Universal screening for prostate cancer?

Seven years ago I blogged here about whether a PSA test should be standard for over 50s - see here - at that time there were strong reasons for and against testing. However the evidence is growing for 'a targeted national prostate cancer screening programme'....

In the most recent Newsletter from Prostate Cancer Research (PCR) (pictured) they cover a report in which they look at the crucial issue of over diagnosis and over treatment - a huge issue - their argument is that with improvements in MRI (mpMRI) and guided transperineal biopsies the picture is very different. There is also more acceptance of active surveillance rather than going straight to invasive treatments.

We know the current situation does not work: "The existing “informed choice” system for requesting testing places the onus on men to understand their risk and actively seek testing. This system is both ineffective and inefficient and contributes to the fact that men from high-risk groups, particularly Black men, are more likely to be diagnosed late and are more than twice as likely to die from this disease."

Deloitte's were commissioned to look at a cost-benefit analysis for change. This indicates that the introduction of a targeted national prostate cancer screening programme for high-risk groups using the current pathway could deliver:

• Around 650 earlier diagnoses annually for men with a family history of prostate cancer aged 45-69 and in the region of 170 for Black men aged 45-69.

• For these groups, almost 230 men with a family history of prostate cancer per year being spared a stage 4 diagnosis, when prostate cancer becomes incurable. For Black men, 60 avoided stage 4 diagnoses.

• Up to £14,000 net socio-economic benefit for every high-risk man diagnosed.

This would be achieved using current technologies and pathways, and by targeting men from high-risk groups:  Black men and those with a family history of prostate cancer (including those with BRCA1/2 mutations).

Here are the headline figures noted in their newsletter:

The report concludes that with the introduction of an effective 'reflex test' between a PSA and MRI in the critical pathway, a universal screening programme for men aged 50-69 could save lives and benefit the country economically. This would also move the UK from being one of the worst OECD performers on prostate cancer to being one of the best.

PCR are taking their report forward and meeting with Members of Parliament to put the case. It is also interesting to note in a further landmark report presenting evidence for change the three key areas to go forward. See here: https://www.prostate-cancer-research.org.uk/PFYP/

Here they are taken directly from their report:

1. Introduce targeted prostate cancer screening for high-risk groups as soon as possible
Right now, we need to optimise screening using a PSA test, focusing on high-risk groups – Black men, those with a family history, and those with a BRCA1 or BRCA2 mutation. This approach, prioritising those at highest risk of prostate cancer, has been shown in our report to provide economic benefits, while requiring the lowest level of health system change.
2. Trial new diagnostic tests in clinical practice
Alongside more targeted PSA testing, we need to focus on getting new diagnostic technologies into trial (e.g. reflex tests), to gather real-world evidence and understand the benefit in diverse populations. Once the value of this has been demonstrated, we should expand the screening programme to cover the general population using a test with greater accuracy, as this will realise the greatest economic benefits.
3. Adopt AI-driven tech to enhance patient outcomes and efficiencies
To further improve patient outcomes and the economic benefits of earlier detection, we need to integrate AI technology into the NHS. We need to leverage its potential to improve the accuracy and reliability of screening, avoiding the need for unnecessary biopsies, while also boosting operational efficiencies. By adopting AI-driven technologies in imaging, we can streamline processes, reduce diagnostic errors and ensure resources are allocated more effectively.

Thank you PCR!

Interview with Prof Rob Thomas

This is a great overview of prostate cancer treatments (and a bit about breast) - Chris Woollams of CancerActive interviewing NHS oncologist Robert Thomas; looking at treatment protocols, hormones, lifestyle and much more. I found it a great reminder but also some stuff I didn't know.

Understanding blood tests

There are many tests that are possible to monitor our health - indeed this blog has covered a fair few in terms of my own treatment. However a lot of those specialist tests are too expensive for many and not available on the NHS. For example my own health service has stopped doing Vitamin D for people with cancer despite it being an important part of the picture; indeed the health team now recommend Vit D supplementation.

