Urgent help needed - dad diagnosed with stage 4 prostate cancer and he is a heart patient with diabetes

[SARA_2025]

Hi - my dad has multiple health conditions and now he is diagnosed with prostate cancer (stage 4) which has spread and not localized anymore. We are looking for opinions for his prostate cancer treatment keeping his heart condition in mind. He is a heart patient with a heart infarction history and he got stents in his heart last year during summer time.

We were suggested to take few opinions and so we did. But we are getting different opinions from urologist/oncologist and that’s confusing to decide what’s the right treatment for his case. His PSA was high 40+ and thats when we were referred to a Urologist who is suggesting to do TURP since he has history of urine passing issue and he is on medication for that and it works 90% of the times but sometimes he struggles but then it goes away. The same dr is recommending radiation after a month of TURP surgery and then HT/injections. We took second opinion from a medical oncologist and his opinion is opposite so we are a bit confused on the next steps. He is 1) recommending not to do TURP because that’s not for curing the cancer and may have negative effects (rays are still used to do this) keeping his age and health condition in mind. According to him, if most of the time medication is doing the job and he is able to pass the urine then no need for surgery at this time. 2. ) For therapy, he would start with hormone therapy/ injections first with no surgery ahead and check PSA and if needed do radiation therapy. 3) He was also saying the HT and RT will also help cure prostate overall so the urine passing issue should get better as well in addition to cancer. Therefore, avoid TURP now.

Now we have few questions and want to hear this forum perspective so we can quickly make some decision on his treatment.

1. Should we take another oncologist or urologist or radiologist opinion and see what they have to say about the treatment?

2. Should we be holding onto TURP first since he is able to pass the urine with his regular medication and had issue for a day or two after PET scan? The surgery might cause some issues as well?

3. His 1st opinion dr have said that they will start with radiation after a month post TURP surgery. Can HT/injections be started right away or it needs to wait since a month recovery is required after TURP?

4. Oncologists have said to start with HT so why urologist said to start with radiation after a month even though the cancer is stage 4? Is it because overall it’s good to give sometime after surgery at his age with heart condition? But the cancer will continue to spread so what about that? Can we start HT right away then?

5. ⁠I was reading online and looks like HT have some cardio or stroke related concerns so could this be reason his urologist is saying to start with radiation first?

6. Can we do this TURP surgery later if needed and if his medicines are not effective? In the middle of HT/RT therapy or afterwards.

7. ⁠Can this HT/RT cause any urine passing issue and also cause medications to be not effective? In that case what if he is suffering and TURP is the only option? Can we do the surgery then?

8. There are forums where folks have discussed similar condition patients (heart, diabetes, Prostate cancer) and said ADT and other some other HT drugs have high risk like heart stroke during treatment. Btw, my dad has a history of 1 heart infarction and post that incident we came to know his all arteries are blocked and afterwards stenting was done.

9. Another huge question is on the sequencing of radiation and hormone therapy since we are getting conflicting opinions in here and so keeping his heart condition what’s the right sequence. What governs the sequence of the treatment? Should we go with Radiation first and then HT like his primary hospital and urologist suggested or HT first then radiation or both in parallel? What would be most effective and less impactful to his heart?

10. His primary hospital is suggesting a wait of 1 month post turp? How critical a month is in terms of further spreading the cancer and starting specific cancer treatment? Also, should we even do turp now because that’s not really taking care of cancer and 1 month wait afterwards is too much at his stage?

[Tall_Allen]

Could you please be more specific. Is the cancer in his bones and/or pelvic lymph nodes, and if so, how many metastases of each were detected, and was it by PSMA PET/CT, bone scan/CT, or both?

