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Rethinking Prostate Cancer Care: Is Active Surveillance Enough? · Intellectual Medicine

• 0:00
  So you've been diagnosed with prostate cancer and your doctor,
• 0:03
  urologist, is recommending watchful waiting or something
• 0:07
  called active surveillance. What exactly is that?
• 0:11
  Does it have any value? Should you embrace it or is
• 0:14
  there a better way? Here's the dilemma.
• 0:20
  Doctors, urologists, the medical profession, they don't know what
• 0:25
  to do with prostate cancer. They are befuddled.
• 0:28
  The standard of care, ripping off prostate glands, irradiating
• 0:31
  them, has been colossally disappointing, guaranteed to
• 0:37
  cause harm with unclear benefit. And it cannot cure cancer.
• 0:41
  I don't care what they tell you. It is not curative.
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  It is hopeful. Maybe it won't die.
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  But the research shows really otherwise.
• 0:50
  But let's go back to this dilemma you're in if you've been
• 0:53
  diagnosed with prostate cancer or if you're ever in this
• 0:55
  position. If you have an elevated PSA,
• 0:58
  first, don't let them biopsy you.
• 1:00
  Listen to my podcast. Then make your best decision
• 1:04
  now. If you've already had a biopsy,
• 1:06
  right? Hope is not lost.
• 1:09
  Watch while waiting. What does that mean?
• 1:11
  You have an elevated PSA, you get a biopsy.
• 1:14
  It shows prostate cancer. However the level of cancer is
• 1:18
  considered to be not that aggressive.
• 1:21
  It's considered to be perhaps perhaps indolent, slow growing,
• 1:26
  if you will. Furthermore, the doctor may
• 1:29
  conclude they don't tell you this, by the way.
• 1:32
  He may look at you and size up. You know, this guy probably
• 1:36
  doesn't have five years to live. He's got chronic lung disease.
• 1:40
  He's had a heart attack. He's had, you know, he's 78
• 1:42
  years old. I don't know.
• 1:44
  They're making these judgments on your behalf silently.
• 1:47
  So watchful waiting sometimes is based upon your likelihood of
• 1:52
  death through other means. Other times it's based upon the
• 1:55
  likelihood of harm through surgery in the absence of proven
• 2:00
  benefit. So watchful waiting is a fancy
• 2:03
  way of saying let's do nothing. That's awful, and it is
• 2:08
  illogical and it defies biological principles.
• 2:12
  When you're faced with that circumstance and the doctor sits
• 2:15
  you down and says you've got three options.
• 2:19
  We can take out your prostate gland.
• 2:21
  No way. That's awful.
• 2:23
  OK, We can irradiate your prostate.
• 2:25
  That's awful. Expose me to Hiroshima and see
• 2:28
  what happens. No thanks.
• 2:31
  Or we can do nothing. Well, doing nothing is
• 2:36
  uncomfortable, and it's difficult for doctors to bill a
• 2:39
  code for nothing. So we have watchful waiting, a
• 2:43
  reimbursable sort of mental delay.
• 2:47
  The watchful waiting is just that.
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  We're going to wait. We're going to wait, and we're
• 2:52
  going to see if the cancer spreads.
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  Yikes. Look, I don't mind being
• 2:58
  conservative in an active way. We'll talk about that.
• 3:02
  My protocol supports intervention that enhances your
• 3:07
  health, that enhances your immune function, that supports
• 3:10
  your body's fight against cancer.
• 3:12
  But the moment at hand now is how do you deal with this
• 3:15
  watchful waiting nonsense? Well, one of the things that I
• 3:19
  advocate is looking at all the pathways.
• 3:23
  Hey, the good thing about watchful waiting is at least
• 3:25
  they haven't harmed you, right? Let's not forget that's the
• 3:29
  golden rule of medicine, isn't it?
• 3:32
  First, do no harm. There's another element to that
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  quote that is so famous, though. If you cannot do good, then do
• 3:40
  no harm. If you can do good, well, it's
• 3:45
  unethical not to take an action. So I guess on that level,
• 3:49
  knowing that there are things that we can do that alter your
• 3:52
  likelihood of dying from metastatic prostate cancer, that
• 3:56
  can alter your health. If we know those things exist
• 4:00
  and we fail to do them, perhaps it's a bit of an ethical lapse
• 4:04
  on our part, right? Well, that's why we do this
• 4:06
  podcast. So watchful waiting.
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  Do nothing. At least they're not ripping
• 4:11
  your gland out and causing you harm.
• 4:12
  But psychologically, that's a tough spot to live in.
• 4:15
  It's a tough spot, Doc. You mean I have cancer?
• 4:19
  Yes, Sir. You have cancer cells in your
• 4:21
  gland. You have cancer, and you're
• 4:24
  going to do nothing. You're going to do nothing.
