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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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October 10 2018

A Primal Guide to Prostate Health

By Mark Sisson
22 Comments

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

Let’s go.

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

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

What Goes Wrong With the Prostate?

There are a few things that can happen.

Prostatitis

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

Benign Prostatic Hyperplasia

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

Prostate Cancer

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

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

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

What Are Symptoms of Prostate Cancer?

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

What Causes Prostate Cancer?

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

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

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

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

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

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

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

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

What About Testing?

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

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

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

Other causes of high levels of PSA include:

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

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

What About Treatment?

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

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

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

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

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

How Can You Reduce the Risk of Prostate Cancer?

1. Inflammation is definitely an issue.

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

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

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

2. The phytonutrients you consume make a difference.

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

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

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

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

3. Your circadian rhythm and your sleep are important.

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

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

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

5. Keep moving, keep playing, keep lifting.

This has a number of pro-prostate effects:

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

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

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

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

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

References:

Perletti G, Monti E, Magri V, et al. The association between prostatitis and prostate cancer. Systematic review and meta-analysis. Arch Ital Urol Androl. 2017;89(4):259-265.

Ilic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519.

Brawer MK, Chetner MP, Beatie J, Buchner DM, Vessella RL, Lange PH. Screening for prostatic carcinoma with prostate specific antigen. J Urol. 1992;147(3 Pt 2):841-5.

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

Watts EL, Appleby PN, Perez-cornago A, et al. Low Free Testosterone and Prostate Cancer Risk: A Collaborative Analysis of 20 Prospective Studies. Eur Urol. 2018;

Neuzillet Y, Raynaud JP, Dreyfus JF, et al. Aggressiveness of Localized Prostate Cancer: the Key Value of Testosterone Deficiency Evaluated by Both Total and Bioavailable Testosterone: AndroCan Study Results. Horm Cancer. 2018;

Dai B, Qu Y, Kong Y, et al. Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8-10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer. BJU Int. 2012;110(11 Pt B):E667-72.

Teloken C, Da ros CT, Caraver F, Weber FA, Cavalheiro AP, Graziottin TM. Low serum testosterone levels are associated with positive surgical margins in radical retropubic prostatectomy: hypogonadism represents bad prognosis in prostate cancer. J Urol. 2005;174(6):2178-80.

Banerjee PP, Banerjee S, Brown TR, Zirkin BR. Androgen action in prostate function and disease. Am J Clin Exp Urol. 2018;6(2):62-77.

Zhou CK, Daugherty SE, Liao LM, et al. Do Aspirin and Other NSAIDs Confer a Survival Benefit in Men Diagnosed with Prostate Cancer? A Pooled Analysis of NIH-AARP and PLCO Cohorts. Cancer Prev Res (Phila). 2017;10(7):410-420.

Russo GI, Campisi D, Di mauro M, et al. Dietary Consumption of Phenolic Acids and Prostate Cancer: A Case-Control Study in Sicily, Southern Italy. Molecules. 2017;22(12)

Russo GI, Di mauro M, Regis F, et al. Association between dietary phytoestrogens intakes and prostate cancer risk in Sicily. Aging Male. 2018;21(1):48-54.

Discacciati A, Orsini N, Wolk A. Coffee consumption and risk of nonaggressive, aggressive and fatal prostate cancer–a dose-response meta-analysis. Ann Oncol. 2014;25(3):584-91.

Dauchy RT, Hoffman AE, Wren-dail MA, et al. Daytime Blue Light Enhances the Nighttime Circadian Melatonin Inhibition of Human Prostate Cancer Growth. Comp Med. 2015;65(6):473-85.

Kim KY, Lee E, Kim YJ, Kim J. The association between artificial light at night and prostate cancer in Gwangju City and South Jeolla Province of South Korea. Chronobiol Int. 2017;34(2):203-211.

Murtola TJ, Vihervuori VJ, Lahtela J, et al. Fasting blood glucose, glycaemic control and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Br J Cancer. 2018;118(9):1248-1254.

Haring A, Murtola TJ, Talala K, Taari K, Tammela TL, Auvinen A. Antidiabetic drug use and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Scand J Urol. 2017;51(1):5-12.

Park JS, Lee KS, Ham WS, Chung BH, Koo KC. Impact of metformin on serum prostate-specific antigen levels: Data from the national health and nutrition examination survey 2007 to 2008. Medicine (Baltimore). 2017;96(51):e9427.

Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340-7.

Ying M, Zhao R, Jiang D, Gu S, Li M. Lifestyle interventions to alleviate side effects on prostate cancer patients receiving androgen deprivation therapy: a meta-analysis. Jpn J Clin Oncol. 2018;48(9):827-834.

Uth J, Fristrup B, Haahr RD, et al. Football training over 5 years is associated with preserved femoral bone mineral density in men with prostate cancer. Scand J Med Sci Sports. 2018;28 Suppl 1:61-73.

Park J, Yoon DH, Yoo S, et al. Effects of Progressive Resistance Training on Post-Surgery Incontinence in Men with Prostate Cancer. J Clin Med. 2018;7(9)

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22 thoughts on “A Primal Guide to Prostate Health”

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  1. Wow Mark,
    I’ve been following and using your excellent work for quite a while now. Another great article right on point. Thank you for your work!

  2. A few things…
    • It’s implied but not stated that being Ketoish should be a good preventative and treatment, however it would be interesting to know if Prostate cancer is one that responds particularly well to keto.
    • I believe high estrogen is a strong risk factor as well
    • There was a study (from the University of South Carolina , I believe) that showed Vitamin D supplements can actually shrink prostate cancers in those who are low in Vitamin D
    • An advantage of the “don’t test” approach is that it avoids the stress associated with any indication, true or false, of cancer, and the stress itself is likely cancer-promoting
    • The problem with involving doctors in the discussion early on is that most are apparently still in the mode of over doing treatment and under-stating the risks of the treatment, so it seem prudent to research first and then selectively get a forward-thinking non-urologist doctor involved
    • Those looking for a survivor’s perspective on non-pharma treatments should seek out the podcasts with Eric Remensperger

  3. Well done, Mark. My doc just prescribed saw palmetto to reduce multiple nighttime visits to the bathroom, though the research I’m looking at says there’s no clinical evidence to support saw palmetto for prostate problems. Your take?

    1. This will kill your DHT, and, it sure as ship isn’t primal. Perhaps you should consider something a little more savage… something like eating some prostate and liver!

      — Based on the ancient ancestral wisdom that “like supports like.” Consuming prostate may nourish and support our own prostate. —

      — Provides healthy prostate building blocks… prostate-specific proteins, peptides, enzymes & cofactors along with nourishment that is fundamental to human physiology. —

      — Contains molecular biodirectors (DNA instructions) to code and/or express the building of healthy tissue. —

      Plus, if you’re not consuming liver (or) desiccated liver, you’re probably deficient… this is a fact. Retinol, and vitamin A derivatives, influence proper cell differentiation, proliferation and apoptosis (programmed cell death for cells that are misbehaving). Real retinol is obtained from animal foods (most notably, liver) in contrast to the beta carotene varieties that poorly convert to this wonder vitamin. Obtaining the recommended Daily Value (RDV) of real vitamin A is fundamental for various biological functions, including dental health, embryonic development, tissue integrity and immune regulation. Vitamin A is nicknamed the concertmaster for good reason.

        1. I wish that I could read this whole paper right now but I can’t… since this paper cites the use of synthetic vitamin A, we’re talking apples to avocados here!

          I believe that every man, woman and child has the right to be strong, healthy and happy (autoimmune-free, eczema-free, allergy-free, fatigue-free and so on)… to live life with robust energy and biological resilience… to go from a mere existence in life, to discovering that which makes life worth living. I believe the path to get there is through ancestral living (AKA) The Primal Blueprint.

          Unfortunately, most people are grossly deficient in vitamin D, A and K. As it relates to vitamin A, our early ancestors would have easily consumed north of 20,000 IUs of vitamin A per day. They probably would have consumed plenty of sunshine too, not to mention that most sources of vitamin A also have plenty of vitamin D as well. Vitamin A and vitamin D work cooperatively and protectively together (to prevent toxicity). Of course, vitamin K plays a key role here too. — Source: https://chrismasterjohnphd.com/2009/04/07/tufts-university-confirms-that-vitamin/

          I’ve never seen a single peer reviewed study that shows vitamin A, from natural whole-food sources, to cause any harm. We evolved with nose-to-tail nourishment since the inception of our species. These are things that our DNA still expects in the modern world to heal and be healthy. That’s what I believe.

          1. The following, in part, is from the Anchorage Daily News, Feb. 5, 2017–not that many people on this comment board are likely to eat polar bear liver:

            “Research has shown that a healthy adult person can tolerate 10,000 units of vitamin A. Trouble, if it comes, comes between 25,000 and 33,000 units. One pound of polar bear liver — a fist-sized chunk and barely a meal — can contain 9 million units of vitamin A”

            The average person is pretty safe eating an average-size portion of liver. But there are a lot of people out there who belong to the “more is better” school of thought. Liver of any kind (and vitamin A) is one of those things that it’s probably wise not to go overboard with. Too much of it can definitely cause harm.

            https://www.adn.com/alaska-life/we-alaskans/2017/02/05/the-perils-of-eating-polar-bear/

      1. Thank you, Liver King. I thought saw palmetto has ancestral roots among the southeast’s natives.

        Where does one procure prostate?

