The Father's Day gift that keeps on giving

Without further ado, here's a Booster Shots tribute to dads and their families, courtesy of Dr. Marc Siegel, a practicing internist who writes the Unreal World column for the Health section, and Dr. David Samadi, a practicing urologist and the chief of robotics at Mt. Sinai Medical Center in New York.
 
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Guys out there, give yourselves a present for Father’s Day -- go to the doctor. Do you want to be around to receive another godawful tie from your kids next year? Go to your doctor now to make sure you have the chance. Are you having problems peeing or difficulty getting aroused? Don’t argue, see your urologist. It could save your life.
 
Unfortunately, statistics show that you guys are just not doing it. The Agency for Healthcare Research and Quality has just released the results of a sobering survey showing that just 57% of American men see a doctor, nurse practitioner or physician’s assistant for routine care on a yearly basis. The number is much higher for women -- 74%.
 
Further, it appears that the men who need care the most are often the ones less likely to seek it. Three-quarters of men who said they were in excellent health sought routine care versus only half of men who reported being in fair to poor health. What better time than Father’s Day to make a resolution to change your ways? If not for yourself, do it for your family.
 
If you come to see your internist or family practitioner, we won’t attack you; we will simply check your blood pressure, your weight, your cholesterol, your glucose and your PSA (if you’re over 40). These are all crucial measurements to make sure you aren’t at risk for a heart attack, diabetes, stroke or prostate cancer.

High blood pressure is the most common chronic disease and the second-leading cause of death in the U.S., affecting one out of three adults, or 65 million people. More than 102 million adults have elevated cholesterol levels. You can learn to change your lifestyle, or if needed, we can give you medicine that will help you. 

Prostate cancer will be diagnosed in one in six men in the U.S., and it kills 30,000 men every year, the second-biggest cancer killer of men after skin cancer. We can screen you for prostate cancer and for colon cancer over age 50, which, when we catch it early, can be cured. We want you to be around next year.
 
What exactly is your prostate? It lives right below your bladder, and although it is just the size of a plum, it causes big problems. The prostate can grow and block the urinary stream, or it can develop a lethal form of cancer. Although recent studies have provided conflicting results regarding the PSA blood test, we continue to value its usefulness. We don’t believe in over-treatment, or that everyone with prostate cancer should be treated. But we do believe that knowledge is power, and a simple blood test can help us gain that knowledge.
 
Make yourself a Father’s Day resolution: Go to see your doctor so that your kids have a holiday to celebrate next year at this time.

And now for some helpful health links ...

- The risk factors for high blood pressure.

- The risk factors for a heart attack.

- How to manage cholesterol.

... and some statistics for U.S. men and cholesterol by age, from the National Center for Health Statistics:

- 11% of men age 20-34 have high cholesterol.

- 21.1% of men age 35-44 have high cholesterol.

- 22.9% of men age 45-54 have high cholesterol.

- 16.5% of men age 55-64 have high cholesterol.

As for information about prostate health, the Centers for Disease Control and Prevention offers a primer on informed decision-making, the National Cancer Institute explains cancer screening, and the Prostate Cancer Foundation offers a look at physiology. 

 -- Drs. Marc Siegel and David Samadi

Become a fan: We've set up a page dedicated to fitness, medical and health news at facebook.com/latimeshealth.

Photo: What better time than Father’s Day to make a resolution to change your ways? Credit: Al Schaben / Los Angeles Times

FDA says certain prostate cancer drugs may increase risk of diabetes, cardiovascular disease

The Food and Drug Administration said Monday it is investigating the safety of a family of drugs known as gonadotropin-releasing hormone agonists, which are used for hormone deprivation therapy to treat men with prostate cancer. The agency said small studies have suggested that the drugs might be associated with an increased risk of diabetes and cardiovascular disease, although the evidence is not conclusive and agency scientists are still investigating.

