Who’s Really at Risk for What?
PCRI Insights May, 2005 vol. 8, no. 2
By Mark C. Scholz, MD, Director, Prostate Oncology Specialists, Marina del Rey, CA, and Ralph Blum PC Survivor

Editor’s Note: This is an article by Dr. Scholz providing advice to prostate cancer patients about health issues unrelated to prostate cancer. The goal of the article is to bring the risks associated with prostate cancer into perspective with the risks of other potentially serious illness, including heart attacks, osteoporosis, colon cancer sarcopenia, lung cancer, and melanoma.

Cancer is the Spur
Like many doctors, I am often struck by the prodigious efforts men make to understand and get appropriate treatment for prostate cancer (PC) while ignoring the fact that they are at greater risk of dying from other causes unrelated to PC. I’ll never forget the unexpected phone call I received from the distraught wife of a 55-year-old patient who had consulted me for the first time only a week previously. “How did you know?” she cried. “How did you know that my husband had heart disease?” At first I didn’t even understand what she was referring to.
Then she told me that her husband had died in his sleep from a massive heart attack four days after our initial consultation. During our initial consultation, I had only recommended that he undergo screening to see if any heart disease was present. There had been no indication whatsoever that he had an underlying heart problem during the initial evaluation. One thing I did know, however, is that silent heart disease is very common among men in this age group.

Deeply sorry for her loss, I explained to her that men come to my office because of their concern about dying of PC. When I see them, they are often found to have low-risk variants of PC, a form of the disease that practically never leads to death. I point out to them that that they are 10 times more likely to die of a heart attack or a stroke than from their early stage PC. See Table 1 for the annual death rates for men in the United States each year.

For this reason, I routinely recommend cardiac screening to our newly diagnosed PC patients, even though they usually try to tell me what good shape they are in, how low their cholesterol is, and generally how good they feel.

For the past decade, my focus has been on treating PC exclusively. Some forms of PC can be quite dangerous. Fortunately, these more aggressive forms are not as common as the lower-grade, less dangerous forms. These days, when men are commonly being diagnosed at an early stage, we can confidently tell them that their risk of dying of PC within 10 years is less than 1%. However, their risk of dying from other diseases can be far greater, so I customarily advise my patients that they at least undergo screening for certain common, preventable, and potentially dangerous diseases.

The place to start is with a simple baseline physical examination that includes some common blood tests looking for any irregularities that might indicate the presence of underlying illness. (The accompanying article describes these laboratory blood tests, discusses what they test for, and projects what the results may indicate.) Screening for unexpected latent medical problems is not always a popular pursuit. It can be inconvenient, uncomfortable, and on occasion, expensive, since sometimes insurance does not pay for screening tests. Also troubling is the fact that the screening process can occasionally produce a false positive or a false negative. So it might take additional studies to validate a finding, causing additional stress and cost for the patient. Despite all these drawbacks, screening is our best defense, and is the best tool available for early detection of certain common and preventable heath problems.

The Scanning Revolution
Fortunately, times are changing and rapid progress is occurring in the field of medical technology. One of the most significant advances has been the refinement of a body scanning technique called computerized tomography, popularly referred to as CT scans. Body scans have been around for some years now, but older technology could not accurately image moving organs. If we use the analogy of a camera, the older scans could not take pictures of the moving parts of the body because they had “excessively slow exposure times. “Pictures” of moving organs like the heart, the lungs, and the colon always came out blurred. Today, however, newer technology renders excellent image quality.

I am not advocating that total body scans should be undertaken randomly or without explicit reason such as those procedures that are being widely advertised on the radio in major population centers. The value of this sort of global scanning is highly debatable because random scanning frequently uncovers what we term “incidental findings” that subsequent tests show to be completely benign. The disadvantage of global body scanning is that when any slight abnormality is seen, it becomes necessary to embark on a stressful, time-consuming, and expensive process to determine that a suspicious area found in the scan does or does not indicate the beginning of some malignant process. This then can require further scans, blood tests, consultations with medical experts and, in some cases, biopsies or even surgery.

