Assessing Prostate Cancer Four Pragmatic Questions to Consider
Phranq D. Tamburri, NMD
When seeing a patient for prostate cancer (CaP), a physician often encounters a quandary when determining how to explain the patient’s risk to him. After all, it is a known fact that the majority of men who are diagnosed with prostate cancer will not die from it. Depending on the source, around 13% of men with CaP die from the disease.1,2 Some influencing factors include age (according to the US Preventive Services Task Force, 71% of CaP deaths occur in patients >75 years of age3), race (eg, more than twice as many African-American men than Caucasian men die from CaP1), and tumor variant and aggressiveness4). Relating these statistics quickly inspires further questioning, which varies for patient and physician:
The patient asks, “Which type of CaP do I have? Do I have the type that will kill me? Regardless of the variant, am I really a candidate for natural treatments, or should I throw in the towel and get conventional treatments?”
The physician asks, “How can I determine which variant of CaP my patient has? If the PSA is not reliable, then how do I know whether any of my treatments are working? Am I treating the CaP or the PSA? How do I protect myself from litigation if I do not recommend conventional treatments?”
A Refresher on the Problem
Lower-mortality cancers were only determined after the introduction of the PSA blood test in the 1980s, a test that would lead to a reflex biopsy. Since biopsies were conducted for men having a PSA over 4 (now even over 2) the incidence of prostate cancer has exploded since the PSA test was introduced. Generally speaking, the only way prostate cancer was diagnosed before prior to 1980 was through observing the 1 out of roughly 10 men who was dying from advanced-stage CaP. If the PSA test had been available before 1980, then those men dying of prostate cancer at that time would most likely have had PSA values in the 100s or even 1000s. Of course, the rest (roughly 85%) would be patients who were statistically unaware of it and would likely die of something else.
An Educated Speculation
This assumption, albeit based upon fact, has led to the belief that most men have prostate cancer in them all the time. If this reasoning is pursued, then one could further argue that this “explosion” in CaP incidence may also apply to other cancers; that is, cancer could be found in most patients in various other organ systems if they were only biopsied enough times. This speculation might eventually be proven out if new blood tests, similar to the PSA, were used for other organ cancers that also led to reflex biopsies. In other words, if physicians could routinely palpate their patients’ spleens and take blood for a “spleen-PSA” test, the suspicion for spleen cancer would increase, and there would be a surge in spleen biopsies followed by a spike in the incidence of spleen cancer. This speculative discussion was detailed in last year’s NDNR article (November, 2013).
Regardless of the exact numbers, this situation of indolent prostate cancer being predominant in the stereotypical fatal cancer trope has ignited countless well-meaning but contrarian opinions published on non-medical authors’ websites, which collectively pose many challenges to a physician confronted by a skeptical patient. For the allopathic physician, whose focus and modus operandi are longevity of life and standard-of-care protocols, the decision process is often myopic: If the PSA is >4, then biopsy the patient. If prostate cancer is found upon biopsy, then determine which conventional treatment option is most appropriate. Of course, in most cases this leads to surgery or other procedures such as radiation, brachytherapy, or other prostate destructive techniques that almost always lead to a decrease in quality of life.
In contrast, the typical alternative practitioner and educated layman will often seize upon the low statistical risk of mortality and thus oppose the conventional approach. As an ironic consequence, alternative providers or laymen sometimes offer solutions to prostate cancer that may be no better than quackery and yet still statistically be concluded to have “cured” the patient.
Oversimplified Myths Our Patients Believe
The naturopathic physician often thus finds his or her patients caught in a game of “prostate ping-pong.” This means that they are caught between the allopathic physician that is pushing for a biopsy or surgery, and the alternative practitioner or prostate cancer support group websites that proclaim that drugs and surgery are wrong because CaP can “most always be cured with diet and supplements.” These patients also often quote many simplistic soundbites, with regard to prostate cancer: “CaP is the best cancer to get because it is the lowest aggression” … “Most men with CaP will die of something else then prostate cancer” … “We all have cancer in us all of the time” … “CaP can be cured by fasting from carbs, since cancer can only eat sugar.”
