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Age, Exercise, and ADT for Prostate Cancer

Insights From: E. David Crawford, MD, University of Colorado in Denver; Matthew T. Rosenberg, MD, Allegiance Health Systems; Daniel Petrylak, MD, Yale School of Medicine
Published: Friday, Dec 23, 2016



Transcript:

E. David Crawford, MD:
Circling back to some of these things, you touched on something about age. There are these cut-offs, like don’t get a PSA on somebody over the age of 72. I see 80-year-old guys that can blow us off. They’re in great shape, they exercise. So, I think that’s where you have to individualize. Your colleagues sometimes criticize you, why did you order a PSA on an 80-year-old guy? And I say, “Well, if the guy has Gleason 9 cancer that’s threatening to his life, then we do it.”

Matthew Rosenberg, MD: I think that is so important, especially for primary care, because when we look at cut-offs, we get these guidelines that we have to follow. And, sometimes, they make sense, but in a case like this, it makes absolutely no sense. We have to individualize that patient, we absolutely do. And, just as you said, if I have a 60-year-old with COPD who just had a bilateral BKA (below-the-knee amputation) and they’re an insulin-dependent diabetic, I’m probably not going to get a PSA. On the other hand, just as you said, I get the 80-year-old who’s going to play tennis before he visits his dad; there’s a guy with good history. Medicine is still an art in a lot of ways, and we have to individualize the patient. And when we put up the guidelines that say don’t screen or stop screening at this age, we’re missing an opportunity to catch the patient whom we can help.

Daniel P. Petrylak, MD: It’s physiologic age rather than chronologic age, and there are always outliers that we have to worry about. And we have to ask our patients how they want to spend their lives.

E. David Crawford, MD: Circling back to the US Services Preventive Task Force, when I give talks, I say they were right. And, people go, “What are you talking about?” That correction was needed. We were overdiagnosing and overtreating Gleason 6s. The way forward with family practice is, with this PSA cut-off of 1.5, you do the next generation of tests, which are urine tests and blood tests. There’s 4Kscore Test, and there’s SelectMDx to find aggressive cancers, and that’s the way you want to go. If we go forward, and talking a little bit about the shared care, Dan, you said something about the guy and the bicycling, and then he didn’t have it. I think there’s a lot of evidence about people really needing to work on physical exercise and weight lifting, and so forth, and so on. There’s a big trial going on funded by the Movember movement about intense exercise in CRPC. What are your thoughts about that? We let that go a lot.

Daniel P. Petrylak, MD: Well, I think that when you counsel a patient about going on androgen blockade, you are obligated to talk to them about all the side effects. That includes how you prevent it. So, clearly, light weights, running, trying to burn calories, those are important overall to maintaining your weight. Because, remember, for men to lose a pound, who have normal hormonal access, they have to burn 3500 calories. It’s 4500 for a man on hormone therapy. I think that this is crucial because weight involves effects on sugar metabolism and diabetes. That, of course, has an effect on the heart, that has effect on blood pressure. So, this all is tied together in that situation.

E. David Crawford, MD: Again, circling back to what this is all about, shared care. The urologist isn’t always on top of that. You’re not always on top of what we’re doing. But, all these pieces need to fit together. The metabolic syndrome that occurs, again, we tend to ignore that. What you just said is that, when we first started using ADT, the survival rate was 18 to 22 months. Now, people are going 10 years. Maybe we’re actually curing some of these people.

Matthew Rosenberg, MD: What you just said about the exercise is so incredibly important, and actually I love to hear that. I absolutely love to hear that because when patients come into my office and they’re getting therapy for metastatic cancer, they’re depressed, obviously. They’re unhappy. I just had a patient yesterday I was seeing and they’re just depressed. So, what do they stop doing? They stop taking care of themselves, and my guess—and I’m going to start teaching on this just from what you just said—is that I should be pushing my colleagues in primary care that more exercise is better. We always said it is better. But, for you to say, in this condition, it’s even more important, that is such a pivotal point you said.

Daniel P. Petrylak, MD: In fact, what they often say is, “I’m too tired to exercise.” And, in fact, using that energy to get yourself out and to do something actually helps with depression. It helps with weight control, and, as long as they get over the hump to start doing something, I think that they really do benefit.

Matthew Rosenberg, MD: So, where I can help you is: I’m the cheerleader.

Daniel P. Petrylak, MD: Right.

Matthew Rosenberg, MD: You’re putting them on the therapy. You need them to exercise. You say, “Go and see Matt,” and they come in the office, and I’m like, “What are we going to do to get you out there?” “Well, I don’t know what to do, Matt.” We set up physical therapy. We can do that. We can help them set up an exercise regimen. There’s a lot of things that we can do. This is where communication just helps so much.

E. David Crawford, MD: There’s really ample evidence that people who have advanced cancer, and not just prostate cancer, exercise, stay in shape, and diet—not a crazy diet. We all see people who come in and say they’re taking Vitamin E and Selenium, and drinking soy, pomegranate juice, and everything else like that. What’s heart healthy is usually prostate-cancer healthy. You don’t have to go overboard. Those are things that we need to obviously work on, but the exercise and staying in shape is really something. And the guys whom I have on ADT, I’ve got a number of them who are in great shape and they’re tolerating quite well. These are the people who are out there, who continue to lift weights, they continue to exercise, they watch their diet. I just learned something from you. I didn’t realize it was 1000 calories more with ADT that you lost because of that.

