PSA levels in 2 studies found not to reflect prostate cancer growth

Thanks to a blog at 'Dan's Journey through Prostate Cancer' I saw this interesting piece of research into PSA levels. The Cornell Chronicle shows that PSA levels do not reflect prostate cancer growth - see the article here. They write: 

"The recent study, published in the Journal of Clinical Oncology, analyzed data from more than 2,500 men enrolled in two multinational phase 3 clinical trials testing enzalutamide to slow or stop tumor growth in patients with advanced prostate cancer. This drug targets the androgen receptor, a protein that prostate cancer cells use to receive growth signals from male hormones such as testosterone. The trials (ARCHES and PROSPER) assessed cancer spread or growth on imaging scans, alongside changes in PSA levels during treatment. The researchers examined cases of radiographic progression – when cancer growth or spread is detected by imaging such as X-rays, CT scans or bone scans."

The results showed up to roughly 25% of patients had radiographic prostate cancer progression without any rise in PSA levels, and they had worse outcomes. The study also found that patients often didn't have new symptoms and felt well, despite the cancer advancing. Both groups were similar and this suggests it may be a broad issue across advanced prostate cancer.

The results surprised researchers and they suggest that "patients receiving potent androgen receptor inhibitors such as enzalutamide may benefit from periodic imaging in addition to routine PSA monitoring, particularly during the first two years of treatment". 

Metformin and prostate cancer

The charity Yes to Life brought my attention to this aspect of the major UK study; the STAMPEDE trial. It recently explored whether adding metformin, a commonly used diabetes medication, to hormone therapy could improve outcomes for men starting treatment for advanced prostate cancer.

The results were not a simple yes or no.

As Yes to Life note "the study did not show a clear improvement in overall survival for most people. But it did show something quieter, and still important. Metformin helped reduce some of the physical strain that hormone therapy can place on the body, including weight gain and changes to blood sugar and cholesterol."

This is a wonderful reminder that care is not only about the tumour. It is about the whole person. The body that is carrying the treatment.

Yes to Life write: "It is also a reminder of why evidence matters. Integrative support should never be about quick fixes or promises. It should be about thoughtful, well-informed care that works alongside medical treatment, not instead of it."

If you would like to read the full article, you can find it here: https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(25)00231-1/fulltext

It is also worth mentioning that Metformin maybe takes a key role in the treatment of other cancers using off-label drugs and others to 'starve' the cancer. See more about that at: https://myunexpectedguide.blogspot.com/2018/09/can-we-starve-our-cancer.html

Glucose monitors: useful or not?

A couple of months ago I had the opportunity to wear a Lingo glucose monitor for 2 weeks. I've often over the years had times when I've craved carbs for an energy boost that when eaten then create a spike then a crash and more craving.....the 'spike-crash cycle'. I also used to get "hangry" - that hunger and irritability/anger that stems from a drop in glucose and creates a perfect storm for our hormones. Since my diagnosis and changing my nutrition this has been much much less so...almost not occurring....but occasionally it has surprised me - hence the interest in the monitor.

Was it worth it? 

I did learn stuff - more of that in a mo....before then by coincidence the week after I finished I came across a new study that calls into question the usefulness of these blood-glucose plans for folks without diabetes.

In two controlled studies using 30 participants, researchers found only weak-to-moderate correlations between the same meals eaten a week apart. This means your body's response to your morning porridge might be completely different from meal to meal. Which if true, makes basing food choices on how you react to one meal pretty pointless (and even dangerous!). See more at: https://examine.com/research-feed/study/1jjKq1/?

Glucose spike dangers?

So glucose spikes are when you have more glucose in your bloodstream than your cells can take up. Some degree of rise is completely normal but it is the dips or crashes that can impact on long term health - research suggesting not least an increased risk for developing insulin resistance, type 2 diabetes, and cardiovascular issues.

Serious sugar spike material

Sugar warnings?

Sugar and carbohydrates are the quickest to be converted to glucose - any not being used gets stored in the body. It is when it is too concentrated in the blood that it is called a glucose spike or blood sugar spike. 

Many of us with cancer have heard the 'warnings' that sugar can impact cancer - but also hear the NHS and and others saying that it is all 'a myth' - see for example this piece by Cancer Research UK here. They write: "All of our healthy cells need glucose too, and there’s no way of telling our bodies to let healthy cells have the glucose they need without also giving it to cancer cells. And cancer cells also need lots of other nutrients too, like amino acids and fats; it’s not just sugar they crave. There’s no evidence that following a “sugar-free” diet lowers the risk of getting cancer, or that it boosts the chances of surviving if you are diagnosed." 

The article goes on to note the concerns about sugar and obesity and the links between being overweight and cancer. However I do not think this takes seriously the growing evidence around the negative impact of refined sugar.

