The usual method of monitoring prostate cancer for changes amounts to neglect in many cases. Instead, a more active approach and alternative treatments may lead to the best outcome. Cate Montana reports
Men with cancer of the prostate, the walnut-sized gland just below the bladder and in front of the rectum, used to be faced with a Hobson’s choice: do nothing, hoping their cancer is the slower-growing variety, or face the possibility of impotence or incontinency if they opt for surgery, radiotherapy or chemotherapy.
Then there was “watchful waiting,” until recently the approach many oncologists recommended for patients newly diagnosed with prostate cancer who were basically symptom-free and had cancer confined to the prostate gland. It was also the recommended approach for men who were over age 70 and/or had other health conditions rendering them risky candidates for surgery or radiation therapy.
The vast majority of diagnosed prostate cancers are adenocarcinomas (gland-forming cancers). These are considered low-grade, slow-growing and thus low-risk cancers, meaning that many men will die with prostate cancer rather than of prostate cancer.
Nevertheless, a subset of prostate cancers called either neuroendocrine or small-cell cancers that are very rarely identified at initial diagnosis are, by their very nature, more aggressive from day one. These more “plastic” cancers can quickly go from looking and acting like adenocarcinomas to becoming something else, all the while getting into the bloodstream and spreading to other parts of the body.
So, on the one hand, watchful waiting for symptoms that may never show up permits patients to avoid the stress, cost and time expenditure of regular testing as well as the possible side effects of radiation, hormone therapy and surgery. On the other hand, there can be anxiety over the unknown possibilities, including the reasonable fear that an unmonitored tumor might start growing unexpectedly.
Into this no man’s land of “no action versus action” comes the new middle ground of “active surveillance,” which includes regular tests monitoring the cancer for any signs of emerging symptoms (see Testing for prostate cancer, below, for testing options).
“Watchful waiting was sort of benign neglect in most cases,” says Robert B. Montgomery, MD, medical oncologist at Fred Hutch Cancer Center in Seattle, Washington (fredhutch.org). “It wasn’t really following the patients very carefully or intervening when something changed.
“With active surveillance, if something changes—if PSAs rise over 10, more of the biopsy cores become positive or the Gleason grade goes up—then as long as patients are candidates for local therapy, which the majority of men are, we can talk about some definitive therapy to try to cure the disease.”
With active surveillance, every patient undergoes an examination and a PSA blood test every six months. The test is the first diagnostic tool used to check for increased levels of prostate-specific antigen (PSA) in the blood indicating the presence of cancer. (Antigens are molecules that trigger an immune response.) The test is also used to determine any progression or remission of prostate cancer.
“The active surveillance approach can be very safe in terms of prostate-cancer-related mortality,” says Montgomery. “Like watchful waiting, the idea is to avoid the side effects of therapy if you don’t have to undergo therapy.
“And with some of the medications we have now, it’s pretty clear from a number of studies that with the more effective androgen receptor pathway inhibitor drugs (ARPIs), such as enzalutamide, there is a higher frequency of development of this neuroendocrine type of cancer that can represent more of a risk.”
Prostate cancer is the fifth leading cause of cancer death in men, responsible for over 375,000 deaths in 2020.1 At diagnosis, about 75 percent of patients have cancer only in the prostate, and the five-year survival rate is nearly 100 percent.
Of that 75 percent, a recent study—of which Montgomery was one author—shows that one-third of those cases are appropriate for active surveillance “with serial PSA measurements, prostate biopsies, or magnetic resonance imaging, and initiation of treatment if the Gleason score or tumor stage increases.”2
This new system improves on the old approach in which treatment decisions were made almost exclusively from PSA readings. As Montgomery puts it, “PSA readings are not perfect. A digital (manual) examination isn’t perfect.” In fact, a recent study claims a digital rectal screening test for prostate cancer is “not useful.”3
The Gleason rating system grades tumors based on how far the tested tissue has deviated from normal prostate tissue. Grades run from 1 (most normal) to 5 (least normal). Because prostate cancer shows up in differing stages of development throughout the prostate, several biopsies are taken at each test, and a grade is assigned to the two areas constituting most of the cancer.
These two sample grades are added to produce the Gleason score, which can run as low as 2 and as high as 10. A score of 6 or less is “low grade,” meaning it has the least possibility of rapid spread. Intermediate grade falls in the middle, and a high-grade score of 9 or 10 is the most likely to grow and spread quickly.
“The reason Gleason grading has held up as such an important part of figuring out what to do for men with prostate cancer,” says Montgomery, “is that how aggressive it looks under the microscope reflects the propensity for the cells to not respect normal tissue boundaries and get into the bloodstream or get into the lymphatics, then spread to other parts of the body and become a problem. If the Gleason grade starts to go up, it means the cancer is starting to look more aggressive.”
