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Mark Moyad: world expert on supplements and alternative medicine talks to men with advanced prostate cancer: Minutes 19 December 2014: Part 1


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Advanced Prostate Cancer Phone-in Meeting Minutes 19 December 2014

Courtesy of Nev Black and Len Weis

Part 1 of 2


These Minutes of the Teleconference are general in nature and not meant as advice. You must consult with health professionals for advice.


Guest Speaker: Dr Mark Moyad


Convenor Jim Marshall: Welcomes all members and Dr Mark Moyad to the telephone meeting and asks Person #9, a new member from Western Australia, to give his story.


Person #9: I am aged 66. In October 2002 I went to my GP for a cholesterol test. He said ‘I will give you a PSA test as well’. I didn’t know what a PSA test was. I got a phone call to say come in quickly. My PSA was 52. My GP referred me to Royal Perth Hospital and I was put on Androcur.


In December 2002 while waiting for an appointment I had prostate enlargement and a TURP. My Gleason score was 9. In 2003 I had 37 treatments of radiotherapy. That got my PSA below 10.


In 2006 I had a PSA relapse and androgen deprivation therapy. In 2008 I had castration resistant metastatic disease and chemotherapy. I had Taxotere (Docetaxel). I started ten cycles. In 2010 I started on Cosudex (Bicalutamide). In 2011 I had more chemotherapy with ten cycles of Docetaxel (Taxotere).


In 2012 I had a TAK 700 (Orteronel) or it could have been a placebo. That has now established that Orteronel is not suitable for post chemotherapy patients. It was unsuccessful.


In November 2012 I started Abiraterone (Zytiga) and continued for two months. I only got two months out of that.


In February 2013 I had more chemotherapy, Cabazitaxel (Jevtana). I started 31 cycles given. I have had that indefinitely for nearly two years now. In July 2014 my PSA reached 420 due to an infection. New options were considered, but my PSA dropped to 260 so I continued with Cabazitaxel.


My condition is most consistent with metastatic castration resistant prostate cancer. Despite much more than average treatment with chemotherapy I have tolerated the therapy very well and have a good quality of life. Prior to consideration of the next therapy, I will need a repeat CT scan of my chest, abdomen and pelvis. One of the treatment options is radium, but to be eligible for this treatment any soft tissue disease must be less than 4 cm. In the past I have had nodal or pelvic soft tissue disease, which was larger than 4cm. 


I have bone metastasis but little pain. They have been treating my bones with Denosumab (Xgeva or Prolia). The oncologist would only stop the Cabazitaxel when there is clear bone scan and/or CAT scan progression. I am currently on Eligard (Leuprolide) hormone treatment. If the soft tissue disease is greater than 4cm he would consider Enzalutamide (Xtandi). That is my story.


Convenor Jim Marshall: Thanks very much for that Person #9. It’s quite remarkable what you have done there. Fifty-one doses of chemotherapy so far, and Person #9 has told me some more about his PSA history and it has been hovering up in those high numbers for quite some time. He still has Enzalutamide available to him and Mitoxantrone, and both of them on the free list. Mitoxantrone does not extend life but it does improve quality of life if you are having issues with pain or blockages or whatever. Mark, do you want to make any comments on that before we move on.


Dr Mark Moyad: I have been able to work with Enzalutamide lately and I have been really pleased by the activity of the drug. In fact while that is missed, in the United States when it got approved earlier this year to be used before chemotherapy, I think that what was missed in a lot of the discussion was what of the five patients in that trial had complete resolution of their bone metastases. So they completely disappeared on imaging, and about 20 percent was the drug and one percent was the placebo. A friend of mine runs the international trial and the question I am trying to figure out is, because these men had a lot of bone metastases, I said how well has the average number of bone metastases where people saw complete resolution or the metastases go away, so they are actually calculating that and that is going to be a paper in the next few months. Nobody has an answer to it, but it was quite a number. 


There wasn’t one or two, so we started seeing that now clinically where people taking the newest drug approved in the States, Enzalutamide or Xtandi, are seeing resolution of all bone metastases. I never thought you would see that, so we’d like to start seeing people test that drug even earlier at a lower dosage because the side effects, apart from fatigue have been, and fatigue is an issue in all this, but the side effects at lower dosages mean they do quite well. That’s one thing to add into Person #9 regimen, but I think it is an incredible story because I think what is fascinating in his history is that he went for a cholesterol test, his PSA was 52, I think he has had a Gleason 9. 


I always tell people the good news is not going to sound like good news, but the good news is if you have a very high Gleason score and a high PSA and you have extensive disease it is a lot better than having a low PSA and a casual disease because once in a while you see maybe one out of every ten cases the man has a very low PSA, his Gleason is nine or ten, and he has very advanced disease. In other words the cancer has taken on a look all of its own. It is so unique that it barely makes PSA. You can’t even utilize the PSA test very well as a marker of how the person is doing. 