The drugs, commonly called GnRH agonists or luteinizing-releasing hormone agonists, suppress the production of testosterone, the male hormone that stimulates the growth of many prostate tumors, by the testicles. Producing what is called chemical castration, they are an alternative to surgical castration, which is also used. They are not a cure for prostate cancer, but can significantly slow tumor growth or even shrink tumor size. Some of the drugs are also used by women to manage pain caused by endometriosis, to improve anemia associated with uterine fibroids before a hysterectomy and for palliative treatment of advanced breast cancer. They are also used in some children to treat a form of precocious puberty. There is no evidence suggesting an increased risk in women or children, the agency said.

Most of the studies reviewed by the FDA reported small but statistically significant increased risks of diabetes and heart disease, the agency said. But the data have a variety of shortcomings, including poor definition of what types of androgen deprivation therapy were used, the amount of drug used and for how long, and a lack of data about the patients' risk factors for the disease before therapy began, among other problems. Those deficiencies made it difficult to establish a cause-and-effect relationship.

While the FDA investigates the drugs, it said that patients should not stop taking them. Physicians planning to prescribe them should evaluate the risks and benefits and, when they are prescribed, monitor the patients for precursors of diabetes, as well as high blood pressure, high cholesterol and increased weight gain.

The drugs involved include:

-- Lupron, manufactured by Abbott Laboratories of Abbott Park, Ill.

-- Eligard, manufactured by Sanofi-Aventis of Bridgewater, N.J.

-- Synarel, manufactured by Pfizer of New York City

-- Trelstar, manufactured by Watson Pharmaceuticals of Corona

-- Vantas, manufactured by Endo Pharmaceuticals of Chadds Ford, Penn.

-- Viadur, manufactured by Bayer Pharmaceuticals of Wayne, N.J.

-- Zoladex, manufactured by AstraZeneca of Wilmington, Del.

This year, an estimated 203,415 new cases of prostate cancer will be diagnosed and about 28,372 men will die from it, according to the Centers for Disease Control.

-- Thomas H. Maugh II

HIV drugs combat virus that might be linked to prostate cancer and chronic fatigue

Four drugs that are used to treat the AIDS virus HIV can also inhibit the replication of xenotropic murine leukemia virus-related virus (XMRV), a mouse virus that has been found in some patients with prostate tumors and chronic fatigue syndrome. Now all researchers have to do is show that XMVR is actually a cause of disease rather than a passenger virus, as most researchers now suspect.

XMRV, a retrovirus that, like HIV, inserts a DNA copy of its RNA genome into the nuclear DNA of its host, was discovered in 2006 by researchers at UC San Francisco and the Cleveland Clinic. It was first found in about a third of tumor tissues from patients with prostate cancer, particularly those with the most aggressive form of the disease. Subsequently, researchers from the Whittemore Peterson Institute for Neuro-Immune Disease in Reno said that they found it in about two-thirds of 101 patients with chronic fatigue syndrome, a mysterious debilitating illness that some doctors think is more psychological than physical. Since then, however, three further studies conducted in Europe have failed to find the virus in any patients with chronic fatigue.

Critics have roasted the European researchers -- charging bias, among other things. One potential problem, advocates of the virus theory argue, is that the European researchers did not use precisely the same assays that the Americans did. In an effort to circumvent this problem, a team led by Dr. John A. Petros, a urologist at the Emory University School of Medicine, developed a new assay for antibodies to XMRV similar to the antibody-based assays used for identifying HIV infection. They reported Monday in the journal Urology that they used the antibody test to detect XMRV in 11 of 40 patients who had undergone a radical prostatectomy, about the same proportion of patients found in other studies. Their results were confirmed by other laboratories using independent assays.

"We cannot as a scientific community begin to answer the basic questions of XMRV transmissions, frequency in the population, association with disease, etc., until we can effectively test for infection," Petros said in a statement.

