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Balance is a skill you don’t think about until you really need it — like when you lose your footing and have to perform an exotic improv dance to keep from hitting the ground. But don’t wait until your sense of balance fails before you give it proper attention. As we age, balance can sharply decline, often with little warning. An exercise program called BEEP can help.

How you keep your balance

While keeping proper balance may seem simple, it involves a complex system with many moveable parts. Whenever you move, your eyes and brain process information about your surroundings. Your feet detect changes in the terrain. Your arms swing to keep you stable, and your lower-body muscles and joints generate rapid power so you can move forward, stop, and change directions.

Unfortunately, this system works less effectively over time. The sensation of our bodies moving through space is not as crisp, and information travels more slowly between the body and brain. Muscles become weaker, and joints lose flexibility.

Any breakdown in your balance system increases your risk of falls, which can cause hip fractures, broken bones, and head injuries.

“Doing more balance exercises and activities can keep your sense of balance in good shape, but you also want to focus on multifaceted movements that work on all the elements of your balance system,” says Dr. Brad Manor, associate director of the Mobility and Falls Translational Research Center with Harvard-affiliated Hebrew SeniorLife.

There are many kinds of balance exercises. Science has not tapped any specific ones as the best; however, some have stood out in many balance-related studies.

For instance, a 2016 study in the journal Gerontology and Geriatric Medicine found that a specific Balance-Enhancing Exercise Program (called BEEP for short) improved balance skills among adults ages 60 to 80. Study participants did better on both solid and uneven surfaces, and increased their walking speed and overall confidence.

Focus on three exercises to improve balance

The BEEP program focused on three exercises: squats, heel and calf raises, and one-legged standing. “These types of exercises increase both the physical and cognition skills needed for better balance,” says Dr. Manor. “Plus, they mimic movements of everyday life.”

He recommends adding these to your regular workouts or doing them daily on their own.

Squats. Stand with your feet shoulder-width apart. Bend your knees and imagine you are sitting down on a stool. Lower down until your thighs are parallel to the ground, or as far as is comfortable. Keep your weight on your heels. Extend your arms forward or place your hands on a chair, counter, or table for stability. Pause for a second or two, then rise back to the starting position. Do this up to 10 times.

Heel and calf raises. Stand with your arms crossed over your chest and lift your heels, so you rise up on your toes. Hold this position for up to 10 seconds, or as long as possible, and then lower your heels. Do this five to 10 times. If you need support, hold on to a door frame, a table, or another sturdy object. You also can place your hands flat on a wall.

One-legged standing. Stand tall and place your hands on your hips or hold on to a table or chair for stability. Then raise one leg, so your foot is about six to 12 inches above the floor. Keep your gaze straight ahead. Hold for 20 to 30 seconds. Repeat on the other leg. Go back and forth three to five times.

You also can perform these exercises with your eyes closed to work on coordination and concentration. Another option is to “distract” yourself by doing unrelated cognitive tasks — count backward, name words that begin with the same letter, or make a mental supermarket list.

“Balance is definitely a use-it-or-lose-it skill,” says Dr. Manor. “But if you work on your balance continuously, you are almost guaranteed to see improvements.”

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Animals renowned for their outstanding night vision include owls, cats, tarsiers (a tiny primate in Southeast Asia) — and even the dung beetle.

But humans? Not so much.

Over time, many people suffer from night blindness, also known as nyctalopia. This condition makes seeing in dim or dark settings difficult because your eyes cannot adjust to changes in brightness or detect light.

What are the dangers for those experiencing night blindness?

Night blindness is especially problematic and dangerous when driving. Your eyes cannot adjust between darkness and the headlights of oncoming vehicles, other cars may appear out of focus, and your depth perception becomes impaired, which makes it difficult to judge distances.

Night blindness also may affect your sight at home by making it hard for your vision to quickly adjust to a dark room after turning off the lights. “This can cause people to bump into furniture or trip and suffer an injury,” says Dr. Isabel Deakins, an optometrist with Harvard-affiliated Massachusetts Eye and Ear.

What happens in the eye to create night blindness?

The ability to see in low-light conditions involves two structures in the eye: the retina and the iris.

The retina, located in the back of the eye, contains two types of light-detecting cells called cones and rods. The cones handle color vision and fine details while the rods manage vision in dim light.

The iris is the colored part of your eye. It contains muscles that widen or narrow the opening of your pupil to adjust how much light can enter your eyes.

