Start by putting
things in context. I've listed here the
top 10 causes of death in 2019 in
the United States. I wanted to highlight is that cancer is the second leading
cause of death in the US, with heart disease
being number 1. Last year with the
COVID-19 pandemic, so in 2020, COVID became the third
leading cause of death. But just take in emphasize
that heart disease and cancer remain the top one and
two causes of death. The World Health Organization
has estimated that 30 to 50 percent
of cancer deaths could be prevented worldwide. A study from the
American Cancer Society focused on the United
States estimated similarly that up
to 45 percent of cancer deaths are linked
to modifiable factors.

Here Here the factors that
that study focused on. Many of these are familiar. The recommendation would be
to avoid tobacco exposure, avoid being overweight or obese, consume moderate
amounts of alcohol, small to moderate
amounts of alcohol, limit consumption of
red and processed meat, and be cautious about
UV radiation exposure, and exposure to specific
infections that happen linked to
specific cancer types.

On the flip side, one would recommend a diet that is rich in fruits
and vegetables, higher in fiber, obtaining adequate amounts of
calcium in one's diet, and getting plentiful amounts
of physical activity. The study also tried to zero
in on those things that are most critical for a
cancer death prevention, and those are what are highlighted
in blue on this slide. What about among men with
prostate cancer specifically? Well, you've probably heard the statement that
men diagnosed with prostate cancer
these days are more likely to die of something else. Where does that
statement come from? Well, there was one
study conducted in the United States using
cancer-registry data, this was a national study, and they looked at
cancer-registry data at all men diagnosed with prostate cancer
between 1973 and 2008.

There were nearly 500,000 men diagnosed during
that time frame. Over the 35 year period
followed in this study, 259,000 of these
men passed away. Sixteen percent
of these men with prostate cancer died
from their disease, died from prostate cancer. It is important
to note, however, that this era spans the
pre and post PSA era. PSA started being used more regularly in the
United States in the 1990s. Among those 259,000 deaths that occurred in this
large population of men with prostate cancer, 30 percent of the deaths
were due to prostate cancer, which means that 70 percent of the deaths were due
to something else. What was that something else? Well, there were many
causes but really one of the leading causes of death in that 70 percent
was due to heart disease. I bring this up
because I think it is important that when one is thinking about what
dietary recommendations to make for men with
prostate cancer, it's really important to
consider the bigger picture. What are such men really at risk for with regards
to co-morbidity, other chronic diseases,
and the risk of death? As you can see, heart disease
remains an important cause of death for adults in general and also for men with
prostate cancer.

What are the risk factors
for heart disease? Well, many of you are
familiar with these, high blood pressure, high
cholesterol, tobacco exposure, as well as diabetes, overweight and obesity, not
getting enough exercise, and an unhealthy diet. Interestingly, many of these overlap with risk
factors that we and others have reported on for reducing risk of lethal
prostate cancer. Similarly, we would recommend avoiding tobacco exposure,
avoiding obesity. Some intriguing associations
have been reported between insulin sensitivity and
prostate cancer outcomes. Then of course, diet and exercise do appear
to play a role. Just a small comment
here about cholesterol. Although dietary
cholesterol itself has not consistently been linked to
prostate cancer outcomes, there are some common
medications prescribed for heart disease prevention
that also appear to have potential benefits for preventing
prostate cancer death. Again, the data are not
entirely consistent.

However, there have been some reports out there stating that statin
use and aspirin use, common medications
prescribed for heart disease prevention
have been associated with a 30 to 40
percent reduction in the risk of prostate
cancer death. This is intriguing and our team is interested to
study this further. I've tried to summarize here on one slide, it's a bit busy, but tried to summarize
in one place the recommendations for
heart disease prevention, cancer death prevention overall, and then prostate cancer
deaths specifically.

These are specifically the
dietary recommendations for each of these major
disease outcomes. What you can see is there's some consistent patterns
and overlap fortunately, which makes it easier for when one is trying to
think about what one should eat and
do in their day. Avoid trans fat,
limit saturated fat, that's generally what would be recommended for heart disease, total cancer, and also
for prostate cancer, as well as specifically for lethal prostate cancer we would suggest
avoiding whole milk, and try to opt for healthy
vegetable fat sources instead such as
olive oil or nuts. What I've tried to
do here over in this column is just
put the nuances, the additional nuances
that we would add on top of these general cancer
prevention recommendations. For heart disease, one
would recommend diets low in cholesterol,
salt, and sugar. Trying to reduce or limit
sugar intake is also recommended for
cancer in general. Skip alcohol just for a moment. Across the board for
all of these things, we'd also generally recommend limiting consumption of
red and processed meat, and having a diet that's
rich in whole grains, fruits, vegetables, beans,
legumes, and fiber.

