Charles Ryan, MD: Biggest Considerations for Elderly Patient Population

What are the biggest considerations and concerns in an elderly patient?

The remarkable part about this case is that the patient has rapid progression of his disease. His PSA increased from 1 to 56 between visits, and not only does he have that rise in PSA but he has symptomatic disease in the spine with a soft tissue component. So there are a couple of issues to take into consideration.

One is the systemic burden of the disease and that’s probably what’s driving this case is that he likely has many sites of metastasis, some of which we aren’t able to measure. But he also has a focal area of disease that’s causing him pain, and so one of the considerations is if we should combine a focal therapy such as palliative radiation with a subsequent systemic therapy such as abiraterone, or enzalutamide, or even chemotherapy in this case.

Now, the fact that he’s elderly is important, of course, because it will impact the treatment choices that we make. His comorbid illnesses may be an issue in terms of the likelihood of selecting treatment, as well as his overall general function. Is he taking care of himself? Living alone? Is he active? Is he inactive? Many of these general lifestyle considerations are important at this point.

CASE: Metastatic Prostate Cancer (Part 1)

Stanley S is an 83-year-old Caucasian male whose past medical history includes diagnosis of adenocarcinoma of the prostate in 2012 with no evidence of metastasis. At the time, he was started on bicalutamide and his serum PSA levels subsequently decreased to 1.2 ng/ml.

During his most recent follow-up exam, the patient complained of intermittent back pain and increasing fatigue.

• His serum PSA level is 56.9 ng/ml and his alkaline phosphatase is 258 U/L
• CT scan shows enlarged lumbar bone metastasis with associated soft tissue component, as well as symptomatic nodes with lumbar bone metastases
• Biopsies of the prostate and transrectal ultrasound reveal the prostate is 42 grams
• Ten of 14 cores are positive for prostate cancer for a Gleason score of 8 (4 + 4)
• His ECOG performance status score is a 2