[SARA_2025 in reply to Tall_Allen]

Both Biopsy and PET/CT are done and dr indicated that the cancer hasn’t spread in the bones yet. This is what the whole body 18-F PSMA PET CT report findings are:

- Diffuse, symmetrical, increased, physiological tracer uptake is seen in bilateral lacrimal gland, parotid and submandibular salivary glands, liver, spleen, and kidneys

- Prostate is mild to moderately enlarged. It measures approximately 4 cm x 3.6 cm x 4.5 cm. Both lobes show heterogeneous enhancement and intense tracer uptake (SUV Max 20.4). There is mild periprostatic fat stranding. Median lobe is indenting the posterior wall of the urinary bladder.

- There are a few upto cm size, intensely F-18 PSMA avid right common iliac and internal iliac lymph nodes (SUV Max 42.6). Few small left common and internal iliac nodes are seen.

[Tall_Allen in reply to SARA_2025]

It can potentially be cured with brachy boost therapy (hormone therapy+ whole pelvic external beam therapy + a boost of brachytherapy to the prostate). To prevent urinary retention, shrink the prostate with hormone therapy (ADT+abiraterone) now and continue for about 6 months before beginning radiation. He will require 3 years of ADT and 2 years of abiraterone, according to our best data.

[Birdwood]

Slow down, listen to T A. I had two stents and kidneys are at 34%. Let the heart doctors do their job and the Oncologists do their's. As long as all parties are aware of the full picture, he will do okay. Over 11 years I have not found that one issue complicates another.

[WisdomSeeking]

I would suggest to start ADT+2nd-generation-HT now and check if within 3-4 months the urinary problems are gone. If not gone, then do TURP and after the tissue heals continue with whole-pelvis-RT. Otherwise only whole-pelvis-RT. After RT, continue with ADT+2nd-generation-HT for approx. 2 years.

Answers to your questions:

(1): See: prostatecancer.news/search/...

(2): ADT+2nd-gen-HT will shrink the tumor - it may help him with urinary problems. So maybe don't rush into TURP now.

(3): ADT+2nd-gen-HT can start right away.

(4): Urologist highly likely doesn't know that much about prostate cancer and its treatments. RT with a stage-4 patient should start after at least 3 months of ADT pretreatment. ADT shrinks the tumor and makes it more sensitive to radiation. Your dad can start ADT+2nd-gen-HT right away.

(5): It's true that Zytiga (abiraterone) can have cardio problems - see below, and that Xtandi (enzalutamide) can have stroke problems, but not, it's not the reason.

(6): Maybe, but definitely not in the middle of RT. See also next answer.

(7): Even though it's highly unlikely, RT can cause urethral stricture or urinary retention. TURP would not be the only option - there's still the permanent-catheter option. I don't know how often is TURP after RT done but I've read that there were even cases when a prostatectomy was made after RT. After RT the irradiated tissue heals much worse, that's why it's better to do TURP before RT and not the other way around.

(8): These possible side effects are high risk but are low-probability. For example, in trials, Xtandi (enzalutamide) had 0.7 % of Grade 3-4 ischemic events against placebo, and seizures were in 0.4 % of patients. Source: Xtandi prescription label: accessdata.fda.gov/drugsatf...

(9): Probably this sequence: Start with classic ADT (Firmagon/Orgovyx/Lupron/Zoladex/...), then wait some time to see if everything is OK. Then add 2nd-generation-HT. ADT+HT goes in parallel and then RT is added to it.

(10): If your dad has the most common type of prostate cancer, then it is one of the slowest growing cancers. It's OK to wait even 3 months. See below.

Other information:

As Tall_Allen said: first approx. 6 months of HT (ADT+2nd gen. HT), then whole-pelvis RT (maybe with brachy boost), then 2-3 years of HT (ADT+2nd gen. HT).

Normally, as Tall_Allen said, abiraterone (Zytiga) is used as 2nd-generation-HT. But if your dad has heart problems then, maybe, use other 2nd-gen-HT like enzalutamide (Xtandi), darolutamide (Nubeqa), apalutamide (Erleada). Zytiga (abiraterone) may raise the blood pressure. You should ask this the medical oncologist.

See Zytiga (abiraterone) prescription label: accessdata.fda.gov/drugsatf...