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  Think about it, folks. What if a cancer is dealt with
• 4:30
  in that manner? I'm sorry, Missus Smith, you
• 4:34
  have breast cancer. But, you know, we just kind of
• 4:36
  wait and see what it does. Or, Mr. Jones, you've got colon
• 4:40
  cancer. Let's kind of lay back, see what
• 4:42
  it does. Like, please, Prostate is
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  unique. I get it.
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  But this idea of doing nothing? No.
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  Mock me absent. Look, I'm an activist when it
• 4:54
  comes to my health. I want you to be an activist.
• 4:57
  Now, when it comes to your health, remember this.
• 5:00
  You do not have health insurance.
• 5:02
  You do not. You have sick intervention
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  insurance. If you want health, you have to
• 5:08
  pay for it. Pay for it with your energy, pay
• 5:12
  for it with your actions, pay for it with your money.
• 5:15
  Where are you going to spend that money?
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  Where is your ROI, return on investment with regard to your
• 5:21
  health? Well, we go through those
• 5:23
  details. They're all my forthcoming book.
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  I promise the book's coming. It's nights and weekends we're
• 5:28
  knocking it out. But this watchful waiting,
• 5:31
  right? I, I have concerns about it
• 5:35
  being way too passive. Now.
• 5:37
  Look, it's not the job of your urologist to know everything
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  about health and vitality. God bless them.
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  They're busy taking care of kidney stones and doing what
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  they do right? You want that knowledge you have
• 5:50
  to acquire for another source. Ideally, it's coming from your
• 5:54
  primary care doctor. I advocate for you to get a
• 5:57
  primary care Doctor Who is not employed by a hospital or
• 6:02
  vertically integrated group. Why do I say that?
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  They have a lot more freedom to render an opinion.
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  Look, if I'm being employed by Hospital Inc and Hospital Inc
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  has a cadre of urologist, and Hospital Inc just spent millions
• 6:18
  of dollars on that new Da Vinci robot, do you think they're
• 6:22
  excited? When I'm counseling patients to
• 6:25
  not get biopsies, I'm likely to get reprimanded by my boss.
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  The independent primary care doctor doesn't have so much of
• 6:33
  that inhibition. And the supreme form of an
• 6:36
  independent family doctor. OK, since you ask my opinion,
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  I'm an osteopathic family doctor.
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  I have a bias in favor of osteopathic family doctors.
• 6:44
  Why? Because we're focused on the
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  body healing itself. I like that.
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  Now, some of my allopathic colleagues, the MD's if you
• 6:51
  will, are equally focused and I applaud that.
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  The very best of them, in my opinion, don't take insurance.
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  They are free to spend more time with you.
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  All right, enough of that soapbox.
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  By the way, there's some other good clinicians out there.
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  I love the nurse practitioners, love their philosophy.
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  By and large a lot more open minded, by and large a lot less
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  rigid, and by and large they haven't been bought and paid
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  for. Look at these journals, folks,
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  urological journals. Who pays for them?
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  Those ads from the drug companies, That's what pays for
• 7:29
  them. Look, it's not that the medical
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  system is corrupt in the sense of Al Capone corrupt.
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  It's that they've been powerfully influenced by big
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  money and the big money drives and colors recommendations.
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  Trust me on that. It's human nature.
• 7:51
  We, Shannon and I, bring this to you out of our own sweat, out of
• 7:56
  our own capital. Why?
• 7:59
  Because we have tried desperately to get sponsors and
• 8:01
  to be brought off, but it's just not happening.
• 8:04
  Oh, really? Really.
• 8:05
  It doesn't seem like anybody wants to pay us anything.
• 8:08
  That's OK. We like our independence.
• 8:11
  But that is worth scrutinizing. So we talked before.
• 8:16
  Ask your doctors. Ask your doctors.
• 8:18
  Do you get paid? Have you received consideration
• 8:21
  from pharmaceutical companies? This is the the standard of
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  care. Prostate biopsies right from the
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  1980s. Good Lord.
• 8:30
  That was 50 freaking years ago. You mean to tell me we haven't
• 8:34
  gotten to a better place? All right, so watchful waiting.
• 8:37
  At least they're not harming you.
• 8:38
  How about active surveillance? I hate this.
• 8:42
  Wait a minute. Let me not be so abrupt.
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  I think actor surveillance is a suboptimal means of assessing
• 8:48
  your condition. Why do I say that?
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  We know you have cancer. The biopsy is in.
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  The results are in. Now let's move past that.
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  The idea that you can periodically biopsy the gland to
• 9:04
  make a judgement about its future behavior or to guide
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  decisions about how to manage it in the moment is wishful
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  thinking. I do a biopsy month one.
