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PSA + DRE saves lives: thanks to the prostate specific antigen (PSA) and digital rectal exam (DRE), more and more men are surviving prostate cancer.

An Interview with Dr. Patrick Walsh

Whether it involves your father, son, brother, uncle, or best friend, prostate cancer at some point touches everyone's life. Fortunately, major inroads in prostate cancer screening, treatments, and prevention over the last two decades have dramatically improved the overall survival rate and quality of life for all victims of prostate cancer patients.

Today, the cadre ,of prostate cancer survivors include such well-known Americans as Bob Dole, Arnold Palmer, Harry Belafonte, Mike Milken, Rudy Guiliani, and Norman Schwarzkopf, all of whom have publicly shared their stories of hope and determination to promote screening, prevention, and early treatment.

The Post interviewed a leading authority on prostate cancer, Dr. Patrick Walsh from Johns Hopkins Medical School and developer of the nerve-sparing procedure for radical prostatectomy that has significantly reduced incontinence and preserved potency in prostate cancer patients. Dr. Walsh is also author of the highly readable Guide to Surviving Prostate Cancer.

Post: What is the role of diet and lifestyle in reducing the risk of prostate cancer?

Walsh: Prostate cancer is probably caused by oxidative damage. Reducing oxidative damage can involve dietary measures, such as adding antioxidants--selenium, vitamin E, and lycopene--to your diet. It could also be something as simple as eating an apple. A study in Lancet showed that an apple contained more antioxidants than many vitamin supplements.

Second, the effect of increased intake of calcium and fat from dairy products on increased risk of prostate cancer has been demonstrated in many studies. For example, men with high intake of calcium and/or dairy are more likely to develop advanced cancer.

There is also new information about a new enzyme called racemase, which breaks down the fatty acids in red meat and dairy products. Racemase is up-regulated tenfold in cancerous, as opposed to normal, tissue. If someone with prostate cancer eats substances with the fatty acid called phytanic acid--found in meat and dairy products--cancer cells get ten times more energy than from any other source, which is another reason why reducing the amount of red meat and dairy products in your diet is a very wise thing to do. Reducing these foods is heart-healthy as well.

Post: Scientists often underscore the decreased incidence of prostate and other cancers among men from Asia, where the diet is low-fat.

Walsh: There is a strong link with environment. Asian men who live in Asia have a two percent lifetime risk of developing prostate cancer. When these men move to the Western culture and live here for more than 25 years, their risk for prostate cancer approaches that of Caucasian males in the U.S. Environment relates to diet, sunlight, and other factors that may affect your risk for prostate cancer during your adult life. If we identify those factors, we should be able to reduce the incidence of prostate cancer. Until we've completed these studies, rational preventive measures for men include getting adequate amounts of antioxidants and reducing dietary intake of fat, especially fat from red meat and dairy products.

Post: Do omega-3 fatty acids from certain fish help reduce the inflammatory process?

Walsh: A very interesting article was just published in the NEJM from three Hopkins' scientists--Bill Nelson, M.D., Ph.D.; Bill Isaacs, Ph.D.; aria Angelo DeMarzo, M.D., Ph.D. As mentioned previously, we believe that prostate cancer is caused by oxidative damage. The sources of oxidative damage, as we have spoken about, are both dietary and metabolic, from cell metabolism.

A third and potent source of oxidative damage is from inflammation. There is a lot of inflammation in the prostate. Dr. DeMarzo has investigated and shown that inflammation in the prostate is associated with precancerous lesions. He has termed it PIA--proliferative inflammatory atrophy. Next to the areas of inflammation, you can find areas of atrophy. The atrophic cells are not just sitting there asleep, however; they are rapidly turning over and have genomic abnormalities. Next to those cells, you often find a premalignant lesion called PIN. What causes this inflammation?

Johns Hopkins' researcher Bill Isaacs and I have been looking at hereditary prostate cancer genes. Last year, we identified two genes that occur in a small number of families that cause prostate cancer; these findings were published in articles in Nature Genetics. These two genes are normally responsible for protecting you against infection. A whole new avenue of thinking about prostate cancer is opening up: Could prostate cancer be caused by infection, like others such as stomach and liver cancer? The infections would be chronic, smoldering, and cause chronic inflammation, which could lead to oxidative damage--a whole cascade of events.

Post: What is the difference between a total PSA and free PSA test?

Walsh: PSA is an enzyme. If you think of the PSA enzyme as a pair of scissors circulating in the serum, they would chop everything. In the serum, PSA circulates in a bound form like scissors inside a case. When you measure total serum PSA, you are measuring bound PSA.

