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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 2


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Advanced Prostate Cancer Phone-in Meeting Minutes 19 December 2014

Courtesy of Nev Black and Len Weis


Part 2 of 2

(Link to Part 1 at end of this post)

Person #97: I would just like to ask Mark, many men when they go onto ADT have hot flushes or hot flashes, do you have any help for some of those men who have a lot of trouble with hot flushes and that sort of thing? 


Dr. Mark Moyad: I am just going to answer something from previously as I know the question is going to come up about the dosage. 


When it comes to metformin, the dosage used in the clinical trial in the androgen suppression patients was 850mg for two weeks. If the person tolerated it, which means they didn’t get diarrhoea, because the biggest complaint you will get is soft stool or diarrhoea. 

If you take it with a meal most people have no issues. I tried it for three months. I am one of those crazy doctors if I am going to recommend something then I am going to try it. I took it with a meal and there were no problems. If I took it on any empty stomach, my stomach would hurt and I would get a soft stool. So they had 850mg in the trial for two weeks if they tolerated it then they went to another 850mg twice a day. That is a maximum. The reason why the researchers chose 850 twice a day is simply because the largest trial globally to prevent type 2 diabetes that was the same dosage. 


So most of the trials you are going to see in cancer are 850mg twice a day or 1000 mg twice a day and that is based on all the heart disease studies. The reason I want you to be careful is and if you talk to your doctor and they approve it I see plenty of guys who go on 500mg for four or six weeks and then add another 500 mg then they are on 1000mg per day and they do just fine. 

They lose weight that way. Just like with aspirin, statin and everything else start with lower doses, you don’t have to go to these larger doses. If you go on a dose where you start to see results so you start with the lower doses. 


The hot flushes are a huge dilemma. The reason it is such a big dilemma is because in clinical trials people respond really well to sugar pills in terms of hot flushes. So it really messes up clinical trials. I always say that if someone took [to selling] sugar pills for hot flashes they would make a fortune but then they would get arrested. We are seeing in clinical trials of women and men there is about a 50% placebo response rate. If someone takes a placebo and they claim less hot flashes and they are getting less hot flashes, then the problem with that is that you need a drug that will work a lot better than 50%. 80% - 90% could be approved as a hot flash medication. The biggest problem in getting more effective hot flash medications is just so you realise is because the sugar filler works so well in these small trials. 


What worked a lot better than sugar pill? It is interesting - progesterone. If you ask your doctor about progesterone, low doses of progesterone, as a pill or injection have worked as well as the most expensive drugs that have been in clinical trials to reduce hot flashes. So they work extremely well. There is another drug that we don’t have in the United States called androcur that also might help. If you are having serious problems progesterone is easy to get. Your urologist should know the progesterone data. You can take a look in any of the books the prostate books I have or anyone else’s and it should mention some sort of progesterone low dose 20/40 mg as an oral agent or some people get it as an injection. It should really control your hot flashes within a month or two. 


Another really good option for those people who don’t get good control of their progesterone, and the trials have already been convincing enough, is what's called Venlafaxine. It is also known as Effexor. 


You will hear this name tied to an antidepressant. It is not because we think you are depressed but it is because some of the antidepressant drugs get into the brain and they go into the temperature regulation centre of the brain and they help control it. So some men do really well on Venlafaxine. It used to be known as Effexor and now it is generic. Some of these other classically antidepressant drugs, [...] are really good at controlling body temperature. 

The other thing is in a large trial it works well for men who have depressive systems. So if men have problem with mood as well as hot flashes a lot of doctors can now talk to them about using a low dose antidepressant to control both. If they are not having a problem with mood or depression then progesterone has been around for 30 years and still continues to work as well as our best drugs and has a really good safety record. There has been a couple trials on supplements for hot flashes and some of them have worked ok. Fish oil went into clinical trial and worked better than placebo. So fish oil has been trialled and red clover has been trialled but they haven’t worked as well as the drugs overall. 


Exercise is really hit or miss. Some people exercise a lot and they get a huge reduction in hot flashes other people exercise a lot and the hot flashes get worse. My recommendation is that you look at every side effect of anything that you are experiencing with prostate cancer in one of three ways. You always break it down into three things.


1. What can I do in terms of lifestyle? We know a certain amount of exercise does help with hot flashes and the reason why a moderate amount of exercise helps is because as people put on body fat when you have a hot flash it doesn’t get dissipated as well. The body fat works as insulation so it holds the hot flash for longer. 

For example, women studies with really severe hot flashes we see in menopausal women tend to be the higher risk of really bad hot flashes in women who are obese. I think we are beginning to see the same thing in men who gain a lot of weight the hot flashes become more so. A moderate amount of exercise is healthy. What can I do in terms of lifestyle? 


2. What can I do over the counter? Over the counter I mentioned a few things there are a couple from my books like black cohosh.

You should try a few of these things. These supplements they are very safe and they work for some men. 


