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When Is Castration Worth Doing? · Intellectual Medicine

• 0:00
  Do you really want to stick around for another 12 months
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  feeling horrible, spending your day contemplating your next
• 0:07
  appointment? I don't think so.
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  And you don't want to spend your life wringing your hands every
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  morning getting up saying, oh, I have prostate cancer.
• 0:17
  Whoa, no, we all have a terminal illness called life.
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  I don't want you to die from prostate cancer.
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  I do not want you to foreshorten your life with a heart attack.
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  I don't want you to get a stroke.
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  I don't want you to die from some other form of cancer.
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  What I want is someday at a ripe old age, you just don't wake up
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  and that's it. Well, you know, I've been
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  telling you not to get a biopsy, not to do surgery, not to do
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  radiation. But what if your prostate cancer
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  goes to the bone? What if prostate cancer becomes
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  metastatic? What should you do if your PSA
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  level is rising, but you feel good?
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  We're going to talk about how to manage that phase of your
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  prostate cancer when things aren't going great.
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  In the ideal outcome, the cancer is suppressed.
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  It is contained within the capsule of the gland.
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  Therefore it never effects mortality.
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  You live with it. We don't try to obliterate the
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  cancer. We don't try to eliminate it.
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  We keep it in its home, right there in the gland.
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  But it can progress. Now, unconventional treatment.
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  When the PSA starts to rise, the standard of care generally turns
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  toward androgen deprivation therapy, a euphemism for
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  castration. That's right.
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  No testosterone. Why?
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  It'll lower your PSA. All right, but does that matter?
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  It's a surrogate marker. The PSA does correlate with the
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  prostate cancer progression to a degree, but it doesn't predict
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  an outcome. The PSA level can gradually rise
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  over years. While you feel great, should you
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  allow castration to occur because your doctor is nervous,
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  making you nervous because your PSA just went from 5 to 25?
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  Now, I'm not rooting for it to go up, and I'm not saying we
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  should be passive. I do believe we should be
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  actively engaged. I've shared with you elements of
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  the protocol that I advocate for.
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  But there is a place and a time to consider a form of androgen
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  deprivation, and it's not early in the course of my opinion.
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  Now there was a recent meta analysis.
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  That's when docs look at an array of studies, 26 different
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  studies, and the question yet to be answered.
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  If we're going to castrate a man to prevent death from prostate
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  cancer or symptomatic progression, when should it be
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  done? So there are some studies
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  supporting the concept that if you do it aggressively and
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  early, the potential outcome that is length of life maybe can
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  be extended. Maybe.
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  We're talking months, people, not years in most cases, right?
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  At what price? When you get castrated, you will
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  lose a vast reserve of your masculinity.
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  Now, I'm not just talking about erection, sex drive.
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  That's important for many men, but it's not the only element
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  that is lost. Brain gets weak, cognition
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  diminishes, dementia goes up. The risk of falling goes up.
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  Bone fractures, gynecomastia, man boobs.
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  Not too many people are advocating for that.
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  The risk of heart disease goes up.
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  It is a toxic, harmful, and dangerous treatment to undergo.
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  Now, despite its toxicity, despite its risk, there's a time
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  and a place that I believe it has merit.
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  I'm going to share that with you.
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  And the time and the place is not because your PSA is rising.
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  So I had a gentleman in my practice, his history of
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  prostate cancer being supportively cared for for over
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  30 years, staying in the box. Then it started to go up.
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  PSA starts to go up, went up from 30 to 7070 to 90.
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  And his doctors, his other doctors were having kittens.
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  Got to got to castrate this guy. He went three years like that,
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  feeling great, going to work every day.
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  When do we consider it? So in my approach, what I'm
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  advocating for is let symptoms drive the train, not your PSA.
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  If your PSA goes up and you feel great, you're not having any
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  symptoms of metastatic spread of prostate cancer, you can safely
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  defer therapy. Now, Why would you do that?
