Prostate Cancer Q&A with Dr. Geo Espinosa, ND
Prostate cancer is the leading cancer among men after skin cancer. According to the American Cancer Society, it affects 1 in 7 men and there will be over 160,000 new prostate cancer diagnoses in 2017. Roughly 1 in 39 men will die from prostate cancer/PrCA, which means that the majority of men diagnosed with prostate cancer do not die from it. Men with localized disease have a 100% survival rate at five years. To put it another way, an American man has a 16% lifetime risk of developing prostate cancer, but the risk of dying from it is only 2.9%.1 An interesting study from 1996 investigated the incidence of prostate cancer via autopsy (died from trauma) and found that one-third of the men in their thirties had prostate cancer. It is also important to note that the majority of deaths from prostate cancer occur in men in their 70s and 80s. These statistics illustrate that prostate cancer is typically a slower-growing cancer and that the majority of men with prostate cancer will die from causes other than prostate cancer.2 There is an opportunity for integrative practitioners to further educate themselves and patients on how to address and modify the lifestyle factors that influence disease progression.
There are ongoing changes in the screening and management of prostate cancer. To help sort through the updates and advances is Dr. Geo Espinosa, ND, an expert in the field who has counseled thousands of patients with prostate cancer in New York City at the Holistic Urology Center at Columbia University Medical Center. Dr. Espinosa is currently working at the Integrative and Functional Urology Center at New York University’s Langone Medical Center.
Q&A with Dr. Geo Espinosa, ND
Q: What do you recommend in terms of screening for prostate cancer?
Dr. Espinosa: The physical exam is of great value and I do recommend regular DREs (digital rectal exams). While PSA (prostate specific antigen) screening is not without its flaws and limitations, there is value to testing patients. The prostate gland does secrete small amounts of PSA and levels can increase secondary to enlargement, inflammation and cancer. If the PSA is greater than 10, then practitioners should screen for PrCA with additional markers related to PrCA. It is also about how the PSA changes over time, called the PSA velocity or doubling time. Men with PSA lower than 10 may also have prostate cancer, so family history, DRE, PSA Density and PSA velocity become important before screening with more aggressive medical methods like biopsies.
I start testing the PSA of every man 40 to 45 years of age, which is ten years younger for men (with average risk of prostate cancer) than dictated by the American Urological Associations guidelines. Men with a strong family history of this disease or from African American descent have an increase risk and should begin screening at 40. I find that men who are diagnosed with PrCA in their 40s have a more aggressive type of cancer than older men who get PrCA. I’m unsure as to why, but have noticed this trend clinically. At a minimum, have baseline testing at 40 years of age. If low PSA at 40 (under 1), then you can do it again in five years.
Q: How does one make best use of the PSA test?
At 40 to 50 years of age, 2.1 is not low and you should test at least every six to 12 months moving forward.
At 60 years of age, 2.1 is low.
At greater than 70 years of age, PSA is irrelevant because if you are diagnosed with PrCA at this age, it is more likely that one will die from other co-morbidities as prostate cancer is such a slow-growing cancer.
Q: What are your guidelines on PSA velocity?
Dr. Espinosa: PSA velocity/PSAV measures the significance of PSA changes over time. If the PSA today is a 2.0, for example, and then in six months it’s at 4.0, then the PSAV score is 2.0 over a six-month period and that may be significant. PSAV can be one measure to determine if a biopsy should be considered as part of your prostate cancer screening. A PSAV of 0.75 in a year has been associated with a higher probability of cancer.
Q: What other screening tests do you recommend?
Dr. Espinosa: Percent Free PSA is an important test in that it lets you know the amount of unbound PSA traveling in the blood compared to total PSA. The lower the percentage of unbound or free PSA, the higher the probability of cancer. If the free PSA is between 5-9%, there is a greater than 25% of prostate cancer. On the flip side, if the free PSA is greater than 25%, there is less than a 10% chance of prostate cancer.
PSA Density (PSAD) is another piece of the puzzle that measures PSA value relative to the size of the prostate gland as measured by ultrasound or MRI. Once you divide PSA value over prostate volume, a value over 0.15 may suggest aberrant cells in the prostate.
I also recommend the 4Kscore Test, a blood test that measures the probability of there being a more aggressive type of PrCA. It includes total PSA, free PSA, intact PSA and human kallikrein-related peptidase 2.
The Prostate Cancer Antigen 3/PCA3 is a genetic molecule found in a urine test that is highly overexpressed in nearly all prostate cancers. Urine is collected after a DRE of three strokes per lobe. PCA3 has been evaluated for guiding biopsy decisions when PSA levels are in an indeterminate range (2.5 to 10.0 ng/mL) and for men with previously negative biopsies but persistently elevated PSA levels.
Q: When do you recommend a biopsy?
Dr. Espinosa: Recommendations for biopsy is a case-by-case basis. If there is a strong family history and the many of the above motioned values suggest prostate cancer is present, then the next step would be a pelvic MRI, targeted biopsy as explained below.
Q: When do you recommend ‘active surveillance’?
Dr. Espinosa: After a biopsy, if the Gleason score (a staging method for prostate cancer) is six, active surveillance is suggested and intensive lifestyle and naturopathic interventions should be the primary treatment.
Q: What type of biopsy do you recommend?
Dr. Espinosa: I recommend a targeted biopsy, also called the MRI ultrasound fusion biopsy. Prior to biopsy, the patient will undergo a multi-parametric MRI because it is the best option to show the locations of the lesions in the prostate gland and it is pretty accurate, although not 100%. In the random biopsy using only ultrasound (TRUS biopsy), important cancer cells can be missed due to the limited image quality of the ultrasound and the TRUS biopsy often gets low-risk cancer cells that we shouldn’t worry about. In addition, sometimes cancer cells are in areas that are hard to reach with the biopsy needle. The MRI image lights up areas of concern and when the physician knows ahead of time which areas to definitely include for biopsy, the technique can be altered to ensure those areas are biopsied. The ultrasound image is fused with the MRI for the biopsy to help guide the sampling. The better the image, the better the biopsy.