3. What can I do for as a prescription? If none of these other things are working and my hot flashes are very severe. The top two are antidepressant drugs and they work in a different way for hot flashes and then also progesterone.


Person #13: There are many people who advocate the importance of use of Avodart to suppress dihydrotestosterone. Do you have a view on that or do you have a view on natural supplements in that area? 


Dr. Mark Moyad: I have got to tell you every time someone tells me a supplement works half as well or almost as well as Avodart, these are the same people I believe that are selling swampland in Florida or somewhere in Australia. In other words, every time someone tells me there is a really good supplement for reducing dihydrotestosterone. they have been completely wrong. 


We spent an enormous amount of money thinking saw palmetto would reduce dihydrotestosterone significantly. 

There has now been two trials at the cost of tens of millions of dollars, it showed that it really did minimal to nothing even when you took megadoses. Can reduce dihydrotestosterone a little bit but not enough to get excited about or to have any clinical activity. 


Some of these other BPH type supplements, zinc is touted for it, (inaudible) - there are all these supplements that are touted to reduce dihydrotestosterone and they have simply failed. Everybody who knows me, knows that if there is something like a supplement that looks as good as the drug I am the first person to buy it and recommend it. 


In the area of dihydrotestosterone, Avodart, dutasteride and finasteride have worked far better than any supplement. About five to ten times better. So the question is - is Avodart or finasteride really providing an anti-prostate cancer effect after day to day around the world. If you look at the trials there seems to be a small, there seems to be an effect there. We know it potentially prevents the disease but does it prevent the disease from progressing? 


We know it can lower your PSA and that takes away a lot of men’s anxiety. I think it has some disease activity there, but I think we can do better. What I mean by that is what I mentioned earlier, and what we are not doing a good job of, and this is where I try and be a pain in the ass. We are not doing a good enough job of research wise. We are not taking all these new agents that are helping men with metastatic disease and applying them early on. 


If you look at my latest paper online, we took a guy and put him on Xtandi, the drug approved for castration resistant prostate cancer, and this guy has been in remission now for a few years. He could afford it though. It is an expensive drug. So we took this drug known for the advanced disease and gave it to a guy in the early stage of the disease and they can tolerate it just fine. The problem is we don’t have enough research there to prove that it works. 


So I think these drugs are going to blow avodart right out of the water. In the meantime I think it provides some activity, we know it helps involved prostate enlargement, it helps with the urinary flow. To answer your final question, if someone tells you that a supplement works as well as avodart or finasteride, they are completely lying to you. 

We have looked at everyone you can possibly imagine. Twenty five different ones and they don’t even come close clinically. In a laboratory with a mouse or a rat they always tend to work well but since we are not mice and rats when used by humans it does very little. I would stick with the stuff that does work. 


Person #6: Flax seed oil do you have a view on that?


Dr. Mark Moyad: If you talk to some experts, when it comes to flax seed, they think the flax seed is like the devil seed and it is bad for you. The problem with that thinking is that flaxseed in a trial at Duke University with over 100 people with a radical prostatectomy ironically one of the largest nutritional studies ever done in prostate cancer history. I think it has been four years since the publication. It was done at Duke University before surgery. I always like to explain the history of the thinking to make it more logical as opposed to willy-nilly throwing out an opinion like anyone can do. 


Flaxseed was always fascinating to me because it has shown it can reduce bad cholesterol and it is a really good source of fibre. It is cheap. So they did this study at Duke where they gave people three rounds of flaxseed fluid for about six weeks for a radical prostatectomy they looked at the stats and it seemed to work as well as a low fat diet and making all these anti prostate cancer effects and some people who approved the studies said it was not that great. 


The problem with that study is that it might not have been great, but it one of the studies we have had in prostate cancer. So flaxseed seems to be heart healthy. I like it. I have always liked it, and I think it will continue to show positive effects because it keeps the heart healthy and it is a great source of fibre. When you deal with the oil though, you are playing a different ball game. When you deal with the oil you tend to get a lot more calories. A tablespoon of flaxseed most of them are about 120 calories. That is a lot. The second problem you have with flaxseed oil is there is zero fibre. One of the biggest benefits to flaxseed and we know now that fibre is not only heart healthy but there is plenty of research to show that it is prostate healthy. 


You have removed it from the oil. I don’t think the oil is dangerous. I think the oil can be healthy. If you look at the supplement handbook we mention it the section on dry eye it seems to work as well as some pharmaceutical drugs for dry eye. I prefer flaxseed if you are going to choose it because it is a good source of the fibre. The flaxseed oil you have to be careful with the calories and there is no fibre. The one piece of good news about flaxseed oil is that when men and women take it the omega fatty acid gets converted into basically the same type as you find in fish oil. 


My bottom line is this I would rather that you do flaxseed powder and put it on any food you want but if you are using flaxseed oil make sure you don’t gain any weight while you are on it otherwise I would take it away.


