The Prostate Cancer Revolution: Beating Prostate Cancer Without Surgery

THE PROSTATE CANCER REVOLUTION

THE

PROSTATE

CANCER

REVOLUTION

Beating Prostate Cancer

Without Surgery                

ROBERT L. BARD, MD

With a chapter on focal laser treatment by Dan Sperling, MD

Edited by Karen Barrie, MS

THE PROSTATE CANCER REVOLUTION

Beating Prostate Cancer Without Surgery

© 2014 ROBERT L. BARD, MD.

All rights reserved. No portion of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopy, recording, scanning, or other,—except for brief quotations in critical reviews or articles, without the prior written permission of the publisher.

Published in New York, New York, by Morgan James Publishing. Morgan James and The Entrepreneurial Publisher are trademarks of Morgan James, LLC. www.MorganJamesPublishing.com

The Morgan James Speakers Group can bring authors to your live event. For more information or to book an event visit The Morgan James Speakers Group at www.TheMorganJamesSpeakersGroup.com.

DISCLAIMER: The information in this book is for educational purposes only and is not a substitute for professional medical care. Dr. Robert Bard and the Biofoundation for Angiogenesis R & D

ISBN 978-1-61448-905-4 paperback

ISBN 978-1-61448-906-1 eBook

ISBN 978-1-61448-908-5 hardcover

Library of Congress Control Number:

2013947438

Cover Design by:

Rachel Lopez

www.r2cdesign.com

Interior Design by:

Bonnie Bushman

bonnie@caboodlegraphics.com

In an effort to support local communities, raise awareness and funds, Morgan James Publishing donates a percentage of all book sales for the life of each book to Habitat for Humanity Peninsula and Greater Williamsburg.

MEDICAL TEXTBOOKS BY DR BARD

DCE-MRI of Prostate Cancer (Springer 2009)

Image Guided Prostate Cancer Treatments (Springer 2013)

HEALTH BOOKS BY DR BARD

Prostate Cancer Decoded

Prostate Cancer Demystified

Focused Prostate Cancer Treatments

MEDICAL BOOKS CO-AUTHORED BY DR BARD

Ultrasonography of the Abdomen

Ultrasonography of the Pelvis

Ultrasonography of the Eye

Imaging of the Foot

Diagnostic Ultrasonography of Skin Cancer

DEDICATION

To my patients, whose courage showed me possiblity

To my wife, Loreto, whose vision generated results

TABLE OF CONTENTS

Foreword

Preamble

Prologue

CHAPTER 1   Taking the Risk to Change

CHAPTER 2   Understanding the Facts

CHAPTER 3   Medical Truths Are Not Sacred Cows

CHAPTER 4   Practical Anatomy, Pathology and Diagnosis

CHAPTER 5   Trust Experience and Gather Information

CHAPTER 6   Focal Laser Ablation of Prostate Tumors

CHAPTER 7   Assessing Treatment Response

CHAPTER 8   Reflections on Conventional Treatments

CHAPTER 9   Promising Scientific Breakthroughs

CHAPTER 10 Boosting The Body’s Defenses

CHAPTER 11 Cancer Screening Pro’s and Con’s

CHAPTER 12 An Open Mind Is Your Best Friend

Epilogue

Acknowledgments

Appendices

You see things: and you say, "Why?"

But I dream things that never were: and say, "Why not?"

—George Bernard Shaw

AUTHOR’S BACKGROUND

Diplomat American Board of Radiology

Member American College of Radiology

Clinical Associate Professor of Radiology New York Medical College

Director, Bio-foundation for Angiogenesis Research and Development

Advisory Board, International Musculoskeletal Ultrasound Society

High Intensity Focused Ultrasound Certification-Prostate Cancer Imaging

Member, International Cancer Imaging Society

Member, Societe d’Imagerie Ultrasonore

Member, Societe d’Imagerie Genito-Urinaire

Member, Societe Francaises de Radiologie

Member, American Society of Lasers in Medicine and Surgery

High Frequency Ultrasound Coordinator for

American Institute of Ultrasound in Medicine

FOREWORD

By Professor David Khayat, MD, PhD

President of the International Cancer Society (Paris, France)

With an estimated 238,590 new cases in 2013, prostate cancer is the most common cancer in men in USA. One man in 6 will be diagnosed with this disease in his lifetime. It is, at the same time, the second biggest killer in men, with an estimated 29,720 deaths in 2013 in the United States.