Approaching These Questions Courageously
Although such soundbites do contain a kernel of truth, they are severe oversimplifications. Combined with the opposite advice from their allopathic sources, these clichés result in much contradiction and confusion for the patient and especially the naturopathic physician. So, let us dissect these clichés step by step, using a typical interaction at my office with a new patient:
Physician: “So, Mr Smith, your PSA is elevated [though <12]. So, why are you here today?”
Patient: “It’s very simple. I just want to know if I have prostate cancer without having a biopsy.”
Physician: “Well I am sure you have heard that doctors now believe we have cancer within us all the time. Have you heard this?”
Patient:” Of course, of course! I’ve known that for a while. Even Dr Oz stated that on TV!”
Physician: “Okay then. So, if we have cancer always in us, then why are you asking whether you have prostate cancer? Of course you likely do. You therefore also likely have forms of brain cancer, lung cancer, and stomach cancer.”
Patient: “I never thought of that. Hmmm. So I guess what I am wanting to know is if I have a real prostate cancer or not?”
Physician: “So how is a real prostate cancer different from an unreal prostate cancer?”
Patient: “Good point. So I guess I want to know whether I have an aggressive prostate cancer?”
Physician: “Well, the only legal definition for “aggression” of a prostate cancer is with the Gleason score via prostate biopsy.”
Patient: “But Doctor, the reason I am here is because I do not want a biopsy!”
Physician: “So how, then, should we determine aggression? Should we use the PSA test?”
Patient: “But Doctor, I read that the PSA test is an unreliable test. I heard, however, that I can image my prostate with color Doppler ultrasound or rectal MRI. I want to do that.”
Physician: “OK. Now you must realize that prostate imaging cannot diagnose a prostate cancer. It can only show high-risk regions that suggest strongly that a cancer might exist. Do you understand?”
Patient: “I understand.”
Physician: “If we refuse a biopsy and do not trust the PSA, then how do we qualitatively determine the aggression with only a suspicious black spot [hypoechoic lesion] on image? A picture of a potential cancer only brings us back to the beginning of whether a cancer exists, not “aggression.” So is this satisfactory? Is knowing whether a “suspicious black spot” exists on your prostate what you really want to know?”
Patient: “I think so. I am so confused.”
Four Pragmatic Questions
The following 4 questions are the result of over 5 years of exclusive prostate cancer assessments. As many experienced physicians reading this article will attest, it often takes years to distill down to what seem to be simple questions, yet can often take years of analysis and experience with patients to pragmatically work out. The following 4 questions, followed by the professional considerations, are now my primary introduction for each prostate cancer patient. They have become a very successful method of formatting a cancer discussion with patients – for the initial visit, as well as subsequent active surveillance consults. These 4 specific questions, worded as they are, eventually identify and answer the myriad questions, anxiety, and foggy logic from alternative medicine soundbites, which the above sample dialogue illustrates. I encourage you to consider implementing them in your CaP cases.
- What is the qualitative percent chance that the patient has a significant and/or reproducible prostate cancer that is sequestered to the gland itself?
Another way of wording this is this: If this patient was (hypothetically) biopsied 10 separate times of 12 cores each, how many would produce a positive result? This question attempts to address the quandary stated above. That is, if they agree that cancer is within us all the time, like bacteria is always within us, then how does answering “yes, you have cancer” pragmatically help the patient? Note that this question specifically does not deal with mortality risk or any qualitative factors. The question is specifically designed to challenge their assumptions and help refine their overall long-term goals. Remember that “Do I have CaP?” is a profoundly different question than “Is it going to kill me?” Question #1 isolates this concern from the next one…
- Having established the risk of having prostate cancer in Question #1, if CaP is present, how aggressive is it?
This is very tricky because the definition of aggression is technically a legal one based on a biopsy Gleason score. Of course, many patients consult a naturopathic physician because they do not want a biopsy and believe that a straight PSA is unreliable. Ultimately, what men are really asking, in terms of aggressiveness, is “what is the chance I will die of this cancer in 5 to 10 years?”
