Prostate Cancer's Elephant In the Room

The WSJ (and pretty much everyone else) asks today, “How in the world could this happen to a man with ostensibly the best medical care in the world?” Gleason 9?? Geez.

But remember, the Gleason scoring system starts at 6. "Gleason 6" is the lowest possible prostate cancer score and simply means you have, if you'll pardon the card game analogy, "a pair of 3's." (A grade of 3 being the lowest histology grading and meaning "normal to near normal tissue." The total adds up to 6 because the pathologists look at the "primary pattern" and then the "secondary pattern" viewed in the biopsy sample-- and simply total them.) So a Gleason 6 means "3-3" and "a-okay"-- or very close.

It was somewhere reported that men who get a prostate cancer diagnosis at Joe's age are more likely to present with more aggressive cancers, but this appears not to be true-- or at least only marginally so: 3.1% vs. 4.1% (70 or younger vs. over 70). Surprisingly low percentages, at least to me. That's four in one hundred! What spectacularly bad luck.

Or is there more than just the luck of the draw at play here? President Biden's "bad luck" very likely reflects the unimaginable stress he has been under since he announced his re-election bid last April. And the effect this has on day-to-day immune surveillance. The viscous & mean-spirited public lynching of his only surviving son. And then, two months later, lifelong friends & foes alike turn on him after an ill-conceived travel schedule (G7 in Italy-- chiefly to maintain momentum for support for Ukraine-- to Beverly Hills fundraiser to CNN HQ in Atlanta) just days before a debate. He literally took one for the team, Jake Tapper (and now even E. Klein piles on??) et cie notwithstanding.

This might actually serve as a teaching moment for ALL OF US: stress (& disrupted sleep & bad food "x time") can quite literally make you sick. Even give you cancer (and elevated blood glucose, and blood lipids, and hypertension, and weight gain/obesity, and diabetes).

Risk Grade	Grade Group	Gleason Score
Low/Very Low	1	6 (3+3)
Intermediate-Favorable	2	7 (3+4)
Intermediate-Unfavorable	3	7 (4+3)
High	4	8
Very High	5	9-10

Here’s the thing. For starters, Scranton Joe decidedly did not receive “unrivaled” (the Journal's words) medical care, at least as one can deduce from the health information shared. Although obviously he deserved to. As do we all.

I remember when his team released his medical records before he dropped out of the race. The prescription list made my skin crawl. Who the heck is prescribing him these things??

Two OTC allergy medicines for seasonal allergies. Another, Pepcid, for acid reflux. The president also takes a blood thinner for a previously identified heart arrhythmia. And Crestor for cholesterol. Lipid levels are remarkably low. No finding of any neurological conditions such as Parkinson’s, although the president does have moderate to severe wear-and-tear osteoarthritis in his spine.

This is not “the best care anywhere.” This is KINDERGARTEN medicine. This is irreflective, lackadaisical symptom suppression. This is "paint-by-number" medicine. This is “Out, damned spot!” Rather than spending the time to stop and think about why and from whence these symptoms stem, the doctors simply put black tape over the proverbial dashboard panel warning lights. Someone who dedicated his life to serving this country certainly deserves better.

"Reflux: purple pill; allergies: red pill; arrhythmia: yellow; cholesterol: puce; insomnia: pink."

What’s become kind of fun after ten or so years of functional medicine training, thinking, and experience is that you can go through this meds list and kind of “reverse engineer” what the most likely underlying physiological conditions are creating his symptoms-- allergy, arrhythmia, OA, reflux-- as well as more macro-level issues.

• Seasonal allergies requiring OTC anti-histamines points you to poor gut health-- even low-level chronic inflammation. Essential fatty acids deficiencies or imbalances are also implicated in what the pros call "atopy." Kara Fitzgerald does a primo lecture on this.

• Acid reflux: Ditto, but this time more the small bowel (or even the pylorus) than large intestine.

• Arrhythmias: This could be several things: need for EFAs, need for minerals, dysbiosis/chronic inflammation in gut, even undiagnosed peripheral insulin resistance-- evident in 80%+ of seniors, especially those with cognitive lapses.