As for other cancers in the past, the science of prostate cancer has changed tremendously during the last ten years. Pre-malignant conditions have been described leading to an extremely active search for genomic signatures of prostate cell transformation. Cohort studies are ongoing. The diagnosis of prostate cancer has become more sophisticated with the introduction of newer criteria, outside of the classical Gleason classification, that could predict an individual’s tumor aggressiveness, with the hope of better and more personalized tailored therapeutic strategies.

Among them, watchful follow-up is more widely accepted and fewer patients are getting an unnecessary prostatectomy, that, due to the widely increased use of PSA screening that occurred during the last decade, was the reason for some real concerns, both in terms of individual risk as well as for the economy of cancer.

All the tools that constituted the classical armamentarium in the management of prostate cancer have had an impressive evolution toward high sophistication and better indication: Surgery with the unquestionable benefit of the robotic technologies. Radiotherapy with the IMRT and endo brachytherapy and ARC-Therapy. Hormonal treatment with two newly approved medicines such as Abiraterone and Enzalutamide and others in clinical developments. Chemotherapy also with Docetaxel and Cabazitaxel.

Finally, prostate cancer, which was for years a disease with very few options, and not really well understood, is now a field of great change, evolving knowledge, and the focus of ongoing basic and translational research.

There is another field of particular attention regarding prostate cancer: this is the diagnostic procedures. Anatomical imaging, functional imaging as well as molecular imaging appear today as useful tools that as an oncologist, one needs to know and understand.

Acquiring this knowledge and these skills in order to improve the management of patients is a real challenge. This is where Robert L. Bard and his colleagues have contributed tremendously, through this fantastic book, to help us in decoding what is significant prostate cancer and offering revolutionary treatments.

Each chapter of this book is a kind of Bible where all existing information in the different scopes that ultimately defines the everlasting, so rapidly evolving field of prostate cancer is explained. Rarely has so much useful data been put together with such efficient communication style as in The Prostate Cancer Revolution.

I already advised all my assistants to read it carefully as I am sure that it will certainly help to improve our patients’ outcomes worldwide.

PREAMBLE

Nothing in life is to be feared. It is only to be understood.

Now is the time to understand more, so that we may fear less.

—Marie Curie

Finally, the doctor became the patient. My role reversal was the result of having found my own prostate tumor. I had undergone an MRI for back pain and the prostate outline seemed abnormal. I performed my own sonogram and saw a small anterior (front) tumor that an examining finger could only miss, being limited to feeling the posterior (rear) side surface of the gland. I knew from my scan that the tumor was not aggressive, but it approached the outer capsule of the gland and could possibly break out of the protective covering at some later point. I decided to put my ass on the line and in the MRI scanner again. After local anesthesia, the tumor was painlessly biopsied. The biopsy confirmed nonaggressive disease several days later. However, not knowing the biopsy results, I immediately underwent the laser ablation. I felt some warmth and then it was over. No catheter and so far, no side effects. No matter what the biopsy would show, I wanted the problem gone. Another reason to have the laser ablation that took less than an hour—start to finish—was to remove the worry about spreading tumor cells after the biopsy. The laser heat cauterizes (burns) the biopsy tract killing any cells that may have escaped during the procedure. This is why it makes sense to destroy the suspicious area at the time of biopsy before the potential cancer cells can spread into other tissues.

