2010-10-14 Mark Scholz MD Prostate Cancer: Invasion of the Prostate Snatchers
Invasion of the Prostate Snatchers
An Interview with Mark Scholz MD
October 14, 2010, By Kirkham R. Hamilton, PA-C
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KIRK HAMILTON: Hi, my name is Kirk Hamilton, your host of Staying Healthy Today, and our mission is simple: To provide you credible usable health information from interviews and our educational resources to help you Stay and Be Well in the busy modern world. Please take a few moments before or after listening to this interview to browse through the Prescription2000.com website, the home of Staying Healthy Today Radio, for our free educational services.
Today's show topic is prostate cancer and we will review the book entitled "Invasion of the Prostate Snatchers. No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." Our guest today is Dr. Mark Scholz, a board-certified internist, oncologist and medical director of the Prostate Oncology Specialists in Marina Del Rey, California.
So welcome Dr. Scholz. Thanks so much for taking time out of your busy day to come on the show.
DR. MARK SCHOLZ: It's certainly a pleasure to join you today.
KIRK HAMILTON: Well thanks for giving me the book when we were at the PCRI conference last week, which is the Prostate Cancer -
DR. MARK SCHOLZ: Research Institute.
KIRK HAMILTON: I gotta say it was very interesting for me. I'm a 53-year-old male and normally when I go to medical conferences there's any, you know, there's people from oh their 30s to the 60s or 70s, and I got off the plane and I got on the shuttle to the hotel and all of a sudden I saw seven or eight single, alone men in their 70s, you know and it was just an unusual experience and I go I gotta be going to the right place.
DR. MARK SCHOLZ: Yes, the average age of diagnosis is around 65, but the youngest guy I ever saw was 28 so it is pretty rare under age 40 but it can happen.
KIRK HAMILTON: Well you know it was pretty profound. The other part about being at that kind of a conference is when you're with I think you said 700 people came to that, the largest public conference on prostate cancer. Was that it?
DR. MARK SCHOLZ: Uh, yes, I think our attendance this year was up to around 750.
KIRK HAMILTON: Right. And again being around you know men 60, 70, 80 years of age with their spouses is a different kind of experience and it's a very powerful experience when you feel the family there and these men there, kind of all walks of life coming for a common reason and that's to learn about prostate cancer.
DR. MARK SCHOLZ: Yea, it is a family condition and the name of the game and that's why I'm so grateful to be with you here today Kirk is it's all about education. There's so many subtleties and variations on the theme that people can get hurt if they do their homework first.
KIRK HAMILTON: Well you know the book title...just, I don't who made it up. I don't know if it was a publicist or you.
DR. MARK SCHOLZ: No, I can't take credit for it. My co-author, Ralph Blum, approached me with it. It's kind of a cute story. He's a patient of mine about five or six years ago and he's a professional writer and he came to me and said he'd like to co-write a book but that the litmus test would be my reaction to his proposed title, which is you were about to say is "Invasion of the Prostate Snatchers" and I didn't bat an eyelid. I thought any book would be great. And so with that we were off to the races and unfortunately he didn't even bother to find out if I could write, and so he was kind enough to sort of hold my hand through the process.
KIRK HAMILTON: Well when I was going through, I've interviewed you before, and when I was going through how would I do this interview, do I just do it from book questions, and actually I went back this morning and I just read the title "Invasion of the Prostate Snatchers. No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency," and you could do a whole seminar just off your title because that reflects the intensity of getting treatment, just thrown into the gauntlet so to speak. It - there's a lot of energy in there so -
DR. MARK SCHOLZ: Yes, I agree with you and that was sort of our guiding light throughout the whole writing process. Whenever we would get off track, it was the title that brought us back to what our real - the energizing concern is that this is the only cancer where surgeons, not oncologists, the surgeons are calling the shots, and people don't realize how intensely indoctrinated surgical training is and how hard it is for a surgeon not to think really good things about surgery. And with most surgeries I would have no argument, but when you start operating on men's prostates more than half the time they become impotent, and as many as 20 to 25% of the time they get - they lose control of the urine. These are really devastating things and if it's true that many prostate cancers aren't life-threatening, then these terrible outcomes in many situations are unnecessary.
KIRK HAMILTON: So I guess the ‘prostate snatchers' are the urologic surgeons?
