Crila, A Solution to Old Men’s Urinary Problems?

BY MARK SCHOLZ, MD

As we get older, we run into all kinds of difficulties.  Poor hearing, sexual dysfunction, memory problems and arthritic joints, just to name a few. Bladder issues in particular can be troublesome, interrupting sleep, making us dread long drives or forcing us to visit the bathroom at an inopportune time.

As a prostate oncologist taking care of many men who are in their 60s and 70s, it’s no surprise that I hear a lot about urinary difficulties. These problems are often thought to result from prostate enlargement, otherwise known as BPH. The swollen gland ends up pinching the urinary passage way (called the urethra).  Slow urination and incomplete emptying of the bladder are the result. 

Prostate gland enlargement with incomplete bladder emptying can frequently be solved with common prescription medications like Flomax, Rapaflo and Uroxatrol which relax the muscles in the wall of the urethra and help to open up the passageway.  Proscar and Avodart can shrink the prostate but they also tend to shrink your libido. The most popular treatment is a nonprescription— Saw Palmetto an herbal product that works by relaxing the muscles in the urethra.

However, after doing thousands of color Doppler ultrasound examinations, which by the way is the most precise way to measure the size of the prostate, I have learned that BPH is a less common cause of men’s urinary problems. So what is the primary reason for men’s urinary frustrations? Prostatitis—low grade inflammation of the gland with secondary irritation. What causes prostatitis?  In a minority of cases it is due to bacterial infection. When this type of prostatitis occurs it may improve with antibiotics. But for the vast majority of cases we simply don’t know the cause.  Virus or autoimmune causes have been theorized but nothing has been proven. Our ignorance, however, has nothing to do with its prevalence. It is not widely realized, but almost all men have some degree of chronic inflammation in their prostate glands.

Though we don’t know the precise etiology, anti-inflammatory medications can be quite effective at alleviating the symptoms of prostatitis. Over the counter products like Aleve and Motrin are effective. Celebrex, is a prescription anti-inflammatory agent that is billed as having less stomach irritation. However, unless the pills are used continuously, the inflammation comes back.

Recently, I have been introduced to a natural anti-inflammatory substance discovered in the flower of the Crila plant. Several of our patients tried Crila with notable improvement to their urinary symptoms. So far we have not observed any side effects.  To investigate Crila’s effectiveness further, I have petitioned the manufacturer to provide a 3-month supply of Crila to 15 of our patients at no cost. Patients who have problems with frequent urination, a strong sense of urinary urgency or have to get up frequently at night to urinate may want to consider contacting Sabrina, from Prostate Oncology, about their eligibility for participating in this clinical trial. 

Article originally posted January 26, 2016, on Prostate Snatchers: The Blog, by Mark Scholz, MD


A board-certified medical oncologist, Mark C. Scholz, MD, serves as medical director of Prostate Oncology Specialists Inc. in Marina del Rey, CA, a medical practice exclusively focused on prostate cancer. He is also the Executive Director of the Prostate Cancer Research Institute. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is the co-author of the book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Potency.  He is a strong advocate for patient empowerment.

Androgen Deprivation Therapy for Prostate Cancer Causes Alzheimer’s Disease?

A blog from our Executive Director, Mark Scholz, MD


Dr.Kevin Nead authored an article published in the Journal of Clinical Oncology this month.  It created a media sensation and generated multiple calls to the PCRIHelpline.  Last week, three separate articles about this topic were posted on the Yahoo home page at the same time.

It’s no surprise that an article on this topic generates wide-spread interest. About 500,000 thousand men in the United States are undergoing prostate cancer treatment with androgen deprivation therapy (ADT). This treatment works by blocking the male hormone levels delivering notable anticancer efficacy and also proven to prolong life in men with prostate cancer. Despite it’s known effectiveness, a variety of side effects can occur, including memory problems.  The previously reported studies evaluating this phenomenon seem to indicate that when memory deficits occur, they usually reverse after ADT is stopped.
The research published in the Journal of Clinical Oncology, relied on a new method of searching through patient’s medical charts with computers.  No human review of these medical charts were performed. The computer software searched the medical records in an attempt to determine if men on ADT had a higher incidence of Alzheimer’s. The authors report that this new computer searching methodology in detecting a specific medical diagnosis is 74% accurate.