However, there are selective ways that these scans can be used to image certain critical areas of the body, especially in groups of patients known to be at high risk. One of the areas where fast CT scans are beneficial is in detecting the presence of cholesterol plaque in the coronary arteries. Patients in our practice (who are usually older than 50) belong to the population most at risk for atherosclerosis, otherwise known as hardening of the arteries.

Simply described, hardening of the arteries occurs when cholesterol builds up in the arteries. In extreme degrees the buildup reaches the point where the artery is totally blocked off. When an artery to the heart is completely blocked, it results in a heart attack. When an artery to the brain is completely blocked off, it results in a stroke. Over 400,000 men die of either heart attack or stroke every year. Perhaps twice that many men have non-fatal strokes and heart attacks each and every year. Clearly, we have an epidemic on our hands. In comparison, the annual death rate from PC is 28,000, only 9% of the rate that men are dying from heart attacks and strokes.

Much of the mortality from heart disease is preventable. The problem is that atherosclerosis is a silent disease until suddenly a disaster occurs. There are indirect means (e. g. cholesterol testing) to estimate the likelihood of impending serious atherosclerosis, yet these tests are too imprecise. Elevated blood cholesterol provides a warning by telling how much cholesterol is floating in the blood, but we want more. We really want to know how much cholesterol is sticking to the wall of the artery. This varies widely from individual to individual even in men with really high or low levels of cholesterol floating in the blood.

Fast CT scanning can accurately evaluate the status of the coronary arteries. Population studies indicate that a lucky minority of men have absolutely no calcified plaque at all. The rest of us have small amounts, average amounts, or extensive amounts of disease. In the United States, having an “average” amount of plaque is a serious situation. With heart attacks and strokes at epidemic levels, is seems foolish to be unwilling to have a simple 10 minute $300 test to determine the status of one’s arteries. This does not require annual testing; reevaluations can probably be done every three to five years.

Figure 1 Progressive development of plaque over time. This process, in various stages of development, can be seen in many areas of the coronary artery system, consistent with the “diffuse” nature of coronary artery disease.

 

Atherosclerosis

Figure 2 The calcium mpregnation of the plaque as would be visualized by the scanner.

Check List for Plaque Management
What should you as a PC patient do if you learn that there is a lot of cholesterol plaque in your coronary arteries?

1. See a qualified cardiologist;
2. Obtain a cardiac stress treadmill annually;
3. Obtain an ultrasound of your carotid arteries;
4. Start Lipitor to diminish your LDL cholesterol to 60;
5. Start aspirin 81 mg a day (if there are no contraindications to aspirin);
6. Check homocysteine. If it is elevated, start taking folic acid 1 mg daily;
7. Reduce blood pressure to 125 over 75 or less;
8. Diet and exercise;
9. Perform a repeat scan in three years to make sure what you are doing is working.

The Specter of Osteoporosis
We must also consider the problem of osteoporosis. Osteoporosis is defined as bone that has been weakened from calcium loss over time. Calcium loss is a silent phenomenon until a bone fracture occurs. Common fracture sites from osteoporosis are the spine, rib, wrist, and hip. Osteoporotic fractures often have dire consequences. Bone fractures are associated with shortened survival in men with PC.1 Compression fractures of the spine can be extremely painful, result in loss of height and, when advanced, result in a forward curvature of the spine known as the “dowager’s hump.”

Osteoporosis is mistakenly thought to occur only in women, but fully a third of all hip fractures occur in men. There are many causes of osteoporosis. Men who are slender have less bone reserve and are more predisposed to osteoporosis. Thyroid or parathyroid hyperactivity can contribute to osteoporosis. Other contributing causes of osteoporosis are excessive use of alcohol, caffeine, or tobacco. Cortisone, used to treat asthma or arthritis, is another common culprit. Excess vitamin A has also been associated with osteoporosis and fractures.2 Lack of exercise, lack of sunlight exposure (low vitamin D), and low calcium intake are additional potential causes.

Osteoporosis-induced bone fractures are even more frequent in men treated for PC with testosterone inactivating pharmaceuticals (TIP).3,4 Testosterone deprivation therapy reduces estrogen levels. Normal levels of both these hormones inhibit excess calcium loss from bone.