Read this blog by Robin Daly looking at this issue and evidence - he notes the views of NHS oncologist Professor Thomas: "Prof Thomas makes the point that, given the sheer volume of good evidence pointing towards dietary refined sugars and carbohydrates as both a source and driver of cancer, along with the catastrophic way that the grim reaper, cancer, is scything its way through developed nations around the globe, a zero-cost, safe intervention such as reducing intake of refined foods should be seen as eminently worth trying. Making utterly confident pronouncements about the absence of a relationship between sugar and cancer depends entirely on a totally suspect system that seeks to portray evidence as a binary ‘evidence/no evidence’ scenario, rather than as a more nuanced sliding scale of ‘more evidence’, ‘better evidence’."

Also see a useful and totally sensible discussion of sugar on this video of a Yes to Life Forum I helped host in October 2020 with nutritionist Kirstin Chick here.

Other factors

Spikes can also be caused by other factors like poor sleep, dehydration, caffeine, certain medications or stress - also during intense exercise. However it is most often eating carbs/sugar. 

Mild, dark and black tahini on toast

Some learning

My own monitor showed how my blood sugar spiked particularly after carbs - even just two oatcakes as a snack in the afternoon had a surprisingly large spike. In contrast the gluten-free toast with tahini's as part of a breakfast with a walk afterwards had less of a spike. Reducing snacking helped - and ensuring I had protein with every meal.

You will see the chart from my first week that I was missing the target but learning about some of the impacts....one noticeable improvement was going for a short walk after my evening meal.

The monitor I used was Lingo - others available - their app recorded great info and some useful tips but you need to download it as it seems to disappear from the app after the 2 weeks. Anyhow this rather basic info was from one of their blogs: 

How to avoid a glucose spike 

There are many ways to avoid a glucose spike naturally, and the best method is to be thoughtful with your food choices. Limit foods that are common sources of spikes such as refined carbohydrates, sugars, and sugary beverages, and instead opt for more complex carbohydrates that have fibre such as vegetables, fresh fruit, brown rice, quinoa, and whole grain bread. Even better, pair your carbohydrates with a source of protein and/or fat for a macronutrient-balanced option. 

Other lifestyle habits that can help keep your glucose steady include getting quality sleep, staying physically active, drinking plenty of water, managing stress, and limiting alcohol.

A lot of this is pretty obvious but I guess for me it was still a useful exercise in helping me think about meals again - over the years since diagnosis some good habits slip a little - it was a good reminder even if the research noted above suggests they may not be so useful. Anyone with any questions re this should speak with their medical team - this blog was just my experience.

See blog on Ultra-processed foods being recommended by NHS (??!): https://myunexpectedguide.blogspot.com/2023/04/ultra-processed-foods-recommended-by.html

See blog on best nutrition/recipe books: https://myunexpectedguide.blogspot.com/2024/02/best-nutrition-on-recipe-books.html

Understanding testosterone

As we know blocking testosterone production halts tumour growth in early disease, while elevating the hormone can delay disease progression in patients whose disease has advanced. This never made that much sense....Now it seems we have an explanation: 

"The researchers found that prostate cancer cells are hardwired with a system that allows them to proliferate when the levels of testosterone are very low. But when hormone levels are elevated to resemble those present in the normal prostate, the cancer cells differentiate....It turned out to be rather simple. When androgen levels are low, the androgen receptor is encouraged to “go solo” in the cell. In doing so, it activates the pathways that cause cancer cells to grow and spread. However, as androgens rise, the androgen receptors are forced to “hang out as a couple,” creating a form of the receptor that halts tumor growth. Nature has designed a system where low doses of hormones stimulate cancer cell proliferation and high doses cause differentiation and suppress growth, enabling the same hormone to perform diverse functions."

Here's the research article: https://corporate.dukehealth.org/news/study-solves-testosterones-paradoxical-effects-prostate-cancer

Here's also Chris Woollams at Canceractive writing in 2020 about hormone treatment (before this recent discovery). His article is an interesting look at current practice and a possibly different approach to hormones: https://www.canceractive.com/article/the-reality-of-lowered-testosterone-and-higher-oestrogen-in-men-counters-orthodox-theories-of-prostate-cancer He concludes rather grimly: "It all really seems a bit of a mess. Low Testosterone makes matters worse and standard treatment is to cut testosterone! Blood fat levels make matters worse, and standard treatment raises them! Anti-oestrogens seem to do a good job and no oncologist thinks to explore an anti-oestrogen, or indole 3 carbinol, or melatonin?. Meanwhile the number of prostate deaths climb, and recurrence is a major factor. As a friend of mine with a prostate cancer a decade ago said 'there doesn't seem to be best practice in prostate cancer'. He could well be right."

We still have a way to go - the latest research is very useful in helping us understand.

Update May 2025: An article by Dr Geo Espinosa at X Wellness (May 2025) concluded: "At best, there is a weak link between testosterone and prostate cancer, but that is primarily based on test tube and animal studies. Well-performed human studies suggest that if there is any link between the two, low testosterone might increase the risk of prostate cancer, not the reverse. It would be a good idea to have an honest and open discussion about testosterone and prostate cancer with your physician at your next medical visit and learn how you can optimize your testosterone levels after prostate cancer. A conversation on TT in men on Androgen Deprivation Therapy (ADT) is mute since the medical approach intends to lower testosterone to minimize androgen receptor (AR) production. There again, testosterone is not the villain, but the AR's might be. "

BPA; what are the issues?