Review of all the charts at Stanford and Mount Sinai hospital unearthed 16,888 prostate cancer patients of which 2,397 were treated with ADT.  After the fancy computer analysis, designed to compensate for multiple factors such as patient age and underlying heart disease (both of which lead to Alzheimer’s more frequently), the conclusion was that the ADT-treated men were twice as likely to have developed Alzheimer’s. A total of about 9 cases would have been expected from normal causes, but 18 were actually detected.  If these conclusions are accepted as gospel truth, an additional 9 out of 2,397 men treated with ADT would equate to an increased risk of less than half of 1%.

The conclusion that there is tiny increase risk of Alzheimer’s with ADT, needs to be put in context based on what we already know about prostate cancer. First, is it possible that these men have reversible memory problems while still taking ADT? There was no attempt in the study made to determine if the “Alzheimer’s” patients were still on ADT when the diagnosis of Alzheimer’s was made. Second, men treated with ADT are substantially sicker than men who don’t need ADT.  There is no way for the computer analysis to compensate for how this may have impacted mental performance. Third, patients getting ADT receive closer medical surveillance and visit physicians more frequently than men who are not receiving ADT.  As such, memory problems are more likely to come to medical attention and be diagnosed when men are on ADT.  Fourth, general anesthesia (from surgery) is known to cause long-term memory problems.  This study did not perform any analysis to determine if surgery was performed with equal frequency in both groups.

In summary, it is not clear from this JCO article whether the men labeled having Alzheimer’s disease had memory problems while still receiving ADT or whether they had true Alzheimer’s, i.e., long-term irreversible memory problems continuing after the ADT was stopped. There is one thing, however, this study does show: At worst, memory problems serious enough to be labeled as “Alzheimer’s” occur in in less than one out of every 200 men treated with ADT.

Article originally posted December 15, 2015, on Prostate Snatchers: The Blog, by Mark Scholz, MD


A board-certified medical oncologist, Mark C. Scholz, MD, serves as medical director of Prostate Oncology Specialists Inc. in Marina del Rey, CA, a medical practice exclusively focused on prostate cancer. He is also the Executive Director of the Prostate Cancer Research Institute. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is the co-author of the book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Potency.  He is a strong advocate for patient empowerment.

For the Loved Ones of Prostate Cancer Patients

Transcript: 

"This video is intended for the wives, husbands, partners and loved ones of men who may be at risk of having prostate cancer or who have been diagnosed with the cancer. Our aim is to help you help him navigate through what can be a complicated, confusing and anxiety ridden time.

First and foremost... don’t panic! And help him not to panic. The word cancer is scary and the immediate impulse for so many men is to rush to some sort of radical treatment to just get it out of their body. Help him to calm down and slow down. 

Here are some points to remember

80% of men who get high numbers on their PSA test do not have cancer. 80% do not!
Of those who do the vast majority have a form of the cancer that is so slow growing that it hardly deserves to be called cancer.
Related to that is this truism that “most men die with prostate not from prostate cancer”
For those who do have the more aggressive cancer there are an ever growing number of options for treatment. The chances that he will live a full and productive life get better every year

First  help him get the screening right. This is really important. Things are changing in big ways in this area. Let’s say he’s had a high PSA number. Up until recently the typical next step would be a referral to a Urologist who would order a random needle biopsy. That entails removing 12 cores from the prostate with a hollow needle. There’s a real problem here. An estimated 80% of men get biopsies that they don’t need! 3% of those suffer infections serious enough to require hospitalization not to mention other side effects like erectile dysfunction. And one more thing... random needle biopsies are not terribly accurate. They can miss serious cancers.
 