Specifically, for
prostate cancer, when you're trying to reduce one's intake of red
and processed meat, we would also then specifically recommend try fish or
skinless poultry instead. These things have been
looked at specifically for prostate cancer outcomes. Then among the vegetable groups, we also highlight trying to consume cooked tomato products and cruciferous vegetables, specifically for
prostate cancer. Back to alcohol,
it's a little bit confusing because in general, alcohol would not be recommended or we
would recommend really limiting or not
consuming alcohol if one is really focused on
preventing cancer death. However, for heart disease, it's a little more
nuance because there are some studies that
have reported that modest amounts of
alcohol intake may offer some benefits for
heart disease so their recommendation is
limit to 1-2 drinks per day. There have been some
intriguing results for prostate cancer specifically where red wine intakes or very modest amount of
red wine intake has been associated with a lower risk of prostate cancer
death or metastasis, but again, they're limited data. A nuance recommendation
would just again be limit to 3 or 5
servings per week.

The level here which the
benefit might have been seen was at a more
conservative amount actually than for heart disease. In general, the recommendation
would be if you have prostate cancer and you do
already consume alcohol, it's not something
that you have to completely eliminate
from one's diet, but try to be rather conservative about
the amount of intake. A little bit more on the
specific recommendations for reducing lethal
prostate cancer. Here is a list of factors
that reported in 2019 as post-diagnostic health
behaviors that might offer benefit for reducing the risk of prostate cancer
recurrence or death. This was presented in this
very same symposium in 2019. All of these, I believe, are familiar with what I just showed on the previous slide. Then what I've done here is
trying to show what update what I make today
or now in 2021. In the past year, our team did a comprehensive
literature review on post-diagnostic
health behaviors and the risk of prostate
cancer recurrence and death.

What I've tried to reflect
here some nuance changes from 2019 till now that we might make based on that
recently lit review. Everything in white is basically
the same or consistent, we would still
recommend those things. The things that are in gray, some of these dietary
factors here, we would generally
still recommend them. However, I grade them out
just to say that there are less data available compared
to the things in white. In the past two years, there's not been new data, more corroborative data to substantiate those
recommendations. There's nothing to contradict it necessarily per se either, but ideally, one
would like to see more consistent
evidence coming out. This is actually a
limitation of our field and something that our team
is trying to work on, which is to gather more data on post-diagnostic
health habits and subsequent risks in
patients with cancer. Things in blue are
our slight updates. I believe this actually just
said high-fat dairy before, but some of them report
to really have zeroed in that whole milk may be
the factor to avoid here, and then I commented
previously about the nuances with regard to wine intake that have come out.

Next, I'd like to share some diet tips from Greta Macaire, who's a registered dietitian
with the UCSF Cancer Center. I had the opportunity to sit in a panel discussion
with Greta recently for a audience comprised of individuals with cancer,
including prostate cancer. Here's some of the
tips that she shared. Aim to have about two-thirds of one's plate filled with
plant-based foods. Animal protein from sources
like skinless poultry, fish, and egg whites are fine
to include as part of a diet that's rich in
plant-based foods. Little bit more detail
about that egg comments. Eggs have been associated
in some studies with an increased risk of lethal
prostate cancer, however, that link is not really been firmly established that there's no need to really totally
exclude eggs in one's diet, and Greta recommended amount of a couple eggs per week or less.

Then with regards to
supplements, again, it's best to meet
nutritional needs through diet when possible. In summary, among men with prostate cancer diagnosed
in the PSA era, heart disease and
other chronic diseases remain important
causes of death. But diet recommendations
to reduce risks of heart disease overlap with those for preventing cancer
death in general. Recommendations for
reducing risk of prostate cancer
deaths are generally consistent with those of
a heart-healthy diet, and I've tried to
provide here a few of those nuances specific
for prostate cancer.

Thank you very much
for joining us. Hi, I'm Stacey Kenfield, an Associate Professor
and epidemiologist that you see at that in the
Department of Urology, and Epidemiology,
and Biostatistics. Today I'll be talking
about exercise as part of your prostate cancer
treatment plan and our trials that you
see at that and beyond. Research shows that
physical activity after diagnosis can lower risk of
prostate cancer progression, and mortality, and
overall mortality. I led the first paper on this
topic published in 2011. This figure shows total activity displayed in MET
hours per week on the x-axis and the
risk of all-cause and prostate cancer-specific
mortality on the y-axis. Looking at the green bars, the graph shows insignificant
protective association between physical activity
and all-cause mortality at levels of about 30 minutes
of walking most days per week or jogging three days per week denoted by
the orange circle.