In 2018 it was reported that since the 1970s more than 78,000 chemicals have been approved for commercial use. Only 1,000 have been formally examined and considered for their carcinogenic potential - and of those the World Health Organisation consider 120 as ‘known’ carcinogens, 81 as probable carcinogens and 299 as possible carcinogens (i). See my previous blog at: https://myunexpectedguide.blogspot.com/2022/01/a-look-at-environmental-toxins.html

One of those chemicals which has been widely used is Bisphenol A (BPA) and it has been linked to cancer. It is a synthetic chemical used since the 1950s in making millions of plastics items including food packaging. By 2008 it was found in 93% of Americans urine. Research has linked it to cancers, hormone disruption and other serious health problems. It seems that when BPA enters the body it latches onto the body’s oestrogen receptors and tricks the body into thinking it’s oestrogen – thus increasing oestrogen levels for both men and women as well as disrupting the natural balance between our hormones. Not great stuff!

A review in 2019 (ii) concluded; “Recent findings support a causal role of BPA at low levels in the development of cancers and in dictating their response to cytotoxic therapy.”

In 2020 a study (iii) found that people who had higher levels of bisphenol A in their urine were about 49% more likely to die during a 10-year period. Even as long ago as 1996 research was indicating concerns around endocrine disruption - sadly since then the list of endocrine disrupting chemicals (which includes BPA) has been steadily growing (iv).

Michael Greger of Nutrition Facts writes (2019)(v): “As the world’s oldest, largest, and most active organization devoted to research on hormones concluded, ‘even infinitesimally low levels of exposure—indeed, any level of exposure at all—may cause [problems].”

Not just plastics

A research review paper in 2018 (vi) noted: “Occurrence of BPA in breast and commercial milk represents a public health concern” and that “infants and children are particularly vulnerable to the effects of BPA exposure.”

While another 2018 report found that 93% of till receipts have BPA or bisphenol S (BPS) which were readily transferred onto the skin when handling them. Thankfully BPA has been banned in till receipts in the UK since January 2020. It seems BPS is still in some UK till receipts, although most major supermarkets are now using alternatives. So largely good news particularly for many shop workers who handle many till receipts in a day(vii).
 

Action on BPA – and alternatives

An EU ban on BPA in baby bottles only came into force in 2011 and in food packaging in 2020. It is hard trying to find out the extent of BPA use today; it is certainly being used in new products and of course in products that were made before the bans. Also while there are moves to reduce exposure to the public it seems there is little being done in terms of the impact on those workers, largely women, in the plastic industry.

Banning BPA may still lead to problems as in some cases it is being replaced by other unregulated chemicals like BPS which some argue could be worse than BPA.

BPS and bis­phenol F (BPF) are the two most common replacements for BPA. Research in animals shows that both chemicals disrupt hormone balance comparably to-and sometimes worse than-BPA. Research also suggests that high levels of BPS may promote weight gain. The good news of the replacement BPS is that it may be less likely to leach into your food or beverage when heated in the container, as opposed to BPA, which is very sensitive to heat.

BPA-free does not mean chemical free. I have personally moved away from storing food in plastic where possible but many foods still arrive plastic wrapped especially supermarket products – even many of the organic ones are shrink wrapped. I remember that it was only a year ago that I came to understand that many canned foods had a BPA lining. I was horrified to find that research from the US in 2016 found that people who had consumed one can of food had 24% higher concentrations of BPA in their urine (within 24 hours after consumption) than people who had not consumed canned food.  

Some companies have gone BPA free like Biona and some Mr Organic products – plus an increasing number of products can be found in jars for a price. However too many companies are not talking the issue seriously and it can be hard to find food labelled as to whether it is free from BPA, BPS or BPF - and of course this doesn’t answer the question about how safe the new liners are?
 

What can you do?

We don’t fully know the impact of the replacements so to avoid these chemicals in your food here’s a list that I’ve pulled together that may help us make better choices;

-       if the container or plastic has a number 3 or 7 recycle code, it more likely contains BPA or BPS so that is one to avoid.

-       Choose food and drinks packaged in glass rather than aluminium and plastics

-       Tetra Pak - many non-dairy, beans and tomato products come in these and they are BPA and BPS free

-       choose BPA-free cans where possible

-       dried organic beans are less likely to be contaminated with chemicals than those from cans also sprouted beans can take much less time to cook

-       use glass and stainless steel for food storage at home

-       age increases the leaking of BPA from plastics so take care to throw away old or damaged plastic containers

-       use bees wax wraps or other non-plastics to cover food

-       never heat food in any type of plastic container

-       silicone maybe safer than many plastics but has not been researched well and food-grade silicone can have many additives and colourings added which are not usually listed

-       use a wooden shopping board; plastic has been shown to have more bacteria than wood and there is a risk of small plastic particles becoming dislodged and mixing with the food

-       some takeaways are fine if you bring your own containers

-       getting an organic box delivered or more regular shops at the farmers market could help reduce supermarket plastic wrapping

-       avoid plastic coffee makers and if using filters use non-bleached paper

-       Use unbleached parchment paper for baking and wrapping food. Parchment is often coated with silicone that is considered inert and safe; but as noted above research is limited

-       Aluminum foil can be used to wrap foods but best used with dry foods; acidic foods like tomato sauce can increase the likelihood of it leaching into foods.