If your irises don’t properly react, the pupils can dilate and let in too much light, which causes light sensitivity and makes it hard to see in bright light. Or your pupils may remain too small and not allow in enough light, making it tough to see in low light.

What causes night blindness?

Night blindness is not a disease but a symptom of other conditions. “It’s like having a bruise on your body. Something else causes it,” says Dr. Deakins.

Several conditions can cause night blindness. For instance, medications, such as antidepressants, antihistamines, and antipsychotics, can affect pupil size and how much light enters the eye.

Eye conditions that can cause night blindness include:

• glaucoma, a disease that damages the eye’s optic nerves and blood vessels
• cataracts, cloudy areas in the lens that distort or block the passage of light through the lens
• dry eye syndrome.

However, one issue that raises the risk of night blindness that you can’t control is age. “Our eyes react more slowly to light changes as we age, and vision naturally declines over time,” says Dr. Deakins.  “The number of rods in our eyes diminish, pupils get smaller, and the muscles of the irises weaken.”

What helps if you have night blindness?

If you notice any signs of night blindness, avoid driving and get checked by an eye care specialist like an optometrist or ophthalmologist. An eye exam can determine if your eyeglass prescription needs to be updated.

“Often, a prescription change is enough to reduce glare when driving at night," says Dr. Deakins. “You may even need separate glasses with a stronger eye prescription that you wear only when driving at night.”

Adding an anti-reflective coating to your lens may help to cut down on the glare of the headlights of an oncoming car. However, skip the over-the-counter polarized driving glasses sold at many drug stores. "These may help cut down on glare, but they don't address the causes of night blindness," says Dr. Deakins.

An eye exam also will identify glaucoma or cataracts, which can be treated. Glaucoma treatments include eyedrops, laser treatment, or surgery. Cataracts are corrected with surgery to replace the clouded lens with an artificial one. Your eye care specialist can also help identify dry eye and recommend treatment.

Ask your primary care clinician or a pharmacist if any medications that you take may cause night blindness. If so, it may be possible to adjust the dose or switch to another drug.

Three more ways to make night driving safer

You also can take steps to make night driving safer. For example:

• Wash the lenses of your glasses regularly. And take them to an optician to buff out minor scratches.
• Keep both sides of your front and rear car windshields clean so that you can see as clearly as possible.
• Dim your dashboard lights, which cause glare, and use the night setting on your rearview mirror.

About the Author

Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Roughly one in six men will be diagnosed with prostate cancer at some point in their lives, but these cancers usually aren’t life-threatening. Most newly diagnosed men have Grade Group 1 (GG1) prostate cancer, which can linger for years without causing significant harms.

Prostate cancer is categorized according to how far it has spread and how aggressive it looks under the microscope. Pure GG1 prostate cancer is the least risky form of the disease. It occurs frequently with age, will not metastasize to other parts of the body, and it doesn’t require any immediate treatment.

So, should we even call it cancer? Many experts say no.

Dr. Matthew Cooperberg, who chairs the department of urology at the University of California, San Francisco, says men wouldn’t suffer as much anxiety — and would be less inclined to pursue unneeded therapies — if their doctors stopped referring to low-grade changes in the prostate as cancer. He recently co-chaired a symposium where experts from around the world gathered to discuss the pros and cons of giving GG1 cancer another name.

Treatment discrepancies

GG1 cancer is typically revealed by PSA screening. The goal with screening is to find more aggressive prostate cancer while it’s still curable, yet these efforts often detect GG1 cancer incidentally. Attendees at the symposium agreed that GG1 disease should be managed with active surveillance. With this standard practice, doctors monitor the disease with periodic PSA checks, biopsies, and imaging, and treat the disease only if it shows signs of progression.

But even as medical groups work to promote active surveillance, 40% of men with low-risk prostate cancer in the United States are treated immediately. According to Dr. Cooperberg, that’s in part because the word “cancer” has such a strong emotional impact. “It resonates with people as something that spreads and kills,” he says. “No matter how much we try to get the message out there that GG1 cancer is not an immediate concern, there’s a lot of anxiety associated with a ‘C-word’ diagnosis.”

A consequence is widespread overtreatment, with tens of thousands of men needlessly suffering side effects from surgery or radiation every year. A cancer diagnosis has other harmful consequences: studies reveal negative effects on relationships and employment as well as “someone’s ability to get life insurance,” Dr. Cooperberg says. “It can affect health insurance rates.”

