The unfortunate news this week about President Biden’s metastatic prostate cancer diagnosis is a stark reminder of just how common this disease is, especially among men 65 and older.
As a physician specializing in integrative oncology with over 35 years of experience, I have treated hundreds of men with prostate cancer. While all cancers range in aggressiveness, that range is particularly significant, from a clinical perspective, in cases of prostate cancer. A thorough review is beyond a newsletter blog. Here, I am providing a few highlights that are often overlooked, while sharing some of my observations from decades in clinical practice.
There are two basic elements to prostate cancer: First is the Stage — how far did the prostate cancer spread? Is it just in the prostate on one side? Is it in the prostate on two sides? Did the cancer metastasize to the lymph nodes and to distance metastasis, usually bones, as in President Biden’s case? As you can imagine, these and other specific details have a big effect on the prognosis.
The second factor is aggressiveness. This is based on the morphology of the cancer cells, which is graded as a Gleason Score. Without getting too complicated, prostate cancer is graded by the dominant percentage of the tumor over 50% and the small part of the tumor. These two numbers are then added to yield a score. So for example, three plus three is a low-grade prostate cancer. Once you get to eight, nine, or 10, the cancer becomes more aggressive (Biden has a Gleason Score of 9).
The Pros and Cons of Hormonal Therapy for Prostate Cancer
Hormone treatment usually involves a combination of medications: a GnRH agonist that reduces testosterone production by the testicles (such as Lupron) and a next-generation androgen receptor (AR) axis inhibitor like Darolutamide, Apalutamide, or Enzalutamide, which blocks testosterone’s action on cancer cells.
Certain types of prostate cancer respond very well to hormonal therapy (aka androgen deprivation therapy); however, the response tends to be short-lived with more aggressive cancers. This means a group of cells has become resistant to testosterone and dihydrotestosterone (DHT) suppression.
Sometimes, the real story is not that the cancer stops responding to hormone therapy but that the therapy has not gone far enough. Certain people can become hypersensitive to dihydrotestosterone and testosterone. So, they’re really not resistant — they’re actually hypersensitive. This means there may still be tiny amounts of testosterone and dihydrotestosterone present, enough for the cancer to stay active. Why does it happen? When you suppress a certain hormone, the deprived cell can increase the number of receptors to the specific hormone on its membrane surface, increasing its sensitivity to the hormone. These patients are often misunderstood, as they actually may need a more effective combination of drugs to completely suppress the cancer.
How do you extend the response to hormonal therapy? When the cancer is aggressive, you have to make sure the hormonal blockade is complete — maybe not only one drug, but two drugs and sometimes even three drugs. Here’s where integrative approaches can enhance the anti-prostate cancer therapeutic effects while reducing the side effects.
Having said that, monotherapy — the use of a single agent, such as Enzalutamide (XTandi)— can be used in specific case when we are focusing on offering superior quality of life. I will use this method in cases of less aggressive disease, where the quality of life and sexual function are a major consideration.
Important Blood Tests for Prostate Health
There are many different tests used to evaluate the health of a man’s prostate. Here are a few of the most essential ones:
Prostate-Specific Antigen
Prostate-specific antigen (PSA) is a protein produced by cells in your prostate gland, elevated levels of which can indicate the presence of prostate cancer. It’s important to measure total and free levels, as well as tracking magnitude of changes and speed at which the PSA is increasing. I could devote a full blog on evaluating the PSA, but for now, remember these key points:
• Low PSA doesn’t necessarily mean a slow-growing disease.
• When coming to the use of PSA as a screening method, we want to be aware that PSA can sometimes have seasonal variations. PSADT (PSA Doubling Time) reflects the peed of increase in PSA levels. It is especially important in prostate cancer that has been treated locally (with radiation therapy of different kinds, radical prostatectomy, or combination), and can predict oncologic and survival outcomes. Posttreatment PSADT in patients with BRPC (Biochemically Recurrent Prostate Cancer) after local treatment is the strongest determinant of metastasis-free and overall survival.
• It’s essential to evaluate the PSA in relation to the size of the prostate. For example, a PSA of 4.5 with a prostate of 30ml is more worrisome than a PSA of 7.5 with a Prostate of 110ml (huge). That’s because a healthy prostate secretes PSA at an average rate of 0.07ng/ml. For the 30ml patient, this natural production accounts for 2.1 out of the total score of 4.5 — only half. For the 7.5 patient, however, it accounts for all of the PSA.
• Prostatitis is quite non-specific, and will also elevate the PSA. So elevated PSA with urinary symptoms (a common complaint in cases of prostatitis) is less worrisome than the same PSA without any complaints.
Hormonal Profile
The hormone profile is very important in men with prostate cancer. For example, a patient with prostate cancer who has a high testosterone level will respond better to treatment compared to a patient with the same disease, but lower testosterone levels.
Here are the basic lab tests that I order on all my patients with prostate cancer:
• Total Estrogens: As men age, testosterone is increasingly converted to estrogens. This tendency is compounded by exposure to environmental toxins, xenoestrogens, and toxic heavy metals. I often see an increase in total estrogen, estrogen to testosterone ratio, and 16-hydroxy estrogen to 2-hydroxy estrogen ratio. These hormonal changes are significant factors in the pathogenesis of prostate cancer and contribute greatly to the increased incidence of prostate cancer. It’s in restoring this critical hormonal balance that complementary and integrative medicine has come to play a leading role in the prevention of prostate cancer.
• Testosterone, total and free
• Progesterone
• DHEA-S (Dehydroepiandrosterone Sulfate)
• DHT (Dihydrotestosterone)
• Prolactin: Higher levels (including high-normal) have a worse prognosis.
• CEA (Carcinoembryonic Antigen): Cancer tends to be more aggressive when this colon cancer marker is elevated.
• IGF-1 (Insulin-like Growth Factor 1):- When elevated, this also indicates a more aggressive disease. However, I haven’t found this one to be as useful as I hoped. It may be a laboratory detection issue.
• Thyroid Function: Thyroid function is also important, as it can indicate the speed of the individual’s metabolism. In cancerous conditions, the body will often attempt to slow down the thyroid in an attempt to slow down the disease. As such, the problem is not really in the thyroid — it’s merely an adaptive response of the body. For that reason, I always exercise caution when considering thyroid support in a patient with cancer. From the perspective of health and disease, if the condition is moving faster than the health aspect, speeding up that aspect is not a good idea. If, on the other hand, the patient is winning their fight, speeding up can allow for more healing to be accomplished in a shorter period.
A Multifaceted Approach
There are many different therapeutic approaches when it comes to treating cancer, and despite what we have been told, we are never stuck with just one treatment method. Cancer is a dynamic condition that changes over time; therefore, we always have to adjust and change treatments or try something new. This is an important point to remember, and it’s almost universally overlooked. The more we can view cancer in a multidimensional way, the more refined our treatments and approaches will be.
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