Do you have any suggestions to add to this list?

It’s worth noting again that we’ve have only looked at BPA here – as the 2018 report at the beginning of this blog suggests we need to look much wider – for example others like phthalates are also known to mimic and disrupt hormones while many others have other effects.
 

Notes

(i)            ‘Anti Cancer Living’ by Dr Lorenzo Cohen and Alison Jefferies (2018)

(ii)           https://pubmed.ncbi.nlm.nih.gov/30848227/

(iii)         https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769313

(iv)         https://link.springer.com/article/10.1007/s11356-009-0107-7

(v)          https://nutritionfacts.org/2019/11/05/why-hasnt-bisphenol-a-bpa-been-banned-completely/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726844

(vi)         https://www.sciencedirect.com/science/article/abs/pii/S0278691518300863

(vii)       https://saferchemicals.org/2018/01/17/new-report-9-out-of-10-receipts-contain-toxic-bpa-or-bps/

 

Impact of radiotherapy 15 months on

Finishing Radiotherapy March 2020

Well its been nearly a couple of months since my last blog on this site - a collection of reasons plus busy times - it has also now been 15 months since finishing radiotherapy - and also deciding to finish the hormone treatment - so it seemed a good place to review where I am at. Some might also be interested in my previous blogs on radiotherapy by clicking on the tag.

I guess it is worth saying that although the radiotherapy was aimed at getting rid of prostate cancer we don’t know whether that is the case - medical teams talk instead of being ‘in remission’; in other words no sign of cancer. Also no doctor can say for certain whether your cancer will come back. Each cancer is different and the success of your treatment will depend on many things. 

Certainly what figures that are available indicate cancer does return in a number of cases; one article suggests up to 40 percent of patients with prostate cancer will show signs of recurrence (i). It is extraordinary that reoccurrence after treatment for early stage prostate cancer is still not properly recorded. This is critical info if we are to understand which men are most at risk of reoccurrence and which treatments are most effective.

However we must remember generally relative survival rates are high. There are many factors that can lead to more likely recurrence like cancer cells in lymph nodes, larger tumours, non-localised cancers, higher grade cancers, diet, men under 60 years and more. Hence, to my mind, an integrative approach where we are still actively working on health is the best call to reduce the likelihood of a return!

Update 22/5/22 - re photo of bell ringing - see this blog re riding the bell - a view that resonates with me: https://blogs.bmj.com/bmj/2019/06/04/jo-taylor-its-time-to-call-time-on-the-end-of-treatment-bell/

Stats

I’ve quoted before the wise words of Sophie Sabbage about avoiding statistics, that she writes in her book, “The Cancer Whisperer”. She says “staying away from soul-sapping, fear-inducing information that discusses indicators, but not inevitabilities.” That doesn’t mean we should settle for half-truths - as she says “Don’t let your oncologist or doctor protect you from the full facts. Push them for answers until you are satisfied you know it all.”

It is also worth noting that fear of reoccurrence can also be hugely damaging. To quote another statistic - approximately 7% of cancer patients develop severe and disabling fear that includes constant intrusive thoughts and misinterpretation of mild and unrelated symptoms (ii). 

I have written before about fear and it can have a huge impact on our lives - it certainly has on me in the past. Things are much easier now but there is no question that fear is just under the surface at times. It remains, in my view, one of the number one areas to target in terms of an wholistic approach. To quote Sophie again; “If you don’t take hold of your fear your fear will take hold of you.” She talks about people dying of fear and shock and the need "to pass through it.”

I have been able, in the past, to attend one of her day workshops and just a few weeks ago caught this excellent webinar from Penny Brohn UK talking about how to reduce the impact of fear on medical outcomes and wellbeing. It is an excellent video and I do recommend a watch. See here: https://www.pennybrohn.org.uk/resource/impact-fear-cancer/

PSA results

I’ve had three PSA tests at 3 month intervals, 0.4 then 0.3 then 0.3 a couple of weeks ago. This doesn’t mean a lot at the moment and it could possibly fall more for up to two years after radiotherapy although it looks like it has possibly stabilised? If it rises more than 2.0 then that is when we have to take action. You can see more about PSA tests and bounces after radiotherapy in my blog where I talk about why I stopped hormone treatment here. 

Side-effects

Cancer Research UK list long term side effects from radiotherapy and hormone treatment:

Radiotherapy: Problems passing urine, Leakage of urine, Erection problems (impotence), Frequent or loose poo, Inflammation of the back passage (proctitis), Swollen legs or scrotum, Cancer of the bladder or lower bowel, Weaker pelvic bones, Tiny cracks in the bones, Low levels of vitamin B12 (iv).