Debate about renaming

Experts at the symposium proposed that GG1 cancer could be referred to instead as acinar neoplasm, which is an abnormal but nonlethal growth in tissue. Skeptics expressed a concern that patients might not stick with active surveillance if they aren’t told they have cancer. But should men be scared into complying with appropriate monitoring? Dr. Cooperberg argues that patients with pure GG1 “should not be burdened with a cancer diagnosis that has zero capacity to harm them.”

Dr. Cooperberg does caution that since biopsies can potentially miss higher-grade cancer elsewhere in the prostate, monitoring the condition with active surveillance is crucial. Moreover, men with a strong family history of cancer, or genetic mutations such as BRCA1 and BRCA2 that put them at a higher risk of aggressive disease, should be followed more closely, he says.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases, agrees. Dr. Garnick emphasized that a name change for GG1 cancer needs to consider a wide spectrum of additional testing. “This decision can’t simply be based on pathology,” he says. “Biopsies only sample a miniscule portion of the prostate gland. Genetic and genomic tests can help us identify some low-risk cancers that might behave in a more aggressive fashion down the road.”

Meanwhile, support for a name change is gaining momentum. “Younger pathologists and urologists are especially likely to think this is a good idea,” Dr. Cooperberg says. “I think the name change is just a matter of time — in my view, we’ll get there eventually.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

By midwinter, our urge to hibernate can start to feel constricting instead of cozy. What better antidote to being cooped up indoors than a bracing hike in the crisp air outdoors?

Winter backdrops are stark, serene, and often stunning. With fewer people on the trail, you may spot more creatures out and about. And it’s a prime opportunity to engage with the seasons and our living planet around us, says Dr. Stuart Harris, chief of the Division of Wilderness Medicine at Massachusetts General Hospital. But a multi-mile trek through rough, frosty terrain is far different than warm-weather hiking, requiring consideration of health and safety, he notes. Here’s what to know before you go.

Winter hiking: Safety first

“The challenge of hiking when environmental conditions are a little more demanding requires a very different approach on a winter’s day as opposed to a summer’s day,” Dr. Harris says. “But it gives us a chance to be immersed in the living world around us. It’s our ancient heritage.”

A safety-first attitude is especially important if you’re hiking with others of different ages and abilities — say, with older relatives or small children. It’s crucial to have both the right gear and the right mindset to make it enjoyable and safe for all involved.

Planning and preparation for winter hikes

Prepare well beforehand, especially if you’re mixing participants with vastly different fitness levels. Plan your route carefully, rather than just winging it.

People at the extremes of age — the very old or very young — are most vulnerable to frigid temperatures, and cold-weather hiking can be more taxing on the body. “Winter conditions can be more demanding on the heart than a perfectly-temperatured day,” Harris says. “Be mindful of the physical capabilities of everyone in your group, letting this define where you go. It’s supposed to be fun, not a punishing activity.”

Before setting out:

• Know how far, high, and remote you’re going to go, Dr. Harris advises, and check the forecast for the area where you’ll be hiking, taking wind chill and speed into account. Particularly at higher altitudes, weather can change from hour to hour, so keep abreast of expectations for temperature levels and any precipitation.
• Know if you’ll have access to emergency cell coverage if anything goes wrong.
• Always share plans with someone not on your hike, including expected route and time you’ll return. Fill out trailhead registers so park rangers will also know you’re on the trail in case of emergency.

What to wear for winter hikes

Prepare for extremes of cold, wind, snow, and even rain to avoid frostbite or hypothermia, when body temperature drops dangerously low.

• Dress in layers. Several thin layers of clothing are better than one thick one. Peel off a layer when you’re feeling warm in high sun and add it back when in shadow. Ideally, wear a base layer made from wicking fabric that can draw sweat away from the skin, followed by layers that insulate and protect from wind and moisture. “As they say, there’s no bad weather, just inappropriate clothing,” Dr. Harris says. “Take a day pack or rucksack and throw a couple of extra thermal layers in. I never head out for any hike without some ability to change as the weather changes.”
• Protect head, hands, and feet. Wear a wool hat, a thick pair of gloves or mittens, and two pairs of socks. Bring dry spares. Your boots should be waterproof and have a rugged, grippy sole.
• Wear sunscreen. You can still get a sunburn in winter, especially in places where the sun’s glare reflects off the snow.