Like I said,  things have changed and nobody needs to be railroaded into the random needle biopsy. If he has a high PSA number here’s a better course of action:
 
●     First get a second PSA test. Labs can make mistakes and PSA can be elevated for reasons other than cancer… things like sexual activity and even riding a bike
●     If the PSA number is still high you have options to see if a biopsy is a good idea:
○     First an MRI. Recent advances in MRI imaging has changed everything. The latest generation of MRI machines called 3 Tesla, or 3T machines enable radiologists to see all but the tiniest tumors. The tumors that they can’t see almost certainly don’t matter. You can find  a list of MRI centers that do “Multi-parametric” testing using a 3T scanner on PCRI.org. Even if you have to travel a bit to get to one, do it. It’s worth it.
○     The second option is a new blood test called the 4K test that can accurately estimate whether he has an aggressive form of the cancer. You can read about the test further at PCRI.org. If the test indicates that you may have an aggressive form of the cancer then you’ll want to move to the MRI.
 
What improvements in MRI imaging mean is that biopsies, when they are needed, can be targeted, right to the suspicious area in the prostate. No more random poking.

Next... help him do research. No matter where he is in the process whether he’s just received his first high PSA number or whether he has been diagnosed with aggressive cancer there are options and you and he need to know what they are.

If he’s diagnosed with prostate cancer he and you are going to have to know more about treatment options than your doctor does. I’m talking about your primary care doctor. Those people are flooded with information and there is no way that they can keep up with it all. They’ve got the whole body to worry about... we’re talking about about one little organ. You’re going to have to educate your doctor and if he or she dosen’t seem like they can be educated... well you might want to start looking for a new doctor. 

A great place to start your research is pcri.org. There is a wealth of information on the site as well as access to a helpline staffed by very knowledgeable people, most of whom are prostate cancer survivors and their relatives,  people who’ve been where you are, people you can talk to.

Next, if he is diagnosed with cancer he might need your help maintaining a medical records folder. Most of us would count on our Doctors to do this but the truth is that when multiple specialists start being part of the picture the amount of information multiplies and the chances of it being scattered and even lost increases. He, with your help, needs to continue to take responsibility here. This folder includes, among other things: 

* A log of all PSA tests
*  A copy of the  urologist or GP’s  notes that give the results of Digital Rectal Exams (DRE).
*  A copy of the Biopsy Pathology Report. 
*  Copies of the radiology reports of any scans (color Doppler ultrasound, bone, CT, MRI), and if available, digital copies of the actual scans.
*  Copies of all information regarding medical history, including any current (unrelated to the prostate cancer) health problems even if they seem minor.
*  A list of all medications and any over-the-counter supplements


Finally, he might need help finding and assembling the right medical team. 

In an ideal world the “coach” of his medical team would be a Prostate Oncologist, a Prostate cancer specialist... a doctor with no particular bias regarding treatment. Unfortunately these doctors are exceedingly rare...probably only 10 or 12 Prostate Oncologists in the whole US!

So, in the real world his Primary Care doc  is almost certainly going to refer him to a Urologist. Now Urologists are surgeons and prostate cancer is the only cancer that the lead doctor is most often a surgeon. So, what could be wrong with that? You’ve heard the saying “when you’re a hammer everything looks like a nail”. Get it? Hammer-nail, Surgeon-surgery. You get it. Be aware, there could be some bias. 

In any case, the coach is probably going to be a urologist so how to pick the right one? 

First let’s look at screening again. If the urologist wants him to go immediately for a random needle biopsy, don’t walk...run! Help him find another doctor. Like I said earlier multiparametric scanning with a 3T MRI scanner is the gold standard. The 4K blood test is also a promising alternative. The random needle biopsy is a thing of the past.

