Question: Dear Doctor,

Facts:
My father,aged 84, diagnosed prostate cancer after biopsy in Sep 2014. 8 out of 12 specimen positive (4 of 10-20%, 3 of 40-50%, 1 of 60%), all XXXXXXX score 3+3. Doctor said stage 2. (T2N0M)

     MRI (end Oct 2014) – no ECE / SV invasion, no pelvic LN
     Bone scan (end Nov 2014) - no bone met

     1st ADT injection (3 monthly) in mid Dec 2014 + antiandrogen pills. Stopped ADT since mid March 2015 and held up RT to look into sudden macrocytic anemia problem (pre-ADT Hgb in Nov 2014: 14.5, dropped to 9.5 in mid Feb 2015.) Since stopping ADT, Hgb improved gradually to 12+ in late May.

     PSA readings:
12 July 2014 (20.9),
16 Oct 2014 (16.7),
26 Nov 2014 (18),
2 March 2015 (0.06, after 1st ADT shot on 18 December 2014),
20 April 2015 (0.03),
30 May 2015 (0.03)

     Medical history - hypertension, renal impairment, heart disease (pAF, mild AR/TR/PR, LVH, normal LV systolic function and size), gout, TIA in late 2008, insomnia/anxiety followed up by Psy, dementia (features of AD + small vessel disease, now mild to moderate stage), enlarged prostate. On long term medication. Down trending platelets of 150k since 4 years ago,

We just learnt from a doctor (internal medicine) that there is a small shadow seen on my father chest x-ray taken on 20 April, i.e. one month after discontinuation of ADT in mid March 2015. Another plain chest x-ray done on 5 May 2015, similar. (Father had severe cough and on-and-off low grade fever since 17 April to mid May. On a few antibiotics courses. Much improved after mid May. Intially with light brown sputum, later changed to white, but started to cough a bit more again in these few days.) Doctor raised the possibility of PCa metastasis to lung. She did not suggest CT at this moment because my father’s kidney function is not good and creatinine has been always high (about 185+). She asked us to take another chest x –ray in early July to see if there is any change to the shadow before deciding on next step. My father has lost much weight since mid April, from 54.6 kg to 48.4 kg now. He feels tired more frequently and sometimes dizzy, no other discomfort and with fairly good appetite.

My questions are –

1.     Are there signs of metastasis to lung? What is the chance of primary lung cancer? We are concerned given the chest x-ray finding and significant weight loss of my father.

2.     Regarding his PCa, we are hesitant whether to do RT with ADT, ADT alone or adopt active surveillance approach. If we go for RT with ADT, in case my father cannot complete RT (e.g. cannot tolerate side effects, or his health conditions do not permit), would it be even worse than if RT is not started at all? Would RT change the biology of the cancer cells and if RT is not completed, the cancer cells will become more aggressive or spread even faster?

3.     One of our oncologists suggest watchful waiting as my father’s PSA has not risen despite stopping ADT since mid March. This doctor suggested to re-start ADT injection or antiandrogen pills only if PSA rise to say above 10 or 20. What do you think of this suggested intermittent ADT approach in my father’s case?

4.     What are your suggested way forward and actions to be taken if you were in our place?

5.     What do you think about my father’s life expectancy, assuming no other lethal conditions come first?

Best Regards,

Dear Dr XXXXXXX

Thanks for your prompt reply. Some further questions -

1.     For lung cancer, what is the rate of progression? How long it usually takes to progress from stage 1 to stage 4? If lung cancer spread, which part(s) of the body is/are likely to be affected first? Why I ask this question is that my father’s whole body bone scan in late Nov 2014 showed no bone met, can we infer something from this finding (e.g. no metastasis of lung cancer at that point of time (if he really has lung cancer already)?)

2.     If lung cancer symptoms (e.g.cough, sputum with blood, etc) have appeared and if it is really lung cancer, would the symptoms persist and cannot be relieved by antibiotics?