Of course it depends lots on the type of cancer you have, but I heard recently Jo Gamble, Functional Medicine practitioner and nutritionist say if you were going for one test then go for a genomics test as that gives a great starting point. More of that in another blog post.

This blog is a bit of a cheat as it is not my blog but rather it links to Chris Woollams' Canceractive website - there in a blog from earlier this month, he does a great simple guide of those blood tests we get from our GPs - sometimes it can be a challenge to get these tests but they can often give a great overview of our health. See it at:

https://www.canceractive.com/article/understanding-your%20blood%20test%20results%20when%20you%20have%20cancer

However we should remember blood tests are only part of the picture - and it can be dangerous to try and self-diagnose from results - talk to your health team. Nevertheless it can be useful to do your own research - see for example my previous blog on low white blood cells: https://myunexpectedguide.blogspot.com/2019/09/low-white-blood-cell-count.html

European Prostate Cancer Awareness Day calls for action; what did I learn?

The European Prostate Cancer Awareness Day (EPAD) aims to raise awareness and enhance knowledge of prostate cancer. Oncology specialists, patient advocates, politicians and policymakers gathered for EPAD20 online and in Brussels on 17 November 2020. I missed the live event but have been catching up with their videos/presentations. Some of the findings that I found interesting are below - scribbled notes as I tuned into these talks - big thanks to EPAD for letting people living with cancer join.

Listen in at: https://epad.uroweb.org/programme/recording-epad20/

Things have improved significantly since PSA was introduced

 

However 1 in 7 men in Europe will develop prostate cancer before they are 85.  Figures show in 2018 107,000 died from prostate cancer in Europe. 

 

Prostate cancer was said not to be a killing disease: “You will die with, not from prostate cancer”. Yet this is plainly not so true. It has been suggested that PSA testing was overused and led to over diagnosis and over treatment. Instead people with early diagnosis should have been offered Active Surveillance. This over diagnosis and treatment led to the anti-PSA propaganda - yes it is not a great measure but it has still helped with early detection that has led to less mortality. 

 

When there was less PSA testing it appears prostate cancer deaths increased. Prof. Hein Van Poppel in setting the scene to the conference challenged that much less was being done for prostate cancer than other cancers and asked why are we are letting this happen.

Prof. Monique J Roobol in her talk started with a quote from 1993 in the BMJ wrote: "About 50-60% of all cases of prostate cancer in the European Community present with obvious metastases or are locally too advanced for potentially curative management. Of those cancers that seem to be limited to the prostate clinically, 25-35% will have lymph node metastases. Of the remainder, another 25-35% will be too advanced for curative treatment and will turn out to be unresectable if surgery is attempted.” 

 

She went on to share the results of clinical trails saying that things "will hardly be different in 2021 and onwards if we do not act.”  She concluded:

• Data from pre-PSA era show that PCa is a disease often related to a lot of suffering over a considerable period
• 2 out of 3 men diagnosed with PCa died of their disease

We now know that: 

• Organized screening with the use of the PSA test reduces suffering and dying from PCa
• Potential harms ( unnecessary testing /over diagnosis and over treatment) can be largely avoided

Indeed the talks repeatedly concluded that early detection should be offered and can save lives. Are we doing enough? It seems not at the moment. As the Prof. Hein Van Poppel said in answer to a question, mortality is increasing in the UK due to the "propaganda against PSA testing" and GPs need to know that and we need to act. He goes onto "say early detection is likely to be the way out of it”.

When asked about prevention Monique J Roobol said it was research was still underway and that it was hard to know what can be done to prevent prostate cancer but we are aware of risk factors - mainly related to diet - particularly red meat being not good and tomatoes being good.

EUPROMS study - some surprises re quality of life after treatment

Key findings from nearly 3,000 responses in this study were highlighted by Mr. André Deschamps in his talk include:

Prostate Cancer is not an old mans disease; average age at diagnosis is 64. Nearly 30% are diagnosed before 60 and 76% before 70. 

 

Anxious and depressed; 42% of men who have been treated for prostate cancer are anxious or depressed to some extent at the time of the survey - with 15% extremely, severely or moderately impacted.