Person #6: I have been taking it for quite some time what they call part of the Budwig protocol which is a mixture of flaxseed oil and cottage cheese. This is supposedly a well-known cancer cure and the Estrogen in the flaxseed was one of the other concerns that I had and that maybe this was working against the prostate rather than helping. Do you have a view on that? 


Dr. Mark Moyad: The Budwig protocol, I will tell you. The problem with that protocol, is that the people that tout it, every time they just publish anything, just these case studies. I understand it is necessary to move science forward or otherwise we are not changing medicine. I always wanted a flaxseed, and budwig protocol which I wish they would go to a trial, but they don’t do that. What I see in some people who do flaxseed and cottage cheese is they actually lose weight and become more health conscious. 


So it is just not those two things in combination. It is those two things are associated with a lot of healthy behaviour. I see them do a lot better. My comment is I don’t see flaxseed and cottage cheese as any miracle. I think in fact I have seen cholesterol go down. Cottage cheese is a good source of calcium. Men need calcium for bones especially when they are on androgen deprivation. I don’t see any harm in it and I think if you want to add it that’s fine. There are other categories of different supplements where I get worried about like vitamin E, selenium, too much hype on pomegranate juice, which we are going to talk about in a minute. 


I see no harm where budwig diet, it is not one of those things I jump up and down. 


Person #6: When I started on the budwig protocol my PSA was 12. It had never hit 12 before and I am 61 years of age. As a result of that I was under an urologist who said let’s just see what happens. The bottom line is I brought my PSA down to 3.5 in a matter of three months. I have got to say that over the last six months I tapered off the budwig protocol and my PSA would be 4.2. For my age group in Australia under 4.5 is considered acceptable. I guess I have got to say I have had a fairly good run with it. I have tapered off it over the last six months and I am concerned whether in fact I should be going back or more importantly get your view on it. 


Dr. Mark Moyad: I think when you are doing the budwig protocol, I see some people get healthier and get well because they are doing other things. A lot of people won’t do that in isolation. They may exercise more, they may eat better overall or they may eat less. I am just a huge fan of the patient knowing what we know. That is what our jobs are. What we know is that if you are getting healthier on anything, even though it hasn’t been studied, even though there is not a major clinical trial. There is not a clinical trial on budwig that we can get people excited. I can’t get doctors excited about it in general. The evidence is more anecdotal. 


In your case if your PSA is getting better what I would encourage you to do is look for also anything else that budwig protocol might be helping. For example with your cholesterol also going down, is your blood sugars going down, is your triglycerides going down. What we started seeing in men who were doing flaxseed is sometimes their bad cholesterol will go down and they would lose weight because of the fibre effect. These were the people who had the flaxseed powder with the cottage cheese situation. 


My advice is that we don’t have the appropriate answer but that is not a bad answer that is just an honest answer. So if you got better and your numbers got better on this protocol even though there may not be a lot of science it tends to be safe that I would continue trying it. I think there are three answers that doctors can give. 

1. Clearly the evidence doesn’t work. 

2. It clearly does work from the evidence. 

3. We have no idea. It is not we have no idea because we are dumb or stupid it is because it is just honest. 


We have no idea because no one has really studied it. I just want to make sure you know that and that once you know we have no idea, I think the person should take on the risk themselves. I don’t like it when patients are treated like children. I have plenty of cancer in my family. I would look at cancer family members and I would go look I have no idea. If you try it you are your own clinical trial. Let me answer the last question. If you are seeing better numbers on it then maybe that was an indication to keep doing whatever you were doing.


Convenor Jim Marshall: Can we now move on to pomegranate juice? I know we have some fans. 


Dr. Mark Moyad: It is probably a good thing sometimes that no one knows where I live. Because I always tell people that, sometimes just speaking your mind and not having any financial connection to any of these companies, sometimes I get nervous when I start my car. That someone is going to put a bomb in my car or something. The reason I say that is because I said for years that I believe the pomegranate juice trial will fail. The reason why I think it is going to fail is because I have been doing this for so long.   I have seen so many people and what you don’t see in a pomegranate trial is you don’t see men lose weight.   You don’t see their blood sugars get better.  You don’t see their blood cholesterol peak.  You see nothing heart healthy but somehow magically it changes your doubling time.  Now, will they beat placebo?


There is this large based retrial that has just completed.  We will not know the answers until Spring.  People have always said to me they appreciate my prediction record.  I probably should have gone into Vegas and betting.  I would have made more money than medicine.  All I have is my prediction records if you look at all my publications. The track record is very good.  They always ask me what do you predict will happen in the pomegranate trial?  My prediction is it won’t beat placebo. 


The reason is why that is, when some men go on pomegranate, they tend to do a lot of other things that are very healthy and that make pomegranate look good.  The second thing is that if you notice from the studies they never go up against orange juice or grapefruit juice or carrot juice which is low in calories and high in potassium.  You don’t go up against anything.  That is not proving anything to me. 