The targeted biopsy is more accurate at targeting higher risk/more aggressive types of prostate cancer cells. Insurance companies are only paying for fusion biopsies in those who have already been diagnosed with prostate cancer and are not being treated, but are under active surveillance. The MRI is about $1,200 out of pocket for those without insurance coverage.
Q: What are your therapeutic goals when working with men with prostate cancer?
Dr. Espinosa: You want to create a hostile micro-environment for the cancer cells:
Lower chronic inflammation
Promote immunity, especially natural killer cell activity
Protect against oxidative stress
Healthy insulin and blood sugar control
Q: What type of diet do you recommend for your patients who are positive for prostate cancer and low risk: those under ‘active surveillance’?
Low carbohydrate diet (less than 150 grams per day) with lots of organic cruciferous vegetables.
Organic, grass-fed meat diet.
Avoid overly cooked or processed animal meats (no charring or high heat) and enjoy smaller (low mercury) wild-caught fish.
No dairy! There is decent research associated with increased risk of prostate cancer with dairy consumption. I’m unsure if this is due to the quality of the dairy or the casein.
A little soy is fine; the research is mixed and some studies do show benefits.
Q: What do you recommend for exercise?
Four hours per week of moderate/high intensity aerobic exercise.
If on hormone androgen deprivation therapy, then add weight resistant training three times per week to prevent metabolic syndrome and osteoporosis.
Q: What do you recommend for supplemental support?
Curcumin, boswellia and grape seed extract/GSE for their anti-oxidant, anti-inflammatory and immune boosting effects. You might be surprised by GSE recommendation but research shows a 24% decrease in incidences of PrCA in men who consume GSE.
Milk thistle to help safely metabolize hormones.
Reishi mushroom extracts as the data is compelling in terms of Cochrane report. It is very useful for increased immune function and natural killer cell activity in cancer patients.
The following antioxidants are balanced; one shouldn’t do high doses of single antioxidants as there is the potential to make things worse.
Vitamin C: 500 mg daily
Zinc: 15-30 mg daily
Alpha lipoic acid: 100 mg daily
Selenium (selenized yeast form): 200 mcg daily
Vitamin E with mixed high gamma tocopherols 200 IUs daily
If you’d like a more in-depth look at prostate cancer, Dr. Espinosa wrote an excellent book called Thrive Don’t Only Survive: Dr. Geo’s Guide to Living Your Best Life Before & After Prostate Cancer. It goes through Dr. Espinosa’s CaPLESS Wellness Method, a sustainable lifestyle approach to improve the prognosis for men diagnosed with prostate cancer.
Prostate cancer is an inflammatory condition and the best medicine is always prevention. While many integrative practitioners routinely guide patients on how to reduce inflammation (good sleep, organic colorful diet, exercise, stress management, healthy digestive biome, and elimination of chronic infections), it is also helpful to remember the wide variety of environmental factors that also influence health and disease.
Perfluorooctanoic acid/PFOA is a synthetic chemical compound and known toxicant that is used in Teflon, Gore-Tex, textiles and carpets and can be found in the air and house dust. Recent EPA monitoring found PFOAs in water supplies that serve nearly 10 million Americans.3 A 2013 study that looked at six contaminated water supplies found that higher PFOA serum levels were associated with testicular, kidney, prostate and ovarian cancers.4 A study done just last year in Illinois found that counties with higher mean arsenic levels in community water systems had significantly higher prostate cancer incidence.5 While grape and apple juice made the news as being contaminated with arsenic, your municipal drinking water supply is still your greatest source of exposure to arsenic! Highlighting just two of the toxicants that can influence prostate cancer warrants consideration when formulating strategies on prevention and management.As there is pervasive exposure to thousands of chemicals every day, professional-grade water and air filters are an important consideration in integrative treatment protocols.
In summary, prostate cancer is a slower growing cancer and the screening tools continue to evolve to allow for better discernment of disease presence and the likelihood of progression. Integrative practitioners can significantly enhance “active surveillance” of prostate cancer with lifestyle modifications, toxicant exposure reduction and supplemental nutrient support.
- Ries, LAG, Melbert, D, Krapcho, M, et al (Eds). SEER Cancer Statistics Review, 1975-2004, National Cancer Institute, Bethesda, MD 2007. Available at: http://seer.cancer.gov/csr/1975_2004/ (Accessed on October 16, 2009).
- Sakr WA1, Grignon DJ, Haas GP, Heilbrun LK, Pontes JE, Crissman JD. Age and racial distribution of prostatic intraepithelial neoplasia. Eur Urol. 1996;30(2):138-44.
- Vieira VM1, Hoffman K, Shin HM, Weinberg JM, Webster TF, Fletcher T. Environ Health Perspect. 2013 Mar;121(3):318-23.
- Bulka CM, Jones RM, Turyk ME, Stayner LT, Argos. Arsenic in drinking water and prostate cancer in Illinois counties: An ecologic study. Environ Res. 2016 Jul;148:450-6.
Geo Espinosa, ND
Dr. Geo Espinosa is an expert in the field who has counseled thousands of patients with prostate cancer in New York City at the Holistic Urology Center at Columbia University Medical Center.
By Tina Beaudoin, ND
Dr. Tina Beaudoin is a licensed naturopathic doctor and Senior Medical Educator with Emerson Ecologics. She enjoys seeing patients in her private practice in Manchester, NH and has been serving as the President of the New Hampshire Association of Naturopathic Doctors since 2012.