Carry essentials to help ensure safety

• Extra food and water. Hiking in the cold takes serious energy, burning many more calories than the same activity done in summer temperatures. Pack nutrient-dense snacks such as trail mix and granola bars, which often combine nuts, dried fruit, and oats to provide needed protein, fat, and calories. It’s also key to stay hydrated to keep your core temperature normal. Bonus points for bringing a warm drink in a thermos to warm your core if you’re chilled.
• First aid kit. Bandages for slips or scrapes on the trail and heat-reflecting blankets to cover someone showing signs of hypothermia are wise. Even in above-freezing temperatures, hypothermia is possible. Watch for signs such as shivering, confusion, exhaustion, or slurring words, and seek immediate help.
• Light source. Time your hike so you’re not on the trail in darkness. But bring a light source in case you get stuck. “A flashlight or headlamp is pretty darn useful if you’re hiking anywhere near the edges of daylight,” Harris says.
• Phone, map, compass, or GPS device plus extra batteries. Don’t rely on your phone for GPS tracking, but fully charge it in case you need to reach someone quickly. “Make sure that you have the technology and skill set to be able to navigate on- or off-trail,” Harris says, “and that you have a means of outside communication, especially if you’re in a large, mixed group.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

As wildfires become more frequent due to climate change and drier conditions, more of us and more of our communities are at risk for harm. Here is information to help you prepare and protect yourself and your family.

How does wildfire smoke affect air quality?

Wildfire smoke contributes greatly to poor air quality. Just like fossil fuel pollution from burning coal, oil, and gas, wildfires create hazardous gases and tiny particles of varying sizes (known as particulate matter, or PM10, PM2.5, PM0.1) that are harmful to breathe. Wildfire smoke also contains other toxins that come from burning buildings and chemical storage.

The smoke can travel to distant regions, carried by weather patterns and jet streams.

How does wildfire smoke affect our health?

The small particles in wildfire smoke are the most worrisome to our health. When we breathe them in, these particles can travel deep into the lungs and sometimes into the bloodstream.

The health effects of wildfire smoke include eye irritation, coughing, wheezing, and difficulty breathing. The smoke may also increase risk for respiratory infections like COVID-19. Other possible serious health effects include heart failure, heart attacks, and strokes.

Who needs to be especially careful?

Those most at risk from wildfire smoke include children, older adults, outdoor workers, and anyone who is pregnant or who has heart or lung conditions.

If you have a chronic health condition, talk to your doctor about how the smoke might affect you. Find out what symptoms should prompt medical attention or adjustment of your medications. This is especially important if you have lung problems or heart problems.

What can you do to prepare for wildfire emergencies?

If you live in an area threatened by wildfires, or where heat and dry conditions make them more likely to occur:

• Create an evacuation plan for your family before a wildfire occurs.
• Make sure that you have several days on hand of medications, water, and food that doesn't need to be cooked. This will help if you need to leave suddenly due to a wildfire or another natural disaster.
• Regularly check this fire and smoke map, which shows current wildfire conditions and has links to state advisories.
• Follow alerts from local officials if you are in the region of an active fire.

What steps can you take to lower health risks during poor air quality days?

These six tips can help you stay healthy during wildfire smoke advisories and at other times when air quality is poor:

• Stay aware of air quality. AirNow.gov shares real-time air quality risk category for your area accompanied by activity guidance. When recommended, stay indoors, close doors, windows, and any outdoor air intake vents.
• Consider buying an air purifier. This is also important even when there are no regional wildfires if you live in a building that is in poor condition. See my prior post for tips about pollution and air purifiers. The EPA recommends avoiding air cleaners that generate ozone, which is also a pollutant.
• Understand your HVAC system if you have one. The quality and cleanliness of your filters counts, so choose high-efficiency filters if possible, and replace these as needed. It's also important to know if your system has outdoor air intake vents.
• Avoid creating indoor pollution. That means no smoking, no vacuuming, and no burning of products like candles or incense. Avoid frying foods or using gas stoves, especially if your stove is not well ventilated.
• Make a "clean room." Choose a room with fewer doors and windows. Run an air purifier that is the appropriate size for this room, especially if you are not using central AC to keep cool.
• Minimize outdoor time and wear a mask outside. Again, ensuring that you have several days of medications and food that doesn't need to be cooked will help. If you must go outdoors, minimize time and level of activity. A well-fitted N95 or KN95 mask or P100 respirator can help keep you from breathing in small particles floating in smoky air (note: automatic PDF download).

