Latest Medical Finding: Hormone Treatments Put Prostate Cancer Patients At Higher Risk Of Alzheimer's Disease

PET-scan showing extent of bone metastases in a prostate cancer patient. Each dark area represents actual prostate cancer cells, i.e. in the spine, pelvis, neck etc.  Such evidence would definitely indicate the need to begin ADT or other hormone therapy.

As I noted in my June 3rd post, as a prostate cancer survivor unsure of how many years he has left, or what the disease is doing now (though the last PSA test did how the velocity slowing  from 0.21 ng/ml / mo. to 0.12 ng/ml/ mo.) I am trying to take an open minded approach combined with a realistic one.  Basically this means (and my wife and primary care doc agree) postponing any hormone treatments until I become symptomatic.   This decision actually was based on advice from leading Hopkins urologist Patrick Walsh, in his book Dr. Patrick Walsh’s Guide To Surviving Prostate Cancer’.


Therein he wrote (p. 338):

"If you have metastases to bone, bone pain, or a large mass of cancer that is obstructing your kidneys or bladder, you need to start ADT right now.    In this situation it's the right course of action - one that can make a huge difference in your quality of life and can protect your body from the ravages of cancer.

But what if you have no cancer in your bones  and no sign that anything is wrong except a rising PSA level after surgery or radiation - or the presence of cancer in your lymph nodes- and you feel fine?   Many doctors would advise you to start hormonal therapy as soon as possible.  Others - and I'm in this group - believe that in most cases there is no evidence that starting hormonal therapy immediately, as opposed to later, will prolong life.

Hormonal therapy does two things: it stops cells from making PSA, and it shrinks the hormone sensitive cell population.  Thus, a man's PSA falls and it takes longer for his bone scan to become positive for metastases.  But it doesn't stop the clock. The hormone insensitive cells keep right on growing silently."

The last sentence makes an important point, and as Dr. Dr. Walsh goes on to elaborate:

“A drug or hormone therapy that targets only one kind of cell won’t have any effect against another variety so the one size fits all approach doesn’t work here. Plus some of these cells have learned to be resistant and to grow in the absence of male hormones…so the drop in PSA may be misleading. These are called androgen independent or androgen sensitive cells.” 

 Adding:

“When male hormones are shut off, the PSA making process may indeed stop, but this doesn’t mean the cancer cells are dead or have stopped growing.”

Now, a study out of the University of Pennsylvania’s Perelman School of Medicine supports this recommendation by Dr. Walsh.  The study, in JAMA Network Open, included 154,089 men whose average age was 74 and who had diagnoses of prostate cancer. Of these, 62,330 received ADT  and the rest did not. The study found a link between drugs commonly used for hormone therapy and an increased risk of developing dementia.as well as Alzheimer's disease.

The study adjusted for socioeconomic status, age, race, severity of prostate cancer and other factors.

The lead author, Ravishankar Jayadevappa, an associate professor at the University of Pennsylvania Perelman School of Medicine, said that for advanced cancer, ADT. can be a lifesaving treatment and should not be avoided because of any increased risk for dementia. But, he said, “Patients with localized cancer should be looking at the risks of dementia, and possibly avoiding A.D.T.”

I totally concur with that but with the additional proviso: that patients with NO  evident symptoms should also be looking at the risks, and not just from cognitive disability.  With diabetes running in my family, and having seen its ravages, I can't simply adopt a therapy to fight a cancer while not recognizing the other - perhaps greater- threat.   (Currently, through the use of diet I am keeping the a1c and blood glucose under relative control, but it's still rated as "pre-diabetic")

Back to the UPenn study:  In an average follow-up of eight years, the scientists found that compared with men who had no hormone therapy, one to four doses of ADT was associated with a 19 percent increased risk for both Alzheimer’s disease and other forms of dementia, and the risk increased with the number of doses. At five to eight doses the increased risk was 28 percent for Alzheimer’s and 24 percent for other dementias.  Since most advanced prostate cancer patients are given doses every 6 months, and this could go on easily for 5 or more years, that threshold is easily crossed.

Further, the  University of Pennsylvania researchers found that 22-percent of prostate cancer patients who received ADT were later diagnosed with dementia compared to 16-percent who did not receive ADT. As well, 13-percent of ADT recipients developed Alzheimer’s disease compared to 9-percent who did not receive the hormone therapy.

Though this hormone-blocking therapy - first discovered in the 1940s -  has been proven highly effective for slowing prostate cancer, it comes with a number of risk factors including:  increased risk of depression, strokes, diabetes, cardiovascular disease, bone density loss (with attendant fractures)  and progressive cognitive decline.

