San Francisco, CA—Men with low-risk prostate cancer are typically offered management with active surveillance, which entails regular office visits, digital rectal exam, MRI scans, prostate-specific antigen (PSA) testing, and prostate biopsy at physician-specified intervals. An expanded protocol called active holistic surveillance (AHS) also incorporates dietary changes, evidence-based supplements, and exercise, but only clinically necessary biopsies. According to a study presented at the 2016 Genitourinary Cancers Symposium,1,2 AHS has the potential to reduce the number of biopsies and even avoid them altogether for some men with low-risk and low-intermediate–risk prostate cancer.
AHS was adopted as a management strategy for low-risk prostate cancer in an attempt to avoid overtreating this form of the disease, since many men will have an indolent cancer that does not transform into more aggressive cancer requiring treatment.
AHS was developed by Aaron Katz, MD, a urologist and integrative physician in private practice in New York City and on staff at Winthrop University Hospital, Garden City, NY. In developing this protocol, he hoped to avoid unnecessary biopsy and further treatment for men at low risk. His experience using this protocol in 200 men shows that the overwhelming majority of patients who follow AHS do not need further treatment.
“Years ago, when I worked with Dr Atkins, I saw patients with cancer treated with diet and nutrition who did not need other treatment. This got me interested in integrated medicine. I think we can do better for our patients than active surveillance. The AHS protocol incorporates evidence-based nutrients, plus dietary recommendations and exercise at least 3 times a week for 30 minutes. We measure PSA every 3 months and perform an annual MRI on our patients enrolled on AHS. If there is no change in either parameter, we don’t biopsy them. We have had extremely low rates of disease progression—about 88% to 90% of men on AHS never need further treatment,” said Dr Katz.
Patients eligible for AHS have clinical stage T1c, PSA <20 ng/mL, Gleason 6 or 7 with tumor volume of <50%, and an initial PSA doubling time of greater than 1 year. AHS relies on counseling regarding diet, supplements, and exercise. Dr Katz and his staff also recommend yoga, meditation, or other forms of stress reduction. Patients have annual MRI scans, PSA tests every 3 months, plus digital rectal exams at each office visit. If the MRI scans and PSA levels remain stable at the next office visit, patients do not go on to biopsy.
Dr Katz and colleagues presented a poster reviewing experience in 200 patients (median age, 65 years) with low-risk and low-intermediate–risk prostate cancer placed on AHS with a median follow-up of 40 months.
A total of 24 (12%) patients discontinued AHS over the study period: 4 for biopsy progression, 7 for MRI progression, 7 for MRI progression confirmed with biopsy, 5 for patient preference, and 1 patient died.
At baseline, 75% of men had a Gleason score of 3+3, 12% had a score of 3+4, and 2.5% had a score of 4+3; data were missing for 10.5%. Forty-three percent had only 1 positive core on initial biopsy, 21% had 2 positive cores, and the remaining patients ranged from 4 positive cores to 9 positive cores. Data on 10% of patients were missing.
“Our rates of discontinuation are low compared to other publications in the literature on active surveillance. We have shown that AHS can be a successful protocol for low-risk and low-intermediate–risk prostate cancer patients, and that a holistic approach can be beneficial for patients eligible for active surveillance,” Dr Katz said.
In general, the dietary and exercise recommendations promote good health—not just for prostate cancer patients. The AHS dietary recommendations include elimination of red meat and increased intake of fish or poultry; increased intake of fresh vegetables (kale, spinach, cauliflower, broccoli); 1 to 2 tablespoons of ground flaxseed added to oatmeal, cereal, yogurt, etc, daily; reduced dairy intake, with the exception of organic yogurt; reduced sugar intake; soy milk instead of cow’s milk; whole wheat pasta instead of white pasta; 1 to 2 cups of green tea per day; and 1 glass of Pinot Noir red wine with dinner 2 to 3 times per week.
AHS-recommended supplements include vitamin D3, Zyflamend, omega 3 fish oils, and a daily multivitamin.
1. Katz A, Fontes AS, Kosinski KE. Initial results of patients with early-stage prostate cancer on active holistic surveillance. Presented at: 2016 Genitourinary Cancers Symposium; January 7-9, 2016; San Francisco, CA. Abstract 19.
2. Fontes AS, Kosinski KE, Katz AE. Initial results of early stage prostate cancer patients on active holistic surveillance. Poster presented at: 2016 Genitourinary Cancers Symposium; January 7-9, 2016; San Francisco, CA.