There is no status quo when you live with cancer. Doug Maddox, a U.S. Army Veteran who served in the Vietnam War, understands this quite well. He has been battling prostate cancer for more than a decade, and has met everything the disease has thrown at him with courage and an upbeat attitude. “I’m okay,” he says. “I’m alive. I’m 76, and I look like I’m in my 40s – that’s what everybody tells me! If you can control the cancer, you’ll be all right.”
Maddox served in the 25th Infantry Division in Vietnam. “I was a radio man,” he says. He wanted to be a doctor, a lung specialist, and read many books about medicine – something he continues to this day. “I have a twin sister, and my mother couldn’t send both of us to college at the same time. I decided to go into the military, and the money I sent home put her through college.” During his service, Maddox was exposed to Agent Orange, which has been linked to the development and growth of prostate cancer.
When he got out of the Army, “I did a lot of things,” including raising three children by himself. He worked as a butcher, washed cars, drove a bus, worked on trains, and drove heavy hauling trucks and tankers. “I’ve been to every state but Alaska.” When his family wanted him to stay closer to home, he got a truck-driving job in Philadelphia, from which he retired in 2011.
When Maddox was diagnosed with prostate cancer, he had surgery. His surgeon “told me afterwards that he had to cut a little more than normal because the cancer had spread outside the prostate.” After the surgery, Maddox experienced persistent urinary incontinence, and underwent placement of an artificial urinary sphincter. Then his PSA came back. He was put on androgen deprivation therapy (ADT), which worked for several years.
Then, when his PSA once again started to rise, he started taking abiraterone, which “brought down his PSA really nicely,” says PCF Young Investigator Ravi Parikh, M.D., M.P.P., his medical oncologist at the Corporal Michael J. Crescencz VA Medical Center in Philadelphia. He also has undergone radiation therapy and chemotherapy. Over the course of his treatment, Maddox has dealt with some of the common side effects of ADT, including weight gain and low libido.
“Mr. Maddox’s case illustrates issues with long-term survivorship,” says Parikh. “Like Mr. Maddox, many men with prostate cancer are going to live a long time, even after diagnosis with stage 4 disease. The most common survivorship problems my patients deal with are related to quality of life: sexual dysfunction, either decreased libido or erectile dysfunction (ED), and fatigue, maintaining bone health – protecting their bones from fragility and fracture – and mental health issues,” particularly depression.
“We need to do a better job screening for depression,” a side effect of lowering testosterone, Parikh continues. “It’s quite prevalent, and it can be associated with not having as good outcomes. Being proactive about mental health screening can make a huge difference in our patients’ quality of life. We shouldn’t be afraid of it, just as we shouldn’t be afraid to ask our patients about their sexual health.”
Maddox wants all the information he can get. “I study all the time, read all the time. People spend their days looking at TV; I’m sitting up here reading books!” He tells Parikh, “You don’t have to hide anything from me. Since I’ve been reading the Bible, I’m not scared of death,” and instead, he wants to live his life to the fullest.
Low libido? “It’s not about sex. It’s about life!”
Worries about bone health? “My bones are okay. I take two calcium pills every day and drink a lot of milk. I still have my strength.” Parikh encourages his patients to face bone density issues of ADT from the get-go. He recommends a half-hour of light weight-bearing exercise twice a week, and aerobic activity (such as walking, swimming, or riding an exercise bike) for 30 minutes three times a week. “It’s not easy, because it can make patients feel tired, but it can help,” and even raise energy levels. Parikh also recommends calcium, a vitamin D supplement (low levels of vitamin D can predispose someone to a fracture), and bone density screening – and, if a DEXA scan shows an increased risk of fracture, he recommends treatment with a bone-strengthening drug such as a bisphosphonate. Parikh’s research focuses on finding better ways to monitor bone health, including blood-based biomarkers of overall bone health, and markers of bone turnover (new cell growth).
Weight gain? Maddox keeps his cholesterol under control with medication, and has lost the weight he initially gained on ADT. “I watch what I eat: all fresh food, fresh fruits and vegetables.” He avoids processed meats, like bologna. “I don’t drink soda; I drink a lot of water.
Fatigue? He rolls with it. “Some days I feel like working, some days I don’t. Some days I don’t feel like doing anything, and that’s okay.” But most of the time, “I’m strong. I can still dance. I can do a lot of things!”
Maddox, says Parikh, “has been amazing. We as doctors can do more to help with these survivorship issues than a lot of guys think, but there’s one big limitation,” and that is communication. “Some men don’t bring it up. Some doctors don’t feel comfortable discussing it – mental health, sexual health, fatigue. The therapies and lower testosterone make people feel less like men. There are ways we can counter that, but we need to be open to discussing it. We have to be proactive about addressing the things that men see, and don’t see, as a result of ADT.”
Just put it on the table, Parikh continues: Whatever the issue, “we shouldn’t feel ashamed to talk about it. There are solutions out there to address some of the real toxicities that ADT has to offer, and we as providers need to address it, rather than just wait for men to mention it.”
Through the PCF-VA partnership, researchers are working on a range of projects in prostate cancer, from the biological underpinnings of the disease, to personalized medicine, to overcoming the challenges of survivorship. Parikh is a clinician-researcher and Maddox a patient at the Jonathan and Plum Simons Precision Oncology Center of Excellence.
Maddox is moving to Florida, but he still plans to stay in touch with Parikh. “I’ll take a plane back to Philly any time he wants to see me!” And, like his future home in Florida, Maddox’s outlook is sunny: “I hope I can make it to 80, but that’s up to God. I don’t walk with a cane, I don’t complain. A lot of people don’t understand why I’m so active, but they don’t know that some days I don’t feel like doing anything. I want to live. I feel great!”