DR. MARK SCHOLZ: Can I tell you a cute story about that? When I was over in New Zealand giving a talk you know about this book and the audience, there were a number of urologists, and it was so funny because after I was done I took questions and one of the urologists stood up and it was like an AA meeting. He says "I want to confess that I'm a prostate snatcher" and the whole place just broke up. It was so cute. Turned out that he was a really excellent doctor. About 25% of his practice was active surveillance and he did do some surgery but he was a very balanced guy and so he wasn't threatened by the name and so the people are laughing about it, thank God.
KIRK HAMILTON: So the title, that deals with the whole concept of you know doing surgery and cutting out part of an individual in a sense.
DR. MARK SCHOLZ: Yes, absolutely. And the also, I think the secondary thing is the fear that is engendered. We're doing about a million and a half biopsies every year and at that rate one out of every two of us guys is going to get a biopsy in our lifetime. And the statistics show that if you go biopsying men with normal PSA levels you find low-grade prostate cancer in about a fourth of the men. It's just so prevalent and of course when it's called cancer people get terrified and they start doing irrational things.
KIRK HAMILTON: So I know that you are a selective biopsy recommender, so to speak, but you threw in the fear there or you threw in the concern of unnecessary biopsies. So on the big scheme of things how many would you say, or what percentage are unnecessary biopsies?
DR. MARK SCHOLZ: Oh I'd say at least half of them. One of the most common things that happens as that we guys get older is our prostates get bigger and they start making more PSA. Now when PSA isn't evaluated from that point of view the doctors, maybe for medicolegal reasons, maybe just out of habit, they tend to just biopsy everybody. But there are methods to measure how big a prostate is and estimate what the normal PSA should be for that size prostate. So instead of just biopsying everybody with a PSA above 4, above 2 ½ or whatever threshold is being recommended, men need to have their prostate size measured and then on the basis of how big their gland is decide whether a biopsy is really needed or not.
KIRK HAMILTON: Well you educated me on that because I think I actually saw it, because I came down with a patient of mine, and do you do that by actual - the digital exam or do you measure it by your Doppler ultrasound?
DR. MARK SCHOLZ: A skilled urologist can get a rough idea of the size of the prostate just with a finger exam. But it is more accurate to do an ultrasound and that's the same equipment that's used to do the biopsy, where they put in a probe, oh you know a little bigger than your thumb in your behind for about three or four minutes and they can then measure the size in three dimensions without sticking needles in the prostate.
KIRK HAMILTON: So staying still with the cover of the book, so we got the unnecessary biopsy part. Now, radical treatment, aside from obviously cutting out your prostate, we know that, what other radical treatments do you consider radical?
DR. MARK SCHOLZ: Well just if you name a prostate cancer treatment it's radical. And as soon as we come up with a nonradical one then we'll just probably do that to everybody like we do with, you know freezing skin cancers and stuff. That's, you know, kind of like why not? But the - you name it - radiation, hormone treatments these all cause devastating effects on male sexuality, and I don't know about you Kirk but there aren't too many things higher in my priority list than keeping my sexuality. So that's why this is such a high stakes game. People think that they're rushing into radical treatment with, then that they're saving their lives, and that losing their sex lives is justifiable, or that there's a good reason for it. But unfortunately we know now that it's maybe as many as a third or a half of the prostate cancers are not life-threatening, and that they don't need radical treatment.
KIRK HAMILTON: But you still, I mean I know you recommend selective radiation, I know - I'm assuming you recommend sometimes forms of chemotherapy. I know you recommend hormone blocking. Now when does it - when does any of those become radical I guess is what I'm saying or -
DR. MARK SCHOLZ: Uh-huh. Well, they're always radical but sometimes, just like with any cancer, you know with breast cancer we sometimes unfortunately have to remove a woman's breast and that's a radical situation. It's justified. We have a nice brochure from the Prostate Cancer Research Institute called "What's Your Type?" and the idea that prostate cancer is not one illness but actually three. We've - or others have called it low, intermediate and high-risk prostate cancer and the low risk type is the type that can safely be watched. The high risk type needs radical treatment universally and the in-between group, it can kind of go either way, though these days most of those individuals are getting treatment. So, I would recommend going to PCRI.org and they'll send a copy of the brochure out for free on "What's Your Type?" That's the first step in prostate cancer if someone is diagnosed is to figure out what they're dealing with.
KIRK HAMILTON: So let's work backwards to low risk. What would high risk be? Is that the easiest one to define?
DR. MARK SCHOLZ: I think so. They - when they do the needle biopsy they grade the cancer from 2 to 10 and it turns out that anything above 7 is high grade. If the PSA test is above 20 that's high risk. And when the doctor does the finger exam on the prostate if he can feel a very large lump on the prostate then we know that's high risk. So, any of those three things can make a prostate cancer in the high risk category.