You have to prove you are heart healthy, and first do no harm.  Unfortunately a lot of guys don’t like it but I am being honest that I believe that trial will fail.  I believe it from experience.  I believe it from the fact it is not changing numbers by itself.  We know that.  Somehow magically it is doubling changing time. 


Let me give you an example of how you can change doubling time.  There was a huge drug going through a trial in the United States in the past few years.  The reason why the trial was stopped is that approximately 80% of the men on placebo had an improvement in doubling time just doing what they were doing every day.  There was lifestyle change. 


We will find out in 2015.   I will come back onto the phone and if I am wrong you can throw eggs at me.


I am worried this trial is going to show nothing. The other reason I want to say that is because all these studies are tied into business in a kind of way. The trial ended a while ago and I just think something would have leaked already if there was something positive. For those of you who don’t realise, in the United States a pomegranate juice company were sued by our government, the Federal Trade Commission.  They were sued for making claims that they could not substantiate. It has been very quiet lately.


I have worked with the government in the United States. I have advised and counselled for everyone you can imagine in this country. And when you hear it go this quiet, what it generally means is something happened that was remotely positive but is not that great or nothing happened. 


There is another reason I believe that is going to happen. If you drink pomegranate juice and you are losing weight and your cholesterol is coming down and you are seeing heart healthy changes, just continue what you are doing. In the clinical trials in the most case scenario, I see the men drink a bunch of the pomegranate juice and taking the pills and spending a lot of money and I see them gaining weight.  That makes me nervous. 


I say that every prostate cancer patient should gauge their cholesterol, their blood sugar, blood pressure and weight. Those four parameters should help them identify whether or not they should continue on the Budwig protocol or the pomegranate. Again that is cholesterol, blood sugar, blood pressure and weight. If those are getting better, that is different. 


Person #9: Can you tell me the benefits of alkaline water? 


Dr. Mark Moyad: The alkaline water has been interesting. It is incredibly safe. In the United States it has been associated with a lot of presumptuousness. There has been a lot of people selling alkaline water to cancer patients in the States and making claims that are absolutely not true. I have no problem with the water. It is incredibly safe. I just don’t think people should be paying a lot of money for it. 


The reason I say that, is physiologically the human body stays within a very narrow ph range. If that ph were to shift too alkaline or too acidic then the person will be in the emergency room. What happens is if anything we eat goes into your stomach which has an incredibly acidic stomach ph of about 2. In fact if we took stomach acid out of most stomachs it would burn a hole right through any rug or any floor.


Then it gets digested and sent off to the intestines where you absorb it. Most of that is alkaline. Then it goes into the blood where it is mostly alkaline. The problem is when you drink water a lot of it does end up being alkaline anyway. I tell people that it is perfectly healthy and safe but I would rather have them save their money and send money to me so I can buy more beer. (Laughter) It is safe, which is important. You just have to be careful of the amount of money you are spending on it.


Going back to Person #9's question, the one thing I would mention about, I would ask the question to him about the question that commonly comes up chemotherapy, I get this question a lot. This is the bigger problem we are seeing with our newest drugs and you can tell me if you have experienced it. It is really bad for teeth. Just exhaustion. What I always tell them again is look at the rule. When people tell me a lot lately about the fatigue they are experiencing with the new drugs and I can guarantee you as this group goes on in time and you try the newer drugs some people will have serious fatigue. 


Once again I always use that rule what can I in terms of lifestyle to combat the fatigue? Well we know now from studies from Perth, Australia that essentially lifting weights or doing resistance exercises a couple of days a week can reduce fatigue because it increases your metabolism and muscle mass. A simple weight lifting a few times a week within a couple of months reduces fatigue. The second thing you can do over the counter that reduces fatigue is caffeine. It used to get a bad name but now it gets a great name. 


Don’t quit your caffeine. Caffeine is essential to reducing that fatigue. I encourage all men with prostate cancer if they like their coke a cola or their diet soda or coffee I don’t care what it is caffeine is a great thing. You don’t want to stop it or it may make your fatigue five times worse. Over the counter there was a huge male clinic trial using ginseng. It is American ginseng and it is a cheap and natural supplement and after a month. There were a number of prostate cancer patients in the study and after a month it worked significantly better than placebo and it was as safe as placebo in improving fatigue and energy levels. 


Let’s say none of that works and you still have really bad fatigue. I would encourage you to ask your physician about possibly prescribing you a stimulant drug. There are a number of stimulant drugs out there that can be low cost. Unfortunately they are associated with bad things. Ritalin is associated with ADHD kids or hyperactive kids. So what people don’t realise is we have a whole bunch of stimulants that oncologists use all the time in breast cancer patients and other cases. 