For this question, instead of “aggression,” I prefer the term “metabolic momentum.” This term, instead of asking a basic aggression question, seeks to determine the overall movement and upward potential that may be exhibited by a cancer that ultimately metastasizes. Keep in mind that a patient can only die from prostate cancer if it spreads from the prostate itself. As long as a carcinoma does not physically block a prosthetic urethra, this cancer never kills if it stays localized and sequestered to the gland. Therefore the real question is: at what point will this cancer leave the gland?
Therefore, the first step is to determine a threshold set of values that is specific for the patient and which suggest at which point his cancer is likely to metastasize. Making this determination is involved and has been discussed in prior NDNR writings. One point to consider, however, is that the PSA is relative to the size of the prostate itself. Therefore, a PSA of 10 may be a threshold value for most men, but a prostate volume >70 mL might normally produce a PSA closer to 15, or even 20, as a cutoff.
Other factors play into the determination of this threshold. One such factor is the patient’s level of risk. Another factor is the patient’s health priority regarding longevity of life vs quality of life. So, for instance, a preference for quality of life would allow me to increase the threshold values, whereas for a man wanting longevity, I would lower the threshold. The threshold is a general term that represents the point of abandonment of natural treatments and active surveillance, in exchange for a conventional approach. Keep in mind that although most patients claim that they are “going natural,” what most men really want is to follow low-invasive treatments as long as they can, up until the point at which their cancer might metastasize. At that point they have no problem switching to conventional. Therefore the crux of this prostate cancer assessment and these 4 questions is really to answer this question: When should the patient “bail”? I recommend that this decision be made jointly between the physician and the patient, and along with his partner if possible.
I might add that the process of determining this threshold jointly engages the patient and empowers him, as he knows what the specific goals and objectives are during a course of treatments.
On a related note, one goal that should be avoided is one that feels obvious to the patient during the initial visit, that being to “eradicate” the prostate cancer. Having this as a goal becomes a never-ending quandary for the physician and can be very frustrating for the patient. After all, how does an ethical physician tell a patient that his cancer is “gone.” How could you clinically tell? If the PSA drops under 4? If the suspect lesion is not observable on ultrasound? If the biopsy is repeated and found negative?… As far as the urologist is concerned, the cancer might not be gone but simply missed! Besides, how does one eradicate cancer when the patient has already understood that cancer is within us all of the time? I recognize that these questions and responses are initially not what they expected their naturopathic doctor to say. It seems defeatist. However when explained properly and honestly, the patient typically will bond with you when recognizing that your points are sensible and what they need to hear, not necessarily what they wanted to hear. If “physician” really means “teacher” in Latin, then this part of the discussion exemplifies the proud heritage of the naturopathic physician.
- Whether a cancer exists or not, what other conditions or pathology can be affecting the PSA kinetics?
Although the patient understandably is fixated on question #1, this third question is typically the foundation for the cancer assessment. Since the PSA is most commonly elevated for non-cancer pathology (BPH, prostatitis, recent trauma, etc) determining other reasons why the PSA may be elevated is paramount when assessing the CaP patient. Keep in mind that most patients found their way to your office because their PSA was elevated. So, regardless of whether cancer has been diagnosed or not, the real question is what is the PSA reflecting? Consider a case study that was detailed in a prior NDNR article. A patient was biopsied and found positive for a scant cancer because his PSA was 13. However, the 13 appeared following a prostate seizure during 2 weeks of a cross-country motorcycle ride that forced him to an emergency room for complete urinary retention. His PSA 2 weeks before the trip was only 1.8. Therefore, although he is legally diagnosed with prostate cancer, cancer had no bearing on his PSA.
Question #3 is also imperative for determining the next step in treatment and management, as it helps to outline the therapeutic order. To illustrate, let us talk about polar bears! Imagine a polar bear representing a man’s prostate cancer that was diagnosed legally upon biopsy. The patient under question #2 understandably wants to know how aggressive – or angry – is the polar bear. Considering PSA as a monitoring factor, we want to know if this poor bear is an angry mama bear or a cute cuddly cub. If this white polar bear is standing outside my Arizona office in the desert by a cactus, I can make him out. However, if the bear is standing upon an iceberg (eg, BPH) and if a blizzard is occurring (eg, prostatitis), then I cannot distinguish the polar bear during a white-out! If we remove the iceberg and blizzard by systematically treating for prostatitis and BPH, then we can easily make out the variety and aggression of the polar bear. On a practical note, I recommend starting treatment for prostatitis in 30-day aggressive increments, then follow up with longer-term BPH treatments to most effectively track the PSA fluctuations and causes.