The UPenn study was cited by at least one member of the prostate cancer survivor's group to which I belong, as he wrote:

"This study has convinced me that I'd rather die from prostate cancer than take ADT overly long and get dementia or Alzheimer's!"

An extreme statement but I agree with him, after seeing the ravages of Alzheimer's and dementia on three close family members (Krimhilde, my sister-in-law, the most recent).  So, as I told my primary doc I plan to postpone beginning ADT until I become symptomatic, and then plan to cut it off after  6- 12 months by which time the most PCa grievous symptoms should subside and before profound cognitive incapacity arises.

This news is definitely a wake up call for prostate cancer patients, many of whom are pushed into hormone therapies much too early - and often as an accompaniment of other treatments, i.e. radiation.

See also:

https://www.youtube.com/watch?v=KtIfsvQh2qI

And:

https://www.pcf.org/c/adt-what-you-really-need-to-know/

Mail Call Brane - Readers Seeking Answers!

(Note all the following questions were received in 'comment' format but with the askee requesting no special comment space rather the question(s) collated into one blog ....this one!)

Q. President Obama in response to a question yesterday at his news conference stated that one can't be sure if superstorms such as Sandy are really caused by climate change. What is the take of the climate science community on this? - Roger B., Minneapolis, MN

A. This is a tricky question, and Obama can be forgiven for dodging it in a way at his press conference, because let's face it: most of the press corps possesses the attention span of gnats.

The truth is that one aspect of climate change does show a causal relation to the genesis of Superstorm Sandy. That is the phenomenon known as the North Atlantic Oscillation (NAO) and its geographical distribution at particular times of the year. The NAO embodies the atmospheric pressure over a particular region (in this case it was the U.S. northeast) and it can be either 'positive' or 'negative'. In the case of the latter, which was what we observed preparatory to Sandy's arrival, the jet stream displayed a pronounced southward dip. In a positive display the jet stream would have more straddled the higher latitudes (e.g. 45N) and not bent so far south.

Now, here's the kicker: research by Charles Greene at Cornell University and other climate scientists has shown that as more Arctic sea ice melts   e.g. in the summer because of global warming (as I noted before, see my blog of  Sept. 21) then the NAO is more likely to be negative, i.e. jet stream sloping way south. This condition then set the stage for a superstorm in two stages: 1) the warm Atlantic water off the eastern U.S. coast fed energy into the system, and 2) the encounter with the cold air ensconced in the southerly jet stream added the energy equivalent of 5 single megaton nuclear bombs to the system and dramatically expanded its reach - incepting the massive destruction we beheld.

We can predict then, that if northerly moving hurricanes become a more common feature, as does a continued negative NAO, then we will see more superstorms like Sandy. The east coast and its cities will then have to decide whether or not it will spend the money, as the UK has, to construct a massive system of dykes etc. to ward off the storm waters, waves. If not, we better have no more wars, because we're going to need all that money for constant rebuilding!

Q. Reading about your brother ('Fighting Cancer, Fighting Your Brother') I can't believe you had to put up with all his crap while you were recovering from prostate cancer! What gives with the dude? Is he 52 cards short of a full deck or just ornery or what? - Mitch C., Stanford, CA

A. Well, what would you think of a guy that once circulated an idea to put all atheists in the country on a "national registry" like sex offenders?  Granted, he had to be saved from himself (he received over 400 death threats via email from outraged atheists across the world) but all that meant is that he shut down the 'Pastor Mike' blog and started a new one ('Straight Talk with Mister Mike'). The bottom line is I don't know what his main problem is, but as I said in blogs from a few years ago, I suspect IF he has mental issues they arise from believing an insane fundamentalist brand of religion. His 'god' - if you can call it that, is totally batshit insane, since it has no problems allowing a son to be killed for mouthing off against parents - as per Deuteronomy 21;18-21, or adulterers (say like Petraeus and Broadwell) to be stoned to death by Deut. 22:22 or chldren to have wild bears set loose on them if they mock "prophets". (By 2 Kings 2: 23-24). Oh, his god also approves of genocide when it means "cleansing the earth" - as in Gen. with the slaughter of the Canaanites.

As I've said many times before, tell me the concept of god in which you believe, and thence the morality you uphold,  and I will forecast your odds of going nuts. Indeed, I can tell how much of a nut you already are. If you accept or believe in batshit crazy gods you will be a batshit crazy person, and likely end up in a straight jacket on thorazine, if not in some other horrendous end.