About the Author

Wynne Armand, MD, Contributor

Dr. Wynne Armand is a physician at Massachusetts General Hospital (MGH), where she provides primary care; an assistant professor in medicine at Harvard Medical School; and associate director of the MGH Center for the Environment and … See Full Bio View all posts by Wynne Armand, MD

Although inflammation serves a vital role in the body’s defense and repair systems, chronic inflammation can cause more harm than good. And that may make you wonder: what can I do about it?

In fact, there’s a lot you can do. And you may already be doing it. That’s because some of the most important ways to fight inflammation are measures you should be taking routinely.

Let’s take a look at key elements of fighting chronic inflammation: prevention, detection, and treatment.

Six ways to prevent unhealthy inflammation

Six of the most effective ways to ward off inflammation are:

• Choose a healthy diet. Individual foods have a rather small impact on bodywide inflammation, so no, eating more kale isn’t likely to help much. But making sure you eat lots of fruits and vegetables, whole grains, healthy fats, and legumes — sometimes called an anti-inflammatory diet — may reduce inflammation and lower risk for chronic illnesses like diabetes and heart disease. Not only can these diets help reduce inflammation on their own, but replacing foods that increase inflammation (such as sugary drinks and highly processed foods) benefits your body, too.
• Exercise regularly.Physical activity may help counter some types of inflammation through regulation of the immune system. For example, exercise has anti-inflammatory effects on white blood cells and chemical messengers called cytokines.
• Maintain a healthy weight. Because excess fat in cells stimulates bodywide inflammation, avoiding excess weight is an important way to prevent fat-related inflammation. Keeping your weight in check also reduces the risk of type 2 diabetes, a condition that itself causes chronic inflammation.
• Manage stress. Repeatedly triggered stress hormones contribute to chronic inflammation. Yoga, deep breathing, mindfulness practices, and other forms of relaxation can help calm your nervous system.
• Do not smoke. Toxins inhaled in cigarette smoke trigger inflammation in the airways, damage lung tissue, and increase the risk of lung cancer and other health problems.
• Try to prevent inflammatory conditions, such as
  • Infection: Take measures to avoid infections that may cause chronic inflammation. HIV, hepatitis C, and COVID-19 are examples. Practicing safer sex, not sharing needles, and getting routine vaccinations are examples of effective preventive measures.
  • Cancer: Get cancer screening on the schedule recommended by your doctors. For example, colonoscopy can detect and remove polyps that could later become cancerous.
  • Allergies: By avoiding triggers of asthma, eczema, or allergic reactions you can reduce the burden of inflammation in your body.

Do you need tests to detect inflammation?

While testing for inflammation is not routinely recommended, it can be helpful in some situations. For example, tests for inflammation can help to diagnose certain conditions (such as temporal arteritis) or monitor how well treatment is controlling an inflammatory condition (such as Crohn’s disease or rheumatoid arthritis).

However, there are no perfect tests for inflammation. And the best way to know if inflammation is present is to have routine medical care. Seeing a primary care physician, reviewing your medical history and any symptoms you have, having a physical examination, and having some basic medical tests are reasonable starting points. Such routine care does not typically include tests for inflammation.

How is inflammation treated?

At first glance, treating unhealthy, chronic inflammation may seem simple: you take anti-inflammatory medications, right? Actually, there’s much more to it than that.

Anti-inflammatory medicines can be helpful to treat an inflammatory condition. And we have numerous FDA-approved options that are widely available — many in inexpensive generic versions. What’s more, these medicines have been around for decades.

• Corticosteroids, such as prednisone, are the gold standard. These powerful anti-inflammatory medicines can be lifesaving in a variety of conditions, ranging from asthma to allergic reactions.
• Other anti-inflammatory medicines can also be quite effective for inflammatory conditions. Ibuprofen, naproxen, and aspirin — which may already be in your medicine cabinet — are among the 20 or so nonsteroidal anti-inflammatory drugs (NSAIDs) that come as pills, tablets, liquids taken by mouth, products applied to skin, injections, and even suppositories.

Yet relying on anti-inflammatory medicines alone for chronic inflammation is often not the best choice. That’s because these medicines may need to be taken for long periods of time and often cause unacceptable side effects. It’s far better to seek and treat the cause of inflammation. Taking this approach may cure or contain many types of chronic inflammation. It may also eliminate the need for other anti-inflammatory treatments.

