Thursday, May 9, 2019

Healthy fats may fight early-stage prostate cancer

During visits with your doctors or other health care providers, do you speak up and ask questions? If the answer is “yes,” congratulations. You’ve taken an important step to getting the most out of your health care visits. You’re also in the minority. Most people have trouble asking their doctors questions. It can be even harder to disagree with health care providers, or make known your worries and preferences for care. It’s such a problem that several organizations have created campaigns specifically aimed at helping people talk more openly with their doctors.

There are many reasons for poor patient-doctor communication. One is what Timothy J. Judson and colleagues call the asymmetry of power. Writing in this week’s JAMA, they point out an obvious reason for the imbalance in this important—doctors almost always have more medical knowledge and experience than their patients. Another reason is that we don’t want to do or say things that might tick off our doctors, for fear that an aggravated doctor might not give the best possible care.

Medical lingo is another key barrier. It comes so easily to clinicians but is gobbledygook to the rest of us. When a person is quiet after getting information from his or her doctor, many doctors interpret the silence to mean the person fully understands what has been said. And that she or he doesn’t have any questions. In fact, write Judson and colleagues, the person may be thinking “‘I have no idea what you are talking about’ but is too embarrassed to say so.”

Judson and colleagues use the term “white-coat silence.” By that they mean a reluctance to ask questions or make suggestions in front of a clinician. The term plays on “white-coat hypertension,” a well-known phenomenon in which people have high blood pressure in the doctor’s office—but not at home. Such silence can get in the way of good health.
Take charge

If you feel like you have trouble talking openly and honestly with your doctor, or asking him or her tough questions, two national campaigns offer help.

The federal Agency for Healthcare Research and Quality’s Questions to Ask Your Doctor campaign is based on the idea that doctors “know a lot about a lot of things, but they don’t always know everything about you or what is best for you.” The website offers a list of 10 general questions you should ask, along with questions to ask before, during, and after appointments. It also has an interactive page that lets you build your own list of questions.

The independent, nonprofit Joint Commission accredits more than 20,000 health care organizations and programs in the United States. Its Speak Up Initiatives offer free brochures and videos to help make the most out of visits to the doctor. The program is named after its seven key points:

    Speak up.
    Pay attention to the care you get.
    Educate yourself about your illness.
    Ask a trusted family member or friend to be your advocate.
    Know what medicines you take and why you take them.
    Use an accredited hospital, surgery center, etc.
    Participate in all decisions about your treatment.

Your doctors may think that if you don’t speak up, you either don’t want a conversation or you understand completely what is going on. Either way, you won’t get the information you need. The June Harvard Men’s Health Watch offers some simple but effective tips for making sure you leave the doctor’s office with what you need. Here are a few of them:

Be prepared. Before the doctor’s visit, take some time to think about what information you need, and what is important to you if you have to make a decision about treatment.

Ask about options. If your doctor suggests a treatment, asking these three questions has been shown to lead to better outcomes:

    What are my options?
    What are the possible benefits and harms of those options?
    How likely are the benefits and harms of each option to occur?

Bring backup. Take a spouse, adult child, or friend with you for support. Sometimes an “outsider” can be very effective at making sure certain questions get asked.
The other perspective

We expect a lot from our doctors. Superb diagnostic skills, unfailing instincts for treatment, warmth and understanding, and excellent communication skills. Exactly what the latter means was spelled out vividly in JAMA by Dr. Abigail Zuger, an associate professor of clinical medicine at Columbia University College of Physicians and Surgeons who often writes about health:

    So what communication skills will be required of the fully evolved 21st century physician? The physician will, of course, be fluent in standard clinical language, including ordinary medical terminology and the delicate phrases of care and compassion. The physician will be adept at translating medical jargon into comprehensible lay terms, knowing how to defuse words, such as obese or psychotic, that might cause alarm or hurt feelings. The physician will know how to explain statistical concepts both accurately and intelligibly with the patience and fortitude to answer patients’ questions about all things evidence-based, even the physician’s own competence.