The reason I don’t think they use them in prostate cancer is I don’t think it has been requested enough. If your fatigue is so bad you can’t function regardless of what you do, there are stimulant medications that are incredibly safe and if you take them in the morning not after that. If you take them later in the day you can’t be able to sleep. People function really well if you need them. Just remember there are always a range of options on any of these side effects.


Person #18: Side effects, I am on hormone therapy and the one I have got is the effect on cognitive ability. Apart from exercise what can you do for that one?


Dr. Mark Moyad: The cognitive problem is a really difficult problem to deal with. I don’t know how you would describe it. People describe to me as a mental fog or a mental fatigue in itself. We haven’t been real good at studying what works. There was a study in Oregon by Tom Beer (Thomasz M Beer). He is a very famous oncologist and he looked at using a little bit of Estrogen. [jm: estrogen = oestrogen. Estradiol is an estrogen commonly used in patches in prostate cancer treatment.] It seemed to help with the mental effects. So have a discussion with your oncologist about having them look at the data on possibly a really low dose of Estrogen if the cognition problem is really bad to see if it might potentially do anything to affect cognition overall. 


The other thing we have people do again it goes back to basics. The people who have been exercising essentially what amounts to every other day to doing a combination of aerobic activity [and strength] exercise are getting a little bit mentally sharp. So that might also help. The third thing is if you look in the supplement handbook and look in the part for memory, in the memory loss chapter, it takes you through a number of different supplements that have been studied in the area of memory loss. Most of it is research from New Zealand and Australia. 


I would encourage you to take a look at the memory loss chapter because it talks about everything basic from the minimal data we see for example in krill oil or fish oil to help with mental fatigue to vitamin D levels that might help. It kind of takes you through all of that stuff and you can try a number of those supplements. 


The other thing we have noticed to and the reason we say it is such a serious issue is if you are intermittent hormone therapy then some people will claim their memory is a lot better when their testosterone comes back. I have found that to be the case to. I don’t know if intermittent hormone therapy is a possibility. There are two supplements and one in particular that has had a lot of research primarily in Australia and one is called Bacopa. I will tell you it is the best twenty bucks you have ever spent on Amazon. Go to the memory loss section.


Bacopa has a very safe study and it has been studied in cases of memory issues. [Ed:

http://www.ncbi.nlm.nih.gov/pubmed/22747190 ]

It has not been studied in patients on antidepressants but it is a similar type of memory issues. Either it had potentially the same side effects of the placebo overall and if it worked it helped essentially within 12 weeks. The Bacopa crossed the blood brain barrier and it seems to help with neurotransmitter function. That is the one we rank number one. 90% of these studies have been done throughout Australia and unfortunately these studies are done with memory loss they haven’ t been done enough in people who have been on LHRH. 


The final thing I will tell you when people discount exercise, if you do a brain scan while someone is alive when they exercise there is a specific part of the brain called the hippocampus that as it shrinks memory gets worse. It is responsible for storing information and what we learned in 2014 was people who exercise their hippocampus stays the same size or increases in size. Then if people drop off from exercise the hippocampus shrinks as they get older and that they exercise less. Exercise is not getting enough credit for cognitive function, which is too bad. 


Those are the three approaches. The hard-core exercise approach for memory loss. The prescription approach which we mentioned and the supplement that I mentioned and you can look in the book to read more about. I would ask or I would at least try the supplement option as you have got nothing to lose and everything to gain. They do sell that supplement in Australia.


Person #13: A question relating to bone health as a result of androgen deprivation therapy. One of the consequences of being on androgen deprivation therapy for an extended period of time I have had my bone health has suffered. 


Dr. Mark Moyad: Osteopenia. Every time a side effect comes in you have to deal with it. Again look at it three ways. What I can do, what can I buy over the counter or what can I do on prescription. So if you look at bone health men who do vigorous exercise twice a week, that has come out again from Perth, Australia twice a week or three times a week even for twenty or thirty minutes have a substantial impact with lower and upper body exercise. It only takes twenty to thirty minutes and it can substantially slow osteoporosis or bone loss. 


Resistance exercise and putting stress on the bones of some kind especially with the weight lifting. If you put stress on your legs like running that is also stress which stimulates bone cell to produce more bone. Lifestyle has a huge impact and it is underplayed completely in prostate cancer. The reason why I know it is underplayed is because when one of our recent bone drugs got approved they looked at the placebo arm and there was very little bone loss and you look back at this grid and see most of these guys are exercising. We have learned in the past that most placebo members were not exercising and the bone drugs work a lot better than they did. 


Now we are learning for bone loss in several ways, just in exercising daily, lifting weights two to three times a week. On top of that every man should be getting their recommended daily intake of calcium which is about 1000 to 1200 mg per day. If you have to take a supplement there are different types. Calcium carbonate, calcium citrate you can do that but a lot of foods in Australia and the United States today can have a lot of calcium. People don’t realise all their milk contains a lot of calcium these days. Most of your milks which just aren’t dairy milks contains a lot of calcium they are fortified. So if you count up the amount of calcium you get from food and drink and then take the rest as a pill to get to about 1200 mg per day. 