Osteoporosis needs to be identified by scanning before a fracture occurs, but not all scans are equally effective. It is important to choose the right scanning technique to diagnosis osteoporosis because the most popular equipment available, DEXA scans, grossly underestimate the incidence of osteoporosis in men.5 The problem with DEXA scans is that men over age fifty usually have some degenerative arthritis of the lower back which results in excess calcium in the tissues surrounding the spine. When the DEXA scan sends x-rays through this area to measure spine density, the excess calcium surrounding the spine results in an artificially high bone density reading, a situation that masks the presence of osteoporosis in the spine.

In these QCT scans, the yellow lines demark the area of bone being analyzed. Courtesy of Parkview Imaging, Santa Monica, CA.

Fortunately, another more accurate technique of measuring bone mineral density is available: the quantitative CAT scan, or QCT. This scan measures the calcium density in the center of the vertebral column thereby bypassing the problem of the excess calcium surrounding the spine. Many health care providers are unaware of the DEXA scan’s limitations, although these limitations have been well documented in a study from Massachusetts General Hospital.6 The study compared DEXA and QCT in 41 men with PC who had never previously been treated with TIP. QCT detected osteoporosis in 63% of the men but DEXA only found osteoporosis in 5%! On the basis of this study, which was done in men whose average age was 68, we can conclude that osteoporosis is common even in men who have never had previous exposure to testosterone-lowering drugs. What do you do if you find out that you have osteoporosis?

1. Start calcium citrate 500 mg twice a day;
2. Start prescription Vitamin D (Calcitriol);
3. Start a bisphosphonate such a Fosamax®,
Actonel®, Aredia® or Zometa®;
4. Exercise (preferably some form of weight
lifting);
5. Repeat bone density testing every year to ensure that the treatment is working;
6. While on treatment, consider checking the urine for signs of excess bone breakdown products with tests such as Pyrilinks D and N Telopeptide to make sure that the treatment is working.

Colon Cancer
This cancer kills about the same number of men in the United States each year as PC does. Early diagnosis with colon screening can detect the disease long before it spreads. Generally, it is recommended that colon screening occur every five years with either a colonoscopy (a scope performed by a physician called a gastroenterologist), or with a fast CT scan, which is termed a virtual colonoscopy.

Beware of Sarcopenia
Sarcopenia is the official word describing loss of muscle mass. Muscle loss is a normal part of aging. Some men age gracefully, but others don’t. Men who allow themselves to get weak are the ones who look and act old. Strength is what we associate with heath and youthfulness. Weakness is associated with advanced age and decrepitude. Muscle loss can have a dramatic effect on health. Studies indicate that poor fitness in the elderly is more dangerous than smoking. Table 2 shows the predicted 10-year survival of normal healthy individuals at an average age of 65. In this study, subjects were divided into three groups: the strong, the average, and the weak. Despite having no specific illnesses at the time, only 60% of the weak individuals were still alive ten years later. Ninety percent of the people in the strong group were still alive 10 years later. Loss of strength is correctable to a large degree with appropriate exercise.

Exercise is unpleasant for most of us. My approach has been to purchase discipline and expertise by hiring a trainer. I spend one hour twice a week taking orders from a ruthless individual who has a mandate to make me stronger. This process is accomplished exclusively with weight machines. Aerobic exercise is great, but optimally it should be done for 40 minutes a day. I just don’t have that kind of time to spare. I have been doing this one-hour, twice weekly regimen for five years. It has been expensive and mostly unpleasant, but the results are rather remarkable. I used to have to eat selectively to avoid gaining weight. Now I eat pretty much whatever I want without any concern for my weight. I am about twice as strong as I was five years ago. I have put on at least 15-20 pounds of muscle and lost 20-30 pounds of fat. In my professional life I can work longer hours at a faster pace, but at the end of the day I still have energy to interact with my family. For our patients, this issue of muscle loss is even more critical. Men with PC who are being treated with testosterone-inactivating pharmaceuticals lose muscle mass very, very quickly. The muscle loss is preventable but only with a consistent weight training program performed for an hour twice a week.7