Second, look at the Doctor’s experience. He or she needs to be a prostate specialist. It’s really important. The learning curve for prostate surgery, for example, and should it be required, is really steep. Studies have shown that surgeons need to do 250-300 radical prostatectomies before they reach a plateau when it comes to achieving the the best recovery outcomes in urinary and sexual functions and the eradication of cancer. 

So there it is. You’ve got a job to do. 

You need to not panic and help him not to panic. 
You need to help him become educated and become educated yourself. 
And you need to help him be responsible for his own health care." 

What’s Going On at the Prostate Cancer Research Institute

A blog from our Executive Director, Mark Scholz, MD

In 2016, the PCRI will celebrate its 20th anniversary.  The PCRI, founded in 1996 by Dr. Stephen Strum and I, was originally funded by a generous grant from the Daniel Freeman Medical Foundation.  This initial grant was spent on hiring Harry Pinchot, aka Helpline Harry. The helpline format adopted at the PCRI was modeled after the work of Lloyd Ney, the founder of PAACT.  PCRI’s helpline presently has four counselors: Jonathan Levy, Silvia Cooper, Bob Each and Charles Kokaska, all who provide unbiased prostate-cancer-related information, free of charge to the public.

PCRI started doing patient-focused conferences in 2006. Since 2006 this has become an annual meeting. The conference has grown in stature through the years by attracting world-renowned prostate cancer experts who are invited to present the latest information on optimal diagnosis and therapy. DVDs of the presentations are distributed throughout the world.  Partly due to the wonderful moderating presence of Dr. Mark Moyad, the conference has grown to be the largest patient-orientated prostate cancer conference in the world.

PCRI makes its biggest impact via its online presence by providing articles and blogs authored by prostate cancer experts from every specialty. But more importantly, PCRI is presently in entering into a new phase, the development of the SHADEs of Blue organizational format, a methodology to help patients sort through the overwhelming amount of information by reducing it into a more manageable bite-sized format.  As we all know, the internet has solved the problem of getting access to information.  Now the biggest problem patients face is information overload. How does one sort through the deluge of unfiltered information?

The development of the SHADES of Blue program will address this problem of information overload by segregating prostate cancer information into five large categories. Three are for the newly-diagnosed, Low, Intermediate and High-Risk, and two are for men with either relapsed disease or metastatic, hormone-resistant disease. The SHADES program is a big undertaking for a small organization like the PCRI, especially considering that we have expanded our conference schedule by now doing two conferences annually with the addition of the Mid-Year Update in March.

Looking to the immediate future, I never been more excited by the PCRI’s potential for making a positive impact in the lives of men with prostate cancer.   If my suspicious are correct, PCRI’s visibility is truly on the verge of taking a big jump.


Article originally posted November 17, 2015, on Prostate Snatchers: The Blog, by Mark Scholz, MD


More about Dr. Scholz:

A board-certified medical oncologist, Mark C. Scholz, MD, serves as medical director of Prostate Oncology Specialists Inc. in Marina del Rey, CA, a medical practice exclusively focused on prostate cancer. He is also the Executive Director of the Prostate Cancer Research Institute. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is the co-author of the book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Potency.  He is a strong advocate for patient empowerment.

Sir Spheres for Liver Metastases from Prostate Cancer

BY MARK SCHOLZ, MD

Cancer that spreads outside the prostate gland is what makes prostate cancer dangerous. Metastatic prostate cancer cells cause malfunction by impeding normal function. Some organs, like lymph nodes for example, continue to function quite nicely, even if the degree of cancer spread is extensive.  Lymph node spread, therefore, is the least dangerous form of prostate cancer metastases.  At the other end of the spectrum is the liver, which is far less tolerant.  The seriousness of bonemetastases, the most common site of prostate cancer spread, lies about half way between that of node metastases and liver metastases.