If an arm of the scissors, for example, was broken, we can refer to that as "free" PSA, which can't cut anything and circulates freely. For reasons that no one as yet understands, the higher the percentage of free PSA, the more likely you are free of cancer. Conversely, the lower the free PSA, the more likely it is you have cancer.

Post: If a man has an elevated total PSA, should the test be repeated?

Walsh: Yes. Today, if a man has an elevated PSA, the test should be repeated, and a recent article in JAMA confirms this finding.

When repeating the test, I have men refrain from sexual activity for several days, forgo a rectal examination before the PSA test, and perhaps take antibiotics for two weeks to make sure that there is not a lingering infection. The PSA test is then repeated. If the PSA remains elevated, a biopsy may be indicated. If free PSA levels are low, it indicates that the elevated PSA may indeed be coming from cancer, and you need a biopsy.

PSA of course refers to "prostate" specific, not "cancer" specific, so elevations in PSA can be caused by cancer, benign enlargement (BPH), or infection. But if the PSA level is elevated, you have some sort of prostate disease.

Post: Would it make sense to refrain from sexual activity and delay the DRE until after your initial PSA test?

Walsh: Ideally, you should. Often, a person doesn't know that he is being tested for PSA. Someone draws a blood sample, and the first thing you know, someone says your PSA is up.

Post: If a PSA is elevated and the biopsy reveals no cancerous cells, are patients off the hook?

Walsh: If the biopsy is negative, it does not necessarily mean that they don't have cancer, because it is possible that the area of cancer was not sampled. They are not totally off the hook. They need to be followed by a good doctor, who can call the shots.

Post: At what age should men begin screening for prostate cancer?

Walsh: The current recommendation is 50 or, if at high risk--African-American or with a strong family history--age 40. A study by Johns Hopkins' researcher Dr. H. Ballentine Carter that was published in JAMA investigated a model for screening that would save the most lives and money. The model that saved the most lives at the least cost promoted the first PSA beginning at age 40, the next at age 45. Then when men reach age 50, a PSA would be done every other year. Of course along with the PSA, you need a rectal exam as well, because 25 percent of men with prostate cancer will have a low PSA.

Post: When faced with surgery for prostate cancer, how important is it for men to select a center where the procedure is performed often?

Walsh: More important than that is to find a surgeon who has dedicated his life to performing the operation well. When you look at the outcomes of radical prostatectomy in the literature, you will find results where potency and continence is quite high, while in others it is quite low. The difference is in the way the operation is performed.

Someone from Korea watched me perform the operation today. He has done this operation himself, yet had never seen the nerves like this before, so you can imagine that his patients do not have the same outcome.

To improve the results of surgery around the world, I have spent the last several years putting together a video presentation of this operation--a DVD--that is over two hours long, with excellent video footage and illustration. I am giving this DVD to every urologist in the world who wants it, free, with the idea that the whole field would be better if more people knew how to do this operation well.

For the best outcome, find a urologist who does these operations frequently and who can answer some of the questions that I bring up in my book:

--How often do you do these?

--In patients like myself, what is the likelihood that I am going to need additional treatment afterward--radiation or hormones?

If either one of the answers to your questions is high, either your cancer may be too far advanced to cure--and maybe surgery isn't the answer--or maybe this person has not developed the technique well enough to take out all the cancer. The final question is, What is the chance that I will have problems with urinary continence and sexual dysfunction? Most urologists tell people the truth. If you don't like the answers, you need to find someone who does a lot of these procedures well and who is more specialized.

Post: Some men who have undergone the procedure may face erectile dysfunction. Are new drugs helping men with this side effect?

Walsh: Certainly, they help a lot. If someone has adequate nerve-sparing during the radical prostatectomy, Viagra and hopefully its successors will offer great assistance.

Post: Are you interested in adding additional families with apparent genetic predisposition to prostate cancers to your database? If so, how can interested Post readers participate?

Walsh: Yes. We have the largest registry of hereditary prostate cancer families in the world and have identified two genes that appear to explain the disease in some families. We are anxious to expand the number of families in our studies. Ideally, we are looking for families with three or more living affected members (father, son, brothers).

To learn more, contact: Hereditary Prostate Cancer Study, The Brady Urological Institute, Johns Hopkins Medical Institutions, 600 North Wolfe Street, Marburg 130, Baltimore, MD 21287-2101. You can also find out more at the Web site urology.jhu.edu/ diseases/pro state/hereditary.html or by calling 410-955-0355 or 410-614-4196.

Before the PSA Test ...

* Don't ejaculate for at least two days before you have your blood drawn (this can raise your PSA level).

* Be sure to have this test before your digital rectal exam (the trauma from the physical exam can raise PSA, too).

* Remind your doctor if you are taking Proscar for BPH, or Propecia for hair loss (Proscar lowers PSA; Propecia is a lower dose of Proscar).

