Prostate Cancer Nutrition

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Excerpts from Mark Moyad's Bottom Line Update ABCs of Nutrition & Supplements for Prostate Cancer full article in August 2002 issue of Urol Clin N Amer Phil F. Jenkins Director of Complementary/Preventive Medicine University of Michigan Medical Center-Section of Urology 1500 East Medical Center Drive Ann Arbor, Michigan 48109-0330 Email Moyad@umich.edu www.nlm.nih.gov.com www.consumerlabs.com www.quackwatch.com PDR for herbal medicines PDR for dietary supplements

Prostate Nutrition Article

I. Lifestyle Changes-Think Heart Healthy=Prostate Healthy

1. Saturated Fat=Hydrogenated Fat=Decrease to less than 10% of calories (ideally~ less than 7 % )
   One of the only studies (Quebec City) that examined diet impact after prostate cancer diagnosis found an improved prognosis for those who consumed less than 10% (read labels) of calories from saturated fat.
2. Trans-Fatty Acids=Partially Hydrogenated Oils=Eliminate these from the diet.
   Epidemiologic research has demonstrated a greater relationship between trans-fatty acids and cardiovascular risk compared to saturated fat. New research demonstrates a possible relationship between intake and cancer risk.
3. Increase Consumption of Fruits & Veggies (not just tomato (products)
   All types of fruits and veggies are getting good data. For example, tomato products, cruciferous veggies (broccoli, cauliflower, brussels sprouts, apples)
4. Soy/Flaxseed Products (just soybeans, soy protein powder, flaxseed…) =1-2 servings/day
   FDA has approved advertising that 25 grams of soy PROTEIN/day (not isoflavones) can reduce cholesterol when substituted for ANIMAL PROTEIN. Flaxseed is high in fiber so it should not be taken at the same time one takes any oral medications/supplements (allow a 2-3 hour window).
5. Maintain A Healthy Weight (BMI) - Calculate your BMI here & Exercise (150 minutes/week)
   Cancer prevention study I & II study showed a greater relationship to prostate cancer mortality with excess weight-more than incidence. The mental health benefits of regular physical activity are as strong as the physical health benefits.

II. Dietary Supplements = Think dietary sources first

1. Selenium=200 mcg/day from a brewers yeast source ideally IF YOU QUALIFY
   Initial evidence suggests that current or recent smokers or those with low levels of plasma selenium are the only individuals who may benefit. I would go for the dietary sources first (fish, garlic, brazil nuts,...) before taking this supplement. Do not necessarily supplement if you are taking a cholesterol-lowering drug (statin) with or without niacin.
2. Vitamin E=50-400 IU/day IF YOU QUALIFY.
   Initial evidence suggests that current or recent smokers are the only individuals who may benefit. Again, I would go for the dietary sources (nuts, seeds, oils=soybean, canola, olive, safflower,...). Vitamin E supplements have been a big disappointment over the past few years in cardiovascular trials (HOPE, PPP,...). In addition, vitamin E supplements reduce levels of dietary vitamin E, and dietary vitamin E was recently found to inhibit COX-2 activity (vitamin E supplements do not). Do not necessarily supplement if taking a cholesterol-lowering drug (statin) with or without niacin and/or aspirin.
3. Low-Dose (81 mg/day) Aspirin/NSAIDs=The Gold Standard IF YOU QUALIFY
   Every major randomized trial (Physicians Health Study, PPP,...) of low-dose aspirin (81- 100 mg/day) has ended early because it reduces the risk of a first or second cardiovascular event by 50% within 5 years. However, only older (>70>60>50 years) individuals who qualify seem to benefit (more aggressive tumors & high levels of C- Reactive Protein=CRP). Side effects from aspirin/NSAIDs are serious = internal bleeding & ulcers, so only take it if you qualify.
4. PC-SPES for Hormone-Refractory Disease??? PC-SPES was removed from the market in December 2001 due to contamination with coumadin (a strong blood thinner)

