Seeking Info for my Dad

arammat

Hi All,

My dad is 94, and in good health. However, he recently had a PSA score of 51, so he had a biopsy done. The doctor said he had rather aggressive cancer and said he had a Gleason score of 9. I have not seen the actual pathology report yet. Dad already had a bone scan. There were a couple of spots for which the pathologist said he "couldn't rule out metastases." I asked the doctor if he would need some type of scan to determine if it was elsewhere in his body, but he recommended against it. His reasoning was that they would recommend hormone therapy as treatment, either way. He also said we could choose to do nothing at this time, which I thought was kind of strange, as dad has no other major health issues, and the doctor characterized the cancer as aggressive. In light of his age, surgery was ruled out as an option even before we had a diagnosis.

I would like your input as to the following few questions. First, why did the doctor suggest hormone therapy only? I've seen a common protocol being external radiation and hormone therapy. Do you think they are concerned with the side effects being too much for a person his age? We could begin hormone therapy with the urology who performed the biopsy. My second question is, do you think we should seek a second opinion? Also, is it common for prostate cancer to be treated without the involvement of an oncologist? I get the impression that at the urologist generally doesn't recommend any treatment other than HT for older patients, just watchful waiting, as most older people die from some other cause. If Dad had heart trouble or some other severe health issue, I could see that approach, but he is healthy, still drives, lives in his own house, and still does some work for the business he started.

I look forward to your input. Thanks!

Rakendra

Age

I am not the guy here who has the most knowledge about treatments and what to do.  But I am the guy here who is 85 with a diagnosed Psa of 300 (now 0.84) six years ago and was give six months due to massive widespread bone matastased.  The only treatment I took was HT and castration, and I would NOT do the HT if I were doing again.  I will advise you that the side effects of treatment can be WORSE for quality of life than the treatment.  Your dad is 94 and apparently  not in pain. I do  not see the value in life extension at 94.   Life extension treatment can have very severe side effects with great deterioration of quality of life.  Many cancer patients death certificates read, "Death due to Cancer and the effects of Chemotherapy."  Surgery surely has side effects and surgery on a 94YO man can be fatal.  My opinion is far from an opinion based on medical knowledge.  But I advise to do as little as possible.  HT can have very unpleasant side effects and deteriorate quality of life.  My adivice is at 94 be grateful for the wonderful like he has had and be grateful for any time he as left and make that time as comfortable as possible.  How long he lives is no longer important. What is important is quality of life.  If he has quality of life the way he is now, why take a chance?  love, Swami Rakendra

Grinder

Agreed

Have to agree with above advice from my own experience. My dad was 90 when we took him to the hospital with what was diagnosed as liver failure. He had also been diagnosed with PC some years before. The doctors were very open at this particular hospital, and told us they could put him through various treatments and medications, but it would ruin his remaining quality of life, keep him in a hospital bed instead of home, and may or may not be successful considering his age. They recommended taking him home and living as comfortably as possible. They then signed us up for medicare hospice. Some 5 months later his organs started shutting down as they predicted, except his heart and lungs kept going and going even when he was comatose and doing the "death rattle". He passed away at home, surrounded by family before and after he slipped into a coma, just the way he would have wanted. Before he slipped into a coma, the pastor was testing his awareness, and asked Dad to hold up two fingers. He did. Then he was asked to hold up one finger. Dad flipped him the bird.

Just to show my dad's sense of humor, a coworker once told Dad to " kiss my ****!". Without missing a beat Dad said "I wouldn't know where to start, you're ALL ****!" Another time a cig smoking "sparring partner" lady friend of his yanked his chain by saying "if you were a gentleman, you would light a lady's cigarette." Dad yanked back right away and said " if you were a lady you wouldn't be smoking cigarettes".

Not trying to give advice here, but it was the best decision my dad and we made. Better to live a few months at home with family, than hope to live a little longer in a hospital bed with a feeding tube and a drip hooked up and probably a catheter and lord knows what else, not to mention meds and side effects, and it may not have prolonged life anyway.

Quite a contrast to my mother, who passed a few years before Dad, alone in a nursing home early in the morning strapped to a hospital bed so she couldn't "escape" and go home with us and I fought with the doctors at THAT hospital to let her go home and they would not but sent her to the nursing home after she had a morphine induced heart attack resulting in a semi comatose state and died shortly after in the nursing home. She had gone to the hospital with a collar bone fracture. She never came home.

We were blessed to find the doctors that treated my dad... Not so much with my mom. 

