Why PSA Panic Hurts Lifters

Philip Pape 0:01

If you're a man over 40 who lifts weights and wants to stay strong for decades, your prostate health might be the most misunderstood risk to your training and hormones. One elevated PSA reading. That's all it takes for most doctors to push you toward a biopsy. And once you're on that conveyor belt, the next step is often treatment that potentially tanks your testosterone and muscle mass. So the question we're answering today is: how do you know when prostate issues require a biopsy? And is there a less intrusive diagnostic path that protects both your prostate and your physique? Today's guest who specializes in men's health and hormones, and he will explain why the standard approach to prostate screening is broken and what you can do about it for your health. You'll discover when elevated PSA actually matters, when biopsies are unnecessary, how common treatments affect muscle and strength, and a proactive protocol to keep you training hard well into your 70s and beyond. Welcome to Wit and Weight, the show that helps you build a strong, healthy physique using evidence, engineering, and efficiency. I'm your host, certified nutrition coach Philip Pape, and today we're discussing prostate health and PSA testing. If you're a man over 40, you may have had a PSA test or been told you should get one. Maybe you've been told your number's high and you need a biopsy right now. But what if that's not the case? What if there's a better, less disruptive diagnostic approach? My guest today is Dr. Steven Petteruti, a board certified family physician and host of the Intellectual Medicine podcast. He has dedicated his practice to men's health, hormone optimization, and smarter approaches to prostate care. He's going to teach you what the PSA numbers really mean, the choice between imaging and biopsy, the effects of various therapies on hormones and muscle, and some steps you can take right now to keep your prostate healthy without sacrificing your health or performance. To be clear, this is not medical advice, but it is information every man listening needs to understand. Dr. Petaruti, Steve, welcome to Wits and Waits. Great, Philip. Thank you for having me. So let's talk about this topic. Um PSA or prostate health and the blood markers that go along with this are confusing. And there's a lot of, I'll say there's misinformation and there's probably a lot of entrenched uh information and advice from generations of healthcare. And I know we need to stay with the times and understand uh for men concerned about cancer, let's say, what is the correlation? What does the science say when it comes to things we're measuring, like PSA results and cancer?

PSA Is Not A Cancer Test

Philip Pape 2:41

Let's start there and then we can go deeper.

Dr. Stephen Petteruti 2:43

It's important to recognize PSA is not a test for cancer. It was never meant to be that. It is a marker that you can follow and its trajectory, its direction can be helpful. But there is no cutoff. All the cutoffs that you read about or that are published are arbitrary and are just kind of throwing a dart at the board. So when they tell men, hey, your PSA is above four and you need a biopsy, that's made up science. There are men with PSAs of 30 are totally fine. So the thing I want your audience to hear loud and clear, you never need a biopsy. I advocate they should never be done. And I'll expand upon that as the conversation unfolds. There's a reason why the PSA is entrenched, and there's a reason why biopsies are recommended. It has more to do, Philip, with historical inertia than keeping up with current technology. If I can give you a quick sweep, maybe that'll illuminate a bit, right? So in the 1980s, there was no PSA, there was no MRI, there was strictly the digital rectal exam where the doc would say, well, it feels a little abnormal. I think you need a biopsy. So now we've established the biopsy as a standard. The biopsy leads to a diagnosis of prostate cancer in some cases, and then they jump to a prostatectomy, removing the gland. I mean, it seems logical. Intuitively, it makes sense. Cancer is in the gland, you take the gland out, I no longer have cancer. Would that it were that simple. Now we know there are several studies that have shown us that taking out the gland doesn't protect you from cancer. I know that sounds weird, but that's what the data shows. So you can get the gland removed, men, you suffer all that adverse consequence, and then here comes the cancer again. What's going on? Why? And this is philosophy that drives it. It's a lot having to do with what you've dedicated your own profession to, right? Live life robustly, guys. Live vitally. Don't do things that suck the energy out of you unless there's a compelling benefit. So 1980s biopsies. Then in the 1990s, a PSA comes on the scene. And really nobody knew what could quite what to do with it. You know, does this predict cancer? Does it correlate? For a while, it was not even advised to be done. So the United States Preventative Task Force at one point said, hey, don't bother doing it. Then they came about. The urology community, and I am a family physician, so my perspective comes from the outside looking in. And the urological community said, Hey, you can't do that. Men need this PSA test. So it went back in the hopper. Well, if there's a test, there's got to be a threshold, and the threshold was arbitrarily created. Thus, we have a PSA threshold. Now we have biopsies that are still there. Instead, we've got an MRI. You have an elevated uh PSA. You're nervous about it. An MRI can be performed, looks at the anatomy. It's kind of like a mammogram for a man's prostate. It gauges risk. Nice study, not carved in stone. It is uncommon to have a completely normal MRI past the age of 50. True. Usually a nodule, there's gonna be something in there, guys. Here's another thing that'll help frame the conversation. If you arbitrarily biopsied 100 men off the street over the age of 50, just biopsied everybody. Half of them would have prostate cancer cells. Here's another variable that you need to reflect upon, guys. In men over 90, they did cadaveric studies looking at people who died of other causes. The majority of them had prostate cancer cells buried in the gland. Now that tells us, Philip, that at some point, if we live long enough, we may, we probably will develop cancer cells within the gland.