PROLOGUE

CHRISTMAS 2012: The white haired professor of surgery suddenly stood up in the middle of the university center medical conference, glared at the presenter and pointedly said: How can this test be accurate? For half a century, he continued, I could tell a patient with liver metastases from malignant melanoma just by looking at the patient. Anyone with a glass eye and a bulging liver had a certain diagnosis of metastatic uveal (eye) melanoma to the liver. And you are saying that the $5,000 PET (positron emission radiation) scan cannot reliably show this?

Unfortunately, some of these expensive tests have limitations; many of them also involve exposure to radiation. Many of the radioactive procedures lack some degree of specificity. We have developed non-radioactive imaging technologies that are replacing many older modalities and are proving more useful for diagnosis and follow up of many diseases. Breakthroughs in computerized ultrasound and robotic MRI systems are leading the path to simpler and better diagnosis and treatment applications.

As these treatments have improved dramatically in effectiveness, education of the medical profession and the patient population must be addressed to ensure that these modalities are discussed and possibly offered. As a patient, you are welcome to show this book to your physician. If he has any questions, all the data can be found on the internet or my website, www.bardcancercenter.com. I will also be happy to speak with a physician about what is possible for his/her patient. I will not be available to discuss the fact that so few physicians have this equipment or even understand this worldwide technology.

You will die in 6 months without immediate surgery

John leaned back in his chair. Then he straightened up, looked his doctor in the eye and said, I will take my chances and wait. That was seventeen years ago. John had prostate carcinoma (cancer). His physician did not tell him that only 3% of prostate cancer was lethal. Unaware of the favorable odds (97% chance that his tumor was nonaggressive), John’s inner faith helped him to avoid the unfavorable and likely side effects of surgery, hormones and radiation.

John died in 2008. His well-intentioned doctor at that time didn’t realize the natural history of minimally aggressive prostate cancer and had been indoctrinated by the medical profession to dismiss alternative medicine as useless, if not dangerous.

I am struck by the increasing number of patients opting for homeopathic therapies and the high percentage of survivors with tumors who see me for assistance. As a diagnostic radiologist, I am not a treating physician, yet people flock to my office looking for reassurance that their chosen treatments are working. Patients taking charge of their medical care and outcomes were unwelcome in the medical milieu of the last century.

I use my imaging technologies to show the progress of cancer treatment because I had a similar experience with the culture of medicine in the past. After polio at age 4, my legs started failing. The doctors at the rehabilitation center specializing in this nationwide epidemic had already warned my parents I would never walk again. Even as I felt some sensation coming back in my legs, we were told I would be crippled for life. Thirteen years after I was told I would be paralyzed, I became certified as a Red Cross Water Safety Instructor and taught lifesaving techniques to lifeguards. I was very happy to prove medical science wrong.

How did this distrust of medical diagnosis and prognosis happen?

I was in the hospital recovering from paralytic polio during the worldwide epidemic in the 1940’s and became short of breath. My father, a bronze star medal recipient as a physician during World War II, came in to examine me. He heard me cough, saw my dusky color, listened to my lungs, felt my hot forehead and went over to talk to my doctors. There was arguing. My father told the physician in charge I had acute pneumonia; they told him I was dying from the paralysis of my diaphragms preventing me from breathing. My father stopped talking to them, came back and whispered to me: See these little white pills? Take one pill before each meal. Do not tell anyone else you are taking them. I will be back tomorrow. I hid the tablets under my pillow. At mealtime I decided to follow my dad’s advice and ignore the specialists taking care of me. The next morning my breathing was better. As a M.A.S.H. medic, my father had brought back with him the antibiotic penicillin from the Pacific theater of war. It was still not widely available in the United States in 1949 and certainly not well understood. Penicillin saved the GIs’ lives during the war. This antibiotic was so powerful that the medics on the battlefield could smell the infections of the wounded who did not have access to this wonder drug. My father saved my life by trusting his combat-tested experience rather than the advice of the so-called experts.