III. Special Conditions

1. During any treatment (seeds, external beam, radical prostatectomy)... Do Not Take Supplements.
   Why would anyone take a chance of compromising a proven and definitive treatment by combining it with a non-proven unknown treatment-it is not worth the risk. Allow 3-6 months to pass at least (talk to your doctor) before going back on supplements. This is a good time to focus on the LIFESTYLE CHANGES.
2. Hot Flashes
   Mild to moderate hot flashes may be reduced with 1-2 dietary sources of soy protein/day (60 grams=76 mg of isoflavones), and/or with 800 IU of supplemental vitamin E (400 IU in morning & 400 IU in the evening). Do not necessarily take vitamin E supplements if you are on a cholesterol-lowering drug (statin) and/or aspirin. Otherwise, black cohosh supplements (Remifemin@) are undergoing several trials. If these do not help than it is time to talk prescriptions (Megace, DES, Effexor@, Paxil@,...has no effect on bone health).
3. Osteoporosis
   Take 400-800 IU/day of vitamin D (400 IU in multivitamin). Fall and winter months require about 800 IU/day. This should be combined with calcium supplements (minimum 500 mg/day to maximum of 1200 mg/day). Calcium carbonate supplements like TUMS@, Rolaids@, Viactiv@,... should be taken with a meal for absorption. Calcium citrate supplements (Citracal) can be taken with or without meals and are the best calcium supplements for those with a history of oxalate stones, but they cost more. If a DEXA scan shows more serious osteopenia or osteoporosis than talk to your doctor about the advantages & disadvantages of drug (bisphosphonate, estrogen,...) therapy.
4. All patients should have a recent cholesterol test HDL LDL that should be included in their vatient history.
   Ischemic heart disease is the #1 or #2 killer of prostate cancer patients-enough said!!!

IV. Recent Research

1. A 3-year randomized trial of individuals on a statin cholesterol lowering drug + niacin found that antioxidant supplements significantly reduced the drug's effectiveness. The supplements used in this trial were a daily combination of 800 IV of vitamin E + 100 mcg of selenium + 1000 mg of vitamin C + 25 mg of beta-carotene. (Brown BG, et al: N Engl J Med 345:1583-1592, 2001)
2. Recent results from the largest vitamin E supplement trial of smokers (A TBC trial) found that those taking 50 mg/day of these supplements had significantly lower levels of testosterone. So, if vitamin E is preventing prostate cancer it may be through partial androgen suppression. (Hartman TJ, et al: Prostate 46:33-38,2001)
3. A multi-center trial of 235 women with metastatic breast cancer found that supportive-expressive group therapy did NOT improve survival, but it DID improve mood and the perception of pain especially in women who were initially more distressed. Support group therapy improves quality of life. (Goodwin PJ, et al: N Engl J Med 345:1719-1726).
4. Saw Palmetto=Alpha Blocker - Number 1 reason cancer patients take supplements=Immune Boost???

Complementary Medicine for Prostate Cancer-aka the Bottom Line"! - Mark A. Moyad, MPH

1. BPH: 320 mg/day (or 160 mg BID) of only Saw palmetto. Pharmaceutical brands like Centrum, Bayer, Warner-Lambert... have the highest standards. The most popular brand in Europe is called "Permixon".
2. Do not recommend Zinc supplements at this time.

PROSTATE CANCER HEALTH=CARDIOVASCULAR DISEASE PREVENTION

1. LIFESTYLE CHANGES
   
2. Lower saturated fat intake (less than 10% of total calories=just compare labels)
3. Encourage regular fruit & vegetable consumption. Not just tomato products, but pick what you like and stick with it. Variety is the spice of life.
4. 1-2 servings of traditional soy products (soybeans, tofu, miso, tempeh, soy protein powder, soy milk...) daily. 25 grams of soy protein per day has been given approval as a possible way to reduce cholesterol.
5. Maintain a normal weight or Body Mass Index (or BMI=kg/m ). This may have a greater effect than any supplement.
6. Exercise or walk regularly (several times a week for at least 30 minutes). This can also improve mental health and recovery from treatment.
7. Other potential lifestyle changes include: regular fish consumption, tea, flaxseed, dietary vitamin E and selenium,... from diet (not supplements).

