ADT or Hospice?

[egretta]

My 96 year old FIL was recently diagnosed with advanced prostate cancer which has metastasized to his liver, lymph nodes, pelvis and spine, with a compression fracture in L12. The family is at a crossroads, deciding between starting him on ADT or having him enter hospice. As the urologist described it, without ADT he will get to the point where his bone structure can't support any body weight. Simply moving him from bed to wheelchair or rolling him over in bed could break bones. And/or cancer masses will grow to the point that they press against nerves in multiple organs.

The alternative to ADT, of course, is entering hospice.

My FIL has other health issues, as you can imagine at 96, including congestive heart failure and has recently recovered from falls/broken hips.

To be clear, the family's objective (and his) is not to prolong his life or postpone an inevitably painful process. It seems that both choices have major downsides though.

I am looking to this community for any experience or advice you could offer. This is my first post, so please let me know if there's any more information I can provide or questions the family should be asking doctors.

Thank you.

[Tall_Allen]

IMO he will get a lot of relief from hormone therapy, and a bisphosphonate to prevent fractures. Maybe you can find a Palliative Care facility rather than a Hospice.

[egretta in reply to Tall_Allen]

Thank you so much for your reply. We've been swirling around the possibilities of both paths, and you make it sound pretty simple. I appreciate it.

[Hidden in reply to Tall_Allen]

But do bone strengthening agents really prevent fractures? My experience is, They Do Not. But I believe he would get great relief with ADT, making whatever the future holds, a tad more comfortable.

[egretta in reply to Hidden]

Any more comfortable than hospice would make him, managing his pain by other means? (I don't know if that's a question anyone can answer).

[Tall_Allen in reply to Hidden]

We have proof that they prevent fractures:

"zoledronic acid significantly delayed the onset of first SRE[ skeletal related event] and decreased the risk of developing an SRE by 53% compared with placebo . "

clinical-genitourinary-canc...

One person's experience is useless for proof, because you have no idea what would have happened had you not taken it.

[Horse12888 in reply to Tall_Allen]

TA: Why not other systemic treatments, like chemo and nuclear medicine?

[Tall_Allen in reply to Horse12888]

The goal is to prevent pain and fractures. While chemo and Xofigo prevent pain, they are much harder on the body of a 96 yo man.

[Horse12888 in reply to Tall_Allen]

Ha. Thanks.

[CAMPSOUPS]

IMHO it has more to due with any other health issues aside from the PC diagnosis. Those issues your family, you, and doctors know most about and so hospice decision should be based on that.

Standard ADT such as Lupron or even Lupron plus Zytiga may or may not add fatigue, etc. but will bring some relief from the symptoms of PC even if he goes into hospice. IMHO hospice or not his remaining life will be more comfortable if he starts hormone treatment.

[egretta in reply to CAMPSOUPS]

I appreciate that angle. His cardiologist will be consulted today. And comfort is of utmost importance. Thank you.

[Luv2fish]

I’d also suggest that you get him to a medical oncologist for another opinion. Liver Mets are very serious and have an extremely poor prognosis. Personally I’d opt for hospice since the goal there is to make him as comfortable as possible for the time he has left.

[egretta in reply to Luv2fish]

Thank you. This is also my main question right now and we are awaiting word from the oncologist. My understanding, from what I've read, is that this may be the single most important factor in the decision making process, as the liver mets could cause him to go more swiftly (and in hospice) than any pain suffered from bone mets.

[Luv2fish in reply to egretta]

I think you’re on the right track. And I think a medical oncologist is better suited to have that conversation with you than the urologist. An MO will have far more experience with liver Mets than a urologist.

[Shamrock46]

I can only speak from experience. Some years ago my dad had PC. At the time he reached 94 he began to deteriorate, getting very thin. He lived around the corner from my sister and she called me one night right before Christmas saying that he called her and needed to go to the hospital...about 4 blocks away. He'd lost bodily function and was embarrassed. Her husband ran over there and immediately took him and by the time I got there his primary care doctor was also there trying to talk him into surgery. Anyone could have seen that my dad was very weak and close to death, but this man who had treated him for many, many years was trying to convince him he needed surgery. I had my dad's Power of Atty. with me and told the doc I needed to speak to my father alone and asked him what HE wanted to do. He said no surgery. I told him I agreed and I wasn't sure if he could even survive surgery of any kind at that point. The doc was upset when we told him. We asked if my dad could be transferred to the hospice floor and he was. The next day they told me he couldn't stay there because there was nothing they could do and I had to find a nursing home for him. I found a very nice one and he died a few days later in peace. If he'd had surgery he would have been in pain for his days and/or probably incoherent. Was it easy to let him go? Of course not but I think we made the best decision for him when evaluating the whole picture. Prayers as your family faces a similar situation.

[egretta in reply to Shamrock46]

Thank you for sharing your experience. It is so difficult to make the "right" decision in the face of a doctor who is painting such an awful picture if the hormone therapy is declined. I really appreciate you taking the time.

[Shamrock46 in reply to egretta]

Glad to help. Has the family asked what your FIL's wishes are? I was lucky that my dad's mind was as sharp at 94 as it was and he was done with the pain and problems...I think he knew he was dying and was more than ready to join my mother who had predeceased him some years before. I was most happy that he got to die with dignity and not attached to all kinds of machines and tubes if he had had the surgery. The doctor/nurses at the nursing home were able to keep him comfortable until the end.

[egretta in reply to Shamrock46]

He ranges from calm and lucid (relatively speaking) to agitated and confused. Overall he has admitted to a poor quality of life and recognizes that he doesn't have long. However, he is confused enough to not have a full grasp on the situation, and easily misinterprets what is being said. It's a shame, he was sharp like your dad until about 94 as well. His overriding emotion though, is probably fear, which I think hospice could help a great deal with.

[Shamrock46 in reply to egretta]

That's too bad. I hope at least that he gave someone his Power of Attorney for health care to help all of you.

[Teacherdude72 in reply to egretta]

There are no Wrong decisions and never look back and say "maybe I should have done ...."

[GARunner in reply to egretta]

I strongly second Teacherdude72's comments. Guided by your love and the information you have, you will make the "right decision". Second guessing neither benefits the family or your FIL. May he find pain relief and peace on whatever path he takes.

[katbel57]

I don't understand why the medical community always goes straight to the full blown ADT therapy. He needs to be on a monotherapy drug like Casodex, this will cut off the supply of testosterone to the cancer without killing the testosterone that is needed for his heart and has very minimal side effects (possible breast enlargement and tenderness), In addition to medication for his bones.

[egretta in reply to katbel57]

I will look into this. Thank you!

[Teacherdude72 in reply to katbel57]

Casodex ®

Generic Name: Bicalutamide

Drug Type:

Casodex is a hormone therapy. It is classified as an "anti-androgen." Often given in combination with "LHRH agonist," another type of hormone therapy. (For more detail, see "How Casodex Works" section below).

[Tommyj2]

is he cogent enough to participate in this decision? What does HE want?

[egretta in reply to Tommyj2]

Unfortunately, no. He is aware enough to be included in the conversation, and we do try to explain everything we can, and interpret or reiterate what doctors have told him. He recognizes his poor quality of life and is fearful. But his cognitive abilities aren't such that he can decide on next steps.

[j-o-h-n]

Unfortunately for myself and for many members here, we too may have to face this same decision in the future..... As for me, at your Father-in-Law's age.....get me a clean soft pillow asap to rest my face....... May God make your decision....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 06/07/2023 11:19 AM PST