3.     My father’s cough has subsided a lot, but he has lost much weight since mid April despite normal appetite. Is this worrisome, taken together with all other signs? Since he has cough from April, we have cut his sugar intake, basically no food and drink with sugar in his diet. Could this no-sugar diet reduce his weight? What do you think my father’s chance of getting lung cancer?

4.     For PCa, you said when “PSA rises again, then give next shot”. Do you mean that when it starts to rise, even just slightly above the latest reading of 0.03, then another shot should be given? Or you mean when PSA rises and reach a certain level, then give another shot? If the latter, what PSA level you suggest for giving another shot, 10? If PSA drops again after giving another shot, should we stop and adopt wait and watch approach again or should we continue the ADT shots non-stop?

5.     After becoming refractory to ADT, would the cancer cells grow and spread at a rate even faster than before the initiation of ADT?

6.     Doctors told us that ADT is usually effective for 2 to 3 years. Is the ADT effective period the same regardless whether there has been metastasis or not before ADT? If so, sounds that ADT should be delayed rather than introduced early when there is not yet metastasis, so as to prolong the survival period? In non-metastasis PCa, if RT and surgery are not intended due to age and health conditions, when is a good timing for ADT intervention? Would earlier ADT intervention keep the disease under control for a longer time and hence longer survival period, as compared to wait and watch until metastasis occurs? How about intermittent ADT approach?

Looking forward to your expert advice.

Best Regards,

Dear Dr XXXXXXX

Thanks for your expert advice. Regarding my father’s PCa, do you think that his macrocytic anemia was caused by ADT?

Our oncologists do not think so and said it might be due to other conditions like bone marrow problem because his MCV is high. However, I still suspect it was caused by ADT because it arose after initiation of ADT and after we stopped ADT, both Hgb and MCV gradually improve. Can ADT cause MACROCYTIC anemia? What is the probability ?

Best regards

Dear Dr XXXXXXX

I recall back to March & April this year, my father got black “blood bubbles” on tongue and inside mouth. These bubbles appeared suddenly, no pain. They subsided within one or two days. Please see attached photos of two episodes of such blood bubbles.

Is this something serious or indication of something serious? Should we be concerned? What is the cause of these “blood bubbles“?

Is this related to my father’s lung lesion seen on x-ray or his severe cough earlier? The timing are very close.

Looking forward to your advice.

Best Regards,

Dear Dr XXXXXXX

Thank you for your quick response. My father’s platelet level is around 90k to 100k. Could this cause his “blood” bubbles?

Regarding his PCa, we are really confused by the different advices from different doctors. A few advised RT and said little side effects. Some advised continuous ADT. One advised wait and watch now and give intermittent ADT shots if PSA rise to over 10 or even 20. We are confused and need further advice/clarifications-

Can intermittent ADT prolong the effective period as compared to continuous ADT, i.e. defer the timing of becoming refractory to ADT? How long can this intermittent ADT approach keep his disease under control, as compared to usually 2-3 years for metastasis cases?

Is PSA a good and reliable indicator of metastasis? If we adopt wait and watch now, besides PSA, is the rate of increase of PSA also an important indictor to monitor while on intermittent ADT? If so, how to consider the speed of PSA rise?

A doctor advised us to do RT or continuous ADT, but not to adopt wait and watch approach now nor intermittent ADT approach. He said that there are cases where PSA does not rise but the PCa has worsened, and so we have risk of disease progression without our knowing about it if we simply rely on monitoring PSA. Is this possible and what is the likelihood?

Doctor suggested RT on reasons that he has no metastasis and health conditions is not that bad, though not top fit. He said side effects of RT are mild and temporary and many old patients can also tolerate them. He has never seen patients (including elderly) not able to complete RT. You earlier advise “I would not venture into RT at all now. He may not be able to complete it and have lot of side effects.” I want to know if my father cannot complete RT due to health conditions, what would be the consequences? Would it make his PCa become worse than before and make his cancer cells spread even faster than if RT is not initiated at all?

Based on your clinical experience, what could be the serious side effects of RT to elderly patients, and the likelihood? What remedial actions can be taken to relieve such side effects?

Thanks a lot in advance for your expert advice.


Best Regards,