* If the PSA reading indicates a borderline elevation, or a significant increase since the last reading, repeat the test in the same laboratory. If there is a clear-cut elevation, ask your doctor about prescribing antibiotics to rule out a possible infection. (Often, men receive ciprofloxacin or levofloxacin for three to four weeks, and have the PSA measured again.) If it is elevated again, you should have a biopsy.

The Rectal Exam: An Insider's Guide

This is the test that men dread. In fact, some men hate the idea of a rectal examination so much that they Jeopardize their health by avoiding it like the plague. The rectal exam is certainly not fun; in fact, it's downright awkward and uncomfortable. But it shouldn't hurt, it's generally brief, and--most important of all--this little exam can provide essential information that simply can't be gotten any other way. (Note: If what you feel during the exam goes beyond the obvious discomfort of having someone's finger in your rectum and is clearly pain, this could be an important signal of another problem, such as prostatitts or inflammation. If the exam is excruciating, don't be stoic--tell your doctor.)

Now, from your standpoint, what can you do to make the rectal examination as painless and productive as possible? First and foremost is how you 'assume the position": The best way for the doctor to feel the prostate is for the patient to bend over the edge of the examining table. (Some doctors perform the examination by having the patient lie on his side. This is not as good: At best, the doctor can feel only the lower edge of the prostate.) For most men, the worst part of the exam is the first--the introduction of the doctor's finger through the rectum, and past the muscles in the pelvic floor. Although the examining finger is gloved and well lubricated, if these muscles are tense (a very normal reaction, especially in men who are undergoing this exam for the first time), the doctor must exert more pressure--which adds to the discomfort, which then makes the man even more tense.

How can you relax these muscles? Don't even try; let your position do it for you. First, don't rest your elbows on the examining table--even though it feels more comfortable. Instead, put all your weight on your upper torso: Bend your knees, so that your feet are Just barely touching the floor. Your feet should not be supporting any weight. This way, your buttocks muscles will be completely relaxed, permitting the doctor's linger to be introduced easily--and ideally, slowly, giving the muscles a chance to relax ahead of time.

To understand what the doctor is looking for, feel your hand. The normal prostate usually feels like the soft tissue in your palm--the fleshy part at the base of your thumb. Now, slide your fingers around to the other side, and feel the knuckle of your thumb. This is how cancer often feels--like a knot, or hard lump.

--Text excerpted from Dr. Patrick Walsh's Guide To Surviving Prostate Cancer.

RELATED ARTICLE: Save $$ with Rx discount cards.

Drug manufacturers are stepping up savings on prescriptions to ease the burden of medical costs on low-income American consumers. Numerous discount card programs are available that can save consumers hundreds of dollars on much-needed medications.

In June 2003, for example, a prescription savings program called Together Rx was launched. Together Rx offers qualified individuals ways to save 20-40 percent (or more depending on prescription and pharmacy) on over 150 widely prescribed medicines. Founded by some of the world's largest pharmaceutical companies--Abbott Laboratories, AstraZeneca, Aventis, BristolMyers Squibb Company, GlaxoSmithKline, Janssen Pharmaceutica L.P., Novartis, and Ortho-McNeil Pharmaceutical--the program is open to Medicare enrollees and others whose annual income is less than $28,000/single and $38,000 for couples (depending on state). An enrollment form is available at www.togetherrx.com or by calling 800-865-7211.

Other prescription discount cards are also available from a variety of drugmakers and organizations to qualified individuals based on income to offset the cost of medications needed to keep them alive. Pfizer, Eli Lilly, Novartis, and GlaxoSmithKline offer discount cards that reduce prices on their medications, as do organizations like the AARP.

The LillyAnswers Card, for example, can provide low-income seniors the opportunity to purchase Lilly prescription drugs for a flat $12 fee for a month's supply. In a recent report on the WebMD Internet Web site, Eli Lilly spokesman Edward Sagebiel noted that about 50,000 seniors signed up for LillyAnswers in the first two months after the program's launch in April 2002.

"For the average Lilly prescription drug--such as Evista (for osteoporosis) or Humalog (for diabetes)--patients can realize savings of approximately $600 a year," Sagebiel reported to WebMD. About 85 percent of the national pharmacy chains, as well as many independent drugstores, are participating in the Lilly program.

To find out more, log on to www.lillyanswers.com or call 877-RX-LILLY (877-795-4559).

Other cards available and contact information include:

* Pfizer Share Card (pfizersharecard.com) 800-717-6005 or 800-459-4156

* GlaxoSmithKline (us.gsk.com/ card/index.htm) 888-672-6436
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Publication:Saturday Evening Post
Article Type:Interview
Date:Sep 1, 2003
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