Hormone treatment: Tiredness, Problems getting an erection (impotence), Hot flushes and sweating, Weight gain, Memory problems, Mood swings and depression, Bone changes, Risk of heart problems (v).

Radiotherapy side effects can and do occur for many years. Research has shown that men treated for their localized prostate cancer have been found to have similar long-term side effects regardless of treatment type. Both surgery and radiation therapy had similar levels of urinary incontinence, erectile dysfunction, and bowel urgency 15 years after treatment (vi). However the hormone side effects such as hot flushes and sexual problems, are likely to improve after treatment stops - but it can take several months for side effects to improve, although I have read that some men never notice any improvement. This is particularly so if hormone treatment is intermittent.

Urine problems

Well I won’t dwell on this but suffice to say I am still needing the loo three times each night and too often in a day, sometimes with urgency but only very occasionally with a tiny leak. It is enough to keep me at the pelvic floor exercises! There are also some bladder training exercises where you learn ways to wait longer between needing to urinate and passing urine. I’ve not got on well with these, as the moment I am thinking about waiting makes me want to go more. 

Cutting down on caffeine and alcohol are also recommended - well I have very little alcohol indeed and can’t take my daily joy of a double espresso away from my day (see my blog on coffee here). Drinking water is important - this seems counter intuitive but limiting your fluid intake makes incontinence worse as it reduces your bladder's capacity.

I have been offered Tamsulosin as it can help urinary symptoms following radiation therapy (vii). However I didn’t feel comfortable taking it as I was managing mostly OK, plus I was concerned about a load of new side-effects and would I then become reliant on it?

Perhaps one of the worst impacts of urine problems like leakage is the accompanying shame. I’ve fortunately not had those moments like some guys who have talked about 'peeing their pants'. Certainly learning how best to manage it successfully can go a long way in easing the pain and embarrassment. I’m hoping that my challenges won’t get any worse!

Sex life

In terms of a love life - certainly the treatments have had an impact - something that perhaps doesn’t get talked about enough? But it isn’t just erections - for many there are other side effects that get even less mentions - climacturia, arousal incontinence plus orgasmic disturbances such as altered orgasmic sensation, anorgasmia, and orgasm-associated pain (dysorgasmia) (viii). 

One article I welcomed was by Elvin Box sharing his prostate cancer story and the impact it had on his sex life: https://www.jodivine.com/articles/perspectives/winning-back-our-sex-life-after-prostate-cancer-a-personal-story-by-elvin-box

There are quite a few other resources online - here for example is a video by Dr Holzapfel who looks at some of the effects: https://pcstoronto.ca/2020/12/03/video-there-is-sex-after-prostate-cancer/

Sex is clearly an important part of our lives - for some much more than others - there is also evidence that it can play a part in healing. See a video by Jem Ayres looking at the 'Healing Power of Orgasm’: https://youtu.be/4wp7GYc4yok  You can also see also my film of Jems' cancer journey here. 

It is also worth noting that there is now research confirming that masturbation boosts your immune system (ix). However I guess if sex is an option then you don’t need such studies to encourage you back to it after treatment?! Then again perhaps too often fear and other stuff gets in the way?

Bones

We know radiotherapy has an impact on bones - and so does the hormone therapy yet it was my Functional Medicine practitioner that advised I get a scan. My GP readily agreed but I wonder why it isn’t standard practice?

A DEXA scan is a bone density scan that uses low dose X-rays to see how dense (or strong) your bones are. They are often used to diagnose or assess your risk of osteoporosis, a health condition that weakens bones and makes them more likely to break. As well as being quick and painless, a bone density scan is more effective than normal X-rays in identifying low bone density (x).

It seems that your T scores are important; they show how your bone mineral density compares with others. Scores of +1.0 are good. Numbers between +1 and - 1 show normal bone mineral density. Scores between -1 and -2.5 indicate Osteopenia (thin bones). Less than -2.5 indicate Osteoporosis (porous bones) , eg. - 2.7, -3.0 etc. And -3.0 shows  serious Osteoporosis. 

Well I have osteopenia. Spine is minus 1.9 and hips are minus 1.6. 

Update 2.10.23: See link between gut and bone health at: https://chriswoollamshealthwatch.com/your-illness/gut-bacteria-bone-density-and-osteoporosis/

So what is recommended?

Hoping dance will be poss again soon!

1. Exercise. Like muscle, bone gets stronger when you use it. The best moves for bones are weight-bearing exercises that force your body to work against gravity. That includes walking, stair climbing, dancing, and lifting weights. I do all those except the weights.

2. Diet. High-calcium foods outlined on most websites include:

• Sardines and salmon, with bones

• Tofu

• Dairy products such as yogurt, low-fat milk, and cheese

• Green vegetables such as broccoli and collard greens

Dairy is largely a no-no for me as it’s linked to prostate cancer so I do try and manage to boost other calcium rich foods. My GP recommended looking at one of the calculators online to see if you are getting enough calcium: https://www.osteoporosis.foundation/educational-hub/topic/calcium-calculator

Interestingly according to the calculator I am getting not even half of what I need. However a lot of things I eat aren’t listed eg sprouted seeds, spinach, kiwi, chia, flax seeds, herbs, spices and more - some of these are very high in calcium - indeed seeds and leafy greens we do lots of and they are best for calcium. Nevertheless the DEXA has led me to think more carefully and increase herb use, occasional organic sheeps yoghurt and oily fish.