Q. I read your blogs on prostate cancer with great interest. My husband, age 43,  recently had a biopsy and it came back with four cores at Gleason 3+4. He's in a dilemma as to the treatment but as in your case, the urologist said watchful waiting wasn't an option. He dreads all the post-operative issues to do with surgery including difficulty with sexual relations, but isn't sure about radiation either, and doesn't want to face the prospect of having the cancer come back after having done the radiation. Any ideas, suggestions?  - Marilyn F., New Orleans, LA

A. In the end the choice of treatment is a highly personal one. Apart from the information already given in the blogs, I can only suggest he obtain the two books cited as well: 'The Invasion of the Prostate Snatchers' and John C. Mulhall's  'Saving Your Sex Life: A Guide for Men with Prostate Cancer". (Note: Dr. Mulhall is the Director of the Sexual & Reproductive Medicine Urology Service based at the Memorial Sloan- Kettering Cancer Center.) Mulhall's focus is also highly on the issue of "penile rehabilitation" : http://brane-space.blogspot.com/2012/10/penile-rehabilitiation-what-most-docs.html .

The aversion to post-op problems following surgery is understandable. Incontinence and erection problems are often mentioned (but the solutions to these were given in the blog link, based on Mulhall's book) but the acute or short term problems are also turn-offs for many men: including risk of infections, having a catheter inserted in the bladder for possibly as long as 3 weeks, coping with the pain, constipation arising from use of pain meds, and risk of rectal injury during bowel movements because the rectal wall becomes much thinner following surgery - after removal of the prostate which originally adjoined the rectum. All this is detailed in the UCSF Patient Guide for Radical Prostatectomy which also includes sections dealing with sexual recuperation, other treatments -meds for incontinence, etc.

I chose the high dose rate brachytherapy because: 1) I didn't wish to be laid up weeks with post-op difficulties or catheters, or bowel problems, 2) I didn't want to be possibly faced with months or years of incontinence limiting my travels, freedom, and 3) I didn't want to go to extraordinary lengths for "penile rehabilitation" including having to have an implant operation, or reduced to continually using Viagra, vacuum pumps or injections. But again, each man has to make his own choices!

Q. I found your blog on solar oblateness fascinating, and wondered if you would be so kind as to provide the oblateness formula for the planets from Earth outwards.to Neptune. Thanks! - Mick, Trenton, NJ

A. The oblateness formula depends on the planet's equatorial diameter, a and its polar diameter, b. Then:

f = (a - b)/ a

The values are as follows for Earth outwards to Neptune:

Earth: 1/ 298.257

Mars:  1/ 154.409

Jupiter: 0.06487

Saturn: 0.09796

Uranus:  0.02293

Neptune:  0.0171


Q. If your Aug. 22 blog on 'the biggest spy center on Earth' is to be believed, Gen. Petraeus had much to worry about churning out all those emails. Should he have known about this spook kingdom and how they can scoop up emails, tweets on a whim? Or was he just dumb? - Andy K.,  Tucson, AZ

A. I don't believe the general was 'dumb' but perhaps in the heat of his affair his brain cells didn't process that anything committed to cyberspace or that gets infused into the 'cloud' - is there for years for any spook to grab, save and see. In the blog you referenced, I specifically mentioned (from the cited WIRED piece, 'The Black Box'):

"The mammoth Bluffdale Center will have another important and far more secret role that until now has gone unrevealed. It is also critical for breaking codes. And code-breaking is crucial because of the data that the center will handle: financial information, stock transactions, business deals, foreign military and diplomatic secrets, confidential personal communications, legal documents and anything else initially heavily encrypted."

I also added:  "Everyone's a target, everybody with communications is a target."


So, it boggles the mind that Gen. Petraeus could have been that careless. Also, virtually anyone that spends any time on the net has to be aware that the FBI's "Carnivore" program - for ferreting out emails- is still in play. Also, the 4th amendment protections against extraordinary searches have essentially vanished since the critical provisions of the Patriot Act (mainly to do with wiretapping without the need for warrants) have been extended twice (by Democrats and Repubs - at least it's one thing they can agree on.)

My advice to anyone is that if you don't want the spooks to be amassing all your (saved) Facebook pages, blogs or tweets, then the best step is not to post them. If you don't care, it's no biggie. Btw, for those who want to learn more about the national security state we've erected (to keep us "safe") since 9/11 be sure to get hold of James Bamford's book: The Shadow Factory: The Ultra-Secret NSA from 9/11 to the Eavesdropping on America.

No Reprieve, No Alternatives! Biopsy Forthcoming!