KIRK HAMILTON: Now let me ask you, those high-risk people, are they the selective group that can have the aggressive disease or -
DR. MARK SCHOLZ: Yes, they're the ones that would need some sort of aggressive treatment. It would be very inappropriate to simply monitor these people.
KIRK HAMILTON: So let's go to intermediate risk. How do we down-size the high risk person?
DR. MARK SCHOLZ: Okay. Those are the people that have instead of a grade 8, 9 or 10, they have a grade 7, or they may have a PSA that's between 10 and 20, or they may have a small bump that can be felt when the rectal exam is done by the doctor. And that is the trickiest situation because it's not a very dangerous situation but occasionally it is, and I think that's the one area where you need the most expertise, the best advice and to exercise the most care because you could argue for doing surgery, radiation, hormone treatments, cryotherapy and in some cases monitoring, active surveillance. And all these things need to be weighed in a very expert fashion to look at the upside and the downside before jumping into a treatment.
KIRK HAMILTON: You know that, I mean I agree with you because that's when as a primary care practitioner I get really nervous, and that's why I love having you around, and that's why I send people down for an hour plane flight down to Marina Del Rey sometimes just to get that kind of monitoring because that's the confusing area and the kind of scary area. And it's also very difficult because, from my world view we have - there's family pressures about active surveillance. Let's say a family member goes, "What are you doing telling your dad to just see somebody to watch the prostate when the urologic surgeon is saying cut..." and that happened to me very you know -
DR. MARK SCHOLZ: Absolutely. It's an ongoing education process. That was the reason that we wrote the book is because there is a lot of heat and not much light in this business. And even if you convince your patient that it's best to monitor it, the patient has a constant uphill battle convincing his primary care doctor, convincing his children, convincing his spouse, and it's a real difficult situation.
KIRK HAMILTON: And that's why it's so critical to have these prostate oncology specialists. I mean that's the truth. Now let me just jump to that real quick as a resource. How does someone find someone like you? Are these people training on the fly, so to speak? I mean -
DR. MARK SCHOLZ: Yeah, it's a real tough situation. Now we did list 60 specialists in the back of the book. There's a table there of doctors that are oncologists who've shown an interest in prostate cancer. I don't know them all personally, but these are people that have published articles on the topic. The other thing is to utilize these reference - or excuse me - these referral centers at large universities, even the urologists at places like UCSF or other reputable universities, they tend to specialize more in prostate cancer and they're - they're definitely more knowledgeable. Now of course they're gonna tend to, you know, have a bias towards surgery because that's what their training is. But at least they're not like the community urologists who are kind of doing prostate cancer in their spare time. And there's one statistic that's just terrifying that was published in the Journal of Urology, in the state of New York, they looked at the community urologists and they discovered that 25% of the urologists in New York do one prostate surgery per year, 25%. And 80% did less than 10 surgeries a year. Now we know that studies show that you need about 250 practice tries to get proficient at this. So there's a lot of urologists out there that aren't studied - they don't have a enough practice to do the operation well.
KIRK HAMILTON: That kind of makes my legs weak you telling me that statistic, you know.
DR. MARK SCHOLZ: It's a great concern. So people that decide that they want to pursue surgery or looking for experts, they need to go to big referral centers where they're doing a large volume. That's an absolute essential.
KIRK HAMILTON: We're talking to Dr. Mark Scholz, director of the Prostate Oncology Specialists in Marina Del Rey, California, and also co-author of "Invasion of the Prostate Snatchers. No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." I'm going through the table of contents and I love some - you know, whoever came up with the - some of the titles of the table of contents. For example you say the very first one is "Welcome to Prostate Country." What the heck does that mean?
DR. MARK SCHOLZ: I think that was the sort of how my co-author Ralph Blum, you know, he was diagnosed in 1990 and his story is great because he doesn't necessarily think - you know, he thinks he lucked out, but for after his diagnosis for nine years he didn't pursue any treatment at all and I didn't see him until he had been, until 2004, when he'd already been living with prostate cancer for 14 years. And we treated him then. His PSA was up to around 13 or something like that. So we treated him with a 12 month course of hormones and that's all he's ever needed. So he still has his prostate. And his story, you know, he writes every other chapter in the book, and his story unfolds over a 20 year period of all the different ups and downs and the doctors he met. And he tells his story from the patient's side.
