and prostate cancer. In men with prostate cancer, the odds of metastasis and death are increased about 1.3-fold in men with a body mass index (BMI) of 30-35 and about 1.5-fold in men with a BMI > 35. Furthermore, carrying the burden of extra weight increases the complication rate following treatments for prostate cancer.
2. Eat right.  Avoid refined, over-processed, nutritionally-empty foods and be moderate with the consumption of animal fats and dairy.  A healthy diet includes whole grains and plenty of vegetables and fruits. Vegetables and fruits are rich in phytochemicals (biologically active compounds found in plants), including anti-oxidants, vitamins, minerals and fiber. Anti-oxidants help protect cells from damage caused by unstable molecules called free radicals, which can incur cellular damage and potentially cause cancer. Fruits such as berries (strawberries, blackberries, blueberries and raspberries), red cabbage and eggplant contain abundant anthocyanins, anti-oxidant pigments that give red, blue and purple plants their vibrant coloring. Tomatoes, tomato products and other red fruits and vegetables are rich in lycopenes, which are bright red carotenoid anti-oxidant pigments. Cruciferous vegetables (broccoli, cauliflower, Brussel sprouts, kale and cabbage) and dark green leafy vegetables are fiber-rich and contain lutein, a carotenoid anti-oxidant pigment.  A healthy diet also includes protein sources incorporating fish, lean poultry and plant-based proteins such as legumes, nuts and seeds. Include fish rich in anti-inflammatory omega-3 fatty acids, e.g., salmon, sardines and trout. Processed meats and charred meats should be avoided.  Healthy fats (preferably of vegetable origin, e.g., olives, avocados, seeds and nuts) are preferred.  An ideal diet that is both heart-healthy and prostate-healthy is the Mediterranean diet.
3. Tobacco: NO; alcohol: light. Tobacco use has been associated with more aggressive prostate cancers and a higher risk of prostate cancer progression, recurrence and death. Prostate cancer risk rises with heavy alcohol use, so moderation is recommended.
4. Keep moving. Exercise has been shown to lessen  risk of developing prostate cancer and to decrease the death rate in those who do develop it. If one does develop prostate cancer, he will be more fit and have an easier recovery from any intervention necessary to treat the disease.  Exercise positively influences energy metabolism, oxidative stress and the immune system.  Aerobic exercise should be done at least every other day with resistance exercise two to three times weekly.  Pelvic floor muscle exercises benefit prostate health by increasing pelvic blood flow and lessening the tone of the sympathetic nervous system (the part of the nervous system stimulated by stress), which can aggravate lower urinary tract symptoms. Additionally, pelvic floor muscle exercises strengthen the muscles surrounding the prostate so that if one develops prostate cancer and requires treatment, he will experience an expedited recovery of urinary control and sexual function.
5. Get checkups. You do this for your car, so be sure to do this for your body! Be proactive and see your doc for a DRE (digital rectal exam) and PSA (prostate specific antigen) blood test once a year. The PSA test does not replace the DRE—both should be done!  Early prostate cancer causes NO symptoms, so must be actively sought.  
6. Meds. Medications can reduce risk for high risk men: strong family history, previous pre-cancerous biopsies, etc.  Finasteride and dutasteride, commonly used  to treat benign prostate enlargement, also reduce the risk of prostate cancer. They  block conversion of testosterone to its activated form–dihydrotestosterone (DHT)– responsible for prostate growth and male-pattern baldness.

The Prostate Cancer Prevention Trial tested whether finasteride could prevent prostate cancer. This trial was based on the facts that prostate cancer does not occur in the absence of testosterone and that men born without the enzyme that converts testosterone to DHT do not develop either benign or malignant prostate growth (nor hair loss, for that matter). This study enrolled almost 20,000 men who were randomly assigned to finasteride or placebo. The study was stopped early because men in the finasteride arm of the study were found to have a 25% risk reduction for prostate cancer.

The original study also demonstrated a slight increase in aggressive prostate cancer in the finasteride arm.  This negative finding resulted in a “black box” warning from the FDA, as a result of which many men were frightened about the prospect of using the drug.  However, long-term follow-up on the original clinical trial (presented at the 2018 American Urological Association meeting) concluded that finasteride clearly reduces the occurrence of prostate cancer and that the initial concerns regarding high grade prostate cancer were unfounded.

Prostates in those treated with finasteride were 25% smaller at the end of the study as opposed to the prostates in the placebo group. It is important to know that finasteride (and other medications in its class) lower PSA by 50%, so any man taking these medications will need to have his PSA doubled to estimate what the PSA would be if not taking the medication.

The bottom line is that finasteride (Proscar and Propecia) and dutasteride (Avodart) help prevent prostate cancer, shrink the prostate, improve lower urinary tract symptoms that are due to prostate enlargement, help avoid prostate surgery, and grow hair on one’s scalp…a fountain of youth dispensed in a pill form!  Furthermore, shrinking benign prostate growth increases the sensitivity of the DRE to detect a prostate abnormality.

Wishing you the best of health and a happy 2020,

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

Tags: Andrew Siegel MD, prostate cancer, Prostate Cancer 20/20, prostate cancer prevention and risk reduction

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