However, for prostate
cancer mortality, looking at the blue bars, a significant
protective association was only observed with much higher levels of physical activity denoted
by the red circle. When looking at the data
by type of activity, we reported that
vigorous activity was important and associated with a 61 percent lower risk of prostate cancer-specific
mortality levels of three or more hours a week. Dr. Erin Van Blarigan led
a complimentary study using the capture registry
based at UCSF and reported that men walking briskly for at least
three hours a week had a 57 percent lower risk of prostate cancer
progression compared to men walking at a slower
pace for a shorter duration. Based on these data, intensity seems to
be important with greater intensity equal
to greater benefit. Since then, other cohort
studies have reported similar findings while showing that moderate exercise
is also beneficial. For example, in this cohort
study done in Canada, four and a half
hours of walking, which is equivalent
to about two hours of vigorous activity, was associated with a
40 percent reduction in the risk of prostate
cancer-specific mortality.

In the last few years, two meta-analyses have
been completed reporting a 31 percent reduction in the risk of prostate
cancer-specific mortality and a 40 percent risk
reduction in all-cause mortality for the
most versus least active prostate
cancer survivors. What's the take
home message here? Engage in exercise for your
prostate and overall health. Our recommendations based on the US Physical
Activity Guidelines and the American College
of Sports Medicine are to build up to a 150
minutes per week of moderate aerobic
exercise or 75 minutes per week of vigorous aerobic
exercise or combination. Keep in mind that two minutes of moderate intensity
aerobic exercise is equivalent to one minute of vigorous intensity
aerobic exercise. You can mix up the frequency and duration to meet these
recommendations. The data show that building
up to 300 minutes per week of moderate activity or
the equivalent in vigorous activity has
more health benefits.

If you can, try and incorporate as much activity as you can. According to the new
2021 ACSM guidelines, bouts of less than
10 minutes are also associated with
favorable outcomes, so any amount of
activity that you can squeeze into your
day is helpful. The benefits of regular
physical activity to lowering risk of dying
from prostate cancer in addition to lowering
risk of dying from colorectal and breast
cancer was added to the 2018 US National Physical
Activity Guidelines. At this point you
might be asking, well, how do I assess, how
far am I exercising? I'm going to spend a
few minutes discussing the different
exercise intensities.

For lighter, mild
intensity exercise, your heart beats
slightly faster than normal and you can
talk and sing. You won't break a sweat. This includes activities
such as leisurely walk, a casual bike ride, and some light yard work. Moderate intensity exercise will raise your heart rate and
you will break a sweat. You will still be able
to talk but not sing. This includes activities
such as brisk walking, playing doubles tennis, swimming laps at a moderate
pace, and some sports.

While vigorous
intensity exercise is when you're breathing
is deep and rapid, your heart rate is elevated, and you are sweating a few
minutes into the activity. You won't be able to say
more than a few words without pausing for breath, and these include
activities such as jogging, hiking uphill, playing singles
tennis, or racquetball. Keep these intensities in
mind when you are aiming for your 150 minutes of moderate intensity activity or your combination of moderate to vigorous intensity activity. Now moving on to
muscular fitness, this type of fitness
is optimized for the implementation of
resistance training. It's particularly beneficial for prostate cancer patients
as the side effects of treatment often lead to a decrease in muscle mass and a loss of physical function.

This type of exercise
done regularly will help you to preserve your
muscle and bone mass, and it can also reduce risk
of falls and fractures. Systematic reviews done on the effects of resistance
exercise in patients with prostate cancer have
demonstrated that resistance exercise
improves muscular strength, fatigue, and quality of life. An updated review
done in 2020 also shows that resistance exercise can improve body composition, has positive effects on
bone mineral density, and sexual health as well. Including self-reported
sexual function as well as sexual activity
and interest in sex, while significantly improved in the exercise intervention groups versus the control groups. For resistance exercise,
we recommend that you perform muscle
strengthening exercise at least two days a week. Try to choose 8-10
different exercises that work major muscle groups, and aim for 2-3 sets of 8-12 repetitions
for each exercise. Start with lighter
weights that you can lift 10-15 times safely. Then over time as
you get stronger, slowly increase the weight. When you do this, really aim for 6-10 reps that you're
doing with good form.

As you get stronger, add another rep a week
until you're back up to your 10-15 reps.
Then at that point, increase the weight
again and so on. There are a lot of
different online videos to help show you proper technique. In addition, we also recommend flexibility exercise and
stretching as important for maintaining full
range of motion and making it easier to perform
activities of daily living. We recommend doing at
least two days per week, a flexibility exercise
and try to do this after you've done your aerobic
or resistance exercise, when your muscles
are already warm. I hope you've
learned a lot about the types of exercise and the dose that will provide
the most benefit to you. I want to conclude
by telling you about some novel research
we are doing at UCSF, and invite you to be part of it. We recently finished
a study called CHAMP to determine the
safety and feasibility of aerobic and resistance
exercise in men with metastatic castrate-resistant
prostate cancer. The study was really designed as a supervised exercise study.

