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Metastatic Disease: Why Prostate Biopsies Can Do More Harm Than Good · Intellectual Medicine

• 0:00
  They were missing the point that testosterone is not the enemy.
• 0:05
  In fact, aggressive suppression of testosterone has been shown
• 0:10
  to cause a phenomenon called trans differentiation.
• 0:14
  That's when the cell type of the testosterone mutates into a more
• 0:19
  aggressive, untreatable form. It goes from adenocarcinoma to
• 0:24
  neuroendocrine carcinoma. Untreatable.
• 0:27
  So you want to be thoughtful about how you're going to be
• 0:30
  shepherding your own healthcare. Dogma always gets in the way of
• 0:37
  thinking when there is a protocol, A dogmatic approach to
• 0:42
  something, a consensus. It kind of is a shorthand.
• 0:47
  We don't have to think too hard. We've already given it thought,
• 0:50
  therefore we're going to jump right into the pathway.
• 0:53
  And I'm talking now about prostate cancer diagnosis and
• 0:58
  treatment. I've shared with you my opinion
• 1:01
  about biopsy. They should never be done.
• 1:03
  Almost never. No, never, in my opinion.
• 1:07
  Now there's a rational basis. No, not even a rational basis.
• 1:12
  There is a historical and psychological basis for doing
• 1:16
  it. After all, don't we want to get
• 1:19
  a tissue diagnosis early? Answer.
• 1:22
  Not really. You know, the question at hand
• 1:25
  isn't whether or not getting the information early is worth
• 1:29
  doing. It's will it help save lives?
• 1:32
  And there's evidence that sticky needles in the prostate can have
• 1:36
  the opposite effect. So what are you to do?
• 1:39
  You have an elevated PSA. You have an abnormal MRI.
• 1:42
  Well, I'd like to turn the attention today to focusing on
• 1:46
  those of you who already have spread of cancer.
• 1:49
  Now you know, from prior studies, I've shared with you
• 1:53
  the majority of men with indolent cancer cells in the
• 1:57
  prostate gland. These are atypical Dorman cells
• 2:00
  that are inside the gland that aren't going to harm you as long
• 2:05
  as they don't leave the capsule. The challenge is keeping them
• 2:09
  there. So in prior podcast I've talked
• 2:13
  about some of the approaches. My protocol is built around this
• 2:16
  concept that our body is constantly fighting cancer and
• 2:21
  keeping it boxed in. But suppose it doesn't stay
• 2:25
  there. No matter what you do, some of
• 2:28
  you men are destined to have the cancer progress.
• 2:31
  And although the majority of men with atypical dormant cells in
• 2:36
  the gland will take them to their grave, it will still
• 2:40
  spread and kill some men. So the objective is to not die
• 2:45
  from prostate cancer, or if it's your fate to die from prostate
• 2:49
  cancer, to delay that moment as long as possible.
• 2:53
  And yes, always, always, always prioritize vitality.
• 2:59
  We'll talk about that. There are are treatments out
• 3:02
  there that are guaranteed to cause you harm, maybe maybe not
• 3:07
  any benefit, but guaranteed to crush your vitality to be
• 3:11
  avoided. So you're, you're listening to
• 3:13
  me speak. Maybe you have bone metastatic
• 3:16
  disease or the lymph nodes have spread or it's extended and now
• 3:22
  the doctors are lobbying you for aggressive therapy.
• 3:26
  We need to do testosterone annihilation therapy.
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  We're going to lower testosterone.
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  There are different ways that can be done.
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  We'll talk about when it should be done first.
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  Never because of what's called a biochemical recurrence.
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  What does that mean? Well, you've had your gland
• 3:43
  removed or radiation done, all right?
• 3:45
  You had that done before you had a chance to listen to me.
• 3:48
  Those of you that are know not to go down that pathway because
• 3:52
  it guarantees harm. And it's not been shown to
• 3:54
  prevent death from prostate cancer, right?
• 3:58
  Let that sit there for a minute. Guaranteed harm, no benefit
• 4:03
  regarding avoiding death. Why would you even do it?
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  But for many of you, that that bridge has already been crossed.
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  Unfortunately, up to 40% of men who subject themselves or are
• 4:16
  convinced that they need to have their gland removed, up to 40%
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  of them are going to have a biochemical recurrence.