Sexual function; there was slightly more impact with radiotherapy than radical prostatectomy - both treatments impacted significantly but this research flies contrary previous thoughts that prostatectomy had worse outcomes re sexual function. Of huge concern was the overall some 28% have a big problem and 22% a moderate problem ie 50%!

Continence: prostatectomy was worse than radiotherapy and its seems after treatment (I think they mean any of the standard treatments) a whopping 37% of men use one or more incontinence pads every day.

The conclusion is that early detection is key and that active surveillance should be considered as the first treatment in order to ensure the best quality of life.

The Awareness Day also heard from November and their campaigns to raise awareness about early detection - see more re UK branch at: https://uk.movember.com/

Supplements update following metabolic analysis

In this blog post I want to update my supplement protocol based on a metabolic analysis of my urine - but first some background info. Six months ago I set out my supplement protocol (see here). As noted then, and remains true now, it is hard to find good advice regarding the efficacy of each supplement. Indeed there are often views diametrically opposing. There is lots of hype, claims and suggestion around many of the supplements that might show considerable promise, for example, one product might look good in a petri dish or animal study, but have never properly been trialled with humans. 

Equally I find, for example, others like Cancer Research UK, are very very cautious with their advice and rely on certain peer reviewed science, but ignore others. For example Cancer Research UK write: 'there is no clear evidence in humans to show that turmeric or curcumin can prevent or treat cancer.’ Yet there are over two thousand studies published on turmeric and curcumin (the active ingredient in the spice); many of these studies demonstrate clear anti-inflammatory and immune enhancing properties with well over six hundred of them relating specifically, and consistently, to it’s anti-cancer properties (i).

In the last six months my protocol has changed and adapted, you can follow most of the key changes and some of the reasoning, by reading through the other blog posts tagged ’Supplements’ (see here). I want too note that the supplements are only part of my approach to cancer. I also say again that we are all different and respond differently. For me, I consider diet, exercise and meditation to be more central to healing than other parts of my protocol, but nevertheless I think supplements can have a place for some people (including me) in their healing journeys. 

Health update

As previous posts have shared, I appear to continue to have an issue with absorbing certain nutrients and minerals. Magnesium for example has remained low despite significant supplementation. Some of this is a bit of a mystery considering my excellent diet and supplement protocol. Recent blood tests have also seen my PSA climb and reveal, among other things, a low white blood cell count. You can see my response to the low white blood cell count here.

So following a couple of visits to an integrative doctor that I see, considering the metabolic analysis of my urine plus some research of my own, I have put together the next steps. Some of this is to tackle the lack off absorption. I will also be seeing the oncologist at the end of September and it might be that then is the time to go for hormones again plus radiotherapy. If you are a regular reader to this blog you will know I have some considerable reservations about the radiotherapy (see some of those here). This blog was mostly written in August but I haven’t managed to publish it so by the time you get to read it I will have already embarked on some of this supplementation. As the protocol changes and develops it is hard to capture it in one blog so I am finding it more useful to explain the possible potential of each supplement for my health.
Malabsorption and more

Several markers from the metabolic analysis indicated malabsorption. I don’t fully understand how all this works but the test showed for example that I have:

(a) Elevated phenylacetic acid (PAA) which is a malabsorption marker; this is often due to the amino acid phenylalanine not being sufficiently digested in the small intestine.
(b) Elevated 3-Hydroxyphenylacetic acid (3HPAA) which is a bacterial dysbiosis marker; this could reflect recent high rates of ingesting quercetin (eg teas, fruits) or a colonic flora population that creates the rise.
(c) Above normal Tartaric Acid which is a yeast/fungal dysbiosis marker; found high in grapes and wine so could indicate recent ingestion but not sure about that - it seems more likely to be the result of intestinal yeast overgrowth.
(d) Elevated Citramalic Acid, which is another yeast/fungal dysbiosis marker; this indicates intestinal dysbiosis and can cause not so great metabolic interference with the ‘malate shuttle’.

