Advice needed for 88 year old dad

Advice needed for my 88 year old dad.

At age 65 nearly 23 years ago way back in 1995 had prostate removed. PSA was checked regularly and no issues. Dad was fully functional and did well for his age. Was living in an independent living facility and was able to walk and get around etc. Last year in early March 2017 his legs gave out and could not walk. MRI showed a compression of the spinal cord along with other lesions . The diagnosis was the prostate cancer flared up 25 years later and metastasized.

Surgery was performed to remove the tumor causing the spinal cord compression. He was barely able to move his left leg and the right leg was only slightly better. No longer could walk and is in a wheelchair and needs full assistance.

Went on Casodex in April 2017 and it was discontinued in July 2017. At the time Casodex was discontinued July 2017 he started with Lupron.

Petscan done in May 2017 as a baseline scan and results below

No hypermetabolic adenopathy or mass.
Heterogeneous uptake in the liver decreases sensitivity for focal
lesion; no hypermetabolic liver lesions detected.
No free fluid.

Osseous:
T12 1.7 centimeter hypermetabolic sclerotic lesion, max SUV 5.5
T11 vertebral body 2 cm sclerotic hypermetabolic lesion, max SUV 5.7
T3 vertebral body sclerosis with hypermetabolic uptake max SUV 4.4
Upper thoracic post decompression/resection change approximately
T2-T4. Mild regional soft tissue uptake max SUV in the 3.2 range
without discrete mass. Defer to MRI.
Right iliac bone 31 the 1.5 cm sclerotic hypermetabolic foci max SUV
5.1-5.3.

L1 inferior vertebral body sclerotic hypermetabolic met inferior L1
vertebral body.
Uptake heterogeneity throughout the remaining osseous structures
additional small sclerotic mets not excluded.

IMPRESSION:
Sclerotic bone mets described above including right iliac bone and
thoracic lumbar spine.
Upper thoracic spine posterior decompression/resection postsurgical
change with mild regional uptake likely postsurgical residual disease
not entirely excluded.


Continued with Lupron and is still on Lupron. Did another Petscan a couple weeks ago and results below

Osseous:
Upper thoracic approximately T2-T4 posterior decompression/resection
change post interval resolution of regional postsurgical uptake.
T3 prior hypermetabolic uptake focus appears resolved
T11 prior focal hypermetabolic uptake appears resolved
T12 focal hypermetabolic uptake shows max SUV 3.5 (previously 5.5)
L1 prior focal hypermetabolic uptake appears resolved
Right iliac prior hypermetabolic uptake foci appear resolved
No new hypermetabolic osseous foci are detected.

IMPRESSION:
Positive treatment response - near complete resolution of prior
hypermetabolic activity associated with osseous metastatic foci. No
new suspicious uptake detected

As you can see he is responding very well to treatment. He is able to stand now with assistance and walk 15-20 steps with a walker with assistance to stand. He is otherwise healthy and living and quality of life is okay for his age, etc. Also all PSA tests since surgery show total PSA levels <0.01. Again keep in mind he will be 88 in a couple months.

Went to oncologist a few days ago and the Dr is wanting to continue with Lupron but add Zytiga Prednisone combo. He issued the RX for both and later that day i did some research and contacted the doctor's office. My email is below

Dad is almost 88 years old and I am concerned with the side effects of Zytiga and how he handles them at his age. I was also thinking maybe it is better to hold off and just continue with Lupron and check PSA every 1-2 months and begin with Zytiga only when we start seeing a rise in PSA levels?

So my questions to all of you who have been through this is in your opinion, do you think going on Zytiga now is the way to go or hold off? His quality of life and potential side affects would be my concern. I obviously want to make the best decision for him as he is not capable of making decisions, he has dementia and no short term memory.

thanks in advance for your responses

It's a difficult decision. All treatments at this point are palliative, so the goal of additional treatment should be for pain relief, QOL improvement, etc.

If this doesn't meet that standard, is it worth it?

Reminding the oncologist of you're father's condition is good and I'd wait for that response.