For example, chronic liver inflammation due to hepatitis C infection can lead to liver scarring, cirrhosis, and eventually liver failure. Medicines to reduce inflammation do not solve the problem, aren’t particularly effective, and may cause intolerable side effects. However, treatments available now can cure most cases of chronic hepatitis C. Once completed, there is no need for anti-inflammatory treatment.

Similarly, among people with rheumatoid arthritis, anti-inflammatory medicines such as ibuprofen or steroids may be a short-term approach that helps ease symptoms, yet joint damage may progress unabated. Controlling the underlying condition with medicines like methotrexate or etanercept can protect the joints and eliminate the need for other anti-inflammatory drugs.

The bottom line

Even though we know that chronic inflammation is closely linked to a number of chronic diseases, quashing inflammation isn’t the only approach, or the best one, in all cases.

Fortunately, you can take measures to fight or even prevent unhealthy inflammation. Living an “anti-inflammatory life” isn’t always easy. But if you can do it, there’s an added bonus: measures considered to be anti-inflammatory are generally good for your health, with benefits that reach well beyond reducing inflammation.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

It used to be that radiation therapy for prostate cancer involved weeks or months of repeat visits to a clinic for treatment. Today that’s not necessarily true. Instead of giving small doses (called fractions) per session until the full plan is completed, radiation delivery is moving toward high-dose fractions that can be given with fewer sessions over shorter durations.

This “hypofractionated” strategy is more convenient for patients, and mounting evidence shows it can be accomplished safely. With one technology called stereotactic body radiation therapy (SBRT), patients can finish their treatment plans within a week, as opposed to a month or more. Several devices are available to deliver hypofractionated therapy, so patients may also hear it referred to as CyberKnife or by other brand names.

An SBRT session takes about 20 to 30 minutes, and the experience is similar to receiving an x-ray. Often, doctors will first insert small metal pellets shaped like grains of rice into the prostate gland. Called fiducials, these pellets function as markers that help doctors target the tumor more precisely, so that radiation beams avoid healthy tissue. During treatment, a patient lies still while the radiation-delivery machine rotates around his body, administering the therapy.

How good is SBRT at controlling prostate cancer? Results from a randomized controlled clinical trial show that SBRT and conventional radiotherapy offer the same long-term benefits.

How the study was conducted

The trial enrolled 874 men with localized prostate cancer, meaning cancer that is still confined to the prostate gland. The men ranged between 65 and 74 years in age, and all of them had prostate cancer with a low or intermediate risk of further progression. The study randomized each of the men to one of two groups:

• Treatment group: The 433 men in this group each got SBRT at the same daily dose. The treatment plan was completed after five visits given over a span of one to two weeks.
• Control group: The 441 men in this group got conventional radiotherapy over durations ranging from four to 7.5 weeks.

None of the men received additional hormonal therapy, which is a treatment that blocks the prostate cancer–promoting effects of testosterone.

What the study showed

After a median duration of 74 months (roughly six years), the research found little difference in cancer outcomes. Among men in the treatment group, 26 developed visibly recurring prostate cancer, or a spike in prostate-specific antigen (PSA) levels suggesting that newly-forming tumors were somewhere in the body (this is called a biochemical recurrence). By contrast, 36 men from the control group developed visible cancer or biochemical recurrence. Put another way, 95.8% of men from the SBRT group — and 94.6% of men in the control group — were still free of prostate cancer.

A word of caution

Earlier results published two years into the same study showed higher rates of genitourinary side effects among the SBRT-treated men. Typical genitourinary side effects include inflammatory reactions that increase pain during urination, or that can make men want to urinate more often. Some men develop incontinence or scar tissues that make urination more difficult. In all, 12% of men in the SBRT group experienced genitourinary side effects at two years, compared to 7% of the control subjects.

“Interestingly, patients who were treated with CyberKnife appeared to have lower significant toxicity at two years compared with those treated on other platforms,” said Dr. Nima Aghdam, a radiation oncologist at Beth Israel Deaconess Medical Center and an instructor of radiation oncology at Harvard Medical School. By five years, the differences in side effects between men treated with SBRT or conventional radiation had disappeared.