• 4:23
  That means the PSA level is starting to rise.
• 4:27
  The patient feels good. You feel healthy, doc?
• 4:30
  I feel great. My energy is great.
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  I'm peeing. Fine.
• 4:32
  Nothing's wrong. Yeah, but your PSA went from
• 4:35
  1:00 to 5:00 to 6:00. It looks like the cancer is
• 4:40
  starting to percolate. Let's get you treated.
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  What do they do? They castrate you.
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  Androgen deprivation therapy. This should not be done just
• 4:52
  because of a lab value. You are sacrificing vitality for
• 4:57
  the sake of numeric comfort. Oh, they caught it.
• 5:01
  My PSA went from eight to two. Big freaking deal.
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  What you care about is your vitality and your lifespan.
• 5:10
  So where does this information emanate from?
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  Well, we know that the PSA does roughly correlate with cancer
• 5:15
  burden, so there is some merit in monitoring it.
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  But beating it down just because the number went up, it was an
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  important study. It was called the TOAD trial.
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  Trial of androgen deprivation. I swear they come up with the
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  acronym before the study, the TOAD trial.
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  So in this trial they had two groups of men with biochemical
• 5:37
  recurrence. In one group they put them on
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  immediate deprivation therapy. The other group they delayed it
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  up to two years, nothing up to two years.
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  And what they found was they had the same mortality outcome.
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  That is no benefit to starting early.
• 5:55
  Now, there may be benefit in delaying when PSA starts to
• 5:59
  rise, when prostate cancer begins to spread.
• 6:02
  And if it's in your bone and causing pain or in organs and
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  causing dysfunction or blocking urinary flow and causing
• 6:11
  compromise, then androgen deprivation therapy can be
• 6:16
  therapeutic. When used properly at the right
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  time, it can reverse some of these symptoms.
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  But here's the catch, men. It always ends up failing.
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  Not now and then, Not some of the time, not maybe 100%.
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  If you stay on androgen deprivation therapy long enough,
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  the cancer will plow through it. Now, if we know the clock is
• 6:41
  ticking, it makes sense to delay implementing it as long as
• 6:45
  possible. Imagine it this way.
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  You're holding an offensive position, the enemy's coming at
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  you, and you've got limited ammunition.
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  The enemy is 2 miles away. You see them, but your ammo only
• 6:57
  shoots for a mile, so you start firing like crazy because you're
• 7:00
  nervous. By the time the enemy is within
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  range, you're out of ammo. Like the androgen deprivation
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  therapy. Hold it in reserve.
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  Now what then? The bulk of evidence is starting
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  to sway opinion here, from constantly depriving you of
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  androgen of testosterone, to intermittently treating.
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  So you hit it for a while, get the symptoms under control, PSA
• 7:27
  goes down, and then you quit. Why?
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  Couple reasons. One, you're going to feel
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  better. Blocking testosterone is bad for
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  your health. It makes you tired, it makes you
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  grumpy, you lose muscle, it increases risk of dementia, It
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  correlates with a bump up in heart disease.
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  So balance in the face of acute symptom, it makes sense, but go
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  for that intermittent pathway, give your body a chance to
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  recover and to feel better. Now what about combining things?
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  So I've had some patients have gone to conventional oncologist
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  who have metastatic prostate cancer and they'll say, well,
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  we're going to hit it with triple quadruple drug therapy.
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  There are different kinds of ways to block testosterone.
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  One of them is Lupron. There's a classic drug in this
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  class, Luporide. It's an androgen, it's a
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  pituitary hormone agonist, the luteinizing hormone agonist.
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  And what it does, it exhausts the part of the body that
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  stimulates the development of testosterone to the point where
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  the body doesn't respond and the testosterone drops.
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  Now, these drugs are harsh. They cause a lot of side effects
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  for many men. Another class of drugs are
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  androgen antagonist or Govic's. Relugal X is a classic drug in
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  this category, and it blocks production of testosterone.
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  Generally speaking, a little more gentle, less side effect.