The second thing you can do is ask for a vitamin D test or you can take about 1000 international units of vitamin D. It sounds like a big number but it is not. It is about 25 millionth of a gram. So taking calcium and vitamin D. lifting weights and doing exercises that put pressure on the arm bones, the leg bones and the body that’s fine. The last but not the least if you are going to be on androgen deprivation therapy indefinitely you have got to ask about any of the bone loss drugs that people use. That stops bone loss in its tracks. In the States the hottest one now is Denosumab also known as Xgeva. 


There are plenty of these drugs for bone loss. Men need to realise is that in combination with weight lifting, calcium and vitamin D in clinical trials because in all the clinical trials the men were taking calcium and vitamin D. The majority of people and 95% of the people I see it stops bone loss completely. Again that breaks bone loss down into three things. What can I do lifestyle? What can I do in terms of soft meds? Calcium and vitamin D can be addressed by every single person. It wouldn’t be bad to get one vitamin D blood test just to see how you are doing. 


The finally point is if you need a drug don’t be shy. You can take it but I will just caution you. These drugs work so well you always have to ask how often you need the drug. I tend to tell a lot of men with prostate cancer that ask your doctor about how often you really need that bone drug because most of the drug bones that are given today whether it is Zometa or Xgeva they sit in your body for years. Some people take a couple different rounds of it and then they quit for the entire year because it works so well. There should be a lot more men go on these drug holidays with these osteoporosis drugs just like they are doing with women now. That part about the drug that it sits in your body forever. That is the worst part about the drug to. It sits in your body forever and we are now seeing side effects from people who get too much of it. 


Person #75: Thank you for that Mark. If I could just make a little contribution here. Rob Newton and Prue Cormie who have been head of research in Western Australia have specifically looked at metastatic men and the exercise and they found that bone health in metastatic prostate cancer was greatly helped with impact exercises.


Dr. Mark Moyad: That is exactly right. They were jumping and putting pressure on the legs. I know Rob Newton and that team very well. When I was in Australia last time, I was with them, and I just did a class in the States with Rob last May. That group is leading the world in terms of showing clearly that exercise works so much better than we realise for men with bone health. There is one last thing I mentioned to Rob Newton last time I saw him and they are studying it now, and I believe it will work. What we have done in prostate cancer is that we have focused on the bone for bone health and that is what makes sense, right, it is all about the bone but it is not though. It is also about the muscle and the nerve. 


What we are finding when people have fractures they fall from a standing height. In other words it is just as much about muscular strength and coordination you don’t want to fall. What we are realising in women’s health is that muscle development and muscle strength is just as important as bone strength because it supports the bone. What we have asked men on androgen deprivation to do is to look into buying a protein powder. You can now buy protein powder with no sugar. You can get 25g of protein on 100 calories. In other words these are much better than a bar. These protein bars are a waste of money. 


The only thing you should get from a bar is a beer. The protein bars get way too much attention. The protein powder you can get a tonne of protein on very little calories and it helps the muscle develop as your exercising. All of our athletes and Rob Newton will tell you they have started to recommend it and seeing very good results. I would have everyone lifting who is doing androgen deprivation to all so look into the possibility of getting whey protein isolates with no sugar. It tastes great and you just mix it with water. You can get it with strawberry, chocolate and vanilla. 


They taste fantastic and they beat every single bar out there and they are as cheap or if not cheaper than a bar. It can help with muscle development after a workout. I think that is an all important point about the bone health study.


Person #6: I heard you talk about hot flushes. I have been experiencing these for the last few months and the doctors don’t even know what it is. I have a hot face flush. From what you said there seems to be possibility progesterone that may help relieve you. Do you have anything further to add that maybe I could pass on to my doctor next time I see him next.


Dr. Mark Moyad: We grade these. Some people get mild ones, some people get moderate ones and some people get severe ones. The people that need the drugs are the ones who get the more severe hot flashes. Severe hot flashes mean it is tough to function. That means it is tough to go to bed, it might be tough to go to work and it is tough to do day to day routines. That is the one progesterone has been a miracle for. There is a drug called Megace [Megestrol acetate]. It is a type of progesterone pill. They give it breast cancer and other type of patients for all types of hot flashes. There is plenty of data now that shows that it works in men. 


The progesterone is a great example. In Canada and Australia they use cyproterone acetate [Androcur, banned in some countries because of its effect on the heart] for hot flashes. That is okay but it has had some issues with cardiac effect. So I do not like people taking cyproterone acetate just for the heck of it. 