KIRK HAMILTON: Yeah, he's kind of like I would be. He's a second-guesser. Doesn't want to really do a traditional approach if he can avoid doing it. And then the honest part of the book that I liked is you know he resigns himself to having to do some of these things after trying maybe an alternative or whatever. He's very - I mean he's in charge but he also has to let go at certain times to keep going in the process. He's not stupid.
DR. MARK SCHOLZ: Yeah, and fortunately you know he had the low risk type of prostate cancer and his - he's sort of like a living example of how this particular type of cancer is so different from what we normally think of when someone gets a, you know, a colon cancer or a lung cancer and those things are so life-threatening. We would never advocate that someone could watch something like that, but this is different.
KIRK HAMILTON: Well you've got some of the chapter titles here. And I think I know what they mean. So you have, we talked about biopsy and then we have the "Return of the Prodigal Hard-On." Is that trying to get your sexual potency back after you get treated?
DR. MARK SCHOLZ: Yes. After you take hormone treatments like he did for a year, you know it pretty much wipes out your sex drive. And so he writes very graphically about the experience of having no testosterone and a lot of the side effects that he went through. And then what it was like when his testosterone started to come back to normal.
KIRK HAMILTON: Let's stay on that point. I know that there's something that I've hammered on my patients since talking to you and I'm always, you know, a big lifestyle advocate and an exerciser, strength training advocate. But when someone gets anti-testosterone therapy or anti-androgen therapy, they lose their muscles and they might get, you know some other problems of feminization. And you were big on strength training and resistance training and I've shared that with so many patients, and could you get into that a little bit?
DR. MARK SCHOLZ: Yeah. I discovered it myself when after advising men for years that they're gonna feel like a limp dishrag when they take this testosterone blockade. I started seeing a trainer myself and building up my strength, started talking to some of my patients and lo and behold I discovered that the patients who are feeling well on the testosterone blockade treatment were all lifting weights. Then subsequently some academic researchers in Canada did a study where half of their patients were put on a weight training program and the others were just treated in a normal fashion and it was like night and day. The men that were able to keep their muscle strength during the testosterone blockade therapy felt so much better. So we kind of get men to sign in blood before we give them any of this type of treatment that they're willing to go to a gym and lift weights for at least an hour twice a week.
KIRK HAMILTON: Well let's kind of scoot on down then to you have a thing on the insulin connection. Now I know lean body mass helps regulate insulin and glucose metabolism, so that would be one reason to strength train. But can you explain what insulin has to do with prostate cancer and/or the treatment?
DR. MARK SCHOLZ: Well a lot of our men are on active surveillance and of course, and then there're the men that have the advanced cancers where it's spread, and we believe that diet is a very important component. They - and of course we're not the only ones. There's a beautiful book written by Colin Campbell called the "The China Study" that showed that in China the mortality, the incidence and mortality of prostate cancer is 17 times lower than in the United States because their diets are more vegetarian based. And if we can cut down on our carbohydrate and protein intake this lowers insulin which is basically just another name for growth hormone. So when our insulin levels go up through these rich diets that stimulates the growth of all cells including cancer cells.
KIRK HAMILTON: So let's stay on diet for a minute because one of the reasons I flew down and went to the conference was I wanted to hear Dean Ornish speak. And obviously he's done some, you know, work on prostate cancer, and his same heart reversal diet he applied to prostate cancer. And I was wondering if you could comment on that and tell how you encourage people do to more aggressive plant-based diets.
DR. MARK SCHOLZ: Sure. Well, Dean Ornish published his results in the Journal of Urology and they showed that they could lower PSA levels with the proper diet, PSA being a measure of cancer activity. And we've observed the same thing in our practice over the years. That the men that adhere to these more stringent diets, they can control the rate of rise of their PSA which is a secondary measure of how the cancer's behaving. The other interesting thing Dean Ornish showed is that when they took the serum of patients that are on the good diet as opposed to those that didn't follow the diet, and fed it to cancer cells, the cancer cells grew eight times more quickly on the American diet compared to the low fat vegan diet.
KIRK HAMILTON: Didn't you originally - I think I heard this in the first interview when you just got in the business -some patients came in and they went on the macrobiotic diet and you said you kind of followed them along and their - some of their nodules went down. Is that correct?