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  There's a third class of drug which is an androgen receptor
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  signaling blocker. This type of drug, Derulo XX
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  Tandy is the Tre name. The generic name for the drug is
• 9:17
  enzalutamide. This class of drug blocks the
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  testosterone receptor. It's a more thorough way to
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  blunt testosterone. Now, the dogma in most of the
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  urological world is the more we can block testosterone, the
• 9:32
  better. We're going to do this, you
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  know, triple drug therapy, and we're going to annihilate your
• 9:36
  testosterone and it's going to help you live longer.
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  Maybe, maybe here's a problem with all the studies, and you
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  have to weigh this because first there's a publication bias.
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  When a study is sponsored, it's sponsored by drug companies
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  because they want to prove the drug works.
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  So there's a publication bias. There's a tendency not to
• 10:01
  publish negative outcomes. There's an interpretive bias.
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  The drug companies often times have their people involved in
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  the study. They fund the study, in many
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  cases, at least a big chunk of it.
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  They also have some of their people involved in interpreting
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  the results. This does not completely
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  invalidate the study, but it creates an inherent conflict.
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  Now, in medicine, conflicts are unavoidable in many cases.
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  Your job is to be aware that they're out there and the way
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  they show up is in the interpretive phase.
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  When they summarize a study results, Often times there's an
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  interpretive bias. The other problem with the
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  studies, you're not like anybody in that study.
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  Everybody's different. Prostate cancer is varied and
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  they try their best to try to organize the studies and
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  organize the patients into categories of similarity, but
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  it's impossible. So for instance, one of the
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  studies cited is called the charted study, the capital
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  CHAARTED. And in this study, they hit men
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  with chemotherapy and with they hit men with multiple drug
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  treatment. And their conclusion was that
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  this aggressive multi drug regimen help people live longer.
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  However, there's a caveat. Only the men with what's called
• 11:31
  high burden disease appeared to benefit.
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  Now high burden disease means not local lymph nodes.
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  It doesn't mean you have some in the pelvic bone.
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  It means you have a lot in the bone outside the pelvis and
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  outside the spine. It's in your femur, it's in your
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  arm, it's in your liver. That's high volume.
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  So there's one challenge, you know, how do you interpret the
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  volume of your disease? That's tough because it'll help
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  guide thought about treatment. Other studies have demonstrated
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  something similar. The Stampede trial looked at
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  multi drug therapy and they found more aggressive treatment
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  help men live longer. What was the difference?
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  The multi drug treatment had 83% survival of three years.
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  The single drug arm had 76% of three years statistically
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  significant but a small delta, small difference.
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  The piece one trial in 2022 demonstrated value with multi
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  drug regimens only in high volume disease.
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  So there's this challenge. When a study is done, it's
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  usually tightly controlled. In the clinical world.
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  The parameters are wider and more docs may be inclined to
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  say, well, it probably will help you.
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  We're going to be aggressive. And you know, in all fairness to
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  them, this disease is going to progress.
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  If you have prostate cancer in the bone, there's no known cure
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  for that. You're dealing with quality of
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  life, survival, extending your lifespan, but unless you die of
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  something else, you're going to die of prostate cancer.
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  So I don't want to be pessimistic, but just let you go
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  into this with our eyes wide open.
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  You get to decide how you want to live.
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  All these drugs harm you, that all make you feel terrible.
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  And in many cases, the extension of life is simply an invitation
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  for extended misery. So you have to be eyes wide
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  open. But back up a step going back to
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  2004, the study that validated chemotherapy can help you live
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  longer. 2004. Now, remember what I said about
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  dogma? When a fact becomes embedded in
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  the mind of doctors, it's tough to shake.
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  Look, a doc who reads a study on Friday that challenges what he
• 14:00
  or she's been doing his whole their whole life, They're not
• 14:03
  going to come in the office on Monday and say, guess what?
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  We're changing everything. They hold onto their dogma.
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  So 2004, the tax trial looked at the chemotherapeutic agent
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  dosataxel, and they looked at men who are on the chemo versus
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  those who are not. We call this beating up a straw
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  man. You're comparing an active
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  treatment to doing nothing. Not hard to really top that,
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  right? Anyhow, in this study, they did
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  conclude that chemotherapy helped men live longer.
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  That's the conclusion. Remember publication bias in
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  these studies. They tend to gloss over or
• 14:43
  minimize quality of life consequence.