Lung Cancer
Early diagnosis of lung cancer is vital, since it is almost universally fatal in men who are not diagnosed until after they have a symptom of the disease such as cough, chest pain, or weight loss. The average survival is only nine months in men diagnosed after they have symptoms. Fortunately, fast CT scans can detect small early stage lung cancers when they are only a quarter of an inch in diameter. When a lung cancer is found at such an early stage, it can often be removed with a telescopic device in a process called thoracoscopy. (This is very similar to laparoscopy for operations in the abdominal area.) Cure rates for men with small lung cancers are high (about 80%). Any life-long smoker would be crazy not to spring for $300 each year to have a lung scan done.

Less Common Cancers

Bladder cancer
Bladder cancer kills about six thousand men each year, five times less than PC. The presence of bladder cancer is often signaled by microscopic amounts of blood in the urine which can be detected by performing a simple urine analysis. So obviously a urine analysis should be done as part of the general annual physical examination.

Melanoma
Three thousand men die each year from melanoma, a pigmented cancer that can look like a new mole in its early stages. There is no effective treatment for melanoma after it has spread, but if it is detected early, it is usually curable with surgical excision. An annual visit to the dermatologist (the doctor with the trained eye for spotting melanoma in its earliest stages) can save your life.

Other Causes
I can’t resist making a common sense statement in an area where I have no specific expertise. Consider that just as many men are dying in car accidents each year as are dying each year from PC. If that is the case, what are some simple precautions? Consider keeping a robust grid of steel around you while you are doing battle on the highways; stay away from sub-compact cars. Drive a heavy car that has front and side air bags. And of course wear a seat belt. Harkening back to my Internal Medicine training leads me to also mention that the next most common killer after PC is pneumonia and flu. While most men have heard of flu vaccines, many are unaware that there are now FDA approved antibiotics to treat flu: Tamiflu, and Flumadine. These are very effective against influenza if they are started promptly after the onset of symptoms. They can also be helpful in the situation where one family member is sick; in that case, the drugs can be taken before the flu develops and thereby may preclude the development of illness. I have also found that many men are unaware that there is now an effective vaccine against pneumonia available called pneumovax. The pneumovax is administered every five years and is recommended for men over age 65 or for men with chronic illnesses.

Conclusion
Many of these illnesses can be prevented by an annual visit to the doctor’s office. But it takes a lot to get us guys to go to the doctor. Prostate cancer seems to do the trick. A diagnosis of PC shatters the illusion of immortality. Men finally sit up and take notice that good health is not a guaranteed right. Therefore, the diagnosis of PC may actually turn out to be beneficial if being diagnosed can lead to an increased awareness of health-related issues that have been previously neglected. Common sense dictates that if it is worth expending considerable time, energy, and resources to minimize the chance of death from PC, it certainly makes sense to expend time and energy to minimize the risks of these other preventable causes of death. 

References
1. Skeletal fractures negatively correlate with overall survival in men with prostate cancer. Oefelein, M, Ricchiuti, V, et al Journal of Urology Vol. 168: 1005-1007, 2002.

2. Excess dietary intake of vitamin A is associated with reduced bone mineral density and increased risk of hip fracture. Ann Intern Med Vol. 129: 770-778, 1998.

3. Osteoporosis after orchiectomy for prostate cancer. Daniell, H, Journal of Urology Vol. 157, 439-444, 1997.

4. Osteoporosis in men treated with androgen deprivation therapy for prostate cancer. Ross, R, Small, E, Journal of Urology Vol. 167: 1952- 1956, 2002.

5. Low bone mineral density in hormone-naïve men with prostate cancer. Smith, M, McGovern, F, et al Cancer Vol. 91: 2238-2245, 2001.

6. Exercise capacity and mortality among men referred for exercise testing. Myers, J. New England Journal of Medicine Vol. 346 page 793 2002.

7. Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. Segal RJ: J Clin Oncol 21:1653-9, 2003.

 

Prostate Cancer Research Institute (PCRI)

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