I often tell people, if someone comes in with a PSA of 50, or 100 or 200 or 400 and their Gleason was nine or ten, the good news is many times that will respond to some type of treatment because the cells are at least making PSA and casting it in some way that it would be sensitive for treatment. But again the one that I worry about are a PSA of 3, extensive disease with a Gleason of nine or ten. That means this is a whole other type of Gleason nine or ten that we see and it is becoming more common. So I think it is incredible story.


I think the final take on that would be for Person #9 story would be, I tend to think that some oncologists have done a very poor job on selling chemotherapy. Chemotherapy tends to get a very bad wrap and people think chemo, they think side effects, they think hair falling out, I’m miserable all the time, but the reality is when it comes to Hodgkin’s Lymphoma it’s a particular cancer and metastatic disease and it can cure that; even metastatic disease if you look at Lance Armstrong, he had metastatic disease in the brain. 


And what we are learning now interestingly enough is the timing of Person #9 story is incredible. And what we have learned in the past four to six months from a new trial that was presented, that may have been receiving a lot of attention, is the chemo-hormonal therapy trial, in other words there is a trial now that shows that possibly using chemotherapy earlier with hormone therapy can provide a substantial benefit. I am waiting to see that paper get published in different journals and get followed up. But chemotherapy was in a sort of a back seat a couple of years ago but now it is looking extremely attractive. It can be used not only in later cases but in early case diseases. So you will be hearing more and more about this trial called ‘CHARTED’, which is Chemo Hormonal Therapy Versus Androgen Abased and Randomised Trial for Extensive Disease in Prostate Cancer. It is making people re-evaluate chemotherapy at all stages in a positive way. 


Convenor Jim Marshall: Thanks for that Mark. Is there any man who won’t be able to stay with us who has an urgent question for Person #9 at the moment. 


Person #17: Can I just ask, I was battling to write down some of those technical names for the drugs. That will all become clearer in the minutes won’t it? 


Convenor Jim Marshall: It certainly will, yes. I must warn people that this will be recorded and Nev Black and Len Wise will write the minutes of everything that is said and I will anonymise them so that anonymity will be fine. OK, I might ask Mark now, do you want to start now by taking ten to fifteen minutes of the best or do you just want to take questions from the start? 


Dr Mark Moyad: There might be quite a number of people that might have questions, and from my part everything is free game, any subject (inaudible). I don’t mind giving a couple minute quick over view about where we are in terms of diet and supplement. People might be surprised about how we can go further into the questions as to what that means for everybody. Do you want me to do that for a couple of minutes?


Convenor Jim Marshall: Yes please.


Dr Mark Moyad: For people that know or don’t know our work, especially over the past twenty-five years, we’ve tried to argue that essentially at least in the United States, and Australia is not much different, that cardiovascular disease is the number one killer of men and women. That is, in the United States, for a hundred and fourteen years out of the last one hundred and fifteen years. And the only year it finished at number two was in 1918 when we had the great influenza epidemic. 


Well, every other year it has been number one killer of men and women. And the reason I mention that constantly to people in public and patients and physicians is that cardiovascular disease, because it such a large killer of the old and young, it receives an enormous amount of funding and an enormous amount of research over the past one hundred years that prostate cancer has not been able to see, and so we have tried to work on that research. What I have learned over the past twenty-five years is that the billions of dollars spent on cardiovascular development has taught us one thing that is incredibly valuable in prostate cancer and other cancers, and that is what turns out in general to be healthy for the heart is very healthy for the prostate. So for a long time I thought that there was a prostate diet, but indeed it is not a prostate diet, it is really a heart healthy diet. 


So I tell men after a radical prostatectomy that if they can do everything possible to reduce their cardiac risk to as close to zero as possible then they are doing everything from a lifestyle standpoint to reduce the risk of aggressive disease or the potential progression of the disease. Interestingly enough we are having this meeting tonight because tonight several large organizations have come out, if you Google it, and they have reviewed the data for example on obesity and prostate cancer and now they are no longer saying that obesity might increase the risk of prostate cancer; they are now saying there is a strong likelihood it increases the risk of aggressive prostate cancer.


So if you think about it, obesity has actually been a risk factor for cardiovascular disease from the beginning of time. So it is interesting now that we are saying weight gain might increase the risk of being diagnosed with aggressive disease and I also believe that essentially a significant amount of weight gain, especially in the early stages of the prostate cancer after you have been treated with surgery or radiation, can increase the likelihood of it coming back. There is plenty of data now that tells high blood pressure levels might do the same thing and might be detrimental not only for prostate health but we also know for cardiovascular health. 


We’ve studied for a long time and other people around the world right now are looking at cholesterol levels and lowering those levels to reduce potentially the progression of the disease. I you look at some notable oncologists they have written lately about some of the better responses they have seen with Zytiga (Abiraterone), for example, on men they found had high cholesterol levels that weren’t controlled and in those that were controlled a little bit better they saw a better response. 