3. Vitamin D. Time outdoors in the sunshine each day helps as do some foods. Here is a list from one website:

• Fish such as salmon, tuna, and mackerel

• Fish liver oils

• Beef liver

• Cheese

• Egg yolks

• Fortified breakfast cereals, juices, milk products, yogurt, and margarine

However some of those foods I am avoiding. A vitamin D test a while ago showed I was at the low end of normal; many nutritionists and functional medicine practitioners like to see levels much higher than that. I have been supplementing around 3,000/4,000iu per day on advice from my practitioner.

4. Don’t smoke, drink less, cut back on salt and reduce caffeine. All great but caffeine intake is sacred at the mo!

5. Supplements. There are various lists online of supplements that can help, but I am very cautious about suggesting any as it is so individual. We also need to be aware that some will interact with other aspects of our health. In the past for example I have taken ashwaganda - a wonderful widely used Ayurvedic herb to reduce stress and so much more - however after taking for a while I discovered that some practitioners view it as oestrogenic - not something someone with prostate cancer wants to be taking. So do do your research!

In the past I have taken boron (recommended by doctors in Germany) for bone health, at present I have been recommended Algae calcium by my Functional Medicine practitioner - incidentally she recommended it some months before the DEXA test.

The GP is recommending another DEXA scan in 5 years. I am of course hoping the results will show an improvement!

Fatigue

Fatigue doesn’t get a mention by Cancer Research UK as a long term effect of radiotherapy. I wonder why as many other websites note fatigue, although most say it typically fades within three to six months. Talking to a number of people with prostate cancer I wonder how accurate this is. The US Government's National Cancer Institute website notes fatigue caused by radiotherapy can in some patients 'last months or years after treatment ends’ (xi).

Doing a quick google search - not always advised - shows research into prostate cancer patients having radiotherapy and hormones showed 'long- term high level of fatigue and high prevalence of chronic fatigue’ (xii).

Cartoon by Russ after reading this blog

My own experience is that levels of tiredness are greater now than before the hormone and radiotherapy treatment. Not by any means dreadful but certainly not back to normal. Of course it is hard to unpick cause and effect as we’ve also had a very strange last 18 months with Covid. I was also made voluntarily redundant from a job I loved and despite having a new role and opportunities, that clearly does have an impact on health.

Another key factor with fatigue following radiotherapy is Vitamin B12 deficiency (as noted by Cancer Research UK). For the last five months I have taken some supplements particularly chosen for my situation as care is needed regarding B supplementation as there is also a link with increased prostate cancer risk. I also do seem to have a bit of a challenge re methylation - more of that in another blog - but it is a key process underlying epigenetic (see earlier blog here on epigenetics).

Lots of factors will impact on tiredness but this is an area that needs more research - there is still not an understanding of why treatments cause fatigue.

Other side effects

Another factor well researched but not listed above is the loss of muscle mass and strength (xiii).  Hormones tamp down the production of testosterone that plays a role in developing and maintaining muscle mass. Resistance exercising is critical here and I can't say enough how important that is to do. I struggled significantly to restore muscles to pre-radiotherapy levels despite a good exercise programme. 

I could also note some very minor rectal inflammation and possibly some memory challenges - but hey I am getting older and also know stress is a key factor with memory. I’m not sure I can put that down to the treatments!

Notes:

(i) https://zerocancer.org/learn/survivors/recurrence/

(ii) https://www.cancertherapyadvisor.com/home/tools/fact-sheets/cancer-recurrence-statistics/

(iii) https://myunexpectedguide.blogspot.com/2020/04/finished-radiotherapy-should-i-continue.html

(iv) https://www.cancerresearchuk.org/about-cancer/prostate-cancer/treatment/radiotherapy/external-radiotherapy/long-term-side-effects-external-radiotherapy

(v) https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/hormone-therapy/side-effects-men

(vi) https://www.cancernetwork.com/view/long-term-prostate-cancer-side-effects-similar-surgery-radiation

(vii) https://www.sciencedirect.com/science/article/abs/pii/S0360301699002461

(viii) https://pubmed.ncbi.nlm.nih.gov/33318637/

(ix) https://bigthink.com/sex-relationships/health-benefits-of-masturbation

(x) https://www.nhs.uk/conditions/dexa-scan/

(xi) https://www.cancer.gov/about-cancer/treatment/side-effects/fatigue/fatigue-pdq

(xii) https://www.tandfonline.com/doi/pdf/10.3109/0284186X.2015.1127417

(xiii) https://www.cancerresearchuk.org/about-cancer/prostate-cancer/practical-emotional-support/hormone-symptoms/sex-hormones-weight-muscle

Intermittent fasting, time restricted eating and more

Fasting has been part of pretty well every culture in the past but features much less so nowadays. I’ve heard about the possible benefits to cancer but because of my low body weight I’ve not investigated further. Indeed my naturopath has advised against it in the past. A couple of years ago I read Chris Woollams who shared research that shows little or no benefit from ’Intermittent Fasting’, where people extend their overnight fast to miss an evening meal or breakfast (i). The study he quotes found; "mild caloric restriction and weight loss, without calorie counting. It may also offer clinical benefits by reducing blood pressure."(ii).