• “High” cholesterol: Here we kind of need more detail. Are they treating a “high” LDL? Which is generally caused by acute stress. Are they treating high triglycerides? That’s a sign of eating the wrong things (too many cookies etc.)-- and easily addressed. Are they interpreting his Total Cholesterol as high? There’s kind of no such thing. In fact, the Women’s Health Initiative found, to the surprise of many, that a “high” cholesterol in post-menopausal women actually correlated with improved survival. (More recently, the Helsinki Study examined this in senior men and came to the same conclusion.) Certainly there is no evidence that a TC of 200-220, possibly even higher, is anything to “treat.” But the inverse is also true: super low cholesterol can cause all kinds of problems, including suicidal ideation, road rage, hemorrhagic stroke (aka intracerebral hemorrhage), and depression.

• “Wear & tear” osteoarthritis: For starters, there is no such thing as “wear & tear” arthritis. That belies a fundamental misunderstanding of the virtually unlimited capacity for the body to perform maintenance and repair. If you, however, are told you have this so-called wear & tear arthritis, you need to immediately look into the potential sources of chronic, low-grade inflammation. It generally comes from the diet (most often wheat) or the gut (most often undiscovered low-grade inflammation from an imbalance of “friendly” and “unfriendly” bacteria, sometimes also yeast). Number 3 would be heavy metals: mercury, lead, cadmium, arsenic are the most common. And you would also, of course, want to make sure the body has what it needs to regularly perform these maintenance & repair functions, chiefly adequate protein (and the stomach acid to break it down), sufficient cofactors for collagen synthesis (Mg, Zn, Cu, Mn, Fe, vitamins C, B5, B6), and adequate essential fatty acids. Go get ’em, Mr. President!

And of course, his Parkinsonian gait is another concern. Maybe he just needs more omega-3’s and a lifetime subscription to StretchLab (or Hatha yoga 2-3x a week). If it really is a kind of pre-Parkinson’s, then we are back to gut health (chronic constipation is a big red flag here, even more so for men than for women) and, secondarily, toxic exposures-- or detox capacity (glutathione the star player here-- which gets you back to amino acid (cysteine, glycine, glutamic acid) & stomach acid sufficiency- and vitamin (primarily C & E, but also B3 (niacin)) & mineral (primarily selenium) co-factors) v. toxic exposure overall balance.

But, again, geez! Who the heck is taking care of this guy?

His almost absence of a voice is another sign that invites a little functional medicine detective work. In Chinese medicine, it would likely be diagnosed as “Lung Qi Xu” or Lung Qi & Yin Xu, or for him, even Lung & Kidney Qi & Yin Xu (kidney in Chinese medicine is more the adrenals than the actual kidney), and probably treated with cordyceps or a TCM formula like Sheng Mai San.

From a functional medicine/nutritional medicine perspective, you’d want to look at vitamin B2 (riboflavin) levels, maybe also B6, at a minimum. Since he’s on a H2 blocker (Pepcid) for reflux, you’d also want to check his vitamin B9 (aka folate), his vitamin B12 (PPIs, hypochlorhydria generally) levels, and his zinc. Low zinc, perhaps not coincidentally, is also a risk factor for development & aggressivity of prostate cancer. Hmmm. But you also don’t want to overdo it. Everything in reasonably physiological quantities! Almost everything in life turns out to be a U-shaped curve.

You want to prevent prostate cancer? Or any cancer for that matter. This is what you want to know, what you want to do, in no particular order (And it can't hurt to read both Robert Lustig's and Jason Fung's excellent books: "Metabolical" and "The Cancer Code," respectively):

1. Know/optimize your toxic exposure/detox capacity balance (mostly heavy metals, especially cadmium, but also POPs and solvents-- but more & more, toxic metabolites produced endogenously (yes, from your unhealthy microflora balance!))