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  It shows an early stage cancer. Now remember folks, the much
• 9:25
  ballyhooed Gleason score is nothing more than a doc looking
• 9:31
  through a microscope and describing what he sees or she
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  sees. It's a description of what the
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  cells look like. It is not rocket hard, fast,
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  objective. Different urologists or
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  different pathologists can come up with different scores on the
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  same specimen. The part of the cells are
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  looking at it just describing cellular anatomy.
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  Saying that it is aggressive or not aggressive is ascribing an
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  animated feature to a stagnant fact.
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  Here's an analogy, And we're talking about Gleason scores and
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  about this this guesswork about what happens next, right?
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  If a tank is sitting there pointing at you, is it
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  aggressive or not? Well, it's a tank.
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  It could be harmful. But suppose nobody's in it.
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  Suppose there's no ammo. There's a difference between a
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  tank that's sitting there and one that's in motion.
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  The motion part of the prostate health requires sequential
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  assessments, looking at a biomarker from day one, day 90,
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  day 120, looking at an MRI at the base and subsequently.
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  Those are objective markers that can tell us change, and change
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  can predict trajectory. A single biopsy doesn't do it.
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  Well, then why not get sequential biopsies?
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  Because they're harmful, because they're disruptive, because they
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  have a potential for metastatic spread, because they do not lend
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  significant discretion to help decide how to treat this
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  disease, this entity, this condition.
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  You do a biopsy month one and say, well, we're just going to
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  kind of watch it. We'll do another biopsy in three
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  months. OK, that's kind of arbitrary.
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  Suppose a biopsy in three months looks the same.
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  Suppose it changes. How do you know if cancer cells
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  are leaving the gland? What are you doing about the
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  condition? How are you acting to prevent
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  these cells from affecting your life quality or lifespan?
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  Biopsying does not cure nor heal nor help anything that causes
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  harm. The idea of active surveillance,
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  the activity biopsies is harmful.
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  The surveillance, the notion of surveillance sounds comforting,
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  but it is arbitrary. I advocate for non biopsy
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  monitoring. The biometrics biomarkers
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  combined with MRI can give you all the information you need.
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  Take an action that is non surgical.
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  Take an action that is non radio graphic.
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  To get this pathway of care, often times, perhaps all the
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  time, you need to step outside of the realm of urological
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  treatment. What they do, they do well, but
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  what they do may not help you when it comes to your condition
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  and the outcome. If a doctor tells you you have
• 12:49
  to get a biopsy, that is a patently false statement.
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  It's optional now, remember, you'll have to be an advocate
• 12:57
  for your own health. That forceful opinion can really
• 13:02
  affect your resolve. Men, we have to stick together.
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  We have to decide for ourselves. How do we want our health to be
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  managed? Because it is a prevailing
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  standard doesn't mean it's the right decision for you.
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  Individuals get to have their say.
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  Watchful waiting, active surveillance, comforting
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  language in the presence of stagnant non active
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  intervention. There are things you can do that
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  are beyond it. I love the idea of non biopsy
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  monitoring. MRI of the prostate came out
• 13:43
  roughly say 2012 2015. This is fabulous.
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  We can look at the anatomy of your prostate gland without
• 13:50
  sticking needles in it. No harm.
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  I prefer it without contrast. If your insurance company will
• 13:57
  not pay for this study, it's only about 800 bucks.
• 14:00
  You could probably negotiate a lower price.
• 14:03
  Typically get a cash discount. You have to ask for it.
• 14:06
  You can shop around. Look, if you're spending the
• 14:09
  money, you do not need authorization from your
• 14:11
  insurance company. Can we please stop relying on
• 14:15
  the insurance companies to keep us healthy?
• 14:18
  They're not going to do that. That's your job.
• 14:21
  That's my job. Let's talk about that like we
• 14:24
  are. Where should you spend your
• 14:26
  dollars, right? Be careful out there.
• 14:29
  There are a lot of black holes that are hollow.
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  You want to spend your dollar on health.
• 14:35
  You want to spend your money on keeping yourself in a cancer
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  resilient environment. Percent body fat folks, fat
• 14:44
  cells stimulate cancer. Period.
• 14:48
  What else is cheap and and can address help?
• 14:52
  There's a correlation between excess fat cells and low vitamin
• 14:56
  D, and there's a correlation between low vitamin D and
• 15:01
  increased malignancy rates. In fact, some studies have
• 15:05
  extrapolated that if your vitamin D level is above 50, it
• 15:10
  correlates with less risk of cancer, less risk of viral
• 15:13
  infection. Hey, these are cheap and easy
• 15:15
  things doc. Please test my vitamin D level.
• 15:20
  If it's above 30, the doctor's likely to say that's fine.
• 15:23
  Which, in fact is pretty decent number.