If the virus can ever be shown to be a cause of prostate cancer or chronic fatigue, Dr. Ila R. Singh of the University of Utah School of Medicine, chemist Raymond F. Schinazi of the Emory University School of Medicine and their colleagues tested four HIV drugs against XMRV grown in cultures of breast cancer and prostate cancer cells. They reported Wednesday in the online journal PLoS One that the four drugs -- raltegravir, Zidovudine, tenofovir and an experimental drug called L-00870812 -- each blocked XMRV replication, but that the drugs were most effective when used in combination. "Our study showed that these drugs inhibited XMRV at lower concentrations when two of them were used together, suggesting that highly potent 'cocktail' therapies might inhibit the virus from replicating and spreading," Schinazi said in a statement.

The drugs cannot ethically be tested in prostate cancer and chronic fatigue patients, however, until it is shown that the virus actually causes disease.

-- Thomas H. Maugh II

Infertile men 2.6 times as likely to have aggressive prostate cancer

Men who have difficulty conceiving children are 2.6 times as likely to have highly aggressive prostate cancer and 60% more likely to have slow-growing tumors, researchers reported Monday. Although the absolute risk of developing prostate cancer was still low in these men, the findings suggest that such men should be screened for prostate cancer at an earlier age, said Dr. Otis Brawley, chief medical officer of the American Cancer Society.

Previous studies have looked at the relationship between prostate cancer and the number of children a man has, but they have produced differing results. Some suggested that fatherhood was protective, while others suggested that it increased risk. Because the number of children a man has may not be an accurate reflector of his fertility, Dr. Thomas J. Walsh of the University of Washington School of Medicine and his colleagues decided to study men who had been evaluated for infertility.

The team studied 22,562 men who had been evaluated from 1967 to 1998 at 15 California infertility centers, comparing them with a similar group of healthy men from the general population. They reported in the journal Cancer that they identified 168 cases of prostate cancer among the men, about the same as the 185 cases that would be expected in a group that size. That suggests that simply being evaluated for infertility does not affect the incidence of prostate cancer.

Overall, 0.4% of the fertile men developed prostate cancer during the decade of follow-up, compared with 1.2% of those diagnosed as infertile. Taking age into account, that translated to a 160% increased risk of developing aggressive tumors and a 60% increased risk of developing slow-growing tumors, the team reported.

It is not clear why infertile men have a higher risk. Walsh speculated that the risk might result from exposure to environmental toxins in the womb that cause damage to the male chromosome, but argued that more research needs to be done, both to confirm their findings and to explore potential mechanisms.

Prostate cancer is the most common cancer in men after skin cancer, striking 192,000 American men each year and killing 27,000. Other risk factors include older age, a family history of the disease, obesity and being African American. Most national organizations now recommend that men be offered screening beginning at age 50, but there is a widespread controversy about this. Some critics argue that the screening leads to an unacceptably high rate of invasive procedures in men who do not have cancer, leading to impotence, urinary incontinence and other problems.

-- Thomas H. Maugh II

Rodent of the Week: A new understanding of how prostate cancer treatment may backfire

The very therapy used to treat prostate cancer patients in the early stage of the disease actually promotes the second, more deadly wave of the disease, according to a new study.

Men with prostate cancer often take drugs to shut down the body’s production of testosterone, the hormone that feeds the initial tumors. But when those tumor cells die, they trigger an inflammatory response that draws in immune cells called B cells. Those B cells, in turn, secrete a molecule that paves the way for the growth of a second wave of deadlier prostate cancer cells that are resistant to the hormone therapy.

The researchers – from UC San Diego, Scripps Research Institute-Florida and the Engelhardt Institute of Molecular Biology in Moscow – pieced this together by studying the progression of prostate cancer in a variety of genetically modified mice. Here’s how they put it in their report, published in Thursday’s edition of the journal Nature:

“The inflammatory response elicited by the dying primary tumor contributes to the failure rather than the previously proposed success of anti-cancer therapy.” (emphasis added)

It sounds like bad news, but there may be a silver lining. Now that the mechanism is understood, the researchers say that any interference with this sequence of events ought to delay the onset of the dangerous secondary tumors.