But either way we know you get a two for one. By reducing the risk of heart disease you reduce the risk of the number one cause of death in men in Australia and the United States and at the same time you are doing everything possible to reduce the risk of the disease progressing. So we are not just talking about diet, we are not just talking about weight loss, we are not just talking about blood sugar, we are also talking about blood cholesterol. 


The one area that is controversial is blood pressure. We know that blood pressure is tied to prostate health because the first effective prostate enlargement drug to help men urinate better was actually blood pressure lowering medication. Then the companies changed those blood pressure lowering medications to make them more selective, so now you have these things you see all over the place all over the world called alpha blockers and so that’s immersed in heart health too. 


The one take home message that I continue to repeat for almost thirty years, and I think it is more important in 2014 than ever before, and that is that heart health is really tied into prostate health. I think that is one of the best things that you can tell your grandchildren or children to reduce or potentially reduce their risk of certain cancers or aggressive cancer. I think at the end of the day this stuff will be found to lower the risk of aggressive disease and not necessarily prostate cancer itself, but that’s what you want. And so that is the first point I wanted to make.


The second point I wanted to make before we talk about different supplements is that we realize now with these supplements, I’m one of the biggest fans of supplements if we need them, but we realize in the area of prostate cancer more is not better. For example, the first major clinical trial that really showed that a completely healthy man taking large quantities of certain supplements might increase the risk of prostate cancer. 


We know now from this gigantic thirty-five thousand man trial, the largest ever done in the world, called SELPCT, [Ed: http://www.cancer.gov/newscenter/qa/2008/selectqa

that high dose vitamin E could increase the risk of prostate cancer. However, as an uptake of that study that has already been stopped years ago, essentially researchers just found in 2014 that men that were getting plenty of selenium in their diet and they were also taking high doses of selenium supplement also had an increased risk of aggressive prostate cancer. 


So we are learning that a number of these supplements in high dosages, that we thought would be protective, can actually be disruptive. So when it comes to over the counter supplements, I tell patients that I don’t take any supplement or recommend any supplement unless I know what its impact is on heart health. If it is heart unhealthy I get nervous that it is bad for the prostate. 


And vitamin E in high dosages or not even high doses is not heart healthy. It does not mean they are worthless and it does not mean they don’t help people with other diseases. It just means in prostate cancer, taking high doses of it could run you into trouble and make the disease actually worse. 


And so what I want to leave my speech with is that there are three pills right now that I ask every man concerned about prostate cancer, whether they are trying to prevent it, whether they were treated for localised treatment, whether they had metastatic disease, there are three pills that every man can ask himself about that I have been writing about in every possible book and magazine and you can remember those three pills. They are so easy to remember by the acronym SAM. 


And it might surprise you what SAM stands for. S stands for statins, blood flow lowering drugs. There is so much research right now about their ability to potentially slow the progression of prostate cancer, and in the United States, I don’t know what the situation is in Australia, but I was in New Zealand and I noticed that many of them were generic. 


In the United States five of the six cholesterol lowering drugs are now generic. So patients are paying pennies per day for them. You can essentially buy some of the brands that used to be very expensive for ten dollars for three months. So, working out with your primary care doctor whether or not you even need one of those is the “S”.


The “A” in SAM is another cheap generic pill called Aspirin. Aspirin to me has had its best year in prostate cancer in 2014. Multiple studies now are not only suggesting it could slow the progression of the disease, but especially in colorectal cancer. So in colorectal cancer some of the largest organizations are now thinking about recommending Aspirin to prevent colorectal cancer if you are at high risk. The reason I mention colorectal cancer is, the amount of research in that area, and that makes me more likely to believe that its impact on prostate cancer is true, that it might slow the progression of the disease or reduce the risk of the disease coming back. So whether or not you qualify for Aspirin could be another discussion. 


And then the “M” in SAM, which I write about all the time, is another generic drug that has been out for thirty years that is actually the number one prescribed drug for type two diabetics still today, and that is called Metformin. And Metformin is not only heart healthy but the reason it works so well is not only that it helps control blood sugar in type two diabetics but we know now it is probably one of the only drugs that doctors are comfortable with globally in giving to treat type 2 diabetes and prevent from coming diabetes. Also it can provide significant weight loss. Right now there are over a hundred clinical trials globally using Metformin to slow or reduce the risk of cancer coming back. And about ten percent of those are prostate cancer studies - from Toronto, to the US, New Zealand, and Australia.