I volunteered to support my country during the Vietnam conflict. With one year of radiology specialty experience, I was sent to Thailand to support the Tactical Air Command as a Captain in the U.S. Air Force. As the only USAF radiologist within 300 kilometers of Udorn Royal Thai Air Base, I assisted in diagnoses in remote places as far-flung as Thailand, Laos, Formosa, Guam, Vietnam and Cambodia. The Air Force medical facility at our base took care of the U.S. General Staff and high ranking officers of our allied forces. This was a state-of-the-art military hospital and boasted physicians of the highest caliber recruited from all over the US according to their specialties.

I also learned that in the practice of medicine, reality did not always coincide with cookbook formulations. For example, the treatment of the Cambodian colonel whose chest x-ray revealed multiple live hand-grenades buried in his chest wall could not be found in any medical textbook. There were also many different ways to treat diseases within our nation-wide American thinking and even more options employing Oriental medicine. Remember, in China, if the Chinese emperor died, so did his physician. Exposed to varied treatment possibilities, I eagerly tried to integrate Eastern medicine concepts with proven Western medicine teachings. I soon learned that there were effective alternative ways to treat many medical problems. I also observed cultural differences connected to anatomical usage. For example, the Thai people would rest by squatting. Americans, trying to fit in with local customs, quickly developed knee joint irritations. The makeup of Asian bodies had adapted to ethnic practices (or perhaps vice versa, since evolution is intertwined with behavior and environment.). Upon completion of active duty, I returned to the United States as a major and as a man who had seen diseases and treatments not common in traditional medical studies. I was humbled by the inexplicable success of Eastern remedies not readily understood by Western standards. I am even more profoundly concerned that the technologies you will read about in this book have barely penetrated the layers of our own medical community. My references are from the years 1998 to 2013. This is 15 years of proven data that should have shifted the standard of care from blind biopsies to imaging the prostate to find the so called index lesion that is clinically significant. Now that we can identify the killing cancer using ultrasound and MRI, image-guided methods are able to destroy tumors with major damage to the malignant cells and minimal damage to the patient.

I am writing this book to inform patients about the leading edge of medical diagnosis and new therapeutic options using image-guided treatments. I have changed my profession from diagnostic radiologist who saw only films to interventional radiologist who examines a patient and provides therapy based on the current picture of the specific disease. Treatment may be tailored for each patient based on newer concepts in radiological imaging, advanced minimally invasive treatments and on a sensitivity to the patient’s personal needs and lifestyle choices.

Life without humor, according to Oscar Wilde, is not worth living. Medicine without compassion may not be worth dispensing. It is too easy today to cure the disease and destroy the patient in the process as we have witnessed with chemotherapies. This book aims at preserving human dignity and controlling cancer at the same time. My purpose in writing this book is threefold:

to provide practical knowledge of this disease

to offer hope and treatment options based on scientific data, and

to encourage realistic empowerment to deal with life’s medical challenges.

Not all cancer kills. In fact, most prostate cancers are now treatable without surgery. Minimally invasive treatment for benign diseases can be done in fifteen minutes while minimally invasive definitive cancer treatments may take from one to four hours. The message here is that a person need not fear prostate cancer and the risk of life-impairing treatment side effects when new and non-invasive modalities are now being utilized to detect and treat malignant tumors quickly, painlessly, and more accurately. The multiplicity of noninvasive and minimally invasive therapies with fewer side effects offers men new health choices.

CHAPTER 1

TAKING THE RISK TO CHANGE

11 PM. Emergency Department. Metropolitan Hospital. New York City, 1973. Twenty-six year old female brought in with stab wound to the chest and increasing shortness of breath. Medical team must know if there is bleeding into the pericardium, the sac that holds the heart. I confer with the heart surgeon, leave the ED and proceed to the obstetrics department. I bring back an ultrasound machine used on a pregnant woman’s abdomen for determining fetal growth and place the scanner over the heart of the bleeding patient. With clear images of the extent of the injury, the patient is rushed to the OR. The surgeon, now armed with a precise picture of the site of the hemorrhage, targets his operation. The bleeding around the heart is stopped at 1:00 AM. The patient lives.