I hope you can see where I am coming from here. The attempt to treat a minor fracture led to my mother's premature death. The decision not to treat my Dad preserved his quality of life, though brief, but not as terribly brief as my Mom's. It was all down to the difference in doctors, and their expertise and experience as well as their empathy for their patients. They must determine if any treatment will benefit your dad versus the cost in quality of life, and whether treatment is even necessary, or if treatment is absolutely necessary, what side effects and consequences of treatment versus the consequences of no treatment.

Its hard to recognize the difference in doctors, but we learned our lesson with Mom, we didn't want that to happen to Dad.

We sure miss the old guy. Be sure to spend some time with your dad if you can. I can tell you for certain he treasures every moment spent with you.

VascodaGama

Quality of life in jeopardy

Arammat,

Welcome to the board. Your inquires are common and the indignation you felt on the doctor's opinion for not treating is understandable but do not be upset as this attitude is recommended worldwide by the medical community. I explain below, however, there are more risks of death then benefits when treating patients with advanced age.
Rakendra above has explained well what you should think regarding your dad's case. Any treatment he may follow will deteriorate his quality of life significantly turning things sour. In any case you and your dad are the ones to decide so I would suggest you to educate on the matter and analyze the pros and cons before engaging in anything. You need to know that only radical therapies (surgery or radiation) can provide cure because they are administered with due targets (localized cases). Palliative therapies (hormonal or chemo, etc) manage to provide relief on cancer symptoms and delay the advance of the bandit wherever this may exist in the body (systemic cases) but do not cure. All of these therapies have associated risks and cause side effects. Some guys decide on a therapy with the intent of prolonging life disregarding the consequences in their daily life.

From the info you share above, they found lesions in bone (positive bone scan) highly probable for metastases. This would qualify your dad with a clinical stage of T4 NxM1, which classification leads the doctor to decide on a therapy. A more sophisticated image exam done with a PSMA PET may provide more precise details of the cancer's whereabouts but it wouldn't change his clinical stage. Apart of that, the contrast agent (PSMA) for the scan requires the patient to be fit and healthy. The kidneys need to be functioning fully to dispose of the injected radio-chemical substances.

Treatments for T4 patients involve always hormonal manipulations as the cancer depends on testosterone to survive. The intent is to try starving the bandit stopping it at its roots. Combine therapies involving a radical (radiation in the case of old guys) with a palliative is recommended but the metastases must be a fewer number located at convenient areas possible for being radiated because one cannot irradiate the whole body (like a pig in the churrasco).

You comment above that your dad looks healthy (... still drives, lives in his own house, and still does some work) but are you sure that there is no hidden illness like the cancer found now? Many things do not cause symptoms and we never know until we test it. . Major surgeries are also not recommended in patients older than 75. Prostatectomy is not a walk in the park. Your dad's doctor may be an urologist with a discipline in oncology, proper to attend Pca cases, however, you can and should get a second opinion by an independent oncologist that is more appropriate to handle hormonal therapies. Old fellas, in particular, need often to take several medications for several aspects, and these may interact with each other, in which case oncologists are the most acknowledgeable.

Hope the above answers your questions. I am sorry for the diagnosis at his age. I hope you both find the best way to confront the situation.

Best wishes,

VGama

arammat

Thank you for your replies

Thanks to each of you for your replies. I appreciate what you have said abou quality of life, but what are the effects of advanced prostate cancer? My though was that slowing cancer growth would both prolong his life and prevent whatever pain or other symptoms the progression of the cancer would cause. That said, I have no knowledge of the typical progression of untreated prostate cancer. Is there a typical pattern? Also, can you recommend a good, reliable source on the side effects of HT and of radiation therapy? And VGama, you have definitely convinced me that he shoould be seeing an oncologist before we proceed with anything. 

Rakendra

Treatment

With Pca NO ONE can forcast what will happen.  One guy gets Pca with a low Psa and relatively mild symptoms and he goes quickly, while a guy like me lives for a long time and my cancer is now under control, and I did not do the Chemo.  However, I had a horrible year with huge side effects from HT.  I have never had a problem from the cancer, but big problems from the HT.  I have made posts about this before.  It is true that treatment MAY prolong his life, but it is also very true that the treatment may destroy quality of life.  It is very easy to underestimate the suffering that treatment can bring.  It is very easy to think that treatment will do as you say.  But the facts are that treatment can be worse than the cancer.  The facts are that no one can tell if the treatment will be successful, and the facts are that treatment may not only destroy his quality of life, but may also make his demise sooner.  Your father is 94, how much is enough?  I know at 85 that life gets more difficult every year.  Do not look at life as a begining and an end.  Birth and death are just markers.  Spirit goes from eternity to eternity.  There is no death.  I had a friend here that I couseled.  He was 90 with terminal Pca, but he was like your father.  He got around, walked every day and was happy.  He did not want to do Chemo, but his family wanted him to have it.  They wanted the "best" for him.  He was very sick from the very first infusion and died three months later, and that three monts was horrible.  He did the chemo for his family.  I know you want to help your father.  Remember that treatment is expensive and makes doctors rich and makes patients very ill.  I know you want your father to live longer.  Believe me, at 94, or even 85, length life is no longerthat important. Your father seems fine just as he is.   Understand that treatment may welll cause misery and early death.just as it did for my friend.  You are compassionate and intelligent, but it is very difficult to know what to do until you have been there and done that.  Love, Swami Rakendra