So progesterone is a good option but I would write down this name down, Effexor and you can google it. Ed: http://en.wikipedia.org/wiki/Venlafaxine


This is an antidepressant and it has gone through a million studies on breast cancer. There is plenty now in prostate and if you do a search the generic name of venlafaxine. It goes into the same place that affects temperature in the body and within four weeks and essentially it helps with mood and it also may help with cognition and not just the hot flash. Both of those become an option. If you are not having depression or mental health issues the first one should be progesterone and the next one should be Effexor. 


Person #6: Could it just be a simple thing as male menopause? 


Dr. Mark Moyad: Yes it is.  That is what people don’t realise. That is why I said a woman goes through menopause for years and years. She watches as her Estrogen decreases and depletes. Women can experience on and off hot flashes for about five years. Then they say overtime they get a little better. What happens with LHRH you are taking a man's testosterone and you are taking it from a high level and going straight to zero in thirty days. 


So you are plunging a man into male menopause immediately. There is no five year stretch or three year stretch. What has happened with hot flashes they can come on immediately? In some people we don’t know why. Some of it can be weight gain, some of it can be genetic, but the point is in about a third to as much as a half of people on androgen deprivation therapy their hot flashes are so severe they cannot function. You people should be put on medication. You can do all the exercise in the world, you take all the supplements, you can take Bacopa, you can take st johns wart you can take anything and it is not going to keep those hot flashes at bay like progesterone or Effexor. You have got to go to the hard-core stuff. I am not saying that every prostate cancer patient should take it.


Person #6: For example in the flaxseed oil and cottage cheese the flaxseed itself has a high level of Estrogen and by taking that would that actually be promoting the hot flashes rather than keeping them at bay?


Dr. Mark Moyad: There was a huge trial in the United States that has just been presented but it has not been published yet. It was a huge trial of cancer patients taking flaxseed for hot flashes. So flaxseed has a lot of plant Estrogen that are called lignans. Here is the biggest problem we run into when books say that soy and flaxseed have a lot of estrogen. It is relative. So if they do have a lot of plant estrogen but relative to estrogen itself it is very little. It rarely changes a man estrogen level even though there is plant estrogen they rarely change estrogen levels. In the trial flaxseed actually helped hot flashes slightly better than a placebo arguable similar. Another option for hot flashes that will go away immediately is estrogen. The reason you may not have heard that. 


Estrogen used to be the standard thing for hot flashes not progesterone. The problem is if someone gets too much estrogen they can get a blood clot. A lot of doctors around the world got nervous about that and nervous about legal aspects of that so most doctors are not giving estrogen in higher or moderate doses anymore. Low doses for hot flashes. The problem was more with the pill. It is such a controversial and risky area for hot flashes that people get nervous about it. Estrogen is supposed to help with your hot flashes and in men. It does come with a cardiac risk which is why I mentioned progesterone and Effexor. 


Flaxseed might help a little bit but for severe hot flashes it didn’t work any better than placebo. In my thirty years of experience I would agree with that. It has worked more with mild hot flashes.


Person #6: It is not a huge problem continuing on with that and it may help the flashes.


Dr. Mark Moyad: Right. When a person says that a plant has food estrogen and don’t get too excited about it because what they try to do is advertise the stuff to sell the product. The amount of estrogen it has compared to pharmacological estrogen is almost negligible. That is where soy and flaxseed got into trouble. Almost all vegetables have plant estrogen, broccoli has plant estrogen, but it really changes a woman's estrogen levels. There is not enough there that can really make a dramatic change unless you hot flashes are really mild. I do recommend flaxseed for hot flashes but mild hot flashes.


Person #15: You were talking about protein supplements and protein powders for helping build muscle mass in the context of resistant exercise. I have been involved in a clinical trial here in Australia around that idea. I spoke to the post op guy who was running it and asked him the relative merits of whey protein isolate versus soy protein isolate for building muscle mass and he was quite ambiguous saying whey protein is much better for that purpose. Do you have any comment on that? 


Dr. Mark Moyad: I do. I think part of me would disagree. Every time someone says a plant product or a certain product is so much better you have got to remember what does better for mean. Does it mean better on a blood test? Does it mean clinically better? Does it really make a difference? Whey protein has had the most studies, whey protein isolates and it enjoys the largest concentrate in the amino acid called branched chain amino acid and really get incorporated into the muscle that is true. 


Whey protein isolate has had about a twenty year jump on soy protein in terms of muscle mass. It has had far more studies and because it has had far more studies a lot of doctors will tend to say its better. Head to head it is either worth a little bit better or the same. Ultimately I believe that ten to twenty years from now if it works better it is not going to be dramatically better. It is not going to make such a difference. What we tell people to do is that they all work fine. Some of the guys want to see benefits of soy. They want to see benefits of pea protein. They want to see benefits of whey. We have some guys who rotate them. They will do whey for a month. Soy protein for another month or they may do soy in the morning and whey in the afternoon. The answer to your question is, yes, whey protein has worked better only because it has had a lot more studies. It is very possible we will wake up in ten or twenty years and soy protein will work just as well. 