In their experiments, such interventions reliably delayed those tumors by three to four weeks. Converting that from “mouse time” to “human time,” they calculated that equivalent interventions in people would slow the development of secondary prostate cancer tumors by 2.3 to 3.1 years.

— Karen Kaplan

Photo credit: Advanced Cell Technology Inc.

With prostate cancer treatment, who you see is often what you get

If you visit a Chevy dealer to buy a new car, the odds are pretty good that he is not going to recommend that you purchase a Ford. And he is even more likely not to recommend that you hang on to the perfectly good car you already own. Perhaps not surprisingly, the situation is very similar when men visit physicians who treat localized prostate cancer: Surgeons are more likely to recommend surgery, and radiation specialists will call for X-rays or proton beams, researchers reported Monday in the Archives of Internal Medicine. Only if a man visits a disinterested primary-care physician is he more likely to be offered the alternative that some experts consider optimal -- no treatment at all until the tumor has begun to progress into a more life-threatening form, a concept known as watchful waiting.

The situation may arise, at least in part, because there is such a smorgasbord of potential treatments available, including surgery, radiation, chemotherapy and watchful waiting. If a man chooses surgery, it can be performed by conventional surgery, laparoscopically or with the assistance of a robot. If radiation, it can be delivered conventionally, with proton beams, or by implantation of radioactive seeds, an approach called brachytherapy. What makes the decision even harder, Dr. Michael J. Barry of the Foundation for Informed Medical Decision Making in Boston wrote in an editorial accompanying the report, is that there is an "embarrassing" absence of clinical trials comparing the therapies. The only trial for men over 65, in fact, found that surgical removal of the tumor was no more likely to improve survival than watchful waiting. The National Cancer Institute is now sponsoring a trial to compare treatment to monitoring, but results are not expected until later this year. Until those results are available, however, men rely on their physicians to help them make a decision, and those decisions, framed by anecdotal experience, are likely to be biased.

A 1988 survey of radiation oncologists and urologists -- who perform most prostate surgeries -- asked them which treatment they would prefer if they developed localized prostate cancer. A full 92% of radiation oncologists said they would prefer radiation, while 79% of urologists would opt for a radical prostatectomy. In a 2000 survey, researchers asked the two groups how they would prefer to treat patients, and the results were very similar.

To determine if the doctors' actions jibed with their words, Dr. Thomas L. Jang, now at the Cancer Institute of New Jersey in New Brunswick, and his colleagues used data from the government's Surveillance, Epidemiology and End Results (SEER) database to study 85,088 men over the age of 65 who were diagnosed with localized prostate cancer. Half were seen only by urologists, 44% by urologists and radiation oncologists, 3% by urologists and medical oncologists and 3% by all three groups. Only 22% of the men visited a primary-care physician during the period between diagnosis and treatment, and only 17% visited one they had an established relationship with.

Among men ages 65 to 69, 70% of men who saw only a urologist had a radical prostatectomy. If they also saw a radiation oncologist, however, 78% had radiation therapy. Among men who saw a urologist and a medical oncologist, 53% had surgery, 17% had radiation therapy, 16% had watchful waiting and 14% had chemotherapy--androgen-deprivation therapy to starve the tumor of needed hormones. Men who also visited a primary-care physician were more likely to be prescribed watchful waiting, which is the only one of the treatment regimens without side effects. Older men were also more likely to be prescribed watchful waiting, reflecting a growing adherence to treatment guidelines that recommend against aggressive therapy in men who may have less than 10 years to live.

Part of the reason for the emphasis on treatment, Barry said, is the large capital investments surgeons make for robotically assisted surgery and that radiation therapists make for proton beam therapy or newer techniques of radiation therapy. Moreover, current reimbursement rules do not allow physicians adequate time to educate patients about the pros and cons of the various procedures.

