A Primal Guide to Prostate Health

October 10, 2018

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Many of you have asked about prostate health in a Primal context. Men are interested because they know men have a decent chance of getting prostate cancer. Women are interested because they’re worried about the men in their lives getting prostate cancer. Today, I’m going to delve deep into the topic, exploring the utility (or lack thereof) of standard testing, the common types of treatment and their potential efficacy, as well as preventive and unconventional ways of reducing your risk and mitigating the danger of prostate cancer.

Let’s go.

First, what does the prostate do, anyway? Most people only think about it in terms of prostate cancer.

It’s a gland about the size of a small apricot that manufactures a fluid called prostatic fluid that combines with sperm cells and other compounds to form semen. Prostatic fluid protects sperm against degradation, improves sperm motility, and preserves sperm genetic stability.

What Goes Wrong With the Prostate?

There are a few things that can happen.

Prostatitis

Inflammation of the prostate, usually chronic and non-bacterial. A history of prostatitis is a risk factor for prostate cancer.

Benign Prostatic Hyperplasia

Non-cancerous enlargement of the prostate. As men age, the prostate usually grows in size. This isn’t always cancer but can cause similar symptoms.

Prostate Cancer

What most of us are interested in when we talk about prostate health… After skin cancer, prostate cancer is the most common cancer among men and the sixth most common cause of cancer death among men worldwide. Yet, most men diagnosed with prostate cancer do not die from it; they die with it. The 5-year survival rate in the US is 98%.

That said, there is no monolithic “prostate cancer.” Like all other cancers, there are different grades and stages of prostate cancer. Each grade and stage has a different mortality risk:

Low-grade prostate cancer grows more slowly and is less likely to spread to other tissues.
High-grade prostate cancer grows more quickly and is more likely to spread to other tissues.
Local prostate cancer is confined to the prostate. The 5-year relative survival rate (survival compared to men without prostate cancer) for local prostate cancer is almost 100%.
Regional prostate cancer has spread to nearby tissues. The 5-year relative survival rate for regional prostate cancer is almost 100%.
Distant prostate cancer has spread to tissues throughout the body. The 5-year relative survival rate for distant prostate is 29%. Distant prostate cancer explains most of the prostate-related mortality.

What Are Symptoms of Prostate Cancer?

The primary symptom is problems with urination. When the prostate gland grows, it has the potential to obstruct the flow of urine out of the bladder, causing difficulty urinating, weak urine flow, painful urination, or frequent urination. This can also be caused by benign prostatic hyperplasia, a non-cancerous enlargement of the prostate.

What Causes Prostate Cancer?

A big chunk is genetic. People with “knockout” alleles for BRCA, which codes for tumor suppression, have an elevated risk of some forms of prostate cancer. That’s the same one that confers added risks for breast cancer.

Ethnicity matters, too. Men of Sub-Saharan African descent, whether African-Americans in the U.S. or Caribbean men in the U.K., have the highest risk in the world for prostate cancer—about 60% greater than other ethnic groups. White men have moderate risks; South Asian, East Asian, and Pacific Islander men have lower risks.

Testosterone has a confusing relationship with prostate cancer. Conventional wisdom tends to hold that testosterone stimulates prostate cancer growth, and there’s certainly some evidence of a relationship, but it’s not that simple.

In one study, men with low free testosterone levels were less likely to have low-grade (less risk of spreading) prostate cancer but more likely to have high-grade (higher risk of spreading) prostate cancer.

In another, testosterone deficiency predicted higher aggressiveness in localized prostate cancers.

In Chinese men, those who went into treatment with low testosterone were more likely to present with higher-grade localized prostate cancers.

Other studies have arrived at similar results, finding that “hypogonadism represents bad prognosis in prostate cancer.”

Many prostate cancer treatments involve testosterone deprivation, a hormonal reduction of testosterone synthesis. This can reduce symptoms and slow growth of prostate tumors during the metastatic phase, but prostate cancer tends to be highly plastic, with the ability to adapt to changing hormonal environments. These patients often see the cancer return in a form that doesn’t require testosterone to progress.

What About Testing?

If you have a prostate, should you get tested starting at age 40?

Not necessarily. The value of early testing hasn’t been established. Some researchers even question whether early testing is more harmful than ignoring it, and most of the research finds middling to nonexistent evidence in favor of broad testing for everyone. Early testing has a small effect on mortality from prostate cancer, but no effect on all-cause mortality.

PSA testing can also be inaccurate. PSA is prostate specific antigen, a protein produced by the prostate. It’s normal to have low levels of PSA present in the body, and while high levels of PSA are a good sign of prostate cancer—even years before it shows up in imaging or digital probes—they can also represent a false positive. Those two other common yet relatively benign prostate issues—benign hyperplasia and prostatitis—can also raise PSA levels well past the “cancer threshold.”

Other causes of high levels of PSA include:

Urinary tract infections
Recent sex or ejaculation
Recent, vigorous exercise
Certain medications.

In fact, if you have a PSA reading of 4 (the usual threshold), there’s still just a 30% chance it actually indicates cancer.

What About Treatment?

Let’s say you do have prostate cancer, confirmed by PSA and a biopsy (or two, or three, as needle biopsies often miss cancers). What next? Should you definitely treat it?