2. Know/fine-tune your antioxidant status

3. Know/fine-tune your EFA balance (neither too little nor too much of both 6’s and 3’s)

4. Know/fix your gut health

5. Know/fine-tune your hormone health (including factors that affect your SHBG)

6. Know/address your insulin health

The NutrEval test (which requires both a blood draw & and a “first a.m. urine” sample, will tell you the first four in the list. A DUTCH dried urine hormone test will tell you #5. You can do a hormone panel with your GP (but be sure to include the estrogens: estradiol, estrone, estriol), but they won’t tell you a really big, important piece of the overall hormone picture: how you are processing & eliminating the estrogens. DUTCH, though, either Dutch Plus (includes 4 salivary cortisol:Dhea samples throughout the day) or Dutch Complete (extrapolates diurnal cortisol via urine), will tell you this.

GI Effects, GI-MAP and GI360 can tell you more about your particular microbial mix as well as how well you are digesting protein and fats (and any undiscovered gut inflammation), but they aren’t really necessary in order to get the basic picture; they are more often used as either follow-ups or for super curious/meticulous folks who want to know EVERYTHING NOW!

The insulin metabolic piece is pretty straight-forward except that doctors don’t typically measure fasting insulin, so you have to either specifically request it or, so long as you don’t live in NY, NJ or RI, request it yourself.

In general, although again I am not a fan, Peter Attia’s super simple advice (and a much longer but also worth looking up version of Robert Lustig in his, okay, tour de force book, "Metabolical" (video interview with Jeff Sachs)) applies here: You want to eat so as to minimize glucose spikes (which will minimize insulin spikes). You can watch a graphical depiction of this on his white board at 59:00 at this YouTube video.

We could write volumes on the pro’s and con’s of regular PSA testing-- and whether or not the advice to stop testing after 70 well-served or ill-served 46. But the real question for me is the Gleason score. What determines an indolent cancer from a (potentially) aggressive one? And how might that be better predicted? (I have since looked this up. Best options at present, it seems: 4K (blood), ExoDx (urine), and maybe one day (after further validation), IsoPSA (blood)). And ultimately prevented.

Problems with PSA (alone):

--> Not specific for p. cancer (but might be decent indicator of overall prostate health)

--> Can be elevated due to inflammation or infection

--> Does not take into account current prostate size (need "PSAD" calculation for this)

--> PSA can be in normal range even when there is an aggressive cancer

--> "Free to total" PSA (> 25% is low risk; 10-24, medium risk; <10% high risk) and PSA "velocity" (change over time: an increase of >0.75 ng/mL per year is said to warrant further investigation) are more more useful

The IFM's only faculty member who focuses on prostate health is Geo Espinosa, and I have not (yet) been that wowed by him. He certainly knows his diagnostics. (Spoiler alert: the 4K score comes out on top, partly because it takes into account total prostate volume. To get that, though, you'll need an MRI.) But he spent a full hour speaking at this spring's "integrative" health conference at the New York Hilton and not once mentioned either preventive strategies or how one might reverse a high number.

Ask me about Toronto-based naturopathic physician Robert Abell's twin equinoxes preventive protocol. (Spoiler alert: prostate needs (not too little, not too much, and in balance) zinc, both omega 3 and omega-6 EFAs, and the antioxidants (and glutathione "rechargers") C, E, selenium. Go green pumpkin seeds!) Naturopathic medicine is basically banned in the U.S. but is openly embraced (& quite popular) in Canada. And who has better health?

I’m putting my money on the "know/optimize/fix" list above: terrain, terrain, terrain, as the naturopathically inclined might opine. And there’s a blog post soon to be released about just this: Tumor Or Terrain? But short story, it’s inflammation (almost always hidden). And although this will fly in the face of everything you’ve both been told and warned about... androgen sufficiency. Yes, even folks diagnosed with prostate cancer have both better outcomes and better survival rates with higher not lower T. I'm not really a gel-cream-patch guy though, and prefer to spur the body to produce it endogenously-- as well as working on signaling, receptors, SHBG, and even receptor density.

More on this (and the evidence & theory) in a future post.