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  They'll report them numerically. While there was a grade 345
• 14:50
  reaction in some of the studies, those grade 3-4 and five
• 14:55
  reactions are 60% or more. Now grade 5 means you're dead or
• 15:02
  in the hospital. A grade four life altering
• 15:06
  hospital level sepsis, IV antibiotics, blood clot,
• 15:09
  strokes, a grade 3 permanent life altering adverse
• 15:14
  consequence. We're not talking, I feel a
• 15:17
  little nauseous here. We're talking holy crap, I wish
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  I never did that treatment. So quality of life you got to
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  consider. Now let's go back to life
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  extension, the tax trial 2004. Here's the difference.
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  Those that were on chemotherapy, 18.9 months survival.
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  Those who were not, 16.5 months, survival to roughly a little
• 15:38
  over 2 month differential between chemo and all of its
• 15:42
  misery, gastric upset, vomiting, hair loss, fatigue, infection,
• 15:49
  low white counts versus two months, two months.
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  You get to live with all that. Is that worth it?
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  Maybe, maybe it is. My point is not to tell you what
• 16:01
  you value. It's to give you information,
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  give you options. If you know you're going to
• 16:08
  eventually die from prostate cancer, in my view, you owe it
• 16:13
  to yourself, to the people around you, to get honest
• 16:17
  appraisals about what that life is going to look like.
• 16:21
  If you're spending two months hugging a toilet bowl or going
• 16:25
  back and forth for yet another clinic visit.
• 16:27
  You know, why do we do this? Why do we do it?
• 16:30
  So quality of life pre eminent. Might there be a better way
• 16:35
  forward? That's the other problem with
• 16:38
  dogma. There may be a better way
• 16:40
  forward. It is possible that we're
• 16:42
  missing the point that testosterone is not the enemy.
• 16:47
  In fact, aggressive suppression of testosterone has been shown
• 16:52
  to cause a phenomenon called transdifferentiation.
• 16:56
  That's when the cell type of the testosterone mutates into a more
• 17:01
  aggressive, untreatable form. It goes from adenocarcinoma to
• 17:06
  neuroendocrine carcinoma. Untreatable.
• 17:11
  So you want to be thoughtful about how you're going to be
• 17:14
  shepherding your own healthcare bottom line.
• 17:17
  You got time, you can take a moment.
• 17:19
  If they're going to do something that's going to obliterate your
• 17:21
  testosterone, then by all means take a time out and think about
• 17:25
  it. I don't think there's any role
• 17:28
  for chemotherapy, period. Based upon the research that
• 17:31
  I've done, what I've observed in the clinic, the published
• 17:34
  studies that are out there, you'll look at the benefit from
• 17:37
  adding chemotherapy to these other treatments.
• 17:41
  It's hard to find any merit. The studies concluded is nearly
• 17:47
  zero benefit, no extension of life.
• 17:49
  Why do we do it? Well, it's emotionally hard not
• 17:53
  to when you're looking at somebody who is facing a mortal
• 17:56
  disease. The problem, of course, is a
• 17:59
  treatment is worse than the illness, at least when it comes
• 18:02
  to chemotherapy and prostate cancer.
• 18:05
  So let me leave you with a a message of hope, guys.
• 18:08
  I don't care where this cancer is.
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  You have time in front of you, manage your life positively,
• 18:15
  fight cancer like a man, don't give up your vitality, cling to
• 18:20
  the straw that somehow, some way, you're going to have a long
• 18:25
  and quality lifespan after they crush you.
• 18:29
  With also some of these treatments, it's quite possible
• 18:33
  that your outcome would have been just as good or maybe even
• 18:37
  better with an alternative approach.
• 18:39
  We'll be talking in the future about actually using
• 18:42
  testosterone to help treat prostate cancer.
• 18:45
  It's a novel concept that is gaining some traction in the
• 18:49
  studies. Until then, keep the faith, live
• 18:52
  strong, live vitally, live like a man, be yourself.
• 18:57
  If they're going to compromise your quality of life, you got to
• 19:00
  know the facts. What's the trade off and are
• 19:04
  there better alternatives? That's what we're here for.
• 19:08
  All right, till next time, team. We'll see you then.