Most of the other markers were in the normal range but other interesting markers included;

(a) Lactic Acid; this is formed from glucose and used by working muscles for energy. This was low for me and there are no known clinical problems associated with low lactic acid. This is likely to be a good thing as lactic acid is an important energy source for tumour cells (ii); indeed cancer cells make your body even more acidic as they produce lactic acid. The more acidic your cells are, the less oxygenated they will be. To make matters worse, the fermentation process cancer cells use to produce energy creates lactic acid, further increasing acidity and reducing oxygen levels (iii). Interestingly endurance athletes tested after exercise have high levels of lactic acid but then later have very low levels (iv). Low levels of lactic acid can be the result of reduced amounts of its precursor, pyruvic acid.

(b) Pyruvic Acid; this was subnormal and there are several possible reasons, a couple of the most likely are deficiency of magnesium and pancreatic insufficiency. Interestingly studies have shown that potentially malignant disorders have shown a significant increase of pyruvic acid levels (v).

(c) Liquid peroxides; these were elevated. Lipid peroxidation is a mechanism of cellular injury and is used as an indicator of oxidative stress, also known as “free radical damage.” The elevation of lipid peroxides serves as an early warning of the potential long-term effects of oxidative stress which leads to chronic degenerative diseases like cancer (vi).
What to take?

Well in a recent blog I touched a bit on epigenetics and SNPs. I loved the Steve Ottersberg quote from this years Trew Fields (vii): "You can’t change your genetics but you are not a victim of your genetics. What you can change is the expression of your genetics and that’s what epigenetic is about.”  

So a lot of this supplementation is part of changing the expression of my genetics - and supporting areas where perhaps I have SNPs. The suggestions for supplements below are based on the metabolic analysis and some of the issues raised already in this blog post. They are suggested in addition to my current/initial protocol. One of the challenges is working out how much of this I can do within my budget, bearing in mind that some can be ‘pulsed’ ie have a break and then return to them. So I won’t purchase all of these extra ones - indeed am using this blog post as a way to understand them better and seek out priorities. I’ll try and look at all this under the following headings:

1. Antioxidants
2. B-Vitamins
3. Minerals
4. Probiotics
5. Amino Acids
6. Additional immune support
7. Initial protocol

Taken from my test results

In details 

1. Antioxidants

The test highlighted a couple of aspects that were considered ‘high need’ for supplementation;

Vitamin A
Apparently an extreme vegetarian diet could deplete vitamin A but that is not me! Chris Woollams writes (viii): "The overwhelming conclusion when studying vitamin A (as opposed to Beta-carotene) is that where cancer is concerned the jury is out. There are research papers that conclude it is helpful; others that conclude it has no effect. Vitamin A does, however, have many health giving properties. Of relevance to cancer, it helps strengthen the immune system (especially the white cells) and, in particular, it strengthens epithelial tissues (and, by implication, blocks the process by which many cancers form). Vitamin A also helps the action of vitamin C, a known anti-oxidant".


Vitamin E
The impact of vitamin E in terms of preventing cancer has been suggested by many epidemiologic studies. Of interest is that several recent large-scale human trials with α-tocopherol, the most commonly recognized and used form of vitamin E, failed to show a cancer preventive effect. There was even evidence of higher prostate cancer incidence in subjects who took α-tocopherol supplementation. However tests in animal models have shown the cancer preventive activity of γ- and δ-tocopherols as well as a naturally occurring mixture of tocopherols, but the lack of cancer preventive activity by α-tocopherol. Yang et al (ix) concludes that "On the basis of these results as well as information from the literature, we suggest that vitamin E, as ingested in the diet or in supplements that are rich in γ- and δ-tocopherols, is cancer preventive; whereas supplementation with high doses of α-tocopherol is not”. 