Swingshiftworker

Get A 2nd Opinion

I definitely think that your and your father should get a 2nd opinion and that he should NOT begin HT (or any other treatment) until he becomes fully aware of the scope of his cancer and the likely effects of the available treatments.

Your father is 94 and has lived a full life already.  That doesn't mean that efforts shouldn't be made to prolong it but at what cost?  I would think that additional scans to determine the scope and extent of the cancer would be in order 1st.

As Rakendra has pointed out, the effects of HT can be devastating and seriously degrade the patient's quality of life.   It is not a cure and can be worse than other actual treatments.  The purpose of HT is to reduce the patient's testosterone levels on the theory that doing so will prevent the cancer from growing.  How much testosterone does a man at 94 still produce?  Not much, I'd think.   So, what's the point of taking an HT drugs?  If it's so important, an orechiectomy would be better but I don't even think that is necessary at your father's age.

If the cancer has not spread beyond the prostate then radiation -- CK or IMRT -- could be used effectively to kill the cancer w/o the need for HT or chemo and with few if any side effects.  If the cancer has spread, the HT is really useless and the only "treatment" would be chemo BUT chemo is far worse than HT.

Personally, in this situation, if it were my father, I would opt to maximizing his remaining quality of life -- not degrade it.  Subjecting him to chemo or HT at 94 will ruin his quality of life, will not significantly prolong it and, as Rekendra again points out, may actually shorten it.

Offer him support and comfort and try to make the rest of his life as pain and trouble free as possible.  Ask him what he has left on his "bucket list" and help him achieve those things while he still can.  That's what I would do.

But what to do is really up to him.  Tell him the truth and let him decide as long as he is capable of making that decision.

VascodaGama

Get two or more second opinions

Arammat,

Swings' post above completes the opinions of all us above regarding the situation. I repeat it;

"... your father should get a 2nd opinion and that he should NOT begin HT (or any other treatment) until he becomes fully aware of the scope of his cancer and the likely effects of the available treatments".

I wonder how old or worn-out is the body of your father. Can he still absorb powerful medications? Is there any bone loss (osteoporosis)? What about the heart and the cardio vascular system? Can you trust he is not diabetic or is not experiencing renal failure?

All of these needs to be checked. My mother-in-law is 95 too, lives alone, does her shopping (loves to walk in the malls) has her friends' parties and goes on excursions. She looks fine and healthy but inside she is not. She needs medical assistance from time to time because her body is worn-out.

Prostate cancer progression is measured by its doubling in time. It grows forming a tumour and spreads, invading surrounding tissues firstly and then travel to far places in the body via the blood. Because it starts at the lower part of our body, far away from upper vital organs, it is a cancer that takes time to cause problems. In comparison with other cancers (pancreas, liver, lung, breast, etc), PCa by average takes longer to cause death. In its journey, it invades the nearby lymph nodes moving to the bones and then to upper organs, typically camping in the lungs or liver. Depending on its aggressivity, it can take more than ten years in its journey to become lethal, if untreated.
Patients may have PCa during many years without knowing, until symptoms take them for tests. Some guys start by experiencing obstruction in passing urine. Some others start feeling back discomfort followed by pain. These are the most common symptoms caused by PCa while growing. Those conditions are then treated to relief the symptom. Pain typically occurs when cancer metastasizes to bone. In such cases the treatment includes painkillers and/or spot radiation when joints are affected. This sort of radiation is recommendable but it differs from any treatment commented by Swing above.

The higher the Gleason grade of the cancer the more risky it turns into becoming lethal if untreated. Do you know his Gleason score? What about the PSA histology? Can you share info on any symptom that took him to get a biopsy?

Here are some links that may answer your last questions;

https://www.verywell.com/prostate-cancer-progression-2782164

On side effects;

https://www.cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html

http://www.mayoclinic.org/tests-procedures/external-beam-radiation-for-prostate-cancer/details/risks/cmc-20204701

Best wishes,

VGama