Transcript Edited for Clarity
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Transcript:

E. David Crawford, MD:
Circling back to some of these things, you touched on something about age. There are these cut-offs, like don’t get a PSA on somebody over the age of 72. I see 80-year-old guys that can blow us off. They’re in great shape, they exercise. So, I think that’s where you have to individualize. Your colleagues sometimes criticize you, why did you order a PSA on an 80-year-old guy? And I say, “Well, if the guy has Gleason 9 cancer that’s threatening to his life, then we do it.”

Matthew Rosenberg, MD: I think that is so important, especially for primary care, because when we look at cut-offs, we get these guidelines that we have to follow. And, sometimes, they make sense, but in a case like this, it makes absolutely no sense. We have to individualize that patient, we absolutely do. And, just as you said, if I have a 60-year-old with COPD who just had a bilateral BKA (below-the-knee amputation) and they’re an insulin-dependent diabetic, I’m probably not going to get a PSA. On the other hand, just as you said, I get the 80-year-old who’s going to play tennis before he visits his dad; there’s a guy with good history. Medicine is still an art in a lot of ways, and we have to individualize the patient. And when we put up the guidelines that say don’t screen or stop screening at this age, we’re missing an opportunity to catch the patient whom we can help.

Daniel P. Petrylak, MD: It’s physiologic age rather than chronologic age, and there are always outliers that we have to worry about. And we have to ask our patients how they want to spend their lives.

E. David Crawford, MD: Circling back to the US Services Preventive Task Force, when I give talks, I say they were right. And, people go, “What are you talking about?” That correction was needed. We were overdiagnosing and overtreating Gleason 6s. The way forward with family practice is, with this PSA cut-off of 1.5, you do the next generation of tests, which are urine tests and blood tests. There’s 4Kscore Test, and there’s SelectMDx to find aggressive cancers, and that’s the way you want to go. If we go forward, and talking a little bit about the shared care, Dan, you said something about the guy and the bicycling, and then he didn’t have it. I think there’s a lot of evidence about people really needing to work on physical exercise and weight lifting, and so forth, and so on. There’s a big trial going on funded by the Movember movement about intense exercise in CRPC. What are your thoughts about that? We let that go a lot.

Daniel P. Petrylak, MD: Well, I think that when you counsel a patient about going on androgen blockade, you are obligated to talk to them about all the side effects. That includes how you prevent it. So, clearly, light weights, running, trying to burn calories, those are important overall to maintaining your weight. Because, remember, for men to lose a pound, who have normal hormonal access, they have to burn 3500 calories. It’s 4500 for a man on hormone therapy. I think that this is crucial because weight involves effects on sugar metabolism and diabetes. That, of course, has an effect on the heart, that has effect on blood pressure. So, this all is tied together in that situation.

E. David Crawford, MD: Again, circling back to what this is all about, shared care. The urologist isn’t always on top of that. You’re not always on top of what we’re doing. But, all these pieces need to fit together. The metabolic syndrome that occurs, again, we tend to ignore that. What you just said is that, when we first started using ADT, the survival rate was 18 to 22 months. Now, people are going 10 years. Maybe we’re actually curing some of these people.

Matthew Rosenberg, MD: What you just said about the exercise is so incredibly important, and actually I love to hear that. I absolutely love to hear that because when patients come into my office and they’re getting therapy for metastatic cancer, they’re depressed, obviously. They’re unhappy. I just had a patient yesterday I was seeing and they’re just depressed. So, what do they stop doing? They stop taking care of themselves, and my guess—and I’m going to start teaching on this just from what you just said—is that I should be pushing my colleagues in primary care that more exercise is better. We always said it is better. But, for you to say, in this condition, it’s even more important, that is such a pivotal point you said.

Daniel P. Petrylak, MD: In fact, what they often say is, “I’m too tired to exercise.” And, in fact, using that energy to get yourself out and to do something actually helps with depression. It helps with weight control, and, as long as they get over the hump to start doing something, I think that they really do benefit.

Matthew Rosenberg, MD: So, where I can help you is: I’m the cheerleader.

Daniel P. Petrylak, MD: Right.

Matthew Rosenberg, MD: You’re putting them on the therapy. You need them to exercise. You say, “Go and see Matt,” and they come in the office, and I’m like, “What are we going to do to get you out there?” “Well, I don’t know what to do, Matt.” We set up physical therapy. We can do that. We can help them set up an exercise regimen. There’s a lot of things that we can do. This is where communication just helps so much.

E. David Crawford, MD: There’s really ample evidence that people who have advanced cancer, and not just prostate cancer, exercise, stay in shape, and diet—not a crazy diet. We all see people who come in and say they’re taking Vitamin E and Selenium, and drinking soy, pomegranate juice, and everything else like that. What’s heart healthy is usually prostate-cancer healthy. You don’t have to go overboard. Those are things that we need to obviously work on, but the exercise and staying in shape is really something. And the guys whom I have on ADT, I’ve got a number of them who are in great shape and they’re tolerating quite well. These are the people who are out there, who continue to lift weights, they continue to exercise, they watch their diet. I just learned something from you. I didn’t realize it was 1000 calories more with ADT that you lost because of that.

Transcript Edited for Clarity
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