How long is long enough is the question we need to ask our-self when we deny treatment to our cancer patients who happen to be old but are otherwise healthy, thinking either they have lived long enough making them unworthy of that chance, or as a result of our unfounded fear of extra-ordinary toxicity of cancer treatment in older, so much so that even curative attempts may be curbed.
Of the many elderly patients that I see and treat everyday, Mr. MLG an 86/M suffering from stage IV prostate cancer came to see me after being referred by one of my old patient. He was diagnosed with stage IV prostate cancer about a year back and was started on usual androgen ablation by orchidectomy to which he responded well but started to progress later. He was depressed as he was denied treatment with chemotherapy which he required now having progressed after androgen ablation, and that to just for his age. Such denial came through several individual medical (mainly non-oncology) and non-medical opinions.
Mr. MLG was active at his age and used to do his daily chores individually with out any help, when he started having increasing abdominal discomfort and difficulty in walking which significantly compromised his quality of life. His disease had progressed to multiple bones and multiple lymph node groups in abdomen compressing venous flow causing pedal edema with venous stasis on Doppler study of lower limbs. His Gleason score was high at 8 and PSA was 55 ng/ml (normal < 4ng/ml). There was no other co-morbidity. This profile favored a chemotherapy approach and we offered him weekly docetaxel chemotherapy along with DVT prophylaxis.
Weekly regimens are often chosen for elderly patients who are relatively unfit or have compromised health status. Through such approaches dose per fraction is reduced to less than half which significantly reduce acute toxicities. Whereas weekly (in-lieu of routine once in 3 weeks) administration maintains good dose intensity, so as actual or total dose delivered per 3 weeks is either same or sometimes even greater. Therefore, weekly regimen help deliver chemotherapy in safer yet effective manner. Sometime such approach is called as “metronomic chemotherapy” – which is low dose continuous chemotherapy – a safer form of administering chemotherapy achieving treatment goals in the compromised.
After 1st cycle his swelling in lower limbs normalized and his mobility improved. Within 3 cycles his PSA was back to normal range (2.5 ng/ml). He did suffer some toxicity in form of mucositis (oral ulcers) which required delay of a couple of doses but was manageable with cautious use of supportive therapy. We stopped his therapy at 3 cycles as he regained good health and was put on second line hormonal manipulation again. He is presently doing well and keeping his normal life style, as previous.
I would like to restate his words when he first met me – “Doctor sahab, I am older not elderly”, which echoed the feeling of most of these aged patient who still have the zest to live. This case argues against our prejudice not to treat elderly and leave them to their fate.
Therefore, age should not be a bar in their quest for life as they may not have lived long enough!!