With all these potential studies of Metformin starting up we are not saying you take all these pills, SAM. But I think the first three pills, outside the obvious one you are supposed to take, whether it is chemotherapy or if you have had a radical or if you are supposed to take Xtandi (Enzalutamide or MDV3100). I am talking about the ancillary ones, the ones you do not hear a lot about and a lot of people focus on supplements and I would love to focus on supplements tonight but SAM is a good acronym to remember because they are all dirt cheap and they are all generic, that’s why they are low cost, and they all have data now against prostate cancer and they are all heart healthy if you qualify for them. And my final point is they are all natural. And the reason they are all natural is because Statins came from yeast, Aspirin came from willow bark and Metformin drug came from a French lilac. So, that is about as natural as we get.


So with that I think the combination of lifestyle, some of these off label drugs and some of the newer drugs that are coming out, even an early look at chemotherapy and Xtandi and some of these newer agents and the immune therapy. I’ve been in this game for thirty years, I started in my early twenties, but I still believe that we are really close now. This is the first time I’ve been able to say this at conferences. I think a combination of these is going to put many of these cancers in remission, maybe even prostate cancer. Is it going to be one year, is it going to be three years? I hope it is in the next couple of years, because if you look at HIV there is a cocktail of drugs that have made HIV patients, now a lot of them, look, they can live a natural life expectancy. 


You were looking at Magic Johnson, the famous basketball player in the United States, in his twenty plus year since he was diagnosed. There is something incredible happening also globally with hepatitis B. There is a combination of drugs that are putting patients into remission and complete cure in eight weeks. Four or five years ago you were watching all these people die of serious hepatitis B infection. They needed transplants and in fact a very close friend of mine died while waiting for a transplant for hepatitis B and now we are thankfully eradicating it. I think that’s what is going to happen here in prostate cancer. I do. 


You are going to see them come at it from an immune standpoint, diet standpoint, androgen inhibiting standpoint, maybe adding chemo and I think a lot of people are going to hold this intact. I think in the twenty-five to thirty years I have been doing this, this is our best year we have seen because we have not seen much progress until especially in the past few years in the drug development. So all these things coming together, I may be the most optimistic I have ever been as I face my first mid-life crisis at the age of fifty. So I think that is where I would like to leave it. 


Convenor Jim Marshall: Great start Mark. Reminder if you are asking questions, say your name first to help Nev Black and Len Wise with the minutes. Any questions?


Person #23: Mark, is SAM widely accepted across the world? 


Dr. Mark Moyad: Well, I appreciate the question “is SAM widely accepted”.


Person #23: Yes, the three drugs.


Dr. Mark Moyad: Well they are widely accepted around the world in terms of cardiovascular and diabetes prevention. If you have a high risk of a heart attack you are put on a cholesterol drug or Aspirin if you have had a heart attack and if you have pre-diabetes you are put on Metformin. So those drugs are widely used and are more popular today than they have ever been in the history of those drugs. So what I try to do is come up with a way that makes it easy for clinicians to have a discussion with patients. 


Because the argument I always get, because I have to do about fifty classes every year around the world for clinicians, and what I hear is I always have only seven minutes or I have twenty minutes or I have only ten or fifteen minutes for a patient because I have to see so many people. There is so much pressure, there is so much stress. 


And then I hear from patients all the time my doctor does not give me enough time. There is an old joke, there are two guys sitting on a bench and the one guy says to the other my doctor gives me way too much time, I’m getting sick of it. Of course that would never happen. So the reality is that I kind of came up with an acronym because they wanted to know what were the top three things right now, outside of the obvious, that had data in prostate cancer. And so I had to come up with a name that sounded like a man, it’s more androgynous, it could be a female’s name and you would never forget at the clinic and you could keep it. So I started publishing articles on SAM - Statins, Aspirin and Metformin. 


So the answer to your question is I think it is well known but I don’t think people realize that those three have as much data as they have ever had before in thirty years in prostate cancer. Someone might know the Aspirin data. A lot of people right now know the Metformin data, that’s really hot right now. The SAM data is becoming better known. 


I think it is very well known by doctors that one of those three look exciting, or maybe two of the three. But I wanted to make sure they understood that all three look good and remember the discussion with patients by remembering SAM. I think it is well known and if you do a search of the literature it will tell you how well known it is. The first major meta-analysis of Aspirin in prostate cancer came out in the past six months and if you look, they looked at thirty-nine studies and they found that essentially what they believe is anti-prostate cancer activity from other studies. It was not a randomised trial but it looks good enough. So if you qualify for Aspirin anyway you can get a two for one benefit. Ed:[ http://www.theguardian.com/science/2014/aug/06/aspirin-could-dramtically-cut-cancer-risk-say-scientists-biggest-study-yet ]


This year is the first time in the history of medicine that cholesterol lowering drugs have now been associated with a lower risk of dying from all causes if you are otherwise perfectly healthy. And now it is published in a journal of the American Medical Association that comes from over fifty thousand people in numerous randomised trials. The data was actually branded very powerful by people from (inaudible). As powerful as it is in heart disease and diabetes it is looking really interesting to add on to prostate cancer. 