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  Why not get started early? Can I prevent bad outcomes?
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  The evidence about its value when started early is not
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  strong. It is ambiguous.
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  It is unclear when there's uncertain benefit but guaranteed
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  harm. You pause.
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  That's my recommendation. You pause because you're going
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  to hurt yourself. Why when there's no proof of
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  benefit at the back end? The time to do this, if you're
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  going to do it, is when symptoms are present.
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  What kind of symptoms? Prostate cancer, when it moves
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  outside of the gland, most likely goes to the bone, and
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  that will often herald itself with bone pain.
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  So if there's bone pain, turns out to be prostate cancer, now's
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  the time. Another consideration, local
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  progression, where you can no longer pee because a prostate is
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  now so enlarged with tumor that it's obstructing urine flow.
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  There's another symptomatic end point.
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  On occasion, the prostate cancer can metastasize to other organs,
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  liver or perhaps even brain. If it goes to other organs,
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  now's the time. You see what happens, man, when
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  you cut on, when you go on androgen deprivation therapy,
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  guaranteed it will end up failing at some point.
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  The prostate cancer, not, maybe not sometimes all the time,
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  progresses through androgen deprivation therapy.
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  The term for that is called castration resistant cancer.
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  At that point, there ain't nothing left to treat you with
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  that's reliably effective. Now we're really groping at what
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  to do next. Castration resistant prostate
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  cancer is a prelude to death from prostate cancer.
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  Therefore we avoid castration resistance.
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  So the analogy is like this. You're a Civil War soldier.
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  You're standing behind a Stonewall.
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  You can see the enemy a mile away.
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  Your musket only shoots for 200 yards.
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  You got so much ammunition, but you're nervous.
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  The enemy is coming closer. PSA rising.
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  Stick with me on the analogy here.
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  PSA is rising, enemies coming closer.
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  You start shooting. Bang, bang, bang, bang.
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  It feels good. The enemy hears the gunshot and
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  pauses, but they're not hurt. They still come forward.
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  By the time they're at the Stonewall, you're out of ammo.
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  That's a bad place to be because androgen deprivation therapy.
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  Always evolves into castration resistance.
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  My my approach is to delay, delay, delay, delay.
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  Then you can get years of good living, years of preserving the
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  merit, if you will, of androgen deprivation therapy.
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  Now when it's administered, this is another area of uncertainty.
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  In most cases, it is continually administered to lower the PSA,
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  to lower the testosterone. That's considered success.
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  Changing a number is not a goal worthy of sacrificing vitality
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  for. Therefore the success I look for
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  reversal of symptom. I had bone pain, it's gone.
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  I couldn't pee, I'm peeing, my liver functions were off the
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  wall. They're back to normal.
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  That is a tangible effect. When that occurs, the standard
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  of care in most cases is to continue androgen deprivation
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  therapy in an uninterrupted manner until the PSA starts to
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  rise and then declare it resistant.
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  Many conventional doctors, and this is something I advocate,
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  are now doing it intermittently. So you do androgen deprivation.
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  There are a host of drugs. We'll we'll get into those in
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  future podcast. There are different generations
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  of them. You want the one that is most
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  gentle and yes, they're out there.
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  Anyhow, you do the androgen deprivation therapy until you're
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  you're feeling better. Symptoms are under control.
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  The PSA, yes, we track it. Yes, it should go down.
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  Testosterone level goes down, but but then you stop.
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  You stop androgen deprivation. Why?
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  Because the theory. The hypothesis is by doing it
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  intermittently, we can utilize it for a longer period of time,
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  preventing resistance and allowing revitalization so that
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  you get a restoration of your vitality, a restoration of your
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  health. The gentleman I'm working with
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  went to a conventional doc at one point.
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  Prostate cancer metastatic. They put him on aggressive.
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  Often times the conventional doctors do this.
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  They'll put them on triple therapy, multiple androgen
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  deprivation, blocking drugs, sometimes even combining it with
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  radiation or chemo. Awful side effects.