DR. MARK SCHOLZ: Absolutely correct. It was the patients that brought this to my attention. This is not something I figured out. Patients would come in and say "I don't want any Western treatments. I'm going to pursue a very rigorous diet. Please check my PSA levels." And I thought well of course when the PSA goes up we'll all agree that they need to take standard treatment but lo and behold they would tend to lose a lot of weight and their PSA levels would stabilize. And so one of the things I noticed in the process, because we always check their serum blood sugar, is that it would be about 30% lower than normal. The sugar in their blood was way down and we all know that cancer cells feed on sugar.
KIRK HAMILTON: So the Dean Ornish group, were they intermediate risk or low risk? I know they weren't -
DR. MARK SCHOLZ: They were mostly low risk.
KIRK HAMILTON: Right.
DR. MARK SCHOLZ: Yeah. Most of the active surveillance studies are low risk. Dr. Klotz's study up in Canada, he has the biggest series, had about 15% of the men were intermediate risk.
KIRK HAMILTON: So I want to - there's two things I want to kind of round up and touch on. We talked about diet. People are gonna ask about supplements and I know that you have a kind of a no list and a yes list of supplements. You want to throw those out there?
DR. MARK SCHOLZ: Yeah. Now we're much more of a short list than a long list type of practice, but the two things that go to the top of the list right away are vitamin D and fish oil. And we find at least half of the patients we test for vitamin D are deficient. So we're putting people on replacement vitamin D all the time. And then one of the things we tend to stay away from is multivitamins. There's one study from the National Cancer Institute showing an increased problem with people taking excess multivitamins and if you think about it, it makes sense. Cancer cells only hurt us when they grow quickly and lots of vitamins and plenty of American diet encourage growth. So by restricting ourself from these excess nutrients that, you know, we're just basically fertilizing the cancers by giving these things.
KIRK HAMILTON: Well I gotta tell you that would be confusing to me because if you eat a nutrient dense plant-based diet, you're going to get more micronutrients so that's kind of a questionable -
DR. MARK SCHOLZ: Yeah, but we're not loading up on things like, you know massive amounts of folic acid, the B vitamins and all these things that can help promote growth.
KIRK HAMILTON: So you have people hold on a multi, don't take a multi, take vitamin D and fish oil. And don't you say don't take zinc and -
DR. MARK SCHOLZ: Yes. Minerals are the same way. The cancer cells can't make new cells without all the basic building blocks. So what I recommend is let's just stay on a simple plant-based diet and that let's just not provide all these excess building blocks to make new cancer cells.
KIRK HAMILTON: I want to close by, just to put prostate cancer in perspective. Most prostate cancers are slow growing, correct?
DR. MARK SCHOLZ: Yes. I'd say - well, relative to other cancers it's probably better to have the worst possible prostate cancer than the best possible any other kind of cancer. So in general, yes across the board they're far far more slow growing. But even in the prostate cancer category, there's a range of very very slow to merely slow. Now some of the high-risk cancers, now they can turn bad on people within five to ten years. But a bad pancreas cancer can hurt someone within one to two months.
KIRK HAMILTON: When you said this - one of the latter chapters - how prostate cancer can make you live longer, the first thing I thought about is you made lifestyle changes to treat the prostate cancer so that might help protect you against heart disease, etc., etc. Is that what you meant or is it something totally different?
DR. MARK SCHOLZ: Well it's partly that, and it's partly based on studies that show that if you can get guys to go to the doctor, check their cholesterol, check their blood pressure, get a colon, you know screening, and do some of these basic things that you will make them live longer. Now what gets guys to the doctor? It turns out practically nothing will get guys to the doctor perhaps except prostate cancer. So when we get someone who comes in the door with a new diagnosis of prostate cancer we try and make the most of it and check their blood pressure, their cholesterol, you know get them screened. And studies show that since the mortality from prostate cancer is so low that men diagnosed with prostate cancer, low risk type of prostate cancer, live longer than the men that have never been diagnosed.
KIRK HAMILTON: We have been talking to Dr. Mark Scholz, a prostate oncology specialist in Marina Del Rey, California, and also co-author of the book "Invasion of the Prostate Snatchers. No More Unnecessary Biopsies, Radical Treatment or Loss of Sexual Potency." So I'm sure Dr. Scholz they can get it through Amazon or just -
DR. MARK SCHOLZ: It's widely available in all the usual outlets.
KIRK HAMILTON: Okay. I want to thank you so much for taking time out of your busy day to be on the show and I'm sure we will be in touch.
DR. MARK SCHOLZ: A great pleasure Kirk. Thank you so much for having me.
KIRK HAMILTON: And you're very welcome. And I want to thank you, the audience, for listening to this edition of Staying Health Today Radio. And until next time, Stay and Be Well.
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