Asking for a friend...

92 y/o male with no significant co-morbidities and an active, keen mind.

Treated for PCa 20 years ago with RT; recently experienced apparent BCR with PSA rise to 12 over last few years. Exact PSA velocity is not known nor was Gleason score at diagnosis. Currently asymptomatic.

Uro is recommending ADT (Lupron).

My question is how old is too old for Lupron?

In other words, are the SE's worth starting ADT now considering his limited lifespan, or should he wait until he becomes symptomatic (if ever) and only try ADT at that point as a palliative?

Thanks,
Paul

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Age: 54 at Diagnosis

12/2016: PSA=4.13; Free 11.9%
12/2016: BX#1 Pathology: 1/12 (Left mid) 3+3(Score=6); 10% of Tissue
12/2016: Oncotype DX Genomic Prostate Score = 5
02/2017: MpMRI... 1 lesion in vicinity of BX positive core; PI-RADS 3
02/2017: AS Decision Made
09/2017: PSA=3.56
01/2018: BX#2 Pathology: 1/12 (Left mid) 3+4(Score=7; G4=30%) in 1/15mm
03/2018: RALP
08/2018: PSA < 0.01

He’ll probably be 105 before experiencing PC symptoms. What do you think?


ADT is not, btw, palliative. Strong side effects.

Not much information to base an opinion on because it depends on a lot of factors we can't know like how bad are the co-morbidities.

But ...

With co-morbidities, and limited life expectance, ADT doesn't make a lot of sense. The SEs of ADT could add to his discomfort rather than help it. In this case, until there are symptoms, there is no reason to treat. The URO needs to be reminded that he's treating a whole person, not a PSA number.

If your friended did start having PC symptoms like bone pain, then a little ADT or spot RT would be palliative.

Andrew

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I'll be in the shop.
Age 58, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17, .3 10/17 .3 4/18, .4 11/18
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012

I was torn on my advice to him as some here are. Part of me thinks wait for symptoms. How much testosterone does a 92 y/o have to suppress anyways?

Thanks for the replies, enjoy the weekend.

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Age: 54 at Diagnosis

12/2016: PSA=4.13; Free 11.9%
12/2016: BX#1 Pathology: 1/12 (Left mid) 3+3(Score=6); 10% of Tissue
12/2016: Oncotype DX Genomic Prostate Score = 5
02/2017: MpMRI... 1 lesion in vicinity of BX positive core; PI-RADS 3
02/2017: AS Decision Made
09/2017: PSA=3.56
01/2018: BX#2 Pathology: 1/12 (Left mid) 3+4(Score=7; G4=30%) in 1/15mm
03/2018: RALP
08/2018: PSA < 0.01

tudor_paul, if you are worried about the loss of libido in your 92 YO friend as the primary side effect of ADT, I frankly think you are worried about the wrong thing. I think for a 92 YO I'd be worried most about the "silent" side effect of bone mineral loss first...the risk of bone fracture/skeletal incident is significant for the very elderly (your friend's category). Second, I'd probably worry about bothersome urinary symptoms--slow urine flow, getting up frequently at night to urinate, and dribbling urine. Frankly, as a SE of his RT treatment, he's probably already got some of those...does he want them getting worse in his last few years? Joint aches/pains...already go that, want more? Fatigue/excessive daytime sleepiness...already got that, want more? Anemia, increase cardiovascular risk, cognition and memory loss, diarrhea, liver toxicity? Come on...loss of libido is the lowest on the list.

Life has a way of accelerating morbidities at 92. One can be doing relatively well and a year later not so well. ADT will undoubtedly take a toll. At 92 he has an actuarial life expectancy of 3-5 more years. I suggest some scans to see where the cancer is and what his odds are of having painful bone mets before age 95.

ADT light.....use Casodex and Avodart. Reduces a bit of T and sets up a blockade with minimal side effects compared to Lupron.

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PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Cognitive impairment is also a danger with ht.