Like in watchful waiting, even though active surveillance is proactive, for some men it’s still difficult to know that cancer is there and they aren’t doing something about it—even if that inaction represents a very low risk. But other tests and monitoring approaches can be employed besides the typical standard of care. As well, there are many alternative treatments for cancer now, such as intravenous vitamin C and peptide therapy.
“Surveillance is key in this age of biomarkers,” says Juergen Winkler, MD, integrative medicine specialist and founder of Quantum Functional Medicine in Carlsbad, California (qfmed.com). “PSA testing is still apparently the standard.
“But there are levels of other testing that can be done. Energetic testing—bioresonance technology, for example, can pick up an energetic imbalance in the prostate to determine if additional testing should be done.”
The primary question is, of course, how many men can sustain life and well-being while living with cancer as opposed to how many will die from the cancer. “This is hard to determine,” says Winkler.
“A decision to stick with active surveillance versus pursuing treatment is based on a number of variables: age and functionality of the patient and the level of aggressiveness of the tumor. Sometimes simple treatments with monitoring are enough. Other times a cancer can be more aggressive.”
At his functional medical clinic, Winkler provides multiple alternative therapies for cancer, including nutritional support, intravenous (IV) nutrition, IV detoxification, peptide and oxygen therapy, pulsed electromagnetic field (PEMF) therapy and dietary supplements.
“I treat the patient and change the terrain of their body to make it hostile to the cancer,” Winkler says, “dealing with multiple levels of emotional clearing, male hormone balancing and lowering estrogens, detoxing mold and other toxins, addressing blood sugar, looking for markers in the body that support cancer, addressing the immune system dysfunction and so on.”
Dietary and lifestyle changes are often part of this process (see What can you do on your own?, below, for some examples). Making healthier choices can not only help keep an existing cancer under control but may also prevent cancer from developing in the first place.
If, despite the use of alternative approaches, active surveillance monitoring reveals cancer progression, the next step might be to undergo a highly accurate PSMA PET scan. It evaluates the entire body using an injected radioactive tracer to target the prostate-specific membrane antigen (PSMA) that prostate cancer cells make and determine whether the cancer has spread (metastasized) before treatments are started.
Once prostate cancer has been diagnosed, doctors typically recommend one or more of the following options for treatment.
Hormone therapy. Testosterone is the major male sex hormone primarily responsible for the development and function of male reproductive organs including the prostate, maintenance of muscle and bone mass, and the growth of body hair. Prostate cancer cells ordinarily require testosterone to proliferate.
Hormone therapy works by stopping the body from making testosterone and preventing it from reaching cancer cells. On its own, this therapy won’t cure prostate cancer, but conventional medicine believes it will help control the cancer and manage symptoms.
It’s most often used alongside other approaches, such as radiation, making them more effective. Intermittent dosing—starting and stopping hormone therapy medications alternately—is thought to reduce side effects without compromising long-term effectiveness.
Hormone therapy for prostate cancer can have the following side effects:
Radiation. Traditional external radiation therapy for prostate cancer, called intensity-modulated radiation therapy (IMRT), is done in 15-minute treatments once a day, five days a week for weeks or sometimes even months.
Another option is internal radiation therapy, called brachytherapy. Most effective in cases of cancer contained within the prostate that is not aggressive, it implants radioactive “seeds” of iodine-125 or palladium-103 into and sometimes around the prostate gland itself.
Today, especially for men with early-stage prostate cancer contained within the prostate, a new form of high-energy external beam radiation called proton beam therapy can be used. Consisting of only one treatment a day for five days, proton beam therapy uses a linear accelerator (a machine that accelerates charged subatomic particles) to shoot highly targeted protons into tumors to kill the cancer cells.
With proton beam therapy, radiation dose exposure is lower and far less damage is done to intervening and surrounding healthy tissues. Doctors also claim it reduces the risk of secondary malignancy from the radiation itself.
“Brachytherapy had a very big heyday probably 20 years ago,” says Montgomery, “because it was a single procedure as opposed to IMRT, which was a big commitment in time and a lot of traveling. And if the results were going to be similar, then why would you not do that?
“Now there’s proton beam therapy, which takes five days and has a very, very exact mode of delivery.”
But basically, he explains, “if you decide to get radiation therapy, none of the various types have been shown to be more effective than the others in terms of controlling the disease. So, it really becomes a personal choice.”
These are some potential side effects of external radiation therapy for prostate cancer:
Surgery. Complete or partial removal of the prostate gland, which is located below the bladder and surrounding the urethra, is called a prostatectomy. Most often done when the cancer hasn’t spread beyond the prostate itself, this procedure may be used alone or in conjunction with radiation and/or hormone therapy. Side effects can include erectile dysfunction and incontinence.
