Feature Article: September 2018 – Prostate Cancer

Prostate Cancer an Age Management Priority

Jeff Morris

Prostate cancer is the second most common cancer and the second leading cause of cancer death in American men, behind lung cancer. About 1 man in 9 will be diagnosed with prostate cancer during his lifetime. With that in mind, AMMG has scheduled a 4-session block on this important topic at the November Clinical Applications for Age Management Medicine Conference.

The block of sessions is a priority for age management physicians, not simply because of the prevalence of prostate cancer among men, but because of the complicated relationship between hormone therapy and prostate health. The four sessions are sure to both open attendees’ eyes and trigger new avenues of discussion.

The sessions begin on Friday morning, November 2 at 8:30 a.m. with Paul Thompson, M.D. and his “Upside-down World of Prostate Cancer.” “There are certain basic things that we, as age management physicians, should know,” said Dr. Thompson. A board-certified practicing urologist since 1988, Dr. Thompson has long dealt with the realities of prostate cancer. He said his goal is not to teach people to be urologists, but to be aware of the possible benefits and possible risk of the things they’re doing in their practice.

As a former chief of surgery who transformed his own practice into a proactive age management medicine approach after a personal health crisis, Dr. Thompson said he experienced a similar transformation as he was planning this lecture. “It really grew and changed and I had several epiphanies as I prepared this,” he said. “There were several things I took for granted and assumed, as 99.9% of my peers have done, as I attempted to explain the history of prostate cancer as we know it. So it really became, what have I done for the past 30 or 40 years, and why hadn’t I read the original paper until now; why did I make the same assumptions that many people are making today—assumptions based on what somebody told them instead of having dug into the literature to see what was there.”

He said he sees himself as a guide, who will help attendees seek out answers. “As I dug into it I realized we really had talked about prostate cancer many times over the past ten years of the conference. I didn’t want to get up there and regurgitate the many things we’ve already done over the past ten years. It started out one place and it ended up another. I hope everybody likes it because it really made me think!”

The session block moves from an overview to detection, as at 9:15 a.m., Sanoj Punnen, M.D. will present “Advances in Biomarkers for the Detection of Aggressive Prostate Cancer.” An Assistant Professor in the Department of Urology, University of Miami Miller School of Medicine, Dr. Punnen has broad experience in urologic malignancies with a special interest in localized prostate cancer. His primary research focus includes biomarker development and validation, innovative imaging and diagnostic techniques, and comparative effectiveness and outcomes research.

Dr. Punnen will look at current prostate cancer screening practices and challenges for early detection of prostate cancer. With PSA a sensitive predictor of prostate cancer mortality, Dr. Punnen will look at the PSA ordering practices of primary care physicians, and will discuss what is a reasonable approach to prostate cancer screening and the validity, safety and effectiveness of a new second stage biomarker test as a follow-up test after an abnormal PSA to identify who should (and should not) receive a prostate biopsy. His presentation will review the relevant peer-reviewed literature on these topics.

From detection to treatment, Daniel Sperling, M.D. is next up at 10:15 a.m. with “MRI-Guided Prostate Laser Ablation for Treatment of Prostate Cancer.” With the advent of PSA screening in the mid-1990s, early detection and diagnosis of prostate cancer (PCa) became feasible. Since PCa was held to be a multi-focal disease, a radical treatment approach such as prostatectomy, radiation, or whole gland ablation has been the standard of care. However, radical treatments come with risks of urinary, sexual and bowel comorbidities. Recent clinical developments such as advanced imaging (multiparametric MRI) and genomic analysis now make it possible to identify PCa patients with low-risk disease amenable to either Active Surveillance, with its advantage of deferring treatment while monitoring for disease progression, or focal treatment via thermal ablation, with its advantage of effective cancer control while sparing urinary, sexual and bowel function. One such modality is laser interstitial tumor therapy, or Focal Laser Ablation (FLA). This presentation will explain patient selection for FLA, the mechanism by which FLA destroys tumor tissue, how FLA is delivered, monitored, and verified, and current data on safety and efficacy. It will conclude with the clinical and quality-of-life benefits to the patient.