The appointment at the urologist's this morning  (10.15) lasted at least a half an hour and included a review of family history (no prostate cancer) as well as previous infirmities, afflictions - from bronchitis to high blood pressure. Also a physical exam, which was passed with flying colors (i.e. no unuusal or abnormal growths, or enlargement of gland in question and no other evidence of anything amiss). These were all good signs, but alas, not enough to convince the urologist to leave out a biopsy.

His primary concern was the unrelenting increase in the PSA (doubling from 2.8 to 5.6 in a year, then increasing again to 6.1 in 3 months, and again to 6.5 in 3 weeks - registered in a most recent blood test that also found a low free PSA percent of 5.1. In combination, he said, all the numbers pointed to biopsy. There was only left the matter of scheduling it.

A range of dates, times was available at the front desk, but since the longer the time the longer the build up of anxiety, I decided to arrange it for next Wednesday morning, at 10.30. This would be the day after my last physical therapy session (for a strained lower back muscle) and also leave ample time to finish necessary chores ....like mowing the already overgrown lawn.

Also at the desk I was advised by a nurse of all the things which had to be done prior to the procedure, including filling prescriptions. The key one is for the antibiotic, Levofloxacin (500 mg), one of which is to be taken 1 hour prior to the procedure and the other the next day.

The issue of antibiotics and their potency is an especially critical one for me, as my wife had to be hospitalized twice for c. diff. infection in late 2006, and early 2007, after taking only four days of Augmentin.(Augmented Amoxycilliin) for a sinus infection.  This high potency antibiotic essentially erased nearly all her "good" gut bacteria, leaving her prey to clostridium difficile, which had her running to the toilet 22-25 times a day for over a week, until she had to be hospitalized for treatment....ending with vancomycin - the only thing that would stop it.

On questioning the urologist about the antibiotic prescribed and possible risks of acquiring c. diff. he assured me that its emergence was more an issue of duration of use. And since I am only on it for two days (as opposed to the normal three or four) there was little chance of redux situation, with me now as the 'star'. He didn't rule out, however, adding yogurt and acidophilus to my diet to ramp up the good guys in the gut. Just as an extra precaution and because I also likely have latent c. diff. spores in the gut.

Also emphasized by the RN was the importance of following instructions on administering an "Adult FLEET Enema"  2 hours prior. The accompanying biopsy fact sheet and summary states in loud caps: IF YOU DO NOT USE AN ENEMA YOUR APPOINTMENT WILL BE CANCELLED! Fair enough! It's probably not as bad as the "cleansing" one must undergo before a colonoscopy, drinking all that disgusting pineapple tasting stuff - then having to sit on the can for eight hrs.

Before the actual procedure I have to provide a urine sample to rule out any urinary infections. Immediately before the actual biopsy there will also be an ultrasound examination, in which an ultrasound probe is inserted into where the sun don't shine. Transducers on the end of the probe then will send sound waves into the prostate. When different textures and densities are encountered to those deemed normal, the waves are reflected back to the transducer. A computer then measures the time for the sound waves to travel out and back, dispatching the information to the urologist.

The importance of the ultrasound can't be overemphasized, as it can well reveal conditions (not cancer) that are present and may have incepted high PSA readings. These include: inflammation, cysts, vascularity, and prostate stones. (One must magine they're somewhat like gall stones except maybe a lot smaller!)

Finally, the biopsy is done by insertion of a spring-loaded device (through the ultrasound tube)  which injects ten fine needles, five on each side of the prostate. The end of each needle snatches tissue each time, which is recovered as a sample for the histology. Ultimately, that histology will be scored on what's called a "Gleason score" with 5 being the highest....and also indicating the worst, cancer. Two samples bearing cancer cell histology are then added together to yield  the total score. What you do not want to see is anything like a '10' which basically means your choice of options for treatment is pretty limited.

I am hoping for a 1, 2 or better, 0! Anything to avoid a next round requiring treatment that can leave you in a hospital and with surgical risks, not to mention having to deal with urinary catheters, associated infections!

As for the pain aspect, the urologist was most sympathetic since not all males experience pain, but many do (leading 1 in 3 to never have a biopsy again!) The difference is attributed to whether the injecting needle hits a nerve or not. Contary to some myths, the prostate is not unenervated! It's got nerves all right, it just depends whether the biopsy needle hits 'em or not! If not, the guy brags he felt no pain. If they do, the guy goes into a ball and lets out a primal scream vowing no more tests....ever.

Anyway, I will be allowed to have a light sedative (versed) during the procedure....and yes, my wife can be there too! Perhaps the ideal nerve-calmer of all!