The Biopsy Conveyor Belt Problem

Dr. Stephen Petteruti 6:45

It doesn't mean you need to go digging them out. When you stick a needle into cancer, you disrupt it. There's a capsule around the prostate. It's like the rind on an orange. And it contains the tissue. It also contains cancer within the capsule. If it stays in the capsule, it'll never hurt you. So I have a philosophy of, you know, think twice. If a urologist tells you you need a biopsy, take a deep breath, get another opinion. The problem, of course, Philip, is they're all reading off the same sheet of music.

Philip Pape 7:21

Yeah.

Dr. Stephen Petteruti 7:22

So for men with an elevated PSA, it's a it's a horrible dilemma. They're told that this could be cancer, the biopsy is needed to make the diagnosis. Both of those are not fully true statements. You can look at things sequentially. So the best use of a PSA, whenever you get it, that's your base number. So if you had a PSA tomorrow, Philip, and it came in at six, the doctors are going to have kittens. You take a deep breath, say, okay, let's check it again in three months. Now the PSA will vary. If you went on a long bike ride, if you had sex, if you did a heavy workout, it's going to bump up.

Philip Pape 8:00

Because it's a protein, right? It's the antigen we're we're measuring from the gland. Correct. Like we didn't even define what it was exactly, but just that's why it could vary. Yeah, okay.

Dr. Stephen Petteruti 8:08

That's correct. The prostate-specific antigen is found almost exclusively in the prostate gland. And when you squeeze it, you ooze out more of it. So monitoring it over time can be valuable and helpful and can give men an opportunity to avoid unnecessary interventions.

Philip Pape 8:28

Yeah. So okay, I'm glad you established all that. That's why I wanted to have you on here because a common theme with a lot of areas of our health and women's health too, because I we have a lot of women in our audience, we talk hormones as well, is that some study or intervention or individual in the healthcare industry, like you said, in the 80s, did something and uh made a logical conclusion that there was fallacies in that chain of logic, even though it looks like it's causal. And then it led to, you know, going into uh texts, medical texts and going into studies. And we've had studies that have completely changed health outcomes for the negative as a result. Like the women's health initiative we talk about has made all women afraid of hormone therapy when they shouldn't be, right? So with men, I'm we're I'm kind of hearing a similar theme. And then when you go to the doctor, you're trusting this man, this person, man or woman to be the expert, right? And of course, many of them act like they know it too, uh, but that's a separate issue in healthcare. Um, the idea that you could actually be causing harm with a biopsy is probably a surprise to many because when you said you may not, you actually don't need a biopsy ever, like that's a very definitive statement versus let's say in women's health where you're like, well, you shouldn't, you don't necessarily need a mammogram or necessarily need this or that because it leads to more anxiety and issues for people that are low risk. You're saying definitively, maybe we should never have a biopsy because of that harm of the intervention past the sheath that then disturbs the cancer cells. Is that the idea here?

Dr. Stephen Petteruti 10:02

That is my that is my approach. But look, put in the context, Philip, of philosophy. Every man has to decide their comfort level. You know, my philosophy, Philip, is we fight cancer like a man. We do not sacrifice our masculine vitality out of some false pursuit of comfort and longevity. Those two are a false choice. So when a man sees the urologist, it can be compelling. When they look him in the eye and say, you could have cancer, you need a biopsy. Totally disagree with the with the emphasis here, right? It's an option. It's not wrong to get one. You have to go into it with your eyes wide open. The biopsy, you should men, you should always reflect upon the consequence of any test before it's done. If the biopsy is done and if it shows cancer, what are you going to do next? You're going to let them take out your prostate gland? Again, that's not a wrong decision. It's one I would never do, and I don't recommend. Why? Because the studies have validated there are two studies in the literature, one called the Protect T, the other one called the Pivot Trial. And they looked at men with prostate cancer. And one group they had the gland removed, the other group did nothing. One study had a third group that had radiation. Followed them out for 20 years. And at the end of 20 years, they found that there was no difference in the death rate between the groups. And there was no difference in the death rate from prostate cancer. That's very sobering.

MRI, Baselines, And Real Risk

Dr. Stephen Petteruti 11:35

Yeah. 40% of the men who get their prostate gland removed end up with a relapse. Now, this is where it starts the dominoes, the downward spiral. Man gets his prostate out. This is a common scenario. I felt great. I went in for my exam, my PSA was elevated, they did a biopsy, it showed cancer. I felt great. It took out my gland. Now I'm wearing pads every day. My erection's never been the same. I don't feel right. They robbed a vital part of me. Then the PSA starts to rise. And this is something I fully disagree with. They call it a biochemical recurrence. You feel great, you have no evidence of metastatic disease, but the PSA number is creeping up. What do they do next? They castrate you, they cut off your testosterone. Oh my goodness, what a horrible thing to do. Take away your life energy, the brain gets weak, depression happens, you develop gynecomastia, man boobs, your muscles wither. It's a horrible thing to do to a human being. And then the prostate cancer, when you go on testosterone blocking therapy because of a rising PSA, it's not curative. The cancer, 100% of the time, is going to progress. So you put all these facts together, Philip, and you're starting to wonder what are we doing? Yeah. You have to start with how you want to live, men. What's your philosophy? Because at some point we're going to die. And when we die, if it's a prostate cancer, a heart attack, or something else, I advocate for what I call a horizontal lifestyle, right? You do things to maintain vitality. Yes, you lift weights or strength train. Gotta do it. You should never wither. There's nothing biologically about us that requires us to wither before we die. So I want you, me, and all your listeners to die in great health after a short illness at a very advanced age. It's like, hey, where's Dr. Petrudy? No, you didn't hear, man, he died last night. Oh, crap. Just saw him yesterday. He just croaked.

Philip Pape 13:45

Yeah, I always joke, I want to croak doing a deadlift when I'm, you know, 95 or whatever. Uh, I I literally just recorded an episode called something like, you know, why now is the perfect time to start building muscle. It targeted more at the narrative that you're too old, you know, too old to start. But I totally agree. And our listeners would agree with that. And I want to get to the lifestyle piece, which again will be not really a debate on this show at all. We're all going to agree with that piece of it. What I'm trying to understand here, though, is this chain of events, because I'm learning a ton already. The idea that taking out the gland doesn't remove the cancer right there sets, you know, puts a massive roadblock in the logic of, okay, then you've got the PSA results, which have to be based on your personal baseline. If, let's say, your PSA goes high versus your baseline and there are cancer cells, then we have to think, okay, well, you said every man gets cancer cells anyway over time. I mean, DNA mutates and gets damaged, and everything we do and consume and are exposed to over our lifetime probably causes lots of cancer cells across our body in all areas. So you're gonna get that anyway. So then when does it matter? When do the PSA results matter? And then when does the fact that you have cancer in your prostate matter? And then what do you do about it, if anything? That's I think the next question.

Dr. Stephen Petteruti 15:00

Yeah, it's a it's an important question, Philip. And I like to designate these cells as atypical dormant cells.

Philip Pape 15:05

Okay.

Dr. Stephen Petteruti 15:06

They're kind of sleeping in the prostate, you let them be. And there are things that can be done. This is a chronic lifestyle management. And we talked before about is it okay to get a biopsy? Is it okay to remove the gland? Although I would never do it, and I don't advocate my patients to do it. It is okay if you're the type of person who can't live with the notion that these cells are in your body. And some men are like that, you know, they'll just drive nuts. The uncertainty factor is there no matter what path is is pursued. So the things that keep them, our job, like why do we not all have cancer? Our immune system, it's killing cancer cells every day. So if those cells are within that capsule, the job is to keep them there. Cancer is like an opportunistic disease, it's there lurking. It's kind of like shingles. That's a good analogy. When we were kids, we had chicken pox and then it went away. It's asleep. Why does it come out later? It never actually went away. We never actually killed all the virus, it's just kept in check by the immune system until the immune system weakens to the point where it becomes manifest. Same with cancer cells. If you've ever had cancer, you are never cancer free, you're tumor-free, the cells are lurking. I don't want to creep

Philosophy Of Vitality Over Fear

Dr. Stephen Petteruti 16:30

people out, but we all have them. So that's why you live every day in a balanced, healthy manner, maintaining immune function. What ruins the immune system? You don't sleep right. That's one. You're on certain drugs that can weaken it, steroids, for instance. Now, um, disease-modifying drugs are quite popular. The biologic agents for psoriatic arthritis and other conditions, they can be life-enhancing, but immune immunologically weakening. A bad diet, stress, these are all variables. Uh, an acute phase of your life, a spouse dies, you go through bankruptcy. These are opportunistic moments where you need to amp up your own vitality pathway. Exercise is really helpful, but you have to be tempered. I like your philosophy, Philip, of being, hey, you can achieve all you need to achieve without going crazy and spending three hours in the gym. There's a tipping point where too much, too intense, can weaken the immune system. So you have these cancer cells that are isolated within the gland. You don't need to biopsy them. You do your PSA level periodically. And my I've developed a protocol to help men avoid the biopsy and take another path. And in my protocol, we do a PSA every three months monitoring levels. We do an MRI typically once a year to look at the anatomy. We use repurposed drugs, and these are prescription agents that have been shown to have anti-cancer power and attributes, even though they're FD approved for other reasons. Many of your listeners may be familiar with ivermectin, uh, fenbendazole, mobendazole. They have merit, guys, but be careful. The online pathways are harmful. These drugs are not meant for daily consumption. So in my protocol, we use them sporadically to emphasize safety. You don't cure prostate cancer by dying of liver failure, right? That's not a good outcome. So the repurposed drugs are put in there. How about lifestyle? Most important variable regarding nutrition, percent body fat. Excess adiposity correlates with increased risk of cancer and cancer relapse. That is settled science, unequivocal. How you get there, whether you're a vegetarian, a carnivore, uh organic eater or not, how you get there is less important than that you get there. Now, there are clearly foods better than others. And when I say food, Philip, I mean food, not junk disguised as food, right? So thoughtful diet, stress reduction. If you're inclined, repurpose drugs guided by a physician, you don't want to fly on the on the internet. This needs to be monitored. Certain supplements can have merit. I like alpha lopoic acid. I like zinc, about 30 milligrams a day. It concentrates in the prostate gland more uh zinc per gram of tissue than any other organ. It also supports immune function.

Philip Pape 19:37

Is that zinc with copper or just zinc?

Dr. Stephen Petteruti 19:40

No, I don't like copper. Okay. All right, all right. Because you mentioned it. Copper is an essential um mineral, it's an essential metal. But there are two kinds of copper. There's cupric and cuprus. Cupras is what we find in food. That's great for you. Cashews, almonds, dark chocolate, etamame, you can find it in your food. The problem with supplements, Philip, is they often use cupric or C2, which is a neurotoxin. In fact, in Japan, they don't allow you to have copper pipes in your house because of the risk to the brain. So I see this frequently. I don't like any supplement with copper in it. I keep cashews. It's not good to know every day, just because the copper is so good for well, immune and skin and all that other cool stuff. But um, yeah, zinc I like, alpha poric acid, and then N acetylcysteine or NAC, which is a precursor to glutathione. As we age, you know, we make fewer uh antioxidants, free radicals tend to become more dominant, and that inflammatory tilt can increase risk uh, you know, kind of across the board. So if you're a man listening to this and you've had a biopsy, don't panic. You can't undo the past. However, going forward, contemplate an alternative. There's something out there called active surveillance, it's a term that is used when they feel your type of cancer is early and therefore they don't want to subject you to the trauma of prostatectomy. And what they'll offer is sequential biopsies staggered, right? This is patently illogical, in my view. You know you have cancer, and now you're gonna stick, not and it's not just a little needle, it's a trocar, and it's multiple jabs. It hurts. I've listened to men who have had complications from the biopsy, hospitalizations due to sepsis, or loss of erectile function or compromise thereof can occur. You stick in these big trochars. But most importantly, it's a false notion to think

Lifestyle And Immune Defense

Dr. Stephen Petteruti 21:50

that you can take a snapshot of the prostate in one moment in time and predict the future. And I've heard that said they'll tell they'll tell you, well, we need to do a biopsy so we can tell how aggressive your cancer is, or how aggressive it may be. That's not true. You tell aggression by a point of change. Your PSA was six, and now it's 25. That's a manifestation of aggression. What should you do then? Right? I just told you, don't take the gland out. Worse than that is irradiating the pelvis. That's a terrible thing to do that causes immediate adverse effect and delayed consequence. Five years later, you ever get a sunburn, you feel rotten, right? It hurts. And then 10 years later, you have basal cell cancer from that sunburn. Radiation has a delayed negative consequence that ends up with radiation proctitis. You can't control your stool. I've seen men 10 years later literally leaking poop all day long. It's horrible. For what? You know, so this leaves a this is it's a problem, it's an unsolved problem. My um departure from conventional recommendations is not that the pathway I've uh espoused is proven beneficial. We are still actively studying it. It has evidence of benefit, it doesn't have proof, but it has proof of not harming people. Conversely, conventional therapies, prostatectomy, radiation, absolute 100% unequivocal harm. Benefit? So I've heard my patients will say, Well, the urologist told me that there's no proof that sticking a trocar in my prostate can spread cancer. Technically, it's an accurate statement. However, they never looked. There's never been a study to see if that's the case. But there are, because I did this research recently, Philip, over 95 articles in the medical literature looking at what's called needle tract metastases. This is a known risk that we have to balance against the potential benefit. So it's a hard space to live in. It's worthy of being slow. It's never, almost never an emergency. Prostate cancer, even if you have it, guys, it's a slow-moving train. So you have time to really think through it. And depending on your age and depending on your global health, it will help you direct your action. If you're 75 and you've had three heart attacks, you know, prostate cancer is not going to take you out. Ironically, getting a prostatectomy and having aggressive treatment is correlated with increased risk of heart disease, dementia, um, other side effects. I do want to mention the testosterone link too, Phillips. So let me know.

Philip Pape 24:43

We'll get to it. So I'm listening because I'm learning so much here. And the protocol you mentioned obviously doesn't sound uh super unconventional when it comes to general advice for any age-related disease or being healthy and living a long life. In other words, lifestyle and strength training and eating well, supplementation. Obviously, the repurposed drugs are kind of a unique thing that we could get into. But you mentioned just cancer in general. I I percent body fat, I believe, is linked to at least 13 cancers, something like that. I forget the magic number, definitively through studies so far. And, you know, some people don't like to say that out loud that you have this massive choice in the matter through your lifestyle to potentially stave off cancer, but it's true, right? So the PSA and MRI, what I'm trying to understand here is where's the preventive piece of this? And where's the, oh, now we think there's some cancer that could develop into something concerning. Is this something you start once you get a diagnosis? Or is this, I mean, lifestyle you're going to do anyway, guys. I mean, anybody listening should be doing those things. But like the protocol you talked about, when when does that begin?

Dr. Stephen Petteruti 25:58

That that's a great perspective, Philip. The protocol really starts with you, with this, what you advocate for people, right? You live a low tox lifestyle. You don't wait to get sick. We're all aging. My wife said to me once, hey, if if you knew you were dying, would you regret anything? And she mentioned it because I'm a I do a lot of advanced anti-aging in my practice. I'm on testosterone, I do some peptides, I you know, I take Cirrellimus, an anti-aging drug. I thought I said, Yeah, no,

An Alternative Monitoring Protocol

Dr. Stephen Petteruti 26:30

no, I'm not going to be the guy that clutches his chest, go into the ground, says, Oh, I should have walked and exercised, or you know, the end comes. What I want for everybody listening is to have peace of mind. When you do all the things you're talking about, Philip, you control percent body fat, a powerful risk factor for cancer, for heart disease, and guess what, gang? Dementia. You know, yeah. I want all the things that are it correlates it. There was a study showing the accelerated brain atrophy in the context of excess adiposity. So you start there and you start with taking charge of your nutritional health and really got to peel away from uh the average American sort of pattern. If you're eating like every other American, that's problematic. If you if other people look at you and say, you're kind of, you know, your nutrition is kind of weird, you're probably closer to a good place.

Philip Pape 27:26

Yes, I like that perspective for sure. If you're weird with most things in life, you're probably doing the right thing.

Dr. Stephen Petteruti 27:31

Probably in a good place. You know, we call that eating abnormal, yeah, but healthy. So yeah, percent body fat's critical. Now, if you're in that position where you've got that high PSA, you have the MRI. Now, the MRI is gauged on something called a pyrad scale, one to five. And it's a subjective look at the anatomy, and the radiologist will say, Yeah, this one looks like cancer, this one might be cancer. It goes one to five. Five means, yeah, you probably got cancer. You got a PSA of let's say it's 12. You get an MRI. It's a pyridge of five, but it's confined to the capsule. No evidence of disease outside of the capsule, the lymph nodes, seminal vesicle. You feel good. That is not a panic moment, folks. It's an opportune moment. The idea behind the repurposed drugs and the amplified lifestyle. Now, this grabs people's attention, Philip. You know, now they're really motivated. They're going to lose weight, they're going to start eating differently. They're really researching this. One of the problems that men and women run into, and you probably noticed this yourself, Philip. You go to the internet, it's a blizzard of information. And then they go to their doctor and ask the doctor, what supplements it look, I'm a board certified family doctor, as you mentioned. I was trained uh osteopathic medical school. I was in the army, did my residency, and I've been in practice for 30 years. 20 years ago, if somebody asked me about supplements, my eyes would have glazed over. Like, what? I know nothing. And doctors usually are limited in their knowledge in the space. So that leaves you know patients kind of on their own in many cases. But there is a growing cohort of physicians, of advisors that can help guide, not something they want to do on their own, right? So the repurposed drugs in my protocol, I really like this approach. It's proactive, it has evidence of potential benefit, and it has this safety feature of not causing harm. So we're applying about six different pharmacologic agents in modest dosing. Technical term for this is called hormetic, which means drugs have different effects at different doses. So that which may seem kind of weird to apply can actually be helpful. We're trying to create an environment in the body that is inhospitable toward cancer cells. You got that pyrides of. Five. It's isolated to the capsule. Now we're going to watch that PSA. It is go 12, 13, 14, 13 again. That's a plateau you can live with. If it goes 12, 45, that grabs our attention. Now we maybe look at that MRI again and maybe modify the treatment, but you never jump the gun. There's no need to put needles in. I tell a man that has that scenario I just described to you, Philip, I'll say, look, you got prostate cancer. The lining up of the PSA in the MRI, in your age, and in some cases your symptoms, are so compelling that even if you had a biopsy and it came back negative, nobody would believe it.

Philip Pape 30:44

There's no point, is what you're saying, yeah, to the biopsy.

Dr. Stephen Petteruti 30:46

Yep. So don't subject yourself to a study that is academic, historical, and petrified in the standard of care. Look, docs are good people, but they're human beings. What do I mean? They're worried about liability, they have time pressure. You see a urologist, I've heard this often, you know, go see a urologist, my PSA

Supplements, Zinc, And Safety

Dr. Stephen Petteruti 31:10

is elevated. It says, okay, when do you want to do your biopsy? Surgeons, folks, they get paid to do things. They don't get paid to talk. And if you want to sit and chat about your PSA with your urologist for 30 minutes, it's unlikely to happen. So you really owe it to yourself to step away, get out of the uh sort of the vortex of intensity, give yourself time to decompress and think a little bit. There are exciting new things happening in the field of intervening for prostate cancer, one of which is actually giving men with prostate cancer testosterone.

Philip Pape 31:46

Okay. Yeah. I I want to talk about that next. One quick thing is alcohol. I just want to touch on alcohol real quick. Um, because there was this, you know, the alcohol um cancer study that was supposed to come out, came out in 2022. The Surgeon General wanted labels on alcohol. And then I believe uh the dietary guidelines were going to be updated to suggest one drink a day instead of two drinks a day can start to cause issues. And I know certain cancers like colorectal and breast cancer have a link to very low consumption of alcohol. Where does prostate cancer fit in on that spectrum?

Dr. Stephen Petteruti 32:22

I laugh because it reminds me of Frank Sinatra's famous quote. He said, you know, those of us who drink feel bad for those of you who don't, because when you wake up in the morning, that's as good as you're going to feel all day long. But to answer your question, these are all um observational studies. The real answer is nobody knows. My dad was a physician. He used to joke the definition of too much alcohol is anybody who drinks more than their doctor. But in all seriousness, alcohol is a toxin. Lots of things are toxins, but they're pleasurable toxins. We call that a hedonistic path. We human beings, we do two things without fail. We avoid pain and we seek pleasure. Avoid pain means don't die, seek pleasure means reproduce. So modifying limiting alcohol is logical, it's good health, it's good psychosocially. You go beyond two drinks, bad things are gonna happen. Not in the future, but that night and the next morning. So that's self-evident. But the idea that alcohol itself is a pure toxin to be avoided at all cost is an exaggeration. Some folks like to end their day with a glass of wine. There's no evidence of compelling harm. If you're deprived, so we talked a moment ago about stress. Stress can occur from a deprivation of pleasurable endeavors. And I've seen like I'll people ask me about nutrition. And sometimes when a man gets this diagnosis, his wife or partner becomes very engaged, says, You have to drink this concoction. And the guy's choking it down. Oh, this is awful. It's not good for you then. It's a stress moment. So where I come down on alcohol is um when you go above one drink per day, you're entering a gray zone. When you go above two drinks per day, you are in a harm zone fairly unequivoc inequivocally, unequivocally, without doubt.

Philip Pape 34:25

Yeah.

Dr. Stephen Petteruti 34:26

So that helps frame it out. Um, but when my patients come to me and say, should I go alcohol free? You can if you want, but you don't have to. You know, you have to live life.

Philip Pape 34:38

It's a matter of degrees, yes. Yeah. Okay. Yeah, I just wanted to touch on that. All right, let's get into testosterone. So you said uh TRT could be a game changer here, could be the, you know, one of the things we're not talking about, and we're going to right now uh in context of prostate health. So lay it on us.

Dr. Stephen Petteruti 34:54

Yeah. Well, let's talk about the settled science first, right? Testosterone does not increase your prostate cancer risk. That likely has been emphasized in the past, and that is pretty solid. And testosterone is not gas on the fire either. So historically, we've been taught, and this goes back to Dr. Huggins in the 1940s. He won a Nobel Prize when his experiments correlated testosterone deprivation with regression of prostate cancer. Since the 1940s, that has been sort of the dogma. You know, testosterone equals prostate cancer. It does not increase risk. In fact, men with low testosterone levels have a higher risk of developing prostate cancer than those with higher. That doesn't mean that going on replacement therapy and elevating your level will make you less likely to get it. That's an unknown. But it is pretty solid evidence that it won't harm you. So those of you that are on testosterone, you ought not to fear it with regard to your prostate health. And you ought not to fear it with regard to prostatic hypertrophy. That also doesn't correlate. It also does not correlate, and this is pretty settled science, Philip. It does not increase cardiovascular risk. So those studies were very comforting to those of us who have been on testosterone for about 20 years, uh, those of us that are using it to benefit, so you can maintain that. The research

Active Surveillance Versus Repeated Biopsies

Dr. Stephen Petteruti 36:20

and the science about testosterone in the face of prostate cancer is rapidly evolving. And this idea that you can never be on testosterone is being challenged. Dr. Abraham Morgenthaler, in his book, Testosterone for Life, he is uh a urologist, a real uh thought leader in this field. And he has uh something called a prostate saturation theory. In essence, your prostate can only hold so much testosterone, and any extra testosterone will give value to the organs, the tissue, the brain, right? We all know testosterone is a neurotransmitter, but it doesn't adversely affect the gland, which is now sort of maxed out. It's like a full cup of water, you keep pouring water in it, you're not gonna get any more in there. There are studies that show that when you go from a high level of testosterone to a low level, that it disrupts the DNA of prostate cancer cells. And that's called the bipolar theory of testosterone's effect on prostate cancer. Now, I want to be clear, this is not standard of care, and there are circumstances where it should never be considered. If you have prostate cancer metastatic to the bone, that has to be controlled before anybody contemplates this. It is a consideration with eyes wide open when you make judgments about philosophy, quality of life, and your willingness to consider risk, simply put. So I'll give you an example from my practice. Gentleman had prostate cancer, you know, before I met him. He actually flew to Europe, had a high food procedure, high intensity focal ultrasound. Doesn't work. I don't like it. He came back and uh had still a prostate cancer. At the time it was diagnosed, he was on testosterone and he suspended its use. And he felt awful. His sex drive went away. His brain wasn't working well. He's an executive and he had trouble functioning in his job. His PSA is 45. He has prostate cancer. And he said, Doc, you gotta put me back on testosterone. This is no way for me to live. So I said, Okay, you know, this is science says that this is not irrational. The science says that this is reasonable to consider, but it is also an unknown quantity. It's possible that the testosterone could accelerate the cancer. And it's likely at his stage, or the stage at which this cancer is for many people, it's likely the cancer will progress regardless of what you do. This comes to that, right? The philosophy of regret. My patient goes on testosterone, he feels great, but five years later the cancer is metastatic to the bone. That could happen. He has to be comfortable with that decision looking back, knowing that he's he's at peace because he had this great window of time with it. On the other hand, he doesn't do testosterone, he continues to feel lousy, and in five years he gets metastatic disease to the bone. He's saying, What did I just I could have, I should have. So the individual has to reflect upon it philosophically, and then what I will do in some cases is a modified approach to this. You go three months high, and here's the irony. If I do this for men, you can't dabble, you can't go low dose testosterone, you have to go high dose because the delta, the high to low shift is where we think the benefit may be. So you go a period with high dose, and then boom, you pull it out. High, low. We're trying really to balance risk and benefit. You know, is this gonna harm you to put you on testosterone? We know the benefit is there, but what about the harm? It's preliminary, and I'm still tracking these cases, Philip, but thus far I've got a cluster of men doing this type of an approach. And what I'm bearing witness to is stability. I'm not seeing PSAs go through the roof. I'm not seeing um, you know, the cancer go on haywire. Um, there's an alpha patient, one of my pioneers, he had a PSA of about 10. He had a pyridge of four, meaning, hey, it's likely cancer. He was on testosterone. He said, Look, I don't want a biopsy, but I do not want to come off my testosterone. I said, Okay, we're gonna do this bipolar, we're gonna monitor things closely. 2018, PSA of 10, pyrides of four. 2025, a PSA of 10, a pyrides of four while on testosterone. Now, granted,

Harms Of Radiation And Surgery

Dr. Stephen Petteruti 41:05

it's a singular case, but this is how new evidence builds, and this is how we acquire insight into other ways we may be able to approach this problem. So out of the mainstream of treatment is an option for some men that are so inclined. It really comes down to your philosophy. And I want to emphasize, guys, it's not wrong to do the conventional pathway. The problem I have with the conventional pathway, Philip, is the monopolistic sort of one-note piano approach that I see.

Philip Pape 41:39

Like this is the only way. Yeah. Are there any controlled trials doing what you're talking about, or or at least planning to observationally look at men who've gone through this?

Dr. Stephen Petteruti 41:48

Well, there are actually there are. So they're not actually in the cohort that I'm discussing. The bipolar uh research is um Johns Hopkins did this. They uh applied this to men who had prostate cancer, had the gland removed, had the PSA go down, and then come back up again, at which point they put them on androgen deprivation therapy, castration.

Philip Pape 42:14

AD2, okay.

Dr. Stephen Petteruti 42:15

When a man starts castration therapy, androgen deprivation, 100% as I mentioned, it will advance. When it advances, that's called castration resistant prostate cancer. Basically, that's the end of the road. There's no treatment left that has been shown to have merit. So they took these men with a theory of bipolar testosterone and they, hey, let's try this. They put them on high dose testosterone and they would go high to low. It was an interesting combination of testosterone. They'd go 400 milligram injection at the beginning of the month while they had them on androgen deprivation, so that they would go from this high level bang down low. And a significant number of them responded favorably. The PSAs went down. In some cases, the sensitivity toward androgen deprivation treatment was renewed. So it's compelling, some evidence of the theory playing itself out, but there is nothing that I'm aware of that's in the pipeline that looks at men that are not castration resistant, which may be a better place to apply it earlier in the course. So it's incumbent upon me and doctors like me to counsel patients honestly and to track the results. And that's what we're doing at Intellectual Medicine. It's an observational cohort. And all the men that enroll in this protocol, we track them and we're looking at PSAs, we're looking at the MRI, we're looking at the metastatic rate. It'll be some time yet, but we'll have that data and hopefully that'll be widely publicized and give people an opportunity to see does this have uh value? If the if the results look good, that type of result may then instigate a study. The type of study you're talking about would take you know tens of millions and need some evidence to help launch it.

Philip Pape 44:09

Well, I appreciate the nuance. Seriously, I the language you're using today is is something I very much appreciate with caution on on drawing conclusions, which is what we need to do, right? It's a about falsification of what is claimed to be true, not proving something necessarily beyond a shadow of a doubt. I do the androgen deprivation therapy. I'm not too um familiar with it. I know it lowers, does it lower testosterone specifically? Yes. And then you're saying, like, why would people be doing that and then add in testosterone? Help me understand this.