The authors advised that men might consider conventional radiation instead of SBRT if they have existing urinary problems before being treated for cancer. Patients with baseline urinary problems are “more likely to have long-term toxic effects,” the authors wrote, adding that the new findings should “allow for better patient selection for SBRT, and more careful counseling.”

“This is an important study that validates what’s becoming a standard practice,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases. “The use of a five-day treatment schedule has been well received by patients who live long distances from a radiation facility, given that treatment can be completed during the weekdays of a single week. As with any cancer treatment choice, the selection of the appropriate patient is crucial to minimize any potential side effects, and this can only be done after a careful consideration of the patient’s other medical conditions.”

“This elegant study will put to rest any questions regarding the validity of SBRT as a standard-of-care option for many patients with prostate cancer,” Dr. Aghdam added. “Importantly in this trial, we see excellent outcomes for many patients who were treated with radiation alone. As this approach gains broad acceptance in radiation oncology practices, it remains critical to carefully consider each patient based on their baseline characteristics, and employ the highest level of quality assurance in delivering large doses of radiation in fewer fractions. As the overall duration of radiation therapy gets shorter, every single treatment becomes that much more important.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

Metastatic prostate cancer can progress in different ways. In some men the disease advances rapidly, while other men have slower-growing cancer and a better prognosis. Researchers are developing various tools for predicting how fast prostate cancer might progress. Among the most promising are assays that count circulating tumor cells (CTCs) in blood samples.

Prostate cancer spreads by shedding CTCs into the bloodstream, so higher counts in blood generally reflect worse disease. Sometimes referred to as a liquid biopsy, the CTC assay can help doctors decide if patients should get standard or more aggressive treatment. Just one CTC assay is currently on the market for prostate cancer. Called CellSearch, its use is so far limited to men with late-stage metastatic cancer for whom hormonal therapies are no longer effective.

Using CTC data

Hormonal therapies block testosterone, a hormone that drives prostate tumors to grow. Research shows that high CTC counts predict poorer survival and faster disease progression among patients with metastatic prostate cancer who become resistant to this form of treatment. But new research shows CTC counts are also predictive for early-stage metastatic prostate cancer that still responds to hormonal therapy.

Why is that important? Because the earlier doctors can predict a cancer’s trajectory, the better their ability to select patients who could benefit from more powerful (and potentially more aggressive) drug combinations or a clinical trial. Conversely, men who are older or frail might be treated less aggressively if doctors had better insights into their prognosis.

How the study was done

The investigators collected blood samples from 503 newly-diagnosed patients with hormonally-sensitive metastatic prostate cancer who had enrolled in a clinical trial with experimental hormonal therapies. The team collected baseline samples at trial registration, and then another set of samples after the treatments were no longer working. CTC counts were divided in three categories:

• more than 5 CTCs per 7.5 milliliters (mLs) of blood
• between 1 and 4 CTCs per 7.5 mLs of blood
• zero CTCs per 7.5 mLs of blood.

What the research showed

Results showed that men with higher baseline CTC counts fared worse regardless of which cancer drugs they were taking. Median survival for men with 5 or more CTCs per sample was 27.9 months compared to 56.2 months in men with 1 to 4 CTCs. There weren’t enough patient deaths among those with 0 CTCs to calculate a survival rate.

Similarly, higher CTC counts predicted faster onset of resistance to hormonal therapy: 11.3 months for men in the highest CTC category, compared to 20.7 months and 59 months for men with 1 to 4 and zero CTCs respectively. Importantly, higher CTC counts correlated with measures of prostate cancer severity, including PSA levels, numbers of metastases in bone, and other indicators.

Observations and comments

“This research emphasizes the continued emergence of CTCs in helping to determine outcomes and potentially treatment options for men with metastatic prostate cancer,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of the Harvard Medical School Guide to Prostate Diseases.

“Still to be determined is how this type of testing compares with more traditional evaluations of disease advancement, such as x-rays, bone scans, and other types of imaging. Ready access to cancer cells in blood that, in turn, eliminate the need for more invasive biopsy procedures of metastatic deposits will be a welcome addition — especially if future studies show that CTCs inform more precise treatment choices.”

Dr. David Einstein, a medical oncologist specializing in genitourinary cancers at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School, agreed with that assessment. “But the Holy Grail is finding predictive biomarkers [like CTCs] that tell you if patients will or will not benefit from particular treatments,” he added. “Answering these types of questions requires randomized clinical trials.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD