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Integrating 4Ps into Prostate Cancer Care

Dr Michael Sagner, bestselling author of Lifestyle Medicine and a pioneer in preventative healthcare, joins OnFocus to discuss the changing narrative around ageing and outlines how a focus on prevention, personalisation, prediction and participation can impact mens’ experience with prostate cancer.

https://www.amazon.co.uk/Lifestyle-Medicine-Environment-Preventive-Disease-ebook/dp/B06XSJ4ST9

Clare Delmar

Hello and welcome to On Focus brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided or even ignored. Prostate cancer is now the most commonly diagnosed cancer in the UK with this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is Dr. Michael Sagner, author of the best selling book Lifestyle Medicine, and a pioneer in the development of preventative health care. Dr. Sagner has developed a large following around his four Ps approach to personal health, which is based on care that is predictive, personalised, preventative and participatory. He’s joining me today to explore how these principles might integrate with the management of prostate cancer and how they can benefit with men with a prostate cancer diagnosis pre and post treatment. Michael, welcome. Thanks so much for joining me today.

Michael Sagner

Thanks, Clare. Thanks for having me.

Clare Delmar

So what you do is really fascinating, and you have indeed developed quite a following. And I understand Lifestyle Medicine is now in its fourth edition. So you’re clearly having an impact on both the medical world and on a whole range of patients.

Michael Sagner

Yeah, I’m quite happy about this obviously, when we started looking into this, this connection between lifestyle factors and health, especially the maintenance of health, people thought that we are not practising medicine because medicine historically was always about fixing diseases, looking at symptoms and treating them with pharmacology. Yet since the very beginning of what we would call Western medicine and obviously also Asian medicine, the influence, the impact of lifestyle factors such as nutrition, diet, stress, sleep and physical activity and some others, on your health, disease progression and ageing are well known. We just for some reason forgot about them and medicine just stopped talking about them.

Clare Delmar

I mean, you mention ageing, and that’s actually really where I wanted to to kick off here, because, of course, prostate cancer is a disease of ageing. And yet we know that people age differently and increasingly there are ways to control the rate and extent of ageing. I know you’ve been involved in this. You know, fundamental to your engagement with patients is understanding something called chronological age versus biological age. So I wonder if you can describe what that means and how it impacts caring for patients?

Michael Sagner

Yes. So the difference between chronological age and biological age is basically the difference between what’s written in your passport and what your cells look like. So for a very long time, we just assumed that after you peak in your mid 20s, early 30s, you just decline. And that decline, that rate of decline would be, we just assumed that it’s the same for every person and men and women totally independent of your job, stress levels, and so and obviously that doesn’t make sense. And we now understand that the number in your passport and the actual age of your cells can be very different. And the last couple of years, we saw a few tools. One of them is epigenetic tests that allow us to determine this biological age, and that is to realise that you want to look at a lot more important than the number, as I said, that, you know the day you were born.

Clare Delmar

So this epigenetic age, is this something that’s that’s measurable? And is it based on what? On biomarkers? On cellular age?

Michael Sagner

Yes, obviously, it’s quite difficult to determine biological age, you will have to take cells and you would have to do very complicated assays. Since the early 2000s. Elizabeth Blackburn won the Nobel Prise in medicine and physiology for her discovery of what’s called telomeres. It’s the sort of the ends, the caps of your DNA. And a very convenient way to measure biological age, and that’s usually how laboratories do it nowadays is instead of, you know, taking apart the whole cell, you just look at these caps, these protective caps of your DNA, of your genetic information. And if they are worn off very short, then we would say that you have a rather, you have a reduced biological age, meaning you are older. And if these caps are longer, thereby protecting your DNA better, then you would be younger.

Clare Delmar

OK

Michael Sagner

That’s how we measure it.

Clare Delmar

It seems to have quite an impact. I mean, one of the questions that I’m really keen to ask you, because it comes from patients consistently, if not increasingly, is. For example, we have a lot of men who are 70, 70 plus and are fit and active, have very positive cognitive, mental, emotional outlook, etc., etc. And when they’re diagnosed with prostate cancer, they feel that they’re actually in the almost the best stage of their life. You get men who are 70 who say they feel like they’re 50 in terms of their physical and mental health, but then they say they’re treated in what they perceive as an age discriminatory way. So I wonder if you can tell me how you think this might be best addressed in a world where we know that there’s a difference between chronological age and biological age?

Michael Sagner

Yeah, as with so many new things in medicine, innovations, medicine, so the traditional healthcare systems, which are more or less, to be a bit cheeky, they’re disease management systems, more than true health care systems. These health care systems globally, doesn’t matter whether it’s the NHS or any other system, they have been very slow when it comes to innovation, and that is both technological, scientific innovation, but also culture. And this is obviously a problem of culture. We now know that a 70 year old in 2021 is not like a 70 year old in the 40s or 50s. People are generally more healthy, they’re more fit, more active. And it is very important that this cultural change, which is both, as you just said, this ageism issue, but also that we look at prevention and the biological age of that patient and then choose the treatment accordingly. I think that these are cultural changes that are going to take place at some point. We know that it’s slow, which is another reason that more and more patients are looking at getting treatments and interventions at private facilities where maybe these cultural changes are already taking place.