So, if you are diagnosed with prostate cancer and considering therapy, the recommendation is to do the same kind of background research you might do in buying a car. Consider all the options, decide which side effects you are prepared to live with or, in the final analysis, think about whether you really need it in the first place.

-- Thomas H. Maugh II

New drug offers last-ditch hope for prostate cancer patients

An experimental drug called cabazitaxel increases survival by 30%  in men with advanced prostate cancer that has become resistant to all other forms of treatment, researchers will report Friday at a San Francisco meeting called the 2010 Genitourinary Cancers Symposium. Although, on average, the drug extended survival to 15.1 months, compared with 12.7 months for those taking another cancer drug called mitoxantrone, it doubled the number of men who lived two years, according to Dr. Oliver Sartor of the Tulane Cancer Center in New Orleans, who headed the study.

Prostate cancer is typically treated with drugs that reduce the body's production of the hormone testosterone, which is required by some tumors for growth — a process called chemical castration. When the cancer continues to grow, it is then often treated with docetaxel, trade-named Taxotere. But somehow the cancer cells learn how to pump out the Taxotere before it can exert its effects, becoming resistant to the drug. Cabazitaxel, trade-named Jevtana, is a chemical derivative of docetaxel that is apparently not recognized by the cancer cells and not pumped out.

Sartor and his colleagues tested the drug in 755 men in 26 countries who had castration-resistant prostate cancer. Half received cabazitaxel and half mitoxantrone. Those receiving the drug lived a median of 30% longer. About 7.5% of men receiving the drug, however, suffered fever and lowered white blood cell counts, compared with 1.3% of those in the control group.

The trial was sponsored by Sanofi-Aventis, which manufactures both Jevtana and Taxotere. When the drug is approved, analysts expect it to cost about the same as Taxotere — about $2,500 per treatment cycle. The company is also sponsoring trials administering the drug to patients earlier in the course of therapy before they become resistant to Taxotere.

About 192,000 U.S. men develop prostate cancer each year, and more than 27,000 die of it.

— Thomas H. Maugh II

Widespread use of PSA test may have reduced suicides after prostate cancer diagnosis

The widespread use of the prostate-specific antigen, or PSA, test for detecting and monitoring prostate cancers since 1993 may have lowered the risk of suicide after a diagnosis of prostate cancer, possibly by showing many men that their tumors are not highly aggressive, Harvard researchers reported this week.

The reduction in risk may also result from improved programs to provide emotional support for such men, a possibility that is reinforced by the observation that the suicide rate is higher in single men than in married ones. The risk of dying from cardiovascular disease was also elevated after prostate cancer diagnosis, the researchers reported in the Journal of the National Cancer Institute.

Dr. Fang Fang of Harvard University's Brigham and Women's Hospital in Boston and his colleagues used the government's SEER (Surveillance, Epidemiology and End Results) database to study 343,497 men with prostate cancer between 1979 and 2004. No cancer-free group was available to serve as a control group, and the team used published figures for expected deaths in the general population. During the period of the study, 148 of the men died from suicide and 6,845 died of cardiovascular disease. During the pre-PSA era up until 1993, men diagnosed with prostate cancer were 90% more likely to commit suicide in the first three months after diagnosis and 30% more likely in the first year, they found. After 1993, however, the suicide risk returned to normal. That contrasts with the same researchers' previous findings in Sweden that showed the risk of suicide there remained about 20% higher throughout the entire study period. The reason for this difference "is unclear," they wrote, but they suggest that the large number of indolent (nonaggressive) prostate cancers diagnosed during the later years and better access to emotional support may have lessened despair among patients, reducing suicide risk.