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  He could not work. If he doesn't work, he doesn't
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  pay for his food and shelter. Now we're talking real life
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  consequence. So he stops all of that and goes
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  back to work, gets his energy back, feeling good, feeling
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  good. Sometime later, symptoms start
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  to creep back up. Now you can cycle, keep
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  vitality, keep working, cycle the therapy.
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  And here's the next leap we're now looking into.
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  By we, I mean some researchers in the prostate cancer field at
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  Johns Hopkins, they have pioneered some research for
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  castration resistant cancer. They're now using testosterone
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  therapy to try to treat castration resistance cancer.
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  Now that sounds weird, right? You've, you've all been taught
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  or many of us and many of you believe that giving testosterone
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  to a man with prostate cancer is pouring gas on the fire.
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  All right. That presumption is being
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  challenged by newer clinical experience and research
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  evidence. In the Hopkins studies, they
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  looked at men who had castration and then the PSA started to
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  rise. So they put him on a high dose
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  testosterone intermittently crashing the T level.
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  So high dose testosterone, Wham, it goes down.
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  It turns out prostate cancer cells don't like that.
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  They end up having their DNA ruptured.
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  It can potentially kill some of them.
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  And in the Hopkins studies, they found many of the men in the
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  study group had the PSA level go down and had the cancers once
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  more become sensitive toward androgen deprivation therapy.
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  Well, that's kind of cool. Now take it a step further.
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  That is in a research protocol. And here's a problem with
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  research protocols. I like research.
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  I read it all the time. I published some papers myself.
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  It's hard to do good research. But the research never gives us
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  the information we really, really, really want to know.
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  It gives us some data. And ultimately, gentlemen, it
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  comes down to you, your doctor, your philosophy to take that
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  data and turn it into an action plan.
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  I've read lots of studies. Here's something I have never
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  seen in the conclusion of any study.
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  This study wraps up all data there is to know about this
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  particular topic. This study can be considered
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  definitive to the point where no further study is needed, right?
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  That'll never happen. The conclusions are always the
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  same. Well, you know, this information
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  is compelling. We call for more studies.
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  Of course you do, and that's not wrong.
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  The point is that you can't lean on them when you have to make
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  decisions. Today, we us.
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  So what do we do with this information?
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  Castration is horrible. It weakens me.
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  But I have metastatic disease. My PSA is rising.
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  What am I going to do? I'm in the box applying the
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  information at hand in a revolutionary way to look at
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  altering outcomes. What I've done in that setting
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  in some cases is preempt resistance with applying the
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  bipolar principles to men prior to castration resistance.
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  In other words, metastatic disease occurs.
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  It's in the bone. Androgen deprivation therapy,
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  gentleman, is OK, in fact important, in fact helpful in
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  that setting. In that setting alone, in my
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  opinion, you don't do it just because your PSA number changed.
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  You wait because the outcome studies validating or at least
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  do not demonstrate a reduction in your risk of death if you
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  start early with these treatments.
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  That's unclear. So you wait.
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  Then you start androgen deprivation.
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  But you plan on doing it intermittently, right?
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  If you're in the midst of a treatment right now with your
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  oncologist or your urologist, ask him about taking a break.
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  Hey, doc, what do you think about this concept of
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  intermittent androgen deprivation?
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  I want to avoid castration resistance.
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  They may well be on board with that because it's in the
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  literature. The next step though, is how
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  about, how about if you're that man with bone metastatic
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  disease, Step 1, you must control the bone Mets.
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  You cannot do testosterone therapy with active bone
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  metastatic disease. That's clear.
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  So step one, control the disease, androgen deprivation.
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  But how about now that it's under control, could you add
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  testosterone in the bipolar manner that they're doing for
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  men with resistant castration, resistant cancer?
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  Would that potentially extend the duration of benefit, extend
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  the effectiveness of the castration therapy, and at the
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  same time mitigate the negative consequence by restoring
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  periodically, restoring the testosterone, getting a burst of
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  energy, a burst of muscle vitality?