Dr. Stephen Petteruti 44:40

It's it's a it's a cruel thing to do to any man. You know, this is just so um it's called in the conventional medicine, they'll sometimes refer to this as androgen annihilation. They will crush testosterone as low as they can make it go with multiple drugs. So there are drugs that will prevent the body from making testosterone. There are drugs that will block the receptor sites of the testosterone, and often will combine these drugs to get a more thorough crushing of testosterone level. The theory behind that is that it will help men live longer. That theory is not strongly validated. The research on this is very hard to do. There are some studies, and I've read most of them. The conclusions are hard because the patients are so different. Do they have metastatic to the bone? Is it isolated to the pelvis? You know, what was their testosterone? So the consensus is that, hey, if we do this, they might live longer at the back end. But would they want to? Are they gonna, is that life gonna be one worth living? You know, it's an easy thing to measure. So there are studies that can show statistically significant increased uh survival when some of these modalities

Rethinking Testosterone And Prostate Cancer

Dr. Stephen Petteruti 46:00

are applied. When I say statistically significant, it doesn't necessarily mean it's clinically relevant to that person. There's a study called the tax trial. They looked at chemotherapy. The conclusion was statistically significant extension of lifespan compared to placebo. This was back in 2003. When you read the study, the actual extension of life was measured in weeks. It's not like you got another five years. So you got to go beyond the headline, kind of like the women's health initiative, right? People read abstracts and then they just draw a conclusion in some cases. And then you have to go beyond even the conclusion. If you live another, I don't know, on average, if it's another 12 months, but you're gonna feel like blah, is that worth it to you? Uh you're willing to kind of make that deal. It's not wrong, but it's something that is optional. Studies that look at strictly longevity, I think they missed the point. You know, Philip, we're talking about vitality, about living great. And um that's what I advocate for all my patients. I don't want to see my patients wither ever. You know, this idea of like shuffling around with a walker, God bless those people for their pluck and their their uh sort of grit. But I don't want to be one of them. You start now like you are, you know, exercise, nutrition. At the right time in life, you add hormones. Everybody should have hormones. The only question is at what age is when, yeah. And then you live boldly, and when the end comes, it comes. I don't know.

Philip Pape 47:44

Yeah. No, I hear you. I so I'm turning 45 in a couple days. And uh I didn't I didn't really get into this lifestyle until I was up almost 40. And I I joke, or maybe not joke, I'm pretty serious about it that every year older I want to get a year younger. So I told my girls I'm turning 35 tomorrow, and by the time I'm 50, I'll be 30. And then from that point, I'm like, I don't know if I can get to be a 20-year-old again, but at least I've set things back to a better baseline. But uh just to end on a positive note here, then when we think of all the things people can be doing and should be doing, which they should be anyway, probably. What's the biggest hitter here? It is it lifting weights? Is it, you know, the the maintaining healthy body weight? Yeah. I mean, just just to give people thought of prior prioritization if they're not doing that today.

Dr. Stephen Petteruti 48:28

Totally. So if you're into the lifestyle, Philip, that you and I espouse, that's how we define health, then yeah, uh percent body fat, right? You want to eat premeditated nutrition. You do not eat based on hunger, you eat when it's time to eat. You're fueling the machine. I don't like fasting for my patients, you're gonna shrink muscle. So I eat every three hours, whether or not I feel hunger, because that's what fuels muscle. You know, I'm 66 now. By the way, happy birthday. That's it's secret. Um, so you do that. And if you only have 20 minutes to exercise, skip the treadmill and lift weights. That's my clinical recommendation. The practical application is people ask me often, what exercise should I do? And the answer is do the thing that you like. If you hate lifting weights, you don't have to do it. But if you're asking me which one has more evidence of benefit regarding vitality, longevity, bone density, brain health, it's strength training.

Philip Pape 49:28

Yep. Yeah, no, that's great. And it's funny because I I I hear that all the time about I don't like lifting weights. My goal is always to get someone to which type of lifting weights will you like? That that's like my inevitable conclusion for them. That's just me. Yeah, but I like I like your premeditated nutrition concept for sure, which is planning, being intentional. You know, it's it's not a whim or hedonism. It's like we have goals, people, and and it's you're gonna feel great anyway, much greater for the rest of your life than you will by satisfying some short-term pleasure. So and that's what it is about you know, being a man and uh going out there and being the best you can be. You remember uh Jack Lelane? Yeah, yeah.

Dr. Stephen Petteruti 50:06

Yeah, he was once asked, you know, how do you learn to love exercise? And he said, I don't. He said, I love the result. And that's another way to look at it.

Philip Pape 50:14

Exactly.

Dr. Stephen Petteruti 50:15

You lift weights so that you can lift your grandkids up, you lift weights so you can carry the groceries up the stairs. You do not buy that ranch and get off of the stairs because you're anticipating withering. You boldly go after it.

Philip Pape 50:29

Boldly go after it. All right. So, with that, Steve, um, where can folks find you? Because I want to send them your way.

Dr. Stephen Petteruti 50:36

No, thank you. It's the intellectual medicine podcast to be a great place to connect with me. I keep updates on prostate health, the protocol. And by probably next month, my book, uh Fighting Cancer Like a Man will be coming out. It describes the research I've done, the history of prostate cancer, why we're stuck where we are, and what my alternatives look like so that people can have this available to them. That'll all be coming out very soon.

Philip Pape 51:06

Okay, might when when this episode comes out, it might be out. So we'll see. We'll include the podcast, we'll include fighting cancer like a man. I love that title, and I'm gonna be checking that out myself. Uh, Dr. Petteruti, thank you so much for taking the time and teaching us a whole lot of very important things about health, prostate cancer, being a man, uh, lifting weights, all of it. Thank you so much for coming on Wits and Weights.

Dr. Stephen Petteruti 51:27

Thanks, Philip. I really enjoyed it.