Soy protein is fabulous as it has the largest diverse amount of amino acids in any plant protein and it is also lower in calories. You can do 80 calories and get 20-25 grams. Maybe the biggest benefit of soy protein is the fact that it also can be very low in calories and even lower than whey protein in some aspects. The other thing you have to realise is that what you are not being told in some cases is that whey protein branched chain amino acids, they cause insulin release. People tend to associate insulin spikes with sugar, and that is true, but what people don’t realise that there are certain amino acids that also cause insulin to be released. Whey protein more than any other protein causes the largest amount of insulin release which is why it probably helps build muscle. 


If you are already on the androgen deprivation therapy and you are trying to build muscle and you're also getting insulin spikes you might end up gaining weight on whey protein. It depends on the patient. To answer your question, I like whey protein, but if you are not losing weight and you are gain a substantial amount of weight I switch people to soy protein. My prediction is ten to twenty years all these protein powders are going to look pretty good in themselves. Not one dramatically better than the other.


By the way, what is the only protein that has a cholesterol lowering advertisement allowed by the FDA? That is soy, because when soy protein is used instead of certain types of carbohydrates, bad cholesterol goes down. Soy is one of the only foods that the FDA (Food and Drug Administration) in the United States allow to use a drug claim that your cholesterol actually drops. Again it is all about using different types of protein powders and I tell people to rotate them. It keeps them interested. It keeps them educated and it gives them the benefits of the different powders is why the different doctors argue back and forth as to which one is better. I think it is better to use a protein powder than milk protein powder. I think it is best to rotate them. Make sure you are gauging your weight and you are not gaining weight on these protein powders because I have seen some men gain weight and when they get too much of it. 


Person #18: I have a follow up question on whey protein isolate. Various vitamin supplement manufacturers, quite a great difference in quality, do you have any recommendations as to which suppliers of whey protein are better to use than others? 


Dr. Mark Moyad: I will tell you one rule I say with supplements, and I am going to sound like a shameless promoter here, If you pick up any of my books that I have written in the last thirty years pick up the supplement handbook. This is a book I use in Australia and all around the world to teach doctors about supplements for the past thirty years. Take a look at essentially when dealing with these issues of what to do on whey protein isolates and ritalin. Here are one of the rules that not many people realise. In the clinical trials and this is rule number one. In the clinical trials they use whey protein isolates and some use concentrate. Isolates basically means it is more protein and no sugar. So it is more of a pure protein. In the clinical trials they didn’t add anything else. 


They didn’t add fibre to it or vitamins and minerals. What a lot of these companies do which I think rips off the consumer is they will sell whey protein with something else in it. If they sell you whey protein with something else in it besides whey protein like different vitamins, minerals, herbs anything like that don’t buy it. That is not the one that was tested they are just charging more money. When protein powders comes out just like supplements they come out as generic they do not come out as a priority trademark like a drug. It is typical for people to get their hands around supplements because in the drug world you come out with a trademark, you have a patent and then after a while you lose the patent. In the supplement world you don’t have a patent you come out as a generic. More expensive products in my world are not better that cheaper products because you start as generic. What they do is fluff up the generic in order to charge more money a lot of the time. You look for a whey protein isolate that has almost no sugar, very low in sodium and essentially high in protein. I like the ones that are about 100 calories with 25 grams of protein. Those are the kind that I used in the clinical trials and there are no fancy extras. I don’t work with any of the companies I have recommended. 


If you look online at a company called Jay-Robb that is the guy who owns the company. [Ed: http://www.jayrobb.com/ ]


He has incredible whey protein powder because it is just an isolate it has about 25 grams to 100 calories and they don’t throw any of these fancy extras in there. It is low in sodium. It has virtually no lactose for the lactose intolerant. Those are the kind you look for. I would compare your whey protein isolate to jay-robb protein isolate. Time and time again when I tell people to do clinical trials, or celebrities, or CEO’S, when they go to jay-robb they basically say I have never meet anyone at the company I do not know them they have been in the protein powder business for twenty years. They are very environmentally friendly. I would compare what you are taking up against their product.


I think that we have decided we need to do a part two. I will give Jim a heads up when I will be in Australia next. It could be late 2015 or early 2016. Next time I will be doing classes and travelling around. I would like to see people come out and we would have a good time. 


Person #88: Is it too early to know if you will be invited to the PCRI conference in LA in September 2015? 


Dr. Mark Moyad: I will be moderating again. I have moderated five years in a row. The PCRI Conference is the largest prostate cancer conference for patients in the world. We work all year long as volunteers. We have an incredible line up. We have already confirmed Dr Larry Klotz, big active surveillance guy for Toronto. It is probably the best line up we have had in the five - six years I have been there.


Convenor Jim Marshall Thank you very much for you time we have enjoyed it and we look forward to hearing from you again in the New Year. 


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

Part 1 here:


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