• 15:26
  It'll protect your bones. If it's below 30, everybody's on
• 15:29
  board that it should be higher. But how about going above 50?
• 15:32
  Yeah, aim for that. My advice?
• 15:34
  Keep it between 50 and 100%. Body fat men, I advocate 20% or
• 15:40
  less. You do those two things, you are
• 15:43
  creating an environment that's inhospitable for cancer cells.
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  Now we're getting past passive, watchful waiting.
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  Now we're making changes that are affordable, inexpensive, and
• 15:57
  globally beneficial. You control percent body fat,
• 16:01
  you modify vitamin D level. Wow.
• 16:04
  They're two cheap things that lower global risk of death.
• 16:07
  Yeah, sign me up for that. By the way, with vitamin D, make
• 16:11
  sure you're taking vitamin K along with it.
• 16:14
  D + K Your doctor should know this, and if they don't, find
• 16:18
  somebody who does. Or continue following this
• 16:21
  podcast for more helpful tips. In my practice, vitamin D, we
• 16:28
  advocate 5000 units per day across the board.
• 16:32
  Vitamin K2 between 203 hundred microgram per day, safe dosing.
• 16:38
  I've never seen anybody taking 5000 units of vitamin D every
• 16:42
  day with a level that is too high.
• 16:44
  Just never seen it. So there are a couple basic
• 16:47
  things. Now, when it comes to the
• 16:49
  watchful waiting and it comes to the act of surveillance, there's
• 16:53
  a third pathway. It's my protocol.
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  It's the pathway of non biopsy monitoring.
• 17:01
  It's a pathway of nutraceuticals to support immune health, to
• 17:07
  create an inhospitable environment.
• 17:10
  These things are not coming to you from big pharma anytime
• 17:13
  soon. They're generic.
• 17:17
  They are natural substances. You cannot patent a natural
• 17:22
  substance, therefore natural substances will never get FDA
• 17:27
  approved for anything. It doesn't mean they lack merit,
• 17:31
  it just means they lack financial viability.
• 17:35
  If you choose to do watchful waiting with your urologist,
• 17:39
  it's not the wrong decision. And if you choose to do
• 17:42
  sequential biopsies, and that's not the wrong decision so long
• 17:47
  as you make it and you're fully informed, that's my advocacy.
• 17:53
  Nowadays, folks, you have the Internet, you can go to pub Med,
• 17:59
  you can Google everything I say. You can AI, it isn't this great.
• 18:05
  You can acquire knowledge that is close to the level of your
• 18:09
  dock. And that folks, is power and
• 18:13
  that folks, is you commanding how you want to live.
• 18:17
  Your doctor now should be a collaborative entity like me.
• 18:21
  Like this podcast, right? It's a piece of information.
• 18:25
  It's a different world. Doctors in general and
• 18:28
  specialist in particular are not horribly comfortable in that
• 18:32
  space. They can remember, you know, the
• 18:34
  good old days when you had no knowledge other than we, we
• 18:38
  decided to share with you. So you had to follow the bread
• 18:42
  crumbs along the path that we laid out.
• 18:45
  I get it. There is psychological comfort
• 18:49
  in clinging to a standard that is hardly endorsed by the wide
• 18:54
  majority of specialists in the field.
• 18:57
  There's a psychological comfort, and it is desperately sometimes
• 19:01
  uncomfortable to step out of that stream.
• 19:05
  But if you want a different kind of a life, if you want a higher
• 19:07
  degree of vitality, the option is there for you to embrace.
• 19:12
  But you have to be the one to advocate for it.
• 19:14
  Watchful waiting. Hey, it's better than traumatic
• 19:16
  intervention, active surveillance.
• 19:20
  OK, apply it without the biopsy. I'm on board with that part.
• 19:26
  MRI, the biomarkers, they are better than ever.
• 19:32
  Which ones matter the most? Well, perhaps we'll talk about
• 19:35
  that in a podcast to come. The most important thing with
• 19:38
  biomarkers is consistency. So you're comparing apples to
• 19:41
  apples? Well, folks, that's all I got
• 19:44
  for the moment. I hope this has been helpful.
• 19:47
  My big message is be prepared before you step into the
• 19:50
  doctor's office. Be prepared if you're a man and
• 19:54
  they're contemplating doing APSA, be prepared to have this
• 19:58
  interpreted rationally. Be prepared if you've had a
• 20:02
  biopsy for them to tell you it's cancer so that you keep your
• 20:07
  balance and you take your time. And you take that vacation to
• 20:11
  Aruba and you sit on the beach and you sip A daiquiri, and you
• 20:16
  contemplate what to do next. Better use of your money than
• 20:20
  getting biopsies. All right, until next time,
• 20:23
  we'll talk to you later. Thanks for watching.