Chris went on to argue that the benefits from fasting come after about 24 hours without food. As I wasn’t ready to fast longer I dismissed the idea of shorter fasts. It is certainly true there is lots and growing evidence about longer fasting. I’ll come to that in a mo but I am also not so dismissive of the shorter 12-16 hour fasts. Although as with so many aspects of health it is hard to unpick what folks are staying - not least as there are so many versions of ‘intermittent fasting’ and of course we are all so different.

A 2016 study looked at over 2,000 women with early stage breast cancer and looked at the role prolonged night time fasting might play in breast cancer recurrence (iii). Women who had a short duration of nightly fasting (less than 13 hours between the evening meal and breakfast) were 36% more likely to experience a breast cancer recurrence than those who had a nighttime fasting duration of more than 13 hours. However the increased risk of recurrence was not associated with increased mortality from breast cancer or overall mortality. The researchers suggest that longer periods of follow-up might reveal an association. But hey this is just one piece of research….

Fasting and nutrition

A lot of the Intermittent fasting research does not seem to say much about our choices of food. Yet we know what we eat is critical. Dr. Valter Longo, Professor of the USC School of Gerontology has done loads of work in this area and written the ground-breaking book, ”The Longevity Diet”. He describes in the book his everyday diet, based in part on research including studies of centenarians and long-lived populations around the world. It is mainly plant-based, low in protein and rich in unsaturated fats and complex carbohydrates. Some fish is allowed once or twice a week - see more at: https://www.createcures.org/cancer/ Interestingly for over 65s there is some relaxation of the diet: https://www.createcures.org/longevity-diet-for-adults/

And of course following any diet should be done with the knowledge of your doctors. This is even more so when we talk below about fasting as it can have many unforeseen consequences and indeed can be very dangerous.

Longo is clear that we need to look for quality in food and not demonise any particular food group. He says in an interview in an article (Feb 2019) (iv): "The truth is fats are good and bad. Carbs are good and bad. Proteins are good and bad. Fats like olive oil, nuts, salmon are actually associated with positive effects. It is saturated fats and trans fats that are associated with a lot of problems. You hear a lot about low-carb or no-carb diets, but the right carbohydrates, including legumes, vegetables and whole grains, are very good for you. In fact, all the populations who have record longevity have a high carbohydrate diet. All of them. No exceptions. It may seem easier to label foods as good or bad, but in the long run this leads to problems”.

So yes to intermittent fasting?

In his book he clearly recommends a form of intermittent fasting - time-restricted eating - and this is in addition to his ’Longevity Diet' and the periodic five day Fasting-Mimicking Diet. In the article where Longo is quoted above, he is asked specifically about the timing of when we eat. His response is: "It turns out that it is important is to stick very close to 12 hours of feeding and 12 hours of fasting. If you eat 15 hours a day or more, that starts to be associated with metabolic problems, sleep disorders, etc. This is a new habit. If you ask centenarians, it is almost unheard of in these groups. But also, if you fast for longer than 12 or 13 hours, that starts to be associated with problems like gallstone formation, and we also know that longer fasts can lead people to skip breakfast. There are a number of studies, and we have our own data supporting this, showing that skipping breakfast is associated with increased risk for overall mortality and cardiovascular disease. So not only is it not good, it is bad for you”.

So daily 12 hours fasting looks good - or as Longo calls it “time-restricted eating” - and he also recommends not eating 3-4 hours before bed. 


Ayurveda and a Nobel prize

This leads me onto a workshop that Dr Sam Watts, a leading Ayurvedic Consultant, ran on Facebook this week on Intermittent Fasting. In that excellent session he shared that in 2016 the Nobel Prize was won by Japanese cell biologist Yoshinori Ohsumi (v). This confirmed what the Ayurvedic tradition has been saying for many hundreds of years. Fasting can be very good for us. Indeed fasting for more than 12 or 24 hours hours triggers autophagy - this is when cells destroy viruses and bacteria and get rid of damaged structures (see film here to explain autophagy) (vi). The word autophagy comes from the Greek for "self" and "phagein", which means "to eat” - and it’s key for the health of our cells and indeed our survival. This links to the reasons that fasting is associated with longevity. 

Granddaughter pic of me rebounding

There is research that that shows benefits to fasting like better blood sugar balance, reduced inflammation, loss of weight loss, and better brain function. Oshumi has now provided some of the understanding about how this happens. What I found very interesting was that exercise also does this - it can cause autophagy so that cells repair and renew (vii). I’ve already noted many times the importance of exercise but this understanding helps me ensure I still exercise when perhaps I don’t feel so like it!

So from this research it would seem the wonderful process of autophagy starts to kick in between 12 and 16 hours which maybe why the research noted above saw some benefits? And why Sam Watts recommends once or twice a week doing a 16 hour fast. This would perhaps then avoid the concerns Longo had around gallstones?


The five day Fasting-Mimicking Diet

Evidence is certainly mounting for the impact of fasting; reduced blood sugar and blood growth hormone (IGF-1), very low triglyceride and insulin levels, immune system regeneration and stopping cancer progression. And wow there are so many ways to fast - the internet is full of them from the 5:2 Diet (viii) to the Vedic way of 24 hour fasts on the 11th and 22nd days of the lunar cycle (ix). I started looking at possibilities ahead of my radiotherapy as it can help with that (x).

I can’t vouch for any of those fasting techniques but I do like the rigorous science behind the work of Dr Longo - in his book he gives a couple of weeks of food suggestions for his ’Longevity Diet’ and covers loads of the research to back his five day Fasting-Mimicking Diet - indeed it has been clinically demonstrated to provide huge beneficial effects on aging and disease risk factors. Of course as mentioned already don’t embark on this without doctor being involved - is is potentially dangerous for some conditions.

Longo has also shown that it looks like fasting significantly improves the performance of chemotherapy while reducing side-effects greatly. However fasting is not always possible on chemo which is why he has developed the Fasting-Mimicking Diet. Sadly this 5 day diet is only covered very briefly in his book - indeed to proceed safely it looks like you need to purchase food boxes at around $250 a time(xi)? And I don’t think these products are even organic or fresh? 

Interestingly new research from Longo is around using fasting as a groundbreaking method to avoid hormone therapy resistance in breast cancer - and I guess other cancers like prostate? I have had hormones twice in the past as part of my treatment so was very interested to hear about this (xii). You can listen to Longo being interviewed by Chris Wark here (xiii)

 

See also Longo's TedX talk: https://youtu.be/dVArDzYynYc

 

There is also an amazing opportunity to hear Longo and ask questions in the second 'Your LIfe and Cancer ' weekend: https://www.yourlifeandcancer.com/expanding-your-knowledge.

So where does that leave me?

1. Time-restricted eating. Eating in a 12 hour window where possible seems to make sense; this is possible but do have tottery and stop the need for nuts or something later in evening.

2.  16 hour fast. Try once or twice a week to go for a 16 hour fast; have done this a couple of times missing breakfast and surprisingly hard for me - I will persist and try missing dinner next time. I am also learning to fit it with the rhythm I mentioned in a recent blog - see here (xiv).

3. A longer Fast? I feel I still need to do some more research; just liquids carry there own challenges particularly when I am just on the bottom end of ideal weight - FMD also doesn’t feel the right place to start with a box sent from the states. Is there anyone who does that in this country?

 

Update 30th Sept 2020; just seen this blog on intermittent fasting by the wonderful Nasha Winters: https://www.drnasha.com/2020/09/14/intermittent-fasting-for-beginners-everything-you-need-to-know-to-get-started

and here's a useful Tedx talk on intermittent fasting: https://youtu.be/A6Dkt7zyImk 

Update 8th January 2021; I also just listened to this Dr Chatterjee podcast: https://drchatterjee.com/episode-21-circadian-rhythms-and-time-restricted-feeding-with-professor-satchin-panda-part-1/ and https://drchatterjee.com/episode-22-why-when-you-eat-matters-with-professor-satchin-panda-part-2/

Update 2.10.22: Must get around to a blog on chemo and fasting but in meantime see: https://nutritionfacts.org/video/fasting-mimicking-diet-before-and-after-chemotherapy/

Notes

(i) https://www.canceractive.com/article/Intermittent-fasting-is-basically-a-waste-of-time
(ii) https://pubmed.ncbi.nlm.nih.gov/29951594/
(iii) https://jamanetwork.com/journals/jamaoncology/fullarticle/2506710
(iv) https://news.usc.edu/135551/fasting-aging-dieting-and-when-you-should-eat-valter-longo/
(v) https://www.nature.com/articles/543S19a
(vi) https://www.bluezones.com/2018/10/fasting-for-health-and-longevity-nobel-prize-winning-research-on-cell-aging/
(vii) https://pubmed.ncbi.nlm.nih.gov/22258505/
(viii) https://thefastdiet.co.uk/
(ix) https://www.learnreligions.com/ekadasi-hindu-lunar-calendar-1770178
(x) https://myunexpectedguide.blogspot.com/2019/11/increasing-effectiveness-of.html
(xi) https://prolonfmd.com/
(xii) https://www.nature.com/articles/s41586-020-2502-7
(xiii) https://www.chrisbeatcancer.com/dr-valter-longo-fasting-mimicking-diet-improves-breast-cancer-treatment/ Also see more re Longo at: https://valterlongo.com/cancer/
(xiv) https://myunexpectedguide.blogspot.com/2020/07/getting-in-rhythm.html