SUPPLEMENTS

1. Selenium.
   200 mcg/day for those with low serum selenium levels. Current and recent smokers may benefit the most from these supplements. Otherwise good dietary sources include: nuts (especially brazil nuts), fish, poultry, garlic,...
2. Vitamin E.
   50-400 I.U. per day for current or recent (past 10 years) smokers. Otherwise nuts, seeds, and oils are a good source. Soybean oil is the best source. Other heart healthy oils like canola and olive oil are okay, but all oils should be used in moderation.
3. Aspirin.
   1 baby aspirin per day or 1 regular aspirin every other day if you qualify (cardiovascular/colon cancer risk). Keep in mind that internal bleeding and ulcers are primary side effects.
4. General Cheap Multivitamin (Centrum Silver, One a Day,...).
   The Nurses' Health Study (the longest study in the U.S.) has revealed potential numerous benefits with long-term use of a daily multivitamin.

SIDE EFFECTS FROM PROSTATE CANCER TREATMENT*

• Radiation treatment (external beam and/or seeds) or cryotherapy.
  No supplements apart from a general multivitamin should be recommended during treatment. This is a very conservative approach because of the lack of studies. Lifestyle changes are always strongly encouraged.
• Chemotherapy.
  No supplements apart from a general multivitamin should be recommended during treatment. This is a very conservative approach because of the lack of studies. There is some new research with vitamin D and chemotherapy that you should keep your eye on. Lifestyle changes are always strongly encouraged.
• LHRH or Orchiectomy Therapy (Medical or Surgical Castration) and Hot Flashes. The only supplements which have data are dietary soy, vitamin E (400 I.U. bid), and black cohosh (remifemin). Whether or not these are better than placebo is controversial. Soy pills have not been found to be effective. Few other conditions in medicine have a greater placebo response than the treatment of hot flashes. Newer antidepressants are getting a lot of attention (12.5 mg bid Effexor up to 75 mg/day, Paxil at 20 mg...). 1 mg of DES may also be effective but comes with cardiovascular side effects. Other conventional treatments are commonly used (Megace, transdermal estrogen,...).
• LHRH or Orchiectomy Therapy (Medical or Surgical Castration) and Osteoporosis Risk.
  400-800 I.U. of vitamin D supplements daily + 500-1000 mg daily of calcium supplements for those without calcium abnormalities. Healthy foods contain large sources of calcium. Many foods are now fortified with vitamin D. Calicum carbonate and vitamin D supplements should be taken with meals, while calcium citrate can be taken without meals for optimal absorption. Look for Viactiv caramels at your local store (each caramel contains 500 mg of calcium and 100 I.U. of vitamin D). Fish is an excellent source of vitamin D, and minimal sun exposure (10-15 minutes several times weekly) is still the best source of vitamin D. Promoting weight bearing exercise, abstaining from smoking, and discouraging alcohol abuse are also important. Bisphosphonates like alendronate (10 mg/day) have shown some success in preventing bone loss but this trial also utilized 400 I.U. of vitamin D daily + 500 mg of calcium daily from supplements. A new once a week alendronate is available. Also, it is important to understand the potential link between statin (cholesterol lowering) drugs and a possible lower rate of osteoporosis. This is controversial. 1 mg of DES has also been used with some success, but the cardiovascular complications need to be discussed. Finally, it is important to know the adverse data with the use of ipriflavone supplements, and the recent adverse data with clodronate in node-positive breast cancer patients.
• Exercise (+ other lifestyle changes) to Reduce Side Effects During and After any Treatment.
  A recent trial in breast cancer patients demonstrated the possibility that self-directed exercise could improve quality of life and enhance recovery during and after treatment.