The risk of dying from heart disease in the United States was about doubled during the first month after diagnosis, but declined below normal during the seventh to twelfth months after diagnosis, creating a slightly increased risk of  9% for the entire year. The initial increase may be due to the stress of being diagnosed and to hormonal effects associated with the treatment. The reduction later could be a result of the fact that men who are tested for prostate cancer are more health-conscious and thus generally healthier than the general population. Alternatively, the diagnosis may have prompted them to alter their behaviors. Other studies have shown, for example, that quitting smoking lowers the risk of heart attack after a few months.

The study emphasizes the importance of emotional counseling for newly diagnosed cancer patients, the authors wrote. It also adds to "the increasingly complex scenario of pros and cons of extensive PSA testing, which entails detection of large numbers of nonlethal prostate cancers."

-- Thomas H. Maugh II

Sorry, guys, extra coffee and gym time aren't enough in the prostate-cancer fight

Drink coffee! Work out! For men who want to prevent prostate cancer (which is to say: all of them), those would appear to be the much-publicized take-home messages of two new studies released this week. This is fine advice -- but then, it was fine advice before the results were announced too.

The first study, by Harvard University researchers, found that men who drank lots of java had a lower risk of aggressive prostate cancer. Here's the release from the American Assn. of Cancer Research, where both studies were announced, and a Bloomberg article.

The other study, also by Harvard researchers, found that even a measly 15 minutes of daily exercise  reduced overall death rates in men with prostate cancer. More vigorous exercise, they found, reduced death rates from prostate cancer. Here's that release and a Time magazine blog post.

But here's a downloadable booklet, Nutrition, Exercise and Prostate Cancer, that highlights the whole puzzle, not just the pieces. Inflammation and oxidation play key roles in disease, it explains. Food, drinks, activity, supplements -- they affect such factors.

It offers a nice reminder as to why research on individual foods and activities should be taken in context. They're part of a larger whole.

(And here's a similar publication, Nutrition & Prostate Cancer, from UC San Francisco. Of note here are the specific food details and recipes. Check out the dilled salmon salad with peas.)

-- Tami Dennis

Photo: Drink up! Or you could just make sure your overall diet is a good one -- full of vegetables and lean protein. (This photo is actually of a tester at the Coffee Quality Institute, but the visual does highlight the peril of taking individual studies too seriously.)

Credit: Francine Orr / Los Angeles Times

 

Cancer deaths down, but statistics are sticky

Our hard work to live more healthfully seems to have paid off, with a new annual report showing that cancer death rates have been dropping since the 1990s. The risks are still higher for men than for women, but men showed the greater drop in deaths, falling 10% from 2002 to 2006 as opposed to 7.5% for women.

Consider also that in 2009, more than 713,000 women and 766,000 men are projected to be diagnosed with cancer, lead author Brenda K. Edwards of the National Cancer Institute said in an interview.

Each year, the report takes an in-depth look at one particular type of cancer to draw conclusions about the why, not just the how much, of cancer death rates. This year, the team looked at colorectal cancer. Aside from being the second most deadly cancer threat, it serves as a good model for studying the declining cancer rate.

Researchers found about half of the decline was due to better screening, Edwards said. (Last year, the report singled out the No. 1 killer, lung cancer, and the team was able to point to smoking controls in California for its comparatively better lung cancer rates.) 

Edwards also raised some concerns that overall numbers would mask certain issues – for example, that lung cancer for women is still on the rise, though it’s going up more slowly than before.

The report, published online in Cancer, is a joint effort of the institute, the American Cancer Society, the Centers for Disease Control and Prevention and the North American Assn. of Central Cancer Registries.

David Agus, director of the USC Center for Applied Molecular Medicine, said in an interview that better screening practices, technologies and healthier lifestyles have contributed to the decline, but he also delivered a reality check on the data.

“This is not acceptable. We need to be down like heart disease, stroke, infectious disease, where the rates are down 50%,” Agus noted. “In the cancer world we’re not much better at doing things than we were five decades ago.”

-- Amina Khan