Chemotherapy. If administered soon after surgery, chemotherapy is sometimes used to improve the outcome of a prostatectomy. It can also relieve symptoms of very advanced prostate cancer that has spread and is often used in prostate cancer patients who no longer respond to hormone therapy.
These are common side effects of chemotherapy:
The therapies listed above are the standard treatment routes for prostate cancers that have become active and aggressive. But none of these approaches is pleasant, and all have pronounced side effects.
Prostate cancer is most prevalent in men over age 50, and age is a big factor influencing treatment. A man in his early 50s with no other health conditions has the widest possible range of choices. However, for men in this age range, most oncologists recommend a prostatectomy (prostate surgery) or radical prostatectomy (removal of the prostate) because of the risk of secondary malignancies from radiation years or even decades down the road—a risk that’s obviously lower for a man over 70 years of age.
The downside of surgery, of course, is the chance of temporary or permanent impotence. Post-prostatectomy, a man no longer produces ejaculate (that’s the job of the prostate), and climax happens without ejaculation. This is known as “dry ejaculation.” If the cancer is outside the prostate, involving the nerves on either side of it, and they have to be removed, most men will experience erectile dysfunction (ED).
Studies have shown that only 20 percent of men return to preoperative sexual function one year after prostatectomy. Just 20 percent report erections strong enough for intercourse at a five-year follow-up, and 60 percent report ED 18 months post-op.
However, robot-assisted laparoscopic prostatectomy (RALP) shows improved potency rates. With its improved surgical precision and lower frequency of complications, erections return in about 76 percent of men by one year and in 82 percent of men by two years post-op.4
Although “penile rehabilitation” is now standard ED treatment following radical prostatectomy, a lot of men are too embarrassed to seek help with this problem.5 A prostatectomy also carries the risk of urinary incontinence. Men over age 75 have a higher risk of complications when undergoing general anesthesia, So, there is a definable risk of mortality related to the surgery.
As for radiation therapy, this pathway also negatively affects the production of seminal fluid, so it’s not unusual for men to experience dry ejaculation afterward. Once the therapy is concluded, erectile problems tend to develop slowly over time and can worsen over about two years. This varies from surgery, in which erectile problems happen immediately but often get better as time goes on.
Complementary and alternative treatments often come with fewer side effects than these standard options, so they may be worth considering (see below). Many of them can be helpful for both treatment and prevention.
“It’s a deeply personal choice which treatments to embrace,” says Montgomery. “Many men have very visceral feelings about what they want done. They walk in the door saying ‘I want this out,’ or ‘I don’t want you to touch me,’ or ‘I want radiation therapy.’ As long as there aren’t contraindications to either of the treatment options, they’re equally effective in terms of controlling prostate cancer for the long term.”
Overall, age seems to have little to do with the choices these men make. Montgomery sees a fair number of men in their 80s who have pretty active sex lives and say they’d rather die than lose their erectile function. “When they start to have severe issues, they often change their mind,” he observes.
“But, you know, everybody’s different. And outcomes are changing. We’ve gone from an average survival rate of two years in men with metastatic prostate cancer up to five to seven years since the time I started work in this field. You have to take every individual as who they are, know what the data is, personalize the approach to the patient who’s in front of you and take it from there.”
The American Urological Association recommends routine prostate cancer screening for men aged 55–69. Here are the options:
PSA blood testing is usually the first diagnostic tool used. It checks for increased levels of prostate-specific antigens (PSA) in the blood, indicating the presence of cancer. This test has a considerable degree of inaccuracy.
Gleason scores grade tumors based on how far the tested tissue has deviated from normal prostate tissue.
Ki-67 testing detects a protein found only in cells that are dividing and has been used as a proliferation marker for human tumor cells for decades. A Ki-67 proliferation index over 30 percent is rated as high.
Biopsy is tissue sampling under ultrasound and/or MRI guidance. The most common type of biopsy uses a thin, hollow needle to pierce through the rectum or the skin between the anus and the scrotum to gather samples, which are then graded on the Gleason scale.
The National Comprehensive Cancer Network categorizes prostate cancer into risk groups based on results from blood tests, PSA tests, genetic testing, exam results and family history. Patients in Grade Group 1 (lowest risk) have a PSA of less than 10 ng/mL, and less than half of their biopsy samples show signs of cancer. The high risk group includes people who have a PSA of more than 20 ng/mL and more than four biopsies showing cancer.
Ayurveda. In one study, Ayurvedic treatment with panchagabya griata, siddha makardwaja, punnavadi kasaya and dasamamula haritaki normalized PSA levels in three months due to these formulations’ strong antioxidant and anti-inflammatory properties. After another three months without the treatment, PSA levels remained low.1
But use caution: This study looked at only three men, so its results may be inconclusive. Some of these substances also include heavy metals, so they should be taken only under practitioner supervision.