Chris Woollams writes on prostate cancer (x): "The Journal of the National Cancer Institute (1998) showed that a Finnish study, whilst studying the vitamin E effects on smokers, spotted that among over 29,000 males, the vitamin E study group had a 41 per cent decrease in prostate cancer over the placebo group. The protected group took 50 mgs of alpha-tocopherol per day for 5-8 years. In a USA test amongst people deficient in vitamin E, a 50 mgs daily supplement reduced prostate cancer cancer by 20 per cent”. It would seem that perhaps the synthetic form of Vitamin E may be more limited in its helpfulness and may even cause harm, but overall research seems to conclude Vitamin E and increasingly tocotrienol vitamin E is essential in the fight against cancer.

α-Lipoic Acid

This one is a great free-radical scavenger and antioxidant, that can regenerate other antioxidants that are used fighting free-radicals. It has been shown that Alpha Lipoic Acid and its metabolite Dihydrolipoic Acid (DHLA) can cause cell death in colon cancer cells and enhance the oxygenation of healthy cells. It can also reduce blood sugar levels which is advantageous in fighting cancer (xi). When taking this I will stop the Berberine as that all has that effect and I am not sure of the impact of both.

2. B-Vitamins

The test showed borderline concerns around Vitamin B1,2,6,9 and 12. My B3 and B7 were considered normal.

B Vitamins are key for correct cellular division and replication and play a role in the nervous system. Increased plasma homocysteine has been shown to be closely related to cancer. B Vitamins can keep this under control. Normally our gut bacteria makes our B vitamins when it gets fibrous foods, however antibiotics and chemo can mess with our guts (xii). Could the malabsorption markers noted above be a reason for the need to supplement? A Vitamin B looks like a useful way forward. See also my previous blog post on B6 and B12 here.

3. Minerals

Once again Magnesium comes out strongly needed. Zinc was normal and Manganese was borderline.However Zinc was only normal with the current protocol of supplementation so it looks like that needs to continue.

Magnesium and Zinc - See previous update on Magnesium and Zinc here and here.

Manganese - this, among other things, is needed for the development and health of the reproductive organs. It is also linked to prostate health and supports bone health (the latter is important as that is often where prostate cancer spreads first). Low levels have been linked to breast cancer (xiii).

4. Probiotics

This topic is huge and having read lots on this I think it is a key area to consider - really should have several blogs of it’s own. However in the meantime see Chris Woollams blogs:

'Gut bacteria and cancer': https://www.canceractive.com/article/probiotics-prebiotics-bacteria-and-cancer-1432

'All cancers start in the gut': https://www.canceractive.com/article/different-cancers-linked-to-different-gut-bacteria

I will continue with a probiotic supplementation and diet that includes fermented foods. The additional suggestion highlighted as a need, was for pancreatic enzymes. This is a complicated area and I need to investigate this further.

5. Amino Acids

Now this is a new area for me to get my head around. For years it was thought that there are only 20 amino acids, but a couple of new aminos were recently discovered making a total of 22 amino acids. Are there more? Amino acids are the basic building blocks of the body, are in abundance within the body (ixx). I had thought Braggs (or similar) Amino Acids might be a good way of ensuring I get all the amino acids but I read that there is some controvesy over the process they use so I need to look further before going down that route. Certainly they do great Cider Vinegar!

Here is just a very brief taster of what the urine test showed in terms of more interesting stuff:

N-Acetyl Cysteine - I previously noted that I have been taking the amino acid supplement N-Acetyl Cysteine; this contains glutamine (which stimulates the liver to produce glutathione), and L-Cysteine, which is particularly important in DNA repair. N-acetyl cysteine is a free radical scavenger on its own, effective at reducing oxidative stress, particularly due to heavy metal toxicity as it can directly replenish glutathione stores (xx). The test indicated that with the supplementation I am in the normal range for this amino acid. It is worth noting that there is some research with mice showing that antioxidants can change cells in ways that fuel the spread of some cancers.

Taurine - This amino acid came out as the one needing significant support. Taurine suppresses PSA and several metastasis-related genes in human prostate cancer cells, LNCaP and PC-3. In addition, taurine inhibited migration of LNCaP and PC-3 (xxi). I’m going for a Magnesium taurate supplement; the mix of magnesium and taurate is thought to help speed absorption of magnesium - so hopefully also tackling the magnesium deficiency at the same time.