    The physician will know the highly technical vocabulary of relevant research agendas well enough to encourage patients to get involved. The physician will also keep up with popular culture, tracking popular direct-to-patient communications and incorporating them into the clinical dialogue. In addition, and most importantly, the physician will have virtuoso data entry and retrieval skills, with an ability to talk, think, listen, and type at the same time rivaling that of court reporters, simultaneous interpreters, and journalists on deadline. The physician will do all of this efficiently and effectively through dozens of clinical encounters a day, each one couched in a slightly different vernacular. Each year, nearly a quarter of a million American men learn they have prostate cancer. Most are diagnosed with early-stage cancer that has not spread beyond the prostate gland. Traditional treatments include surgery, radiation therapy, and a “watch and wait” strategy called active surveillance. A new study published online this week in JAMA Internal Medicine indicates that diet may be an important add-on. The study, part of the ongoing Harvard-based Health Professionals Follow-up Study, suggests that eating more foods that deliver healthy vegetable oils can help fight the second leading cause of cancer death in men.

“It’s one of the first studies to look at dietary interventions after men have been diagnosed with prostate cancer,” says Dr. Marc B. Garnick, a prostate cancer specialist at Harvard Medical School and Beth Israel Deaconess Medical Center. “It supports the idea that you can potentially modify the behavior of prostate cancer that is still confined to the prostate gland.”
Healthy fats

The study involved about 4,500 men who were diagnosed with nonmetastatic prostate cancer, which means it had not yet spread beyond the walnut-sized prostate gland. Since 1986, they have been reporting what they usually eat by completing detailed food surveys every four years.

Study participants who ate the largest amount of vegetable fats were less likely to die from prostate cancer—or any other cause—than men who consumed the most animal fats. Most of the vegetable fats consumed by the men came from oils in salad dressings and nuts.

The men who consumed the most vegetable oil lived longer, in part because their cancers were less likely to spread beyond the prostate gland. That suggests, but does not prove, that a diet rich in vegetable oils can slow the progression of the prostate cancer.

Earlier studies have implicated the traditional Western diet, which is relatively high in red meat and other sources of animal fats, with a higher risk for developing prostate cancer in the first place, while eating more vegetable oils and vegetable protein may help prevent it.

“One of the things I tell my patients is not to eat animal fat, or to at least limit its consumption,” Dr. Garnick says. He bases this advice on decades-old data that show a direct relationship between the amounts of animal fat consumed and incidence of prostate and other cancers. It’s never been possible to prove cause and effect between dietary fat and cancer, but this new study lends support to the idea that animal fats may modify the characteristics of prostate cancer.
Switching carbs, too

Although the study focused on oils and fats, it’s important to consider what the men who consumed a lot of vegetable oils were not eating: refined carbohydrates, such as processed white bread, white rice, and desserts.

In the study, men who replaced 10% of their total calories from carbohydrates with calories from vegetable oils were 29% less likely to die from prostate cancer or any other cause over eight years of follow-up.
A generally healthy diet

This one study, of course, can’t prove that a healthful diet fights prostate cancer. For one thing, this type of long-term follow-up study can only show an association between diet and prostate cancer. There were also some differences between the groups. The men who ate the most vegetable oil were healthier to start with. At diagnosis, their blood levels of PSA—a marker for cancer activity—were lower than in the group that ate the most animal fat. Conversely, the men who ate the most animal fats had more unhealthy characteristics. They were more overweight and less physically active, and more of them smoked (7% compared with about 1% in the vegetable-fat group).

Researchers used statistical methods to compensate for these important differences. “Any of these negative influences would independently lead to a worse outcome,” Dr. Garnick says. “Have they accounted for everything? In these studies, you can never be sure.”

So we don’t really know what contributed most to keeping prostate cancer in check—eating more beneficial vegetable oils, eating fewer (or healthier) carbohydrate-rich foods, or eating less meat. It may not matter, since all three are part of a healthful diet.

The JAMA Internal Medicine study, like so many others before it, endorses an overall healthy diet that goes easy on red meat and includes generous amounts of plant foods that deliver healthy mono- and polyunsaturated fatty acids. These come from foods like avocados, walnuts, and soybean, canola, and extra virgin olive oils. That kind of diet has been linked with lower risks of heart disease, cancer, and a host of other chronic conditions.

This week is Men’s Health Week. As we cruise toward Father’s Day, I hope that all men will give themselves the gift of health. One important step in that direction is adopting a diet that may fight prostate cancer and will benefit everything from the head to the feet.
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