What's the standard of care for men over 85?

The first thing I learned about Prostate Cancer -> "More men will die with it...than from it."

I would think the doc would want to test his urine for an infection.

Melanie, hopefully and more than likely it could be BPH. As men get older BPH becomes a bigger problem. I would think a urine test would rule out an infection and a DRE would more than likely find an enlarged prostate. Both can cause a rise in PSA levels. Protastitis is usually found in men under 50 who are sexually active. I hope for the best for him and you,
Jack

Melaine - FWIW, my Dad is 95 and was treated with brachytherapy almost 20 years ago. His PSA started rising in his late 80’s (13 years later). The treatment was just ADT (Lupron) which beat the PSA down to nothing. He is now at PSA = 9 which is the first time anyone checked in years (new doctor ran battery of tests on him). It is absolutely the least of his problems at this point in life.

Obviously, all the other simpler causes have to be eliminated first as others have noted. I seriously doubt anyone would push aggressive treatment at his age unless it was causing other issues. I think I would like to meet the few men who make 88 and don’t have some sort of urinary problems. The prostate is just problems later in life when it has nothing to do anymore but get fat and cause trouble…

Like my Dad, your father’s warranty expired a while ago so you hope that the doctors can keep him going with baling wire and duct tape as long as he can.

if treatment is deemed necessary i imagine it would be ADT

Thank you all for your replies and all the good info. My father had been pretty fit (for his age anyway), but the last few years have taken their toll on him physically and a bit health-wise. He's got little problems (asthma, vision issues) but nothing major. It's hard to know how aggressive he'll want to be--assuming it's cancer.

Djin, what kind of scan are you talking about? Would they do a PSMA scan if there hasn't been a cancer diagnosis?

Melaine - Hard to say this but my father was in pretty good shape at 88 and not so good at 95 although he still can think and is getting real tired of this stage of life. For most, the body starts breaking down and combinations of various maladies take their toll at his age. It has been tough watching this over the last five years so I don’t envy what you have ahead of you. Hope for the best, prepare for the worst, as they say.

I assume Djin is thinking of a MRI and possibly CT scan as a general check of local area for the usual stuff. PSMA might come after that if warranted.

Djin - I don’t disagree but a PSMA-PET scan is binary, it lights up an area or it does not. At 88, there are any number of possible issues that require a detailed scan to evaluate to get the total picture. My guess is they would do both as part of the evaluation as well as all the blood tests necessary. I only personally know one person who has had a PSMA scan and he had the MRI first which led to the second scan.

I definitely agree that the bone scan for PCa should be shelved. Sorry about presuming your answer…

Thank you all again for your info and for your kind words and support. My parents are at Kaiser in LA, so probably no PSMA-PET there. I believe UCLA has it though.

I think I need to talk with my parents in advance of the call, explain the possible options, and gently push them toward the advanced scan. Probably in conjunction with an MRI. I'm afraid that Kaiser may opt to do nothing given his age. I'll let you know how it goes.

Mumbo, I'm so sorry you've been going through that. It must be very difficult to watch. Best wishes for you and your father.

Quick update: We spoke via telephone with a urologist today. At first he was only discussing my dad's urinary issues. My dad finally interrupted him and said that he's more concerned about the blood test results.

The doctor basically said that the PSA test shouldn't have been done, and that it is not an accurate number. He also said that the PSA of 25 was meaningless (his words) for any man over 70.

Other statements: PSA of 6 is normal for 70 years old. 25 is normal for an 88 year old. Actually there is no real range known for an 88 year old since they don't do PSA tests for 88 year olds. Also: 25 is not high. If it were "hundreds of thousands" (again, his words), then that would indicate something serious.

There were other statements that I found dubious. (I thought he said that pain is relatively rare for metastatic PCa?!?)

We're going to take it one step at a time but I can tell that this doctor is not going to encourage treatment unless there's clear signs of metastatic disease. And, even then, he doesn't think RT or HT will extend life. (I did mention that my father's grandfather lived to 109 so it's possible my father has many, many years to look forward to, and I didn't want them to be painful.)

As has happened too many times, I went into the appointment with certain expectations--and the reality was completely different. I had to pause at one point to wrap my head around what he was saying because it sounded very much like he was going to do nothing. And it wasn't until I said that it sounds like he's just going to observe that he came around. "Oh I was always going to suggest a scan . . . ."

Next steps: physical exam including a DRE. He's also ordering a CT to see if lymph nodes are enlarged. He said that a PSMA-PET scan is only done for men who already have a PCa diagnosis, not for someone in my dad's position. Once the DRE and CT are done, we'll have a better idea of what's going on--hopefully.

I find it disconcerting that society is still willing to shrug its shoulders while discarding "old people." I don't want to be hooked up to a bunch of machines while I'm unconscious, but a 90 year-old who tolerates ADT well enough could have many good years added to his life while also avoiding an uncomfortable PCa death.

I sense that the Uro is patronizing you and your dad with his own personal notions.

Melaine said...

Next steps: physical exam including a DRE. He's also ordering a CT to see if lymph nodes are enlarged. He said that a PSMA-PET scan is only done for men who already have a PCa diagnosis, not for someone in my dad's position. Once the DRE and CT are done, we'll have a better idea of what's going on--hopefully.

Makes sense; some of what the Kaiser urologist told you is questionable. I do think that his statement about PSMA scans is correct though.

Best wishes with the follow-up.

I wanted to have the scan results before posting an update about my 88-year old father. The good news (we thought) was that, according to my parents, the physical exam and DRE were normal. (What 88-year old man has a normal feeling prostate?)

But then the urologist called my parents to discuss the scan results, and it wasn't good news. (I wish someone had thought to conference me in on the call but that didn't happen, so now I'm trying to piece together all the information.) I was able to see the CT report so I know that my dad's prostate is heterogeneous and markedly enlarged, and that there are sclerotic lesions in the pelvic area "concerning for metastatic disease." I guess it's possible that the lesions are benign but the fact that the urologist is now recommending treatment probably means that he thinks it is metastatic disease, and not something benign. (This is the same doctor who was upset that someone had ordered a PSA test for my father, and who seemed inclined to ignore my father's PSA of 25.)

My parents weren't sure about the kind of treatment. I'm assuming it's Lupron because the doctor mentioned the possibility of hot flashes--but my dad thought the doctor said it would be a liquid oral treatment. Does Lupron come in a liquid form?

Also, the urologist wants my father to have a bone scan. My parents believe that this is to establish a baseline. I may have my parents ask about the PSMA-PET scan again but I don't think Kaiser will approve it.

On Friday my husband had an appointment with his MO, and his MO was nice enough to answer some of my questions about my dad. These are his main points:

--Every patient is different. Some may get fatigue so bad that it's hard to get out of bed. Others won't. Some will have excessive hot flashes and others barely any. You just don't know in advance how they'll tolerate Lupron.
--Which is why, for patients getting Lupron, he usually starts them off with a one-month shot to see how they'll tolerate it;
--He thought my dad should be seeing a medical oncologist for treatment
--He also said that my dad could start treatment now OR wait until he has symptoms/pain. Given my dad's high pain threshold, we're not inclined to wait until he feels pain. That may be too late.
--He hasn't seen the scans, but he thinks it's likely that it's metastatic disease given the PSA of 25--which he said is high for any man--regardless of age.

So that's where we are right now. I don't really trust this urologist. I'm hoping my parents can find an MO (or even a urologic oncologist) to take over my dad's treatment. But first the bone scan which is a couple weeks out.