- How do I track the patient?
Although the patient is not even considering question #4, this is, by far, the most important question for the naturopathic physician considering active surveillance and long-term treatment. After all, assuming that the patient is not whisked away for surgery but continues under your care, how do you know that the treatments are working? More importantly, the patient should not be crossing into dangerous metastasis territory that for which you may be held accountable. Remember that the issue of an unreliable PSA crosses both ways. On the one hand, an elevated PSA value does not necessarily reflect an aggressive cancer that needs treatment. However, a low PSA does not necessarily reflect a low-aggression cancer, nor one that is being controlled. Some cancers, typically following exposure to known carcinogens, like Agent Orange, can result in super-aggressive variants measuring as high as Gleason 10, yet yield PSAs that never go above 2.0.
How does a physician track improvement of a prostate cancer that is PSA-independent? Most prostate cancer cases are admittedly not this atypical; however, the point is for the physician to tailor a custom tracking plan for the patient. Keep in mind that Active Surveillance has 2 parts: “active” suggests that regular tracking and management is necessary, and “surveillance” demands that specific parameters (PSA, biopsy, color Doppler, TRUSP, symptoms, etc) be determined in order to effectively link them to the patient’s specific CaP variant. Therefore, determining a proper active surveillance protocol is paramount for the naturopathic physician, regarding question #4.Overall, you must determine what data to track and how often to track it. Of course, the answers are (and should be) individualized for both the patient and his unique cancer.Remember, however, that the data yielded by this question feeds directly into question #2, discussed above (determining the metastasis threshold, ie, metabolic momentum).
These 4 questions, as stated, have taken a career to synthesize. This article, in summary, is a conclusion to a series of articles exclusive to NDNR that have outlined the overall assessment strategies for prostate cancer. I deeply encourage my colleagues to utilize these 4 questions in their own practice and customize it to their own practice style. Although I claim no specialty in any cancer other than prostate, I warmly encourage my peers with other cancer specialties, especially those of the esteemed ONCANP, to determine if these 4 questions can apply to other forms of cancer in practice. It is my sincere and professional belief that the treatment of all cancer begins in a new understanding and paradigm of what constitutes cancer. Prostate cancer, for many reasons both medical and economic, has been placed in the vanguard position for determining this new paradigm. By comparing and contrasting the experiences and achievements of all forms of cancer treatment within our profession, it is my belief that our unique naturopathic profession will become the leader in cancer management.
- Surveillance, Epidemiology, and End Results Program. SEER Stat Fact Sheets: Prostate Cancer. National Cancer Institute Web site. http://seer.cancer.gov/statfacts/html/prost.html. Accessed August 15, 2014.
- Centers for Disease Control and Prevention. Prostate Cancer Statistics. CDC Web site. http://www.cdc.gov/cancer/prostate/statistics/. Accessed August 15, 2014.
- Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement. U.S. Preventive Services Task Force Web site. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs2.htm. Accessed August 15, 2014.
- Prostate cancer survival statistics. Cancer Research UK Web site. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/prostate/survival/prostate-cancer-survival-statistics. Accessed August 15, 2014.
Phranq D. Tamburri, NMD, is medical director for Prostate Second Opinions (PSO). As a 3-office international practice, PSO is a specialty service dedicated to assessing prostate cancer treatment options from Active Surveillance, to surgical, and natural. Dr Tamburri is a graduate from the Southwest College of Naturopathic and Health Sciences (SCNM), 2001. He was resident and chief resident, and eventually the first naturopathic physician to conduct rounds with Mayo Clinic urologists. Prior schooling was at Penn State, Temple University (masters degree), and eventually Kansai Gaidai, Japan. Outside of medicine, he lectures on Austrian Economic vs Keynesian theory and, as an INTJ, the Myers-Briggs Personality Type Indicator.