But we found that it
was really hard to have patients come
on site three days a week so we redesigned it
as a remote intervention. We offered a concierge service
to help link people to a local gym and were able to
demonstrate good adherence. Eighty two percent completed
the 12 weeks study, and 90 percent or more of the prescribed
workouts were attempted. We did see changes in performance tests corresponding
to the prescription. No safety concerns
were identified, and the study had a
high satisfaction, with 90 percent willing to recommend the
program to others. This remote exercise protocol
from CHAMP was added to the global exercise trial for metastatic prostate
cancer patients, which is opening at
UCSF very shortly. Our overarching goal is to offer an intervention to every
patient with prostate cancer to answer novel questions
regardless of the cancer stage or treatment
that the person received. We're now at the point where we have finished a lot
of the pilot work. Those studies are
highlighted in gray. In some instances, we
moved on to version 2.0, offering an updated or extended version of the original study. Our open and rolling
trials are in green, while our studies that are
opening soon are in blue.

The studies in blue
and green are funded by the National
Institutes of Health, The Movember Foundation,
and Myovant Sciences. I want to highlight a few
of these studies to show the breadth of our work across
different disease stages. ASX is as far as study of
man on active surveillance. It's a remote four-month
aerobic exercise trial, evaluating as the
primary outcome, change in
cardiopulmonary fitness. Prostate 8-II is for
men choosing surgery. It's a forearm two-year
diet and exercise trial, and men must enroll at least
two weeks before surgery. There's a number of outcomes of interests, including
PSA recurrence. We're also part of a
global study of exercise, as I mentioned earlier
called INTERVAL-GAP4. This is for metastatic
prostate cancer patients. I lead the Global Steady Coordination Center
based at UCSF.

It's a two-year trial
to examine if exercise prolongs life in metastatic
prostate cancer patients, and we plan to
open in July 2021, just a few months from now. The other two studies
are currently open. For all of these studies, participants do not need
to be a UCSF patient. If you're interested,
please check out our studies using
the link below. Lastly, I just want
to mention all of our new resources
available for patients. Our research group is dedicated
to creating resources, and you can access
these at the link shown and get on this link to
join our mailing list.

We will update you when we
have new resources available. Some are specific
to prostate cancer, but others are more general, such as our booklet
for diet, exercise, and mindfulness during
COVID-19 pandemic. We hope you find these useful, and we encourage feedback
from you as well. Thank you so much for your
listening and for your time. There is a clarifying question
about whole milk intake. The person says they've
seen articles that all dairy should be

Can I clarify? That might be prudent, I guess, is how I
would answer that. The reason it's a little
bit confusing is that studies have looked at
this two different ways. Some of the studies that
have looked at risk of developing prostate
cancer identified dairy as an entire group or
entity that appeared to be associated with
increasing the risk of developing prostate cancer, and actually this is work that I contributed to
several decades ago. In those studies, we didn't see one product over the other really coming
to the forefront. That's why I think some
of the recommendations have just been to
be prudent to try to limit dairy intake overall.

I can say though,
that the studies that have really focused
on diet after diagnosis in men who've already had prostate cancer or
have prostate cancer, in those studies, it
does appear to be the high-fat dairy or whole
milk intake that is linked. That was the difference
between the studies, and why the recommendation might be a little bit confusing. That being said, I
could also qualify that the post diagnostic
data are limited. There's only four
studies that have been able to look at dairy
intake after diagnosis. But at least in those studies, it was more the high-fat whole milk item that appeared to be linked to metastatic fatal
prostate cancer outcomes.

I hope that's helpful
for whoever asked that. I can mention that Dr. Canfield show those books, the resources. We do have a little section
up on there about dairy, and it does recommend
if you do take dairy, try to reduce, avoid
the high-fat types, and then try alternative sources like milks and things like that. There was another question
about dark chocolate, which I think is a
nice way to close on a Friday, the end of the day. What do I think about high
cocoa dark chocolate? I'm guessing this is going
with that dark chocolate that tends to be lower
in fat and sugar. I guess I would say if you're
going to have a treat, this is a good one. I can share more anecdotally
that Walter Willett, who led the Department
of Nutrition at the Harvard School of
Public Health for 30 years, and is the "father" of modern
nutritional epidemiology, condones a desert
comprised of nuts, fruit, and dark chocolate
as a way to continue to enjoy life while being mindful
of one's dietary intake.



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