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  Could we achieve a better quality of life at the same time
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  we're extending lifespan? That's kind of exciting to
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  contemplate. And I think that there's enough
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  data, enough evidence to consider this approach.
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  But you've got to be eyes wide open, guys.
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  This is a challenging arena. No matter what you do, death
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  from prostate cancer may occur. Ultimately, you have to be
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  comfortable with the path you're walking because nobody's got a
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  guarantee. I never want to see people have
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  a retrospective regret looking back the consequences.
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  I should have done X instead of Y.
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  Don't do that to yourself. Look, if you had your prostate
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  removed and you have metastatic disease, do not lament your
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  decision. It was the best you could make
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  at the time. If you choose to pursue the
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  protocol I'm advocating and your disease progresses, you can't
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  look back with regret. You have to look forward with
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  optimism, living well, accepting decisions in the moment.
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  You have to make them and then take your hand off the wheel.
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  I've seen some men so overwhelmed by their diagnosis,
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  it's treatment and the Blizzard of information that's available.
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  Consume their days. Google searching, Consume their
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  days. Worrying getting APSA every
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  week, every month. Look, it wasn't my PSA.
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  Back off. Don't let the cancer win by
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  sucking the vitality out of you. You have relationships, you have
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  things you like to do. Stay connected.
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  Work with a provider you have confidence in.
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  If it's me, if you're my protocol, good, I'm happy.
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  If it's not, and there's another lots of good docs out there, you
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  got to make a choice about the path you're on.
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  Make periodic, reflective moments to study and contemplate
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  what to do next. And then forget about it, right?
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  Go out and live your life. Why?
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  Because you're probably going to live a long time and you don't
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  want to spend your life wringing your hands every morning getting
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  up saying, oh, I have prostate cancer.
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  Whoa, no, we all have a terminal illness called life.
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  I don't want to be trite. You guys are different.
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  You have cancer. I get it.
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  But remember, you're more likely to die from other forms of
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  cancer, heart disease, stroke, perhaps even pneumonia.
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  More likely to die from those consequences than the prostate
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  cancer itself. Now we want it all.
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  I want it all for you. I don't want you to die from
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  prostate cancer. I do not want you to foreshorten
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  your life with a heart attack. I don't want you to get a
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  stroke. I don't want you to die from
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  some other form of cancer. What I want is someday you just
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  don't wake up. Someday you go to bed with a
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  chest cold and that's it. At a ripe old age with prostate
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  cancer buried in your gland while you lived.
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  Vitally, that's the key. Another 12 months, another 14
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  months on balance, I'd say I would take that, but it's never
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  on balance. These treatments, they sometimes
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  correlate with extending lifespan.
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  You got to look beyond the headline and look at the
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  quality. Do you really want to stick
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  around for another 12 months, feeling horrible, spending your
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  day contemplating your next appointment?
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  I don't think so. Well, maybe you do.
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  That's your that's your prerogative.
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  Anyhow, castration therapy has a niche.
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  I advocate for it only in my view, in my approach, when the
• 19:02
  disease has extended and is causing symptoms in the bone, in
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  the organs, or in the capacity for urine flow.
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  Treating a number with a toxic therapy may well be more harm
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  than benefit. Whenever there's a guaranteed
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  harm and an ambiguous potential benefit, you avoid the harm.
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  All right, well, I hope this helps a little bit guys.
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  I know it's complicated. I know you're thinking about
• 19:30
  your prostate cancer and wondering what to do, What will
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  come next. I hope you take some reassurance
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  with the knowledge that it is safe to wait for a metastatic
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  moment to occur. With the advances in late stage
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  disease treatment, that may well be your best approach to enjoy
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  life out the fullest and to make these treatments more effective
• 19:56
  when you need them. All right, until next time guys,
• 19:59
  gals, everybody, thanks for spending time with me.
• 20:01
  Talk to you then.