Andrew

When someone asks a question I can't answer I will often start Googling for studies, ostensibly I am looking for answers to the question, but actually it is just something to do while I wait for Tall Allen (or one of the other smart guys) to show up. But, since Tall seems to be a little slow responding to the bat signal this time, here's what I found.

There have been two big recent studies that almost apply to your dad's situation -- almost but not quite.

The first is Efficacy and Safety of Abiraterone Acetate in Elderly (≥75 Years) Chemotherapy-Naïve Patients with Metastatic Castration-Resistant Prostate Cancer that looked at adding Abiraterone acetate (Zytiga) to the ADT for elderly men with castrate-resistant disease. They divided patients into two groups by age < 75 vs ≥75 Years. They found a nice benefit for both age groups and the older guys seemed to tolerate the Zytiga about as well as the younger one, basically pretty well. But that study was for castrate resistant disease which your dad doesn't have... yet, anyway.

The second study -- Adding abiraterone to androgen deprivation therapy in men with metastatic hormone-sensitive prostate cancer: A systematic review and meta-analysis looked at results for treating hormone-sensitive cancer (like you dad appears to have) with Zytiga. Again there was a pretty clear survival and QOL benefit and the treatment was well tolerated but nobody in the study was as old as your dad.

So if you put both studies in a jar and shake it up you get no compelling reason why your dad shouldn't try Zytiga and Prednisone. It's usually well tolerated and might give him a few more comfortable months. But it costs money and it will give him almost the same benefit if you wait for him to become castrate resistant and then start the Zytiga.

thanks for the responses so far

Fairwind, dad is no longer on Casodex. he was only on Casodex for a brief time. Went on Casodex in April 2017 and it was discontinued in July 2017. At the time Casodex was discontinued July 2017 he started with Lupron.

Right now only Lupron and Xgeva

PeterDisAbelard.

so basically your opinion is what I was thinking that maybe it is better to hold off and just continue with Lupron and check PSA every 1-2 months and begin with Zytiga only when we start seeing a rise in PSA levels?

Steve,

I guess if it were my dad I'd want the oncologist to explain what benefit would come from starting the Zitiga now as opposed to waiting for early signs of the onset of castrate resistance. Probably there is a sensible reason -- his oncologist is, after all, an oncologist and I am just a random guy on the Internet -- but I'd want to hear the explanation.

I understand Halbert's question about how much heroic treatment makes sense for an 88 year old man with advancing dementia. I lost my father two years ago. He was three months shy of his 90th birthday and suffered from severe dementia near the end, arguably that's what killed him. He was a physician and we were fortunate that he had made clear what he wanted and what he didn't want while he was still able to make such decisions.

But it's not clear to me that Zytiga necessarily falls into the category of such heroic measures. It's pills you take with water. Most guys find it fairly tolerable. If your dad doesn't tolerate it well you could stop.

halbert said...
...A serious question is....what does HE want? It's not giving up if he decides he's had enough. Personally, at 88 I'd be asking what the goal of treatment is?

Exactly! My RN wife has been in this situation with elder care and the doc and family insist this and that be done and it breaks her heart to see some of the little old folks put through procedures for little or no benefit.

just read this forum and feel that i must say something.. i'm 81 and on zytiga (6 mo) and have little to no side effects, other than a round face from the prednisone.. i guess my first thought is do i want this life for another 7 years, not that it is likely to happen.. So i'm sure that i would want to decide my own treatment no matter my age.. and then on top of everything else you have to deal with a lack of cognitive ability, i just have a touch of that and i don't think zytiga has anything to do with it. Wish i had answers rather than just chatter, but i don't.. Good luck, and keep in mind that we all have to deal with father time..

Perhaps these might be of some help for family viewing and as discussion starters?

/www.pbs.org/wgbh/frontline/film/being-mortal/

passing-on.org/

Perhaps followed by a review/update of any Estate Planning or related documents, in particular any Power of Attorney for Health Care , or Advanced Directive for Health Care, etc.?

With dementia issues, the need for clarity in these areas can very quickly become even more important as physical health declines.

Just some thoughts....

Charles