Cannabidiol (CBD)
Recent studies show that cannabinoids, chemical components of the cannabis plant, weaken cancer cells and stop them from multiplying and spreading. One study found 48 hours of CBD treatment reduced the number of new cell colonies formed by 25 percent in only a week.2
Traditional Chinese Medicine. Many extracts used in TCM could protect against prostate cancer. For example, Scutellaria baicalensis, commonly known as Baikal skullcap, blocked cancer cell growth in both human and animal cells. In animal studies, tumor volume decreased by 50 percent after seven weeks of treatment.3
Homeopathy. Sabal Serrulata, derived from saw palmetto, is commonly prescribed for prostate problems. One study showed tumor cell proliferation reduced by a third 72 hours after a one-day treatment with Sabal Serrulata 100C.4
Hyperbaric oxygen therapy. Besides inhibiting growth and causing cancer cell DNA damage and cell death, studies show hyperbaric oxygen at 3 atm can force tumor cells into a stage of the cell cycle that makes them vulnerable to other treatments.5
Pulsed electromagnetic field (PEMF) therapy. PEMF treatment at 1450 V/m decreases cancer cells’ ability to spread.6
Changes to your diet, supplements and lifestyle are also keys to starving cancer.
Diet
Cruciferous vegetables. Studies of over a million people show eating cruciferous vegetables like broccoli and cabbage reduces prostate cancer risk by about 5 percent for every 15 g of the veggies eaten per day.1
Omega-3 to omega-6 balance. One study showed a diet with the proper ratio of omega-3 to omega-6 fats, achieved by supplementing with fish oil, reduced prostate cancer cell proliferation by 15 percent over a year, while those not eating the diet saw a 24 percent increase in proliferation.2
Tomatoes. Cooked tomatoes are high in lycopene, a bright red antioxidant compound. Among other research, a study of 47,000 male healthcare workers found those eating at least two servings of tomato sauce per week had a 30 percent lower risk of prostate cancer.3 A similar study found men with the highest lycopene intake had a 53 percent lower risk of lethal prostate cancer than those with the lowest.4
Mushrooms. Research shows men who eat shiitake, maitake and oyster mushrooms (with high levels of the antioxidant ergothioneine) once or twice a week have an 8 percent lower risk of prostate cancer than men who don’t eat mushrooms at all. The risk drops 17 percent if they eat mushrooms three times per week.5 White button mushroom extract, 200 mg/kg per day, has been shown to suppress prostate tumor growth and decrease PSA levels.6
Olive oil. In mice, a daily dose of extra-virgin olive oil containing 10 mg/kg of the polyphenol oleocanthal inhibits tumor growth in even the most aggressive prostate cancer types, a response that may not necessarily apply to humans.7
And here are two foods to consider avoiding:
Milk and milk products. Several large studies have shown a link between milk consumption and prostate cancer. For instance, a meta-analysis of 32 studies showed every additional 400 g of dairy products consumed per day increased the risk by 7 percent.8
Processed meats. A review of 25 studies found each 50 g of processed meats eaten daily may raise the risk of prostate cancer by 4 percent.9
Supplements
Curcumin. The anti-inflammatory compound found in turmeric inhibits the formation and development of prostate cancer tumors while promoting cancer cell death (apoptosis).10 One study found it reduced proliferation by 60–80 percent in non-hormone-sensitive cancer cells.11
Quercetin. A plant flavonoid with anti‐inflammatory, antioxidant and anti‐proliferative activities, quercetin was found to reduce cancer cell viability by about 50 percent within 72 hours, among other effects.12 It’s more effective in metastatic forms of the cancer.
Resveratrol. A polyphenol found in the skin of grapes and berries, it can interfere with prostate cancer initiation and progression.13
Vit D3. A greater lifetime exposure to the sun is related to a reduced risk of developing prostate cancer. Men with higher blood levels of vitamin D have a lower risk of the cancer and especially a lower risk of dying from it.14 Over half of men with prostate cancer taking 4,000 IU daily saw improvement in cancer markers over the course of a year.15
Lifestyle
Exercise. Endurance exercise for 45 minutes five times a week before surgery among men with early-stage prostate cancer improved two key biomarkers of prostate cancer outcomes. The best results came from 75 minutes five times a week, but the researchers said this might not be realistic for many men.16 It’s also important not to overdo it.
Don’t smoke. Interestingly, prostate cancer risk is 16 percent lower among smokers than non-smokers, but continuing to smoke if diagnosed with prostate cancer results in a 42 percent higher risk of death.17
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