The earliest stages of metastases are microscopic and therefore invisible even with the best available technology. To be detected with the best available PET scan technology, small tumors must measure more than 1/8 of an inch across. For detection with standard CT scans and MRI scans, more than a half-inch sized tumor is necessary. Since the presence of metastases is such a defining issue when describing a cancer’s character, men who are newly-diagnosed are labeled as low, intermediate or high-risk depending on their estimated likelihood of micro-metastatic disease. Liver metastases are extremely rare at the time of initial diagnosis of prostate cancer. When they occur it is usually after many years of ongoing treatment for known metastatic disease in the bone.


Prophylactic treatment with hormone therapy, chemotherapy or radiation to treat the possibility of micro-metastases is common for high-risk prostate cancer and occurs maybe half the time in intermediate-risk prostate cancer. The goal is to cure the micro-metastases at an early stage when they are most susceptible to eradication, thus preventing the future development of detectable metastases which is what makes cancer life threatening.


When talking about prostate cancer, even though this is a blog about metastases, it should always be remembered that many common types of prostate cancer never spread. These low grade “cancers” are genetically distinct and represent a totally different category of disease.  However, when discussing the type of prostate cancer that is capable of metastasis, the following factors impact how dangerous it is:

  1. The site of spread.

  2. The extent of spread

  3. The tumor cell growth rate

  4. The efficacy of available treatment 

As noted above, the liver is far less tolerant to metastatic invasion than bone or lymph nodes.  In addition, because liver metastases tend to occur in men with advanced disease, tumor growth rates tend to be brisk. Also, the most commonly administered treatments, hormone therapies and chemotherapy, have often already been tried before liver metastases first develop. The advent of liver metastases, therefore, usually represents a very serious and life threatening issue.


Liver metastases may first be suspected when standard blood tests such as ALT, AST or ALP which are components of a hepatic panel blood test, register outside the normal range. Investigation into their cause often leads to doing a CT scan or MRI scan of the abdomen and pelvis to confirm the presence of disease in the liver. Alternatively, a scan may detect abnormal spots in the liver during routine periodic scanning that is being performed as regular surveillance.


Hormone therapy with Lupron, Zytiga and Xtandi, or chemotherapy with Taxotere, Jevtana and Carboplatin, is the standard approach to treatment for liver metastasis.  However, these treatments may have already been tried or may no longer be effective.  Since liver failure is tantamount to death, prostate cancer growth in the liver needs to be stopped immediately, regardless of how the disease is faring in the bones or nodes.


Much that has been learned about the treatment of liver metastases comes from reviewing common methods for managing metastatic colon cancer. The liver is the cancer’s preferred site of metastatic spread for colon cancer.  Treatments that have been employed include surgery, radiation and blockage of the blood supply to the liver by embolization of the arteries, all with variable success.  More recently, radioactive microspheres injected directly into the tumor, called SIR-Spheres, have shown notable efficacy with very tolerable side effects.


Prostate cancer and colon cancer are similar in that they are both adenocarcinomas which means they are derived from glands. Therefore, they are likely to have similar susceptibility to radiation.  As such, we have been administering SIR-Spheres to a limited number of prostate cancer patients with liver metastases.  Results have been encouraging with a notable improvement of survival compared to our historical experience treatment patients with liver metastases without SIR-Spheres.  Our preliminary results using SIR-Spheres in six patients is being presented at the 2016 Genitourinary Cancers Symposium - San Francisco in January 2016. 

Article originally posted December 03, 2015, on Prostate Snatchers: The Blog, by Mark Scholz, MD


A board-certified medical oncologist, Mark C. Scholz, MD, serves as medical director of Prostate Oncology Specialists Inc. in Marina del Rey, CA, a medical practice exclusively focused on prostate cancer. He is also the Executive Director of the Prostate Cancer Research Institute. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is the co-author of the book Invasion of the Prostate Snatchers: No More Unnecessary Biopsies, Radical Treatment or Loss of Potency.  He is a strong advocate for patient empowerment.