See also: healthunlocked.com/advanced...

.

But, please, calm down. Prostate cancer is usually a very slow growing cancer:

See posts on Tall_Allen blog:

"... Get your information directly from the experts, and assess it yourself. It can be a formidable task, so take your time. There is no rush - even men with high-risk prostate cancer did no worse if they waited 3 months between diagnosis and treatment ..."

Link: prostatecancer.news/search/...

and

"... I have come to believe that no doctor ought to accept as final any prostate cancer primary treatment decision made by a low, intermediate, or high risk patient within a month of receiving his diagnosis, and preferably within 3 months. The emotional temperature has too strong an effect on decision making, and time is our friend in this regard. Similarly, doctors should insist that second opinions have been acquired."

Link: prostatecancer.news/2016/08...

[SteveTheJ]

;tldr. I am diabetic and have taken Erleada and Lupron for almost 5 years. At first these medications caused my TSH to go up so I had to increase my dosage of synthroid; at the same time, A1C also went up. Eventually, with more synthroid, TSH and A1C came back down to earth.

I do not have cardiac disease that I know of.

[Noname1960]

I am a Gleason 9 prostate cancer patient and had it removed in 2017. I am not sure where you are but I flew to Tacoma Washington to let Dr. Willis do the surgery because my son-in-law is a certified first assist in the O.R. and he said Dr. Willis was the best he had ever worked with. He had done his fellowship at M.D. Anderson and he takes 2-3 hours longer than anyone he has ever worked with. I had surgery less than a month after it was discovered and it was only in 3 of the 12 biopsies they took but by the time I had surgery it had already spread to 19 of the 22 lymph nodes he removed. I am seeing the head of Levine Cancer Dr. Burgess atriumhealth.org/locations/... and have had it come back twice but we have stayed on top of it. When I first saw him he said he didn't even want my PSA get to 0.1 even though at my age of 64 it is normal to be between 3-4. The reason he doesn't want it to get to that point is because with a Gleason 9 it can spread so fast. A little over a month it hit that point a second time. I asked him how when I no longer had a prostate and he said it is because the cancer cells can still be present in my body no matter how good the surgeon was that did the surgery and once they start growing again it will produce PSA. So I go for a PET Scan on the 21st of this month and see Dr. Burgess on the 22nd to see where we go from here. I suspect it will be another 40 radiation treatments like I had in 2019, but as long as it is monitored and treated I should live to a ripe old age. I agree it is best to listen to the cancer doctors that have the experience with these kind of problems and it needs to be a good one. I flew across the country to find one and he kept calling me and checking on me after I returned home. He also found Dr. Burgess for me and for that I will be forever grateful to him.

[NecessarilySo]

I am not a doctor, but I would say that PSA 40 is at a point where he should start ADT without delay. Cancer cells divide on a regular basis and any delay risks spread to bone. Radiation to prostate would help shrink prostate, kill any prostate cancer cells in it, and possibly reduce urination problem. Ask a radiation oncologist.

P.S. Exercise regularly and consume low-saturated fat and low cholesterol diet, for heart health.

[j-o-h-n]

Greetings SARA_2025,

Would you please provide us with your dear Dad's age? location (city/state)? Treatment center(s)? Doctor's name(s)? All info is voluntary but will help him/you and help us too.

Thank you and Keep posting (update bio too)!!!

Good Luck, Good Health and Good Humor.

j-o-h-n

[Jewelrylady]

I would suggest you see if there is a cardiac oncologist you could meet with.

[fast_eddie]

If his inability to pee or completely empty his bladder is due to an enlarged prostate (whether benign or cancerous) and he is in danger of retention (complete inability to pee, requiring an ER visit / catheter) then TURP surgery is not an outlandish idea. Retention is dangerous especially if immediate treatment isn't available. TURP is a rotor-rooter type surgery. The tissue removed can be biopsied too. Retention is painful and scary. I've been there. TURP was the remedy. This was 10 years prior to my prostate cancer diagnosis.