Healthy, active 87 year old with Gleason 8(4+4) 2/12 PSA 29. Treat or not?

Hi Lube.

From what you described so far, key points of your 87 Y.O. dad’s case is that he is asymptomatic (he is experiencing no symptoms today) and but prostate cancer was found yet apparently confined to the prostate.

It would likely be meaningful to add information on why—at age 87—he was given a prostate biopsy. In other words, what history of prostate monitoring and/or PSA history does he have. (Typically, if a man has had normal PSA test results testing is discontinued at age 75; has he had past prostate issues?)

For newly diagnosed men, we typically suggest that they have their prostate biopsy slides read by a prostate pathology expert. This step is highly recommended because hospital pathologists read a lung cancer sample, then a breast cancer sample, then a prostate cancer sample, and they are expert in none. As a result, many prostate samples are “re-graded” when read by an expert…they could go up or down, but we often encourage men to get good data to start with. The cost is only a couple hundred dollars, and there are names/links in the “sticky” thread (“Newly diagnosed…”) at the top of the page for this well-known service.

He should be aware that all prostate cancer treatments have side effects detrimental to quality of life. All of them. He should also be aware of the term “watchful waiting.” Confined, asymptomatic prostate cancer in this age group is usually managed conservatively. The previously mentioned sticky thread has a great definition of “watchful waiting,” which is:

What is “WATCHFUL WAITING?”
Watchful Waiting (WW) is a strategy of using less intensive follow-up (fewer monitoring tests) and relying on changes in a man’s symptoms to decide if a treatment is needed. If symptoms appear, whether it is a lower urinary tract obstruction or bone pain from metastatic disease, treatment is introduced to relieve symptoms…so it is a palliative (not curative) therapy. This strategy is usually applied when the doctor & patient agree that he has fewer years of life expectancy and/or has other concomitant health problems, or because the patient believes strongly that he would prefer the risk of disease progression to the risks associated with aggressive treatments.

WW has been around a long time, but the fundamental basis for modern forms of this strategy is that one is trying to avoid receiving treatment of any type for as long as possible so that the patient may optimize his quality of life, while recognizing that it may be necessary in the long term to intervene so that he has minimal impact from the potential morbidity and mortality associated with prostate cancer.

WW may also be appropriate for a man who is suspected of having PC but for whom a biopsy is perhaps an unnecessary intrusion because of age or health. In such cases, even if a biopsy proved to be positive, curative therapy would not be recommended, which makes the biopsy somewhat futile.

Your dad may or may not be interested in watchful waiting, but the term should be added to his vocabulary…particularly if quality of life is paramount. Older patients may be more inclined to avoid risk and less willing to sacrifice quality of life for prolongation of life, but this is a very personal choice.

Hope this helps.

If I was diagnosed with PC at 87, I would not do anything except maybe pop a few pills. I am way over my life expectancy. The way I look at it, I may be able to squeeze a five more years doing squat.

Hi Lube, thanks for the additional background information...no change to the big picture: 87 Y.O., 4+4, contained, asymptomatic. At 4+4 he is at a high-risk for eventually developing advanced disease, but you should know that eventually developing advanced disease is typically then years away from starting to show any symptoms. Help him to consider that as he balances the doctor's opinion on life expectancy and quality of life.

Medicine is definitely a business, and in the US medical professional get paid by generating "pills and procedures." It's important to balance that by becoming an informed patient (or an informed care-giver)...you are off to a great start learning all about PC.

A colonoscopy, while somewhat unpleasant, is not altogether painful or invasive...ok, it's invasive, but not bad invasive. (If you've got an 87 Y.O. dad, you already know this...right!) It doesn't seem to me to be inconsistent with the "watchful waiting" strategy I pasted above, and some minor issues may be resolved during the procedure.

Post Edited (JackH) : 10/6/2016 8:18:00 AM (GMT-6)

PC doesn't general grow fast. Normally it's a slow grower.

If it is still contained, the RT is a good choice. Likely he'd do just fine with it.

Andrew

I agree with Peter. Why wait? If you get started you will be done well before the six months is up. Of course G8 will continue to develop and be worse in six months. If you want to slow it down and delay the eventual speed and problems then start treatment.

Just a ps...if he is delaying radiation a bit and they are starting Hormone Therapy right away that is usually ok from my understanding. But the HT is technically when treatment is starting and while it may delay the radiation it may extend the time on those drugs which have their own side effects that one would like to avoid. When I was considering delaying treatment until after my work season that was one option given to me if I was going the radiation route, though they still preferred the 6 months of HT with radiation starting at the 2 month mark after HT started.

Lube said...
Thoughts on SBRt vs EBRt? Would his age play a role here? One study suggested SBRt had more bladder side effects?

I don't know what study you're referring to, but there has only been one randomized comparison of SBRT vs. conventional EBRT. They actually used an outmoded less-accurate technology, called 3D-CRT to deliver the SBRT. In spite of that, toxicity was no different.

Toxicity equal for SBRT and conventional external beam radiation

However, he may be hard-pressed getting an SBRT RO to treat him with his GS 8 and high PSA. Most treat only low or intermediate risk patients. Where is he located?

They may not need ADT with SBRT.

NKinney - Those charts are seriously good! I have often thought in that manner, intending to stay as fit as I can for as long as I can, but just seeing the comparison gives me yet more evidence that it is worth the effort.

Thanks for posting them. All of us should see them, not just those of us who have tried to live our lives that way. Even chart 3 looks better than chart 1.

With any/all doctors that you meet with, be sure to ask this simple question: "With the PC apparently contained in the prostate at this time, how many years do you think this would typically go without showing any symptoms whatsoever?"

Any doctor will be initially reluctant to give a single number, but with a bit of nudging will give their best professional estimation...and they will (should) recognize that this is an important and relevant question for any 87 year old to ask.

Any if they are responsive to that, a decent follow-up question would be to ask how many years after symptoms start showing up do they typically become a challenge to manage...because initially they are less so.

Hi everybody,
My Dad will be starting hormone therapy next week. He will be CAB for three months and if his psa doesn't drop he will start Lupron. Fingers crossed that the casodex will do the trick and quality of life won't be too compromised. His Dr. would not in "good conscience" give him radiation due to his age.
Looking for advice and coping ideas as side effects of HT come up. Also any herbal supplement ideas or people's thoughts on this course. The cancer has left the capsule and 2 lymph nodes suspected, suspicious area of early mestasis in part of pelvis.
My dad is in pretty good spirits. He was very against HT but "has no choice".
That's the latest....thanks for being here.
Lube

Thank you Halbert,
I haven't read much about mental decline as a HT side effect so thank you for mentioning. My Dad is mentally sharp and not your typical 87 year old so hoping for the best. We do what we can do....thank you for responding. Best, lube

Lube, your dad's situation is interesting. It is just very hard to know up front how men will react to HT. Many men have troubling side effects, and yet others have them very mild. I am in the latter group. My HT side effects have really not affected my QOL at all, especially compared to other problems like bone mets, or pain med side effects. I think your dad has chosen a wise treatment plan, for his age. His PSA is not outrageous and its doubling time doesn't seem too bad either. I think he has a great chance at continuing a high quality of life for many years to come. Keep a positive attitude; that helps a lot, too. Wishing you well.