Clare Delmar

So what can men who have or have had a prostate cancer diagnosis do to optimise their health and wellbeing?

Michael Sagner

The interventions that we would recommend and the interventions that are evidence based are very similar to the interventions that we would recommend to prevent the cancer from occurring in the first place. Most of them are related to lifestyle, obviously nutrition, as I said, diet, stress management and sleep and so on. That is the foundation, both of treatment and prevention. And then there are a few things, many of them experimental, that might help to support the treatment or might be a standalone treatment. There are some studies showing that very, very strict lifestyle interventions could be used in early stage prostate cancer. This has to be discussed with the treating physician. In any case, no matter what treatment the patient and the clinician decides to go for, the lifestyle intervention, the lifestyle support should be there, no matter whether it’s surgery, radiation or something else. It’s very important that this basic foundation of a healthy lifestyle is in place both to prevent cancer, not just prostate cancer, but many other cancers. And then to continue with this, let’s just call it healthy lifestyle, while you’re undergoing treatment and obviously after the treatment to prevent recurrence.

Clare Delmar

So that leads me to my next question was which was actually honing in on your four P approach and how you think that specifically might integrate with the prostate cancer diagnostic and treatment pathway that would improve patient care? I mean, I know you’re suggesting that patients become a lot more attuned to their health, without doubt, once they have a disease diagnosis such as prostate cancer. But do you think that the four P approach could actually become something that is actually integrated into clinical pathways or certainly care pathways?

Michael Sagner

Yes, absolutely. The four PS are again, more of a cultural change, and these changes are absolutely necessary because if we continue treating our patients the way we’ve been treating them, then we are going to deny them a lot of the innovation that is available, but just not being deployed. So the four P’s, just to repeat is preventive, meaning that we have to be a lot more proactive. We can’t continue with this mindset that we just wait for symptoms and diseases to happen. And very often we see them coming like prostate cancer, very often colon cancer, heart attack, stroke. These are things that you can very often you can predict to a certain extent, meaning if you have as a guy, you know, older than 40, you should think about your prostate, you should think about prevention and not just wait until that unfortunate day that your doctor says, OK, that’s it now. So be a lot more proactive. Prevention is obviously the centrepiece of this approach. Then we have to be a lot more personalised in our approaches. This one size fits all approach is very obviously old fashioned. And when you think about how we prescribe medicines, very often we use 500 milligrams of this or 500 milligrams of that. And we don’t think about the age of the patient, whether it’s a female patient, a male patient, whether the patient is pregnant, maybe, maybe the patient is obese so might need a lot more. This personalisation aspect, I think, shows us how much we lack true innovation and sophistication of medicine very often, even though medicine and health care is perceived in the public as this, you know, almost science fiction like enterprise, where everything is brand new and we’re doing it using the latest science. It’s not true. Anybody who has worked in medicine knows that that is not true. And the bigger the hospital, very often, the worse it is. So that’s two Ps. That’s prevention personalisation, then prediction. So a more predictive approach that we actually look at the patient and say, OK, that it is very likely. There are a few red flags that we should look at just based on your age, maybe genetic history, family history. So trying to predict certain issues and then be proactive about them. And the fourth P is the patients have to be less passive; health care professionals, doctors have to be a lot more inviting. So the fourth P would be participatory. We have to really let the patients participate in their health care and not just disease management, but true health care, making decisions based on also the patient’s preferences, presenting different options, discussing all the options, and very often doctors, obviously they are good at a certain, using a certain technique or things they have been doing like that forever. And very often we still unfortunately, we still see clinicians talking down to the patients. And I think it’s time to change that. And we really, especially when it comes to prevention, because prevention obviously happens to a large extent outside of the clinic without the doctor being present. It’s what you do at home, the food you eat,  stress management. So we need the patient to participate, but there needs to be a better interaction between the health care professional and the patient.

Clare Delmar

Absolutely. And patients are crying out for that, don’t you think?

Michael Sagner

Absolutely. Absolutely. The four P approach was initially proposed by Lee Hood, a colleague and friend of mine. And it’s really a cultural change in how we practise health care.

Clare Delmar

Michael, this has really been fascinating and I hope we get a chance to speak again because it’s clearly a field that is evolving. And I think particularly at this time when we’re coming out of a pandemic and most of us are much more attuned to our health and the systems around us, this is only going to gain steam. So thank you so much for speaking with me today. It’s been a real pleasure.

Michael Sagner

Thanks, Clare. Thanks for having me.

Clare Delmar

Further information on Dr. Michael Sagner and a link to his book is available on our website, along with a transcript of this interview and additional interviews and stories about living with prostate cancer. Please visit thefocaltherapyclinic.co.uk. Thanks for listening and from me, Clare Delmar, see you next time.

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