So I think this is a trickle- down effect and it is one of the reasons we are having this discussion today. I haven’t got a lot of doctors yet that realize that Metformin was studied and published two years ago in the British Journal of Neurology. They published a trial of taking Metformin if you were on hormone therapy and in that trial, up against control, men who had a very low dosage of Metformin actually lost weight in the first six months they were on hormone therapy. And now that same group has been seeing success in men at all different stages of hormone therapy who would have trouble losing weight are potentially able to lose some weight when they are on hormone deprivation. So the SAM part, we have for example, even if it does not slow prostate cancer it may reduce the effect of some of the side effects like weight gain. So that’s why I can’t think of three other pills right now that are more interesting, outside of the obvious one that we have approval for, to be added. 

Ed: [ Australian doctors have started recruiting metastatic prostate cancer patients for a pilot study to evaluate the benefits of metformin during androgen deprivation therapy (ADT)




A lot of people ask about Vitamin E, Selenium, Calcium and Vitamin D. I don’t know any pills that are close in terms of data we have for SAM. I think your doctor will know about one or two of those but I think it is all of our jobs to tell them about all three. 


Convenor Jim Marshall: Thank you Mark. Another Question?


Person #5: Just a quick one to Mark. The ‘S’ I presume stands for Statin does it?


Dr. Mark Moyad: Yes, the S stands for Statin.


Person #5: Thank you, right.


Dr. Mark Moyad: Now keep in mind again that Statin came from a yeast product. There is a supplement called, Red Yeast Rice, which is actually where the first Statin came from. I just find it interesting that the three proven pills over thirty years in heart disease and diabetes and the most commonly used pills in the world in those categories, now look interesting in the area of cancer. It goes back to what I intend to pass on today. What a man could do outside the obvious is that anything that reduces the risk of heart disease seems to pay off in some fashion potentially against prostate cancer. 


I’m often challenged at meetings that people say Ok, lets say you do a big study of Statins and cholesterol lowering or Aspirin and it does not reduce the risk of prostate cancer, it does not slow the disease and you feel like you failed. I say no I just feel like I have to get up and apologize for reducing the number one cause of death in men in the world with heart disease. So in other words what I like about the SAM discussion is if it does not always win for you, you still win. 


And the problem I always have with selenium and Vitamin E is that if it doesn’t work, well then what? Then is it neutral, can it make the disease worse? So we are realizing in these three pills that the reason they are also most fascinating to me including SAM is that they did not make the disease worse and, if anything, they should provide a heart healthy benefit if you need those pills. I mean some guys don’t need them. Some people just need one of those. Some people are at high risk of heart attack and they need Aspirin anyway and some people end up needing all three. But I think it is something to be aware of, not something to go on tomorrow. 


Convenor Jim Marshall: Thanks. Another question?


Person #13: Mark, I have read your book on supplements and I found the section on Red Yeast Rice very interesting. Do you suggest taking a supplement or a prescription for Statin?


Dr. Mark Moyad: That’s a great question. Did you read the new one that just came out, the supplement handbook? Is that the one you read?


Person #13: Yes.


Dr. Mark Moyad: Very good. The one that was just released a month ago? 


Person #13: Correct. I’ve got it on my Kindle. 


Dr. Mark Moyad: Ok. I appreciate that commercial for me because I love that book.That book took us three years to write, it is five hundred pages.The cheapest place to get it is on Amazon. I want to tell people where to get it. There is an extensive part on red yeast rice. So what do you do? So this is ten years ago. If you don’t mind let me explain the story and you will understand why the recommendation.


If this was ten years ago we used to have people take red yeast rice to lower their cholesterol naturally instead of Statins. The reason was because the Statins ten or fifteen years ago, especially in the States, were ridiculously expensive. Lipitor was ridiculously expensive. If you look at one we have right now still on patent and you will pay hundreds of dollars a month for it, in some cases. So they were too expensive so we loved red yeast rice ten years ago. What happened in the past ten years, as I mentioned, is that most of the Statins now have gone generic. And in them going generic they have now become, in many cases, cheaper than the supplements, so cheaper than red yeast rice. So that’s a good thing. 


The second thing that you should know is that there is a new problem that exists now with red yeast rice. It is the dumbest rule I have ever heard. Supplement companies are not allowed to standardize the active ingredient, and you will read about this in the book. They are not able to standardize the active ingredient that lowers your cholesterol in red yeast rice. So basically it is a (inaudible). So when you take red yeast rice it might lower your cholesterol, it might not, it depends what the company is doing. You are sort of a guinea pig. 


So to answer your question based on that explanation, I now recommend more often taking a cheap generic Statin instead of red yeast rice. Where we still recommend red yeast is that if someone goes on a low dose Statin, they have muscle pains and aches, and they just can’t tolerate it and they have tried everything that we have recommended. Maybe they go to a lower dose, maybe they take it less often. There are a number of Statins that you don’t have to take seven days a week. Sometimes you can take them three times a week and still get a nice reduction in cholesterol because they sit in your blood so long. 