It’s unclear whether treatment improves survival outcomes. One study took men aged 50-69 with prostate cancer diagnosed via PSA testing, divided them among three treatment groups, and followed them for ten years. One group got active monitoring—they continued to test and monitor the status of the cancer. One group received radiotherapy—radiation therapy to destroy the tumor. And the last group had the cancer surgically removed. After ten years, there was no difference among the groups for all-cause mortality, even though the active-monitoring group saw higher rates of prostate cancer-specific deaths (8 deaths—in a group of 535 men— vs 5 in the surgery group and 4 in the radiotherapy group), cancer progression, and metastasis.

In another study of men with localized prostate cancer, removing the prostate only improved all-cause mortality rates among men with very high PSAs (more than 10). In men with lower PSAs, “waiting and seeing” produced similar outcomes as surgery.

Prostate removal also carries many unwanted side effects, like incontinence and sexual dysfunction. No one wants prostate cancer, but it’s no small thing to have problems with urination and sex for the rest of your life. Those are major aspects of anyone’s quality of life.

Before you make any decisions, talk to your doctor about your options, the relative mortality risk of your particular cancer’s stage and grade, and how the treatments might affect your quality of life.

How Can You Reduce the Risk of Prostate Cancer?

1. Inflammation is definitely an issue.

For one, there’s the relationship between prostatitis, or inflammation of the prostate, and prostate cancer that I already mentioned above.

Two, there’s the string of evidence linking anti-inflammatory compounds to reductions in prostate cancer incidence. For example, aspirin cuts prostate cancer risk. Low-dose aspirin (under 100 mg) reduces both the incidence of regular old prostate cancer and the risk of metastatic prostate cancer. It’s also associated with longer survival in patients with prostate cancer; other non-steroidal anti-inflammatories are not.

Third, anti-inflammatory omega-3 fatty acids (found in seafood and fish oil) are generally linked to lower rates of prostatic inflammation and a less carcinogenic environment; omega-6 fatty acids can trigger disease progression. A 2001 study of over 6,000 Swedish men found that the folks eating the most fish had drastically lower rates of prostate cancer than those eating the least. Another study from New Zealand found that men with the highest DHA (an omega-3 found in fish) markers slashed their prostate cancer risk by 38% compared to the men with the lowest DHA levels.

2. The phytonutrients you consume make a difference.

A series of studies on phytonutrient intake and prostate cancer incidence in Sicilian men gives a nice glimpse into the potential relationships:

The more polyphenols they ate, the less prostate cancer they got.

The more phytoestrogens they ate, the more prostate cancer they got. Except for genistein, an isoflavone found in soy and fava beans, which was linked to lower rates of prostate cancer. The Sicilians are eating more fava than soy, I’d imagine.

How about coffee, the richest source of polyphenols in many people’s daily diets? It doesn’t appear to reduce the incidence of prostate cancer, but it does predict a lower rate of fatal prostate cancer.

3. Your circadian rhythm and your sleep are important.

Like everything else in life, tumor suppression follows a circadian pattern. Nighttime melatonin—which is suppressed if your sleep hygiene is bad and optimal if your sleep hygiene is great—inhibits the growth of prostate cancer cells and reduces their ability to utilize glucose. One way to enhance nighttime melatonin is by getting plenty of natural, blue light during the day; this actually makes nighttime melatonin more effective at prostate cancer inhibition. On the other hand, getting that blue light at night is a major risk factor for prostate cancer.

4. Get a handle on your fasting blood sugar and insulin.

In one study, having untreated diabetic-level fasting blood sugar was a strong risk factor for prostate cancer. Another study found that insulin-lowering metformin reduced the risk, while an anti-diabetic drug that raised insulin increased the risk of prostate cancer. Metformin actually lowers PSA levels, which, taken together with the previous study, indicates a causal effect.

5. Keep moving, keep playing, keep lifting.

This has a number of pro-prostate effects:

It keeps you insulin sensitive, so neither fasting insulin, nor fasting glucose get into the danger zone.

If you’re doing testosterone suppression treatment, exercise can maintain (and even increase) your muscle mass, improve your quality of life, and increase your bone mineral density.

Oh, and do some deadlifts. Men with prostate cancer who trained post-surgery had better control over their bodily functions, as long as they improved their hip extensor strength. If you don’t know, hip extension is the act of standing up straight, of moving from hip flexion (hip hinging, bending over) to standing tall. It involves hamstrings, glutes, and the entire posterior chain. Deadlifts are the best way to train that movement pattern.

The prostate cancer issue is frightening because it’s so common. Almost all of us probably know someone who has or had it, even unknowingly. But the good news is that most prostate cancers aren’t rapidly lethal. Many aren’t lethal at all. So whatever you do, don’t rush into serious treatments or procedures without discussing the full range of options in a frank, honest discussion with your doctor.

That’s it for today, folks. Thanks for reading. If you have any questions, comments, or concerns about prostate cancer, feel free to chime in down below. I’d love to hear from you.

References:

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Castro E, Eeles R. The role of BRCA1 and BRCA2 in prostate cancer. Asian J Androl. 2012;14(3):409-14.

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