George H.W. Bush, age 94. Active and alert just a week ago. Started the day last Friday with three 5-minute soft-boiled eggs, a large cup of yogurt and two fruit drinks. Died "of old age" that evening. As hrpufnstuf intimated, co-morbidities have a way of accelerating when one has already outlived normal life expectancy by so much (already far more than a dozen years more).

This is totally opinion based on life (and death) experiences, coupled with a rich understanding of the frailties of illness and age plus an meaningful comprehension of the "natural history" of prostate cancer--and everyone can have their own opinion because what I'm expressing here is only an opinion...but I don't care what a doctor may say, largely because I will be aware and wary of their profit motives preying on elderly which may or may not come into play, but moreso because doctors are more focused, due to their training, on treatments, less on patient well-being. For someone I love and care about, with the PC history you (and every single case is unique and different; no one-size-fits-all) have described here, it is absolutely asinine crazy to be talking about toxic chemical treatments (or essentially any treatment with the exception of--years away--possible palliative care only as needed)...absolutely crazy. Modern medicine has skewed our attitude on mortality. Compassion.

Our reluctance to honestly examine the experience of aging has increased the harm we inflict on people...we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers.

Post Edited (Blackjack) : 12/4/2018 11:25:35 AM (GMT-7)

Saipan Paradise said...
Just last week I asked a South Florida urologist about Lupron for the superelderly. If a 90 year old spikes a PSA greater than his age, he recommends a trial on Lupron, and if the patient tolerates it well, keeps him on it for the rest of his life. The thinking is to prevent bone breaks, which can be catastrophic in nonogenarians, and painful end of life from mPCa. Makes sense to me.

GnRH agonists (Lupron) significantly decrease bone mineral density in men with prostate cancer, and therefore increase the risk of clinical fractures (known mutely as "skeletal incidents"). In fact, Lupron therapy independently and repeatedly predicts fracture risk after controlling for other covariates (age, race, geographic location, and comorbidity). So then your treatment-driven physician will co-prescribe a bisphosphonate to attempt to mitigate the Lupron bone loss...but guess what, you've then compounded & multiplied the side effects. Yes, you CAN prescribe drugs, and more drugs to counteract the drugs, but where's the QoL; where's the compassion? Common sense is being blinded by medicine. Makes no sense.

You make good points, blackjack. The actual PSA number this uro used in his example was 400. I think his position was, don't treat till the cancer's in the bones already.

Writeblock, the question came up specifically about an 89 year old man who is already in declining health. Maybe I shouldn't have generalized.

Yeah, Saipan, cuz at 400 it may, but def may NOT be in bones...for which palliative spot radiation may then be the best choice. Radiation and ADT are two very different things, and radiation is NOT a systemic treatment. So, decide then (at 400, or when symptoms show up), because no 2 cases are exactly alike and the number is nothing more than a possible guidepost. But more notably, after tracking for years and only now up to 12 in this 92 YO, that threshold is a LONG way away and maybe never going to be seen. OP said doc recommended Lupron...that’s crazy. (that's my opinion)

Treat the patient, not the number. This patient was treated 20 years ago; 20 years later, PSA is only 12 ng/mL. He's 92 YO. Think

Post Edited (Blackjack) : 12/4/2018 4:07:06 PM (GMT-7)

I can only use myself as the best example of someone advanced in years who is benefiting greatly from treatment. I've had 45 rt sessions for localized g9 pc and experienced NO side effects. I began all that with a psa count so far of 1.8, way down from 15 originally, thanks to firmagon, then lupron. I am finding the side effects from the ht tolerable, at most annoying. But--bottom line--I still am enjoying life a lot and am doing fine. Yet there were some who expressed indignation that I had ever even had a psa lab workup to begin with, or was urged to get a biopsy. I find that shocking--and profoundly arrogant. This 92 yo individual was said to be in good shape physically and mentally. Why shouldn't he take advantage of any available tx to ward off any future mets and perhaps even prolong his life a few more years?