So we still use red yeast rice if someone can’t tolerate the cholesterol lowering drug and they are miserable on it and they have symptoms. Some people tell me why not recommend another supplement CoQ10 with a Statin drug to reduce muscle problems. The reason I’m not a big fan of that is because CoQ10 in the States is extremely expensive. 


There are plenty of people I see that don’t have problems with Statins and if they have a problem I would rather see them switch or do something different rather than add another expensive pill. So they can take CoQ10 as an option, but to go back to the answer to your question, we now recommend more of the cheap generic Statins than we do red yeast because they are cheaper and they have more evidence in prostate cancer overall and they are more reliable. They are more reliable in the way they actually reduce your cholesterol. Based on this ridiculous history I was telling you of the past ten years that the manufacturers of supplements of red yeast are not allowed to standardise the active ingredient anymore. 


Convenor Jim Marshall: Thank you, Mark. Any other questions? 


Person #24: I would just like to ask Mark. One prominent doctor in America has advised some of his patients that some of the Statins can block the pathway of Zytiga (Abiraterone) and they should take Crestor (rosuvastatin calcium), a Statin Crestor if they are on Zytiga. Do you have any comment to make on that at all? 


Dr. Mark Moyad: Well I know which one you are talking about. He is a friend of mine. I’ve been doing this long enough, I know all these boys and girls and I understand the concern there. There is a potential interaction there with some of them. Crestor is interesting because, Crestor, we tend to use a lot of it and recommend a lot of it. The reason we recommend a lot of it, and it is probably the one I would take if I had to take something, is because the half life is so long and it does not interact with the pathway. That is correct. And it does not interact with grapefruit juice for example. But it is enormously expensive. 

But what people don’t realize is the half life is the longest of any Statin. So the Cleveland Clinic and other people who have done studies whereby people took Crestor just once or twice a week and they still got about a thirty percent reduction in their bad cholesterol. So some people take it every day and that’s fine, but for people who need to take (inaudible) don’t want the side effects. I know plenty of people who take it just once a week or just Monday, Wednesday, Friday and it lowers their cholesterol just about as much as taking it seven days a week and they save hundreds and hundreds of dollars. Also it is the most potent Statin at the lowest doses. 


So for example you can buy 5mg but a lot of people can cut that 5mg in half. If you put 2.5mg it will work as well as 15 to 20 to 30 milligrams of the old generic. I like it for other reasons. I’m not sure about that interaction yet because there has not been enough studies. I understand the concern, but at the end of the day I would just choose Crestor first because of long half life and because it is one of the only drugs that was actually studied in healthy men, otherwise healthy men, that lowered the risk of dying from all different types of causes. 


There was a huge trial called the Jupiter Trial. So it is actually one of my favourites for all those reasons. Plus, if you look at the money you would spend on taking it three days a week instead of seven it comes out almost as to what you would spend on a generic. Does that answer your question?


Person #24: Yes, thank you very much.


Dr. Mark Moyad: Let me add there, everything has a downside. We all tend to talk about the positives. Before we move on, let me clearly mention why everybody needs to figure out they qualify for these things because like chemotherapy, like any drug, they all come with catches. Statins come with one major catch. If you rely on very high doses of it there is a small chance, if the cancer is real, I believe that it can increase your risk of type-two diabetes. 


Which is why now there has been real discussion about what kinds of risks of types of diabetes is there. We are seeing it is cells related, so I get nervous when a man says I am on the highest dose of a Statin and I don’t mind, I don’t need exercise because it lowers my cholesterol more than exercise. But what they don’t realize is the higher the dose you go on Statins and Aspirin and anything else, the higher the risk of toxicity. So we are starting to see all these bizarre side effects that we never could have predicted, especially in people who chronically take massive dosages and don’t make any lifestyle changes. 


With Aspirin we see the same thing already. In the old days, which is only about twenty years ago, we used to recommend a regular sized aspirin and now the reason we don’t is because in most cases a baby Aspirin works just as well to reduce the risk of heart attack and stroke and it lowers the risk of toxicity because at higher dosages we see the increased risk of internal bleeding that we call haemorrhagic stroke. So, less is more when it comes to Statins, Aspirin and Metformin. I get nervous when someone wants to go on really high dosages of any of those things, or their doctor puts them on really high dosages. I just wanted to add that part.


Convenor Jim Marshall: Thank you, Mark. We have a pharmaceutical benefits scheme (PBS) here which, except for the most enormously expensive drugs, pays most of the cost of the drug except for a few dollars, so long as a doctor figures that you need it. Crestor is covered by the PBS here if the doctor thinks you need it. [jm: Correction: Patient must also be covered by a care plan. All men with prostate cancer are eligible to have such a plan drawn up by their GP. A bonus for getting a care plan is that 5 visits per year to allied care professionals you may need will be subsidised or free. Includes Audiologists, Diabetes Educators, Dietitians, Exercise Physiologists, Mental Health Workers, Occupational Therapists, Physiotherapists, Podiatrists, Psychologists, Speech Pathologists, Aboriginal Health Workers or Aboriginal and Torres Strait Islander Health Practitioners.]