        1. Go to your local butcher and ask for it… if that doesn’t work, try a Google or Amazon search for “Grass Fed Prostate Glandular.” I’m obviously biased but there are many good, high-quality brands out there. Remember this… it’s just food!

  4. I’ve had BPH for the last 10 years. I treat it naturally using a two items:
    1. Prostaphil-2 (pollen extracts) and,
    2. Combined formula of Pygeum, saw palmetto and stinging nettle.
    I have little to no symptoms except having to get up once at night.
    Really enjoy your articles Mark. Hope this helps others.

  5. Mark, You hit a hot controversial topic. The information is overwhelming so I will not add to it. I will only add my personal experience. I have been a “health nut” all my life and at 62 maintain a rigorous workout schedule and have always had a very healthy diet. I have a full physical each year and all tests, including PSA, normal, in fact low PSA each year. This year I did an advanced preventative physical that included a full body MRI. That is the only way the spot on my prostate showed up. Biopsy confirmed intermediate grade prostate cancer. Treatment options are many and choice is very personal. The shape you are in is an important factor in recovery. If you want to know what is going on inside your body advanced testing and screening will tell you. I was lucky. I took the exam which I thought would confirm my excellent health. I found it early and my treatment was successful with full recovery! Only 3% of men with low PSA have cancer but if you are one in that 3% that is all that matters. My message is be proactive – it could save your life!

  6. You obviously researched this topic in depth and provided your always excellent perspective, thanks Mark, much appreciated.

  7. My husband had a PSA of 9. His doctor (an internist) pretty much told him he had an aggressive form of cancer. He scared the CRAP out of us for 3 months while we waited to see a specialist for a biopsy. That specialist took 12 samples (they normally only take 6) and NONE were cancerous. The specialist said he didn’t like the PSA for thisvery reason and really wasn’t concerned by the elevated number.

  8. Your urologist is the damned last person you should talk to about prostate issues. 80% of the surgery they recommend is absolutely not necessary and does not improve the quality of life or extend life. Urologists get rich off reducing the quality of your life. The ^%$#! bastards should be subject to a class action law suit.

  9. Incredibly helpful article thanks Mark, given the medical minefield this represents to us older men having to navigate this.

    I’m 69. My PSA is elevated at 7.2, but not too far adrift of an age normalised score that most folk don’t seem to acknowledge

    For me at 69 as a heart attack and triple bypass survivor, having a good remaining quality of life is critical whatever that is – sex, love, companionship, laughter, good food and heaps of daily physical activity.

    Anything that compromises that quality through being further “medicalised” is not welcome.

    Your article was useful in helping me further cement that view.

  10. From one on the androgen deprivation path. Hot flashes are an issue. Ground flaxseed, and acupuncture really help with this. And yes, number 5 is very important.

  11. Great article Mark – thank you for the information.
    I am a 58 year old male following your primal life style.
    Though there is no 100% guarantee that living primal will future proof you from disease, I feel that at least I have some control in reducing the risk significantly.
    Keep up the excellent work with these important discussions.

  12. Good article; HOWEVER, as a now 51 year old male who was diagnosed at age 47, I can attest to the value of starting testing at age 40. As I went through my mid-40’s my PSA started to rise each year. At 47, it hit a score of 5, I got a biopsy, and sure enough I had PC contained in 30% of my prostate with a Gleason score of 7. I made the decision with my wife and Dr to remove the prostate and now 3.5 years later, I remain cancer free. Yes there are the side effects of ED and Incontinence; HOWEVER, with treatment and therapy, I have overcome these and living an active, (better than normal) life. We should not dissuade guys <50 from getting tested. Sure, I probably would have survived if I had been diagnosed at age 50, but I believe my recovery went smoother than it would have if I had waited because I was still young and relatively fit (MDA was big part of that as I was moving thru my mid-40's).

  13. So, this article focuses solely on prostate cancer. What about urinary urgency and incontinency? I know several older men for whom this is becoming a major issue. Will the same dietary and exercise interventions help? Is there research I can provide to my friend/family? Thanks in advance!

    1. Diane, those are great questions. Check out today’s Dear Mark for some commentary on that. I’ll likely be covering more in the next several weeks though. Thanks for your note – M