Let's Revisit the Prostate Cancer Debate

Courtesy of John R. Lee, M.D. Medical Letter

Conventional treatments clearly aren't working - what's a guy to do?

Prostate problems are the fastest-growing health concern among men in Westernized countries, and the rate of prostate cancer is increasing steadily. I receive plenty of mail on the subject, and I'm afraid my response isn't always welcome news. I have to tell them that prostate cancer becomes progressively more common with age, and that conventional treatments (surgical or chemical castration, radiation, or surgical removal of the prostate) don't do much good and in fact are likely to cause rather undesirable side effects.

The Journal of the American Medical Association (JAMA) of June 28, 2000, carried an article comparing treatment recommendations by radiation oncologists and urologists for men with moderately well differentiated, localized prostate cancer and greater than a 10-year life expectancy based on age. In such cases, 92 percent of urologists recommend radical prostatectomy (removal of the prostate gland), whereas 72 percent of radiation oncologists recommend radiation treatments. An accompanying editorial points out that the treatment advice is determined by the services the doctor provides rather than by any clear-cut evidence of the superiority of either treatment, or even whether or not either treatment is any better than watchful waiting. And I find it interesting that none of them recommended any nutritional or hormonal alternative management.

Worse than Doing Nothing

The value of PSA (prostate specific antigen) testing to detect prostate cancer, though touted as a proven strategy for early detection, is also questionable. IN Sweden, for example, physicians rarely screen for prostate cancer or use radical therapies, choosing watchful waiting instead. Despite this, mortality rates for prostate cancer have declined in Sweden. In the U.K., prostate cancer mortality rates are similar to the U.S. even though PSA screening is not routinely performed. In older men, when prostate cancer occurs, the cancer is slow-growing and early intervention may be of little consequence.

A Better Way to Treat Prostate Cancer

If radical treatments such as castration, radiation or prostatectomy are no better than watchful waiting, I believe it is time to reanalyze our underlying hypotheses concerning prostate cancer. The present treatments are based on a war metaphor - find the abnormal cells and obliterate them by radiation or surgical removal. Little thought is given to the underlying metabolic causes that change normal cells into cancer cells. As with any disease, once the cause is identified, successful prevention and treatment strategies emerge.

Conventional medicine has fixated, despite lack of credible evidence, on testosterone as a presumed cause of prostate cancer. When looking at the many studies that compared hormone levels with the occurrence of prostate cancer, there is no correlation with elevated testosterone levels. If high testosterone levels caused prostate cancer, why don't 18 year-old men get it? The fact that some evidence shows a modest survival benefit from orchiectomy (castration) does not mean that testosterone reduction was the operative factor. The testes make other hormones as well, and the observed prostate benefit of castration may stem from reducing one or another of them.

The role of estrogen dominance provides a more probable hypothesis. Estrogen dominance is the only known cause of endometrial (uterine) cancer. The prostate is the male equivalent of the uterus; they both developed from the same embryonic cells. They both contain the oncogene, Bcl-2, and the cancer-protective gene, p53. And it has been shown that estradiol "turns on" p53 which blocks Bcl-2 in both breast cells and prostate cells. This suggests that if the ration of testosterone to estradiol in men changes so that the estradiol effect becomes dominant, prostate cancer cells develop. Recent studies no find that this correlation is fact.

What's Happening with Men's Hormones?

Estrogen levels are rising in the general population in Westernized countries due to pervasive pollution of the environment by chemicals that are estrogen mimics (aka xenoestrogens), such as pesticides, plastic residues and dozens of industrial chemicals such as dioxins and PCBs. This is partially why most postmenopausal women need progesterone (to oppose or balance the estrogen), and it's no doubt one reason that the incidence of prostate problems is increasing so rapidly in men.

Estrogen levels increase in aging men who are overweight because fat cells convert the male hormone androstenedione into estrogens, which then stimulates prostate growth. Thus, the more fat a man carries on his body, the higher his estradiol levels are likely to be. Regular exposure to pesticides through spraying in the home or garden only adds to the problem. Even if a middle-aged man's testosterone levels are normal, if his estradiol levels are high he can have estrogen dominance symptoms such as weight gain, larger-than-normal breasts, gall bladder problems, anxiety and insomnia, and prostate enlargement that leads to urinary problems.

The crux of the present confusion about men's hormones is the matter of achieving hormone balance. Hormone balance refers not to absolute concentrations of any given hormone, but to the ration of one hormone with another. It is the ratio of salivary concentrations of testosterone to estradiol that best reflects the hormone-related risk of prostate cancer.

To sum up, as men age, their testosterone concentrations decline but their estradiol concentrations do not; those commonly rise a bit, and the ration of testosterone to estradiol falls. Testosterone is a potent antagonist of estradiol and its effects on the body. When testosterone levels decrease, estradiol becomes dominant. Estradiol not only stimulates prostate cell proliferation but also activates the oncogene Bcl-2. One by one, normal prostate cells become cancerous prostate cells.

This fits with findings of ultra-scans and prostate biopsies - the cancer cells are found in various small clusters here and there throughout the prostate, and not as a single prostate cancer mass.

Treatment of Hormone Imbalance in Men

Hormonal treatment should correct the estrogen dominance by supplemental testosterone. If saliva tests find progesterone deficiency, progesterone supplementation is also indicated since it inhibits 5 alpha-reductase, the enzyme that converts testosterone to dihydrotestosterone (DHT). High levels of DHT are correlated with prostate cancer.

Conventional treatments such as surgical or chemical (e.g., Lupron) castration stop the testes from making all sex hormones. The observed cancer benefit is not due to testosterone reduction, but is more likely due to the decrease in estradiol production. However, this approach sacrifices the potential benefits of testosterone and progesterone (men make small amounts of progesterone in their testes and adrenal glands). Restoring physiologic levels of testosterone and progesterone to prevent estrogen dominance is a happier solution to the problem.

The clinicians I've spoken to who are working successfully with men who have prostate problems prescribe 4 to 6 mg of testosterone daily, preferably delivered by a patch or cream. The high dose of testosterone often prescribed by conventional physicians (as much as 300 mg daily!) is an invitation to hormone imbalance in the other direction and a wide range of physical and emotional side effects. It is absolutely not necessary to take high doses of testosterone to achieve hormone balance.

My friend David Wastchak, R.Ph., Ph.D. is a pharmacist and biochemist who specializes in compounding hormone creams, and he has quite a bit of experience in putting together progesterone and testosterone creams for me. You can have your doctor call him for a consultation and prescription at (602) 271-9577.

Up to this point the discussion has concerned the treatment of prostate cancer, but prevention is your best bet. In addition to maintaining a healthy hormone balance as mentioned above, prevention of prostate cancer undoubtedly involves other factors such as diet, specific nutrients, essential fatty acids, stress managements, and antioxidants. Whole foods such as broccoli and cabbage are attracting great interest as cancer fighters. The nutritional advice on cancer that I give to women in the chapter in my "PREmenopause" book also applies to men.

In conclusion, the conventional testosterone hypothesis is a 60 year-old mistake. Present treatments are fraught with undesirable side effects and their purported benefits are little different than that of watchful waiting. Extensive usage of PSA tests has done little to change prostate cancer mortality rates. Fortunately, new studies teach us that estrogen dominance (a falling testosterone to estradiol ratio) may have a great deal to do with getting prostate cancer. This is where we need to start.

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