Dr. Mark Moyad: That is good to know because in a number of places where I travel, that have, whether it is socialised or nationalised, health care a lot of people won’t cover Crestor because of the price difference. But they put patients on generic Lipitor instead. So that is good to know. 


Convenor Jim Marshall: Good, thanks. Another question? 


Person #18: A query to Mark just on the dosage of Statin and I can see you can get Crestor in anything from about 5 mg tablets to 50 mg tablets.


Dr. Mark Moyad: I like to see people start with two and a half. I like to see people start with the lowest dose possible in any drug to get the effect, especially when you are talking about whether it is a supplement or whether it is one of these tried drugs. We have always found after thirty years you start low, go slow and you will save side effects and dough. You know, money. So it always works out in your favour. I think people start too high, in too many cases. You could easily take that 5 mg pill, cut it into two and a half, see how you do. For a lot of people, including myself, when I tried it, it lowered cholesterol by twenty to thirty percent and that is plenty. So two and a half is what I think the starting dosage should be, but you have to cut those fives in half. 


The highest dosage you should have to go to is twenty. Twenty works extremely well. To give you an example, in the large international trial, twenty cut bad cholesterol in healthy and non-healthy people by as much as fifty percent. But with Aspirin, with Metformin, with Statins or Vitamin D and everything on my list we always start with the lowest dosage because then you can see how you tolerate it and you can see how you do. Then you know, if you run into a side effect, where to back off. What happens if you start right at ten or twenty you can go straight into a side effect. 


I’ll tell you one of the examples of problems that I see in the United States a lot. People will start on a really high dosage of Crestor or start on a high dose of another Statin and it drops their cholesterol so much that you think that is a good thing, right. But cholesterol is needed to make Vitamin D. It is needed to help in the production of neurotransmitters. And naturally you start running into all of the problems you hear about with Statins. We might have a memory issue or a muscle ache. And another thing is you need cholesterol to make testosterone. 


So if you are not on ADT, what I was starting to see was that I think too much Crestor and their cholesterol goes so low and their testosterone goes so low and everyone goes this guy has low testosterone. He does not have low testosterone, he is taking too much cholesterol lowering drugs. And then what happens there is a discussion about going on testosterone replacement. So everything comes with a catch. It is just a matter of whether or not you find out what the catch is, and the biggest catch I’m seeing is you don’t want to go to a high dose of statin because you need a certain amount of cholesterol for just basic body function. Otherwise we would take it to zero. 


So in the United States there was a big trial that showed that somewhere between 1.8 millimoles and 2.59, in the American system that would be between seventy and one hundred, that was perfectly fine. Once you start going much below that you can start messing with the production of common everyday hormones and things that the body needs. 


Convenor Jim Marshall: Thank you for that, Mark. I’ll be reducing my levels of Crestor when this will be finished. 


Dr. Mark Moyad: If anyone has read the supplement handbook or looked at it they know the philosophy. The philosophy is you go on the lowest dose. And you know there is great work that we don’t teach enough. It’s called tachyphylaxis. What the word means is that the human body is really smart. If it gets too much of a drug you become desensitised to a large portion of it, so you need more of the drug to see and effect. 


So what we see in people who start out with too high a dosage and they stay on it, today they will need about twenty and then five or ten years from now they are going to need thirty, even though they are doing everything I tell them to do right because they develop a certain level of tolerance to it. So one of the ways you prevent that, you essentially always start with the lowest most effective and safest dose and make up the rest with lifestyle change. 


If you think about the greatest selling drugs in the States right now, the ones that are really making a billion dollars, most of them are immersed in the obesity epidemic. In other words there would be no profit there if a lot of people were able to, for example, lose weight. So most of the testosterone replacement therapy studies were men who had BMI [Ed: body mass index] of thirty or thirty-two who were obese men who in general have low testosterone because of weight gain. Weight gain is a huge killer of testosterone. It might sound like a healthy thing when you have prostate cancer that low testosterone, but it is not always a healthy thing. So if you look at acid reflux, sleep apnoea, any of these things, a lot of these things are immersed in the obesity epidemic. One way we can get rid of that epidemic is that we make lifestyle changes that put us on the lowest effective drug. 


Person #15: Thank you Mark for the great amount of positivity you are bring to this discussion. The three drugs you have mentioned if you were trying to set out the strategy to minimise the effects of ADT or other treatments using those three drugs. Would you be looking at using all three drugs together at the outset? If so, or if not, what would you be monitoring? Would you be monitoring blood sugars, blood lipids together or would you creep up on this issue one step at a time?