Dr. Sperling is uniquely qualified to lead this presentation. As Medical Director & Chief of Interventional Uroradiology at Sperling Prostate Center in Florida and New York, Dr. Sperling is a globally recognized leader in magnetic resonance imaging (MRI) and multiparametric MRI (mpMRI) for the detection and diagnosis of a wide range of conditions.  He is a pioneer in image-guided Focal Laser Ablation (FLA) for targeted prostate cancer treatment. He has also adapted this treatment for an innovative approach to correcting urinary problems caused by BPH. Dr. Sperling is a contributing author on more than 25 peer-reviewed MRI studies.

Last, but certainly not least, at 11:15 a.m. is the always provocative Neil Rouzier, M.D. presenting “A Literature Review of the Controversies in Treating Men with Aromatase Inhibitors: Is Estrogen Good or Bad and Can it Treat Prostate Cancer?.” The Director of The Preventive Medicine Clinics of the Desert, in Palm Springs, CA, Dr. Rouzier is still a practicing board certified emergency physician, as well as former assistant director of a large trauma center in Southern California. His Preventive Medicine Clinic specializes in hormone replacement for both men and women, and he teaches the most popular and successful courses in the U.S. on bioidentical hormone replacement and preventive medicine that focus on the research and evidence-based medicine supporting hormone replacement. Attendees to AMMG conferences have enjoyed his unique and passionate teaching style since their inception.

Dr. Rouzier explained what he intends to cover. “My lecture will focus on prostate cancer, from the standpoint of, estrogen can be used as a treatment for prostate cancer; it is an excellent treatment for prostate cancer. And my lecture will also evaluate the importance of estradiol levels in protecting against prostate cancer occurring in the first place. Because the overall emphasis that we commonly hear from these courses is that men need to block estrogen with aromatase inhibitors, and there’s probably nothing worse that men can possibly do than block their estradiol with aromatase inhibitor, because estradiol has been shown to protect against cancer, and is also a great treatment for cancer as well as for BPH. And when you block estradiol with an aromatase inhibitor you can also increase BPH symptoms.”

Dr. Rouzier went on about the benefits of estrogen. “What most people don’t quite realize is that it’s been used to treat prostate cancer for 50 years; there’s a plethora of data and studies showing the beneficial effects of it; there’s a big study that recently came out of Oxford and Adelaide where they emphasized the need and benefit of estrogen replacement in men to treat active prostate cancer. Unfortunately, most of the world doesn’t know or understand or realize that’s a great treatment for prostate cancer, but more importantly, as a preventative measure. And seeing as prostate cancer is the number one cancer in men, it would only make sense to try to prevent it, but yet everyone is using aromatase inhibitors because ‘someone said.’ ‘Someone said’ is not evidence-based medicine. When you look at all the evidence-based medicine, there’s no study to say that using an aromatase inhibitor in men is beneficial, and every study shows that using aromatase inhibitors in men is actually harmful. And yet everyone teaches it and preaches it at AMMG, which is very unfortunate.”

Doesn’t this, we asked, mean he’s going to have a conflict with others at the conference? “I absolutely am, I always do,” said Dr. Rouzier. “Yet none of them can ever show me that giving estrogen or raising estrogen in men is harmful, and they can never show me a study that shows using aromatase inhibitor is beneficial—it’s only harmful. Even so, they say it; but they say it based on the fact that there’s a few studies that show high estrodial levels are harmful in men, and that’s purely an association—and the high estrodial is in people that have visceral fat, and the visceral fat makes the high estrogen levels, which puts them at risk for heart disease. But they don’t quite understand that when you raise estrogen in men by giving them testosterone that’s the beneficial effect and you’re protecting against heart disease. The adage is, observation does not prove causation. What they don’t realize is, they’re observing something but what they’re observing is not the cause of the problem, it’s simply an innocent bystander. And they attribute that it’s the high estrogen that’s causing the harm, whereas it’s not. They don’t know how to interpret the studies correctly, and I will review how to interpret studies when I do my lecture, the way I always do.”

Dr. Rouzier will, as usual, present a meticulously researched collection of literature references to back up his points. “And I do introduce those studies that they introduce,” he said, “that basically show that high estradiol levels are harmful, but the problem is those are baseline levels, and you can’t take a baseline observation to prove causation—but they do it anyway and they do it incorrectly and inappropriately. It’s part of the religion to block estrogen in men because one or two people say it. I will show them all the studies to show when you block estrogen it’s harmful. And they can’t show me any studies, because there aren’t any, where blocking estrogen is beneficial. What they’re teaching and preaching is the opposite of what the scientific literature supports.”

It promises to be a compelling Friday morning.

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