Glycine - Another amino lacking is this one. Glycine has been used in cancer prevention (xxii). Dr Brind writes (xxiii): “...many human cancers are selected for, and therefore arise in, bodies which are chronically methionine-loaded and glycine-deficient. Thus, they underscore the need for the proper balance between glycine and methionine.”

Lysine - another amino acid I was lacking - interestingly a unique amino acids-plus formulation of lysine, proline, arginine, ascorbic acid, and epigallocatechin gallate was proved to have anticancer properties, and could become a natural anticancer agent to treat prostate cancer (xxiv). Some research also shows it could have a role with blocking cancer growth (xxv).

Methionine - this was only slightly lacking in my test but interestingly it along with tyrosine (that was also low) and phenylalanine, it has been found to play a key role in preventing prostate cancer (xxvi).

Tyrosine - as noted this was also a little low - the thyroid makes two hormones - triiodothyronine (called T3) and thyroxine (T4) which are tyrosine-based hormones and both are partly composed of iodine. Tyrosine is a non-essential amino acid has been linked with cancer regulation (xxvii).

Leucine - this also showed low but only just and I would be reluctant to supplement this as I’ve read that prostate cancer cells need leucine to grow, multiply and spread. This was in a "Journal of the National Cancer Institute" study published in 2013. However it is not known if taking supplemental leucine and significantly increasing the amount of available leucine in the body could increase your risk of prostate cancer or speed the growth of tumors in men (xxviii).

6. Additional immune support

Lots mentioned above and below clearly supports my immune system - see also my blog post here on the additional immune support.

7. Initial protocol

My initial protocol that has developed over the months is here; there are still some key elements which I am using or will use again.

Notes

(i) https://www.bmj.com/rapid-response/2011/11/01/tell-us-truth-about-nutrition

(ii) https://www.sciencedaily.com/releases/2008/11/081120171325.htm

(iii) There are some mixed views about the acid/alkaline balance and cancer; read one view at: https://www.cancerfightingstrategies.com/ph-and-cancer.html 

(iv) https://www.sciencedaily.com/releases/2006/04/060420235214.htm 

(v) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860908/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6406929/ 

(vi) https://healthmatters.io/understand-blood-test-results/lipid-peroxides-genova 

(vii) See quote in my film at 13.09 minutes: https://myunexpectedguide.blogspot.com/2019/09/trew-fields-festival-my-long-film.html 

(viii) https://www.canceractive.com/article/vitamin-a 

(ix) https://cancerpreventionresearch.aacrjournals.org/content/5/5/701 

(x) https://www.canceractive.com/article/vitamin-e

(xi) https://www.canceractive.com/article/alpha-lipoic-acid-cancer-and-diabetes 

(xii) https://www.nature.com/articles/s12276-019-0216-4 

(xiii) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443096/ 

(ixx) http://aminoacidinformation.com/about-us/ 

(xx) https://www.lifeextension.com/Protocols/Metabolic-Health/Metabolic-Detoxification/Page-03 

(xxi) https://link.springer.com/chapter/10.1007/978-3-319-15126-7_18  and https://www.researchgate.net/publication/274641219_Effect_of_taurine_on_prostate-specific_antigen_level_and_migration_in_human_prostate_cancer_cells
(xxii) https://www.webmd.com/vitamins/ai/ingredientmono-1072/glycine
and https://aminoacidstudies.org/glycine/ 
(xxiii) https://180degreehealth.com/glycine-cancer/ 
(xxiv) http://aminoacidinformation.com/lysine-benefits-for-men/ 
(xxv) http://www.stimulife-ind-dist.com/ARTICLE-block-cancer-growth-L-Lysine.htm and

https://draxe.com/nutrition/supplements/l-lysine-benefits/

(xxvi) http://aminoacidinformation.com/amino-acids-cancer/

(xxvii) https://www.canceractive.com/article/is-the-synthetic-thyroid-hormone-thyroxine-behind-your-cancer  

(xxviii) https://www.livestrong.com/article/290596-leucine-supplement-side-effects/