This real life story shows that a medical technology dedicated to a single use may have other potential uses. Eye scanners were used on the breast in 1978 to perceive mammary problems. Breast scanners looked at joints and tendons in 1990. Tendon imaging devices that showed blood vessels and demonstrated actual live blood flow near a joint were adapted to imaging the prostate in the mid 90’s. Scanners, showing the face of the fetus using 3-Dimensional (3-D) pictures inside the uterus fifteen years ago, were soon placed on the shoulder and knee to assess injuries. Technology that improved shoulder imaging with 3-D pictures became available for the prostate ten years ago. For a while, medical imaging was mainly limited by the lack of curiosity of the physician and the paucity of semiconductor technology to make more powerful computer chips. Medical breakthroughs are sometimes as simple as thinking outside the box. There are similarities between the resistance of medical science to embrace innovations in diagnosis and treatments, and the tendency of individual persons to resist embracing constructive new ideas and behaviors. To understand how an entire profession can be slow to welcome advances, let’s first examine human nature.

The following story of the Rat and the Cheese illustrates a how a laboratory animal changes its habit when experience showed the behavior was no longer meaningful. A rat was put in a tunnel with a piece of cheese at the end. The rat ran down the tunnel and ate the cheese. Day after day the rat was able to wend its way down the course to find unerringly the tasty morsel. One day the cheese was removed. The rat went down the tunnel and tried to find the cheese. The next day the rat entered the tunnel and searched without success. The third day the rat went into the tunnel and came out without any cheese. At the end of the fourth day the rat refused to enter the tunnel.

The difference between rats and human beings is this: the rat quickly learned what worked and what did not work, while people often continue outmoded or futile behavior patterns despite the absence of tangible rewards. For example, if one goes into a room full of people and asks those who are 10 pounds or more overweight to raise their hands, and then asks those who know that exercise and dieting will control their weight to raise their hands—the same hands go up. Being overweight is not rewarding physically or psychologically. Those who raise their hands know better, yet that knowledge is not sufficient for them to override their self-destructive habits.

Here’s another example from nature. Do you know hunters trap wild monkeys? You see, these primates are similar to humans in important ways. A banana is put into a jar with a narrow neck. The monkey reaches into the jar and grabs the banana in his closed fist. The width of the clenched hand with the banana is wider than the jar opening. As the hunter comes to catch the monkey, the animal gets frantic, but will not let go of the banana. All it has to do is give up its grip—simple, but the monkey’s instinct to hang onto food interferes with its ability to risk letting go for a greater good.

Unlike the rat, people often don’t listen to their own experience. Instead, like the monkey, they cling to old ways. In particular, men may avoid dealing with health issues due to denial based on fear—will the treatment be worse than the disease (impotence or incontinence)? A man’s first approach to a medical problem is to wait, hoping it will go away. When the condition worsens, he waits again hoping his health won’t deteriorate further or that his body’s natural immune defenses will come to the rescue. Finally, when he can no longer put up with the alteration of his lifestyle, the entreaties of his concerned wife or the intolerance of his physical state, he decides to get help. FEAR stops men from being proactive in their health. Women complain about the inconvenience of mammograms, yet few miss their yearly appointments. In fact, demand is so great that in New York City the current wait time for this often uncomfortable test is up to 6 months.

What’s behind the fear of seeing the doctor? Patients who delay seeking medical help fall into four risk-avoidance categories:

The stoic, who sees sickness as unmanly or a sign of weakness

The worrier, who knows too much about possible medical side effects

The ostrich, who is in denial

The victim, who gets attention from others for maintaining suffering.

Then there is the perfect patient, who overcomes his fear or anxiety and attends to potential problems early.

Fear thwarts and contradicts our natural need for survival, just as the monkey gave up the long-term survival of freedom for the short-term gratification of having a banana. Fear is a physiologic byproduct of our concerns over pain, interruption of daily routine by long waits, extensive recovery periods, and possibly, death. For countless men, the idea of seeing a doctor activates these concerns. White collar hypertension (high blood pressure) is a real phenomenon. Our blood pressure often rises in the doctor’s office with the