Dr. Mark Moyad: Did you say in the case of being on the androgen suppression or just in the case of prostate cancer?


Person #15: Given that the androgen suppression causes or leads towards type 2 diabetes and potential heart issues and weight gain. I was just wanting to know if you are trying to reduce the risk of those things being on androgen suppressions by whatever means. Would you be risking your body with all three of those and if so how would you strategically do it in terms of monitoring? 


Dr. Mark Moyad: I would try not to be on all three of them. The reason is that and I just want to bring up the three most interesting. If I was on the androgen suppression one of the first things I would look at is the possibility of metformin. The reason why metformin, weight gain is a huge problem with androgen suppression especially when you first start out. As you gain the weight at the years go on it becomes very difficult because you are essentially going into male menopause in four weeks. Women get five years to go through female menopause. I say to men you are going to go into menopause in four weeks. 

We don’t have this pre -menopausal period. So it is very rapid, for the weight gain can become very rapid and you can doing everything right and read all the Moyad books and still not lose weight. Then your blood sugars go up and that is a problem and that just leads to other problems. 


The number one cause of death in prostate cancer patients is still cardiovascular disease. It is still a huge burden it is a problem in patients. So the reason metformin works so well for androgen suppression is for several reasons. One, it is covered by most national programs. 

The second is it has a great safety record. Number three there has already been a trial now published in the British Journal of Neurology which shows you can keep the weight off. The worst case scenario it helps you lose weight or reduces one of the worst problems with androgen suppression which is that weight gain. 


What we realise from CT scans is that you gain what is called subcutaneous visceral fat with androgen suppression. So not are you only putting on fat right below the belly but it is all you are putting on weight around the organs. We just used to think it was fat around the belly but then people started doing CT scans and we realised no it actually puts fat around the organs too. We don’t like that, so how are you going to prevent that? 


We had a little talk and metformin does that. The shame about metformin is that nobody ever applied for the drug to be a weight loss drug. We have four new drugs for weight loss in the United States and I swear if we put up metformin against all those new drugs I bet it would do just as well or near enough that there would be no statistical difference and the side effects would be a lot lower. The reason why metformin has worked so well from pre-diabetic becoming diabetic is it basically inhibits or reduces the amount of glucose that your liver makes, so gluconeogenesis. It also might block carbs we think and it also might reduce the growth factor. 


Either way we know over decades and decades of research the way it works potentially it also just helps people lose weight. Helping them to lose weight reduces their risk from going to pre-diabetes to diabetes. We are starting to see the same thing in the areas of the prostate. So one of the first things and by the way just so you know I should bring this up in the past few months a phase two study men on castrate resistant prostate cancer ,a small study, showed that men on metformin it seems to stabilise their disease and slow the progression of the disease. 


Now we are getting data that not only suggests it might lower the risks of side effects of weight gain and diabetes but it also may slow the progression of these so a lot of doctors are warming up for metformin. To answer your question I would look at the (inaudible) of the androgen suppression, because the act is easy if you have been following your cholesterol you know whether or not if you need a cholesterol lowering drug. The one that would be most talked about is aspirin, there is no blood test to figure out whether or not you are going to have a side effect. If you are on metformin and your liver enzymes or you have some kidney issues or if you are going to have something like (inaudible) we know when you are experiencing some potential toxicity with metformin. So your dose can be reduced and be brought off the drug. The same thing to do with statins, if your liver enzymes go up or your muscle enzymes go up there are tests to tell you way ahead of time whether or not your body is experiencing toxicity from the statin or metformin. 


In aspirin you just have an ulcer or you just have an internal bleeding event. It is a great question my advice is take them one at a time. Metformin should be the most examined on androgen suppression just for the reasons you have nothing to lose except weight and everything to gain. Cholesterol lowering you know whether or not or your primary caregiver is going to know whether you need a cholesterol lowering drug or not. Aspirin is the one you have to be careful. 


In all the books I have written in the supplement handbook we have mentioned tools to work with your primary care doctor. I will be happy to give a couple of these online to Jim. One is called Reynolds risk score, where you can figure out your benefits to risk scenario whether or not aspirin would be of benefit. In other words is there a greater chance that it will provide a benefit or is there a greater chance it could increase your risk of internal bleeding event or an ulcer. Aspirin is the one that scares me the most. I have seen more doctors in my career and more patients come to me after ten years and say I didn’t realise how toxic aspirin was. 


I just popped aspirin like it was candy, not realising they have to be a lot more scientific with aspirin to see if they qualify. Just last week the largest trial of aspirin in Japan was just published. What it showed was in men over 60 who are otherwise healthy there were so many internal bleeding events that we are not sure if we could be recommending to healthy Japanese men for example aspirin anymore. It was just published in the American Medical Journal this week. So be especially careful with aspirin. 



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