Tough choices

An 85-year-old gentleman was referred for further management of his osteoporosis. He had initially presented with a vertebral fracture 18 months ago and was successfully managed by vertebroplasty followed by bisphosphonates orally. He had done fairly but now presented with increased back pain. On examination he had the classic features of a lumbar vertebral fracture — flattening of the lumbar lordotic curve, lower ribs abutting the pelvic rim such that no fingers could fit between the ribs and the pelvis, and protuberant abdomen.

But that was only part of his problem. His spine was still tender and because he is on therapy for prostate cancer, before I saw him in clinic, the possibility of a metastasis had to be considered and excluded.

That still didn’t get to his problem. He was a lively gent, looking younger than his stated age and was accompanied by his wife of 60 years, also lively and looking younger than her stated age. He had confidence that something could be done to help his back pain because he had had such a good response before. The main concern for this couple is that he really could not tolerate the androgen deprivation therapy prescribed for his prostate cancer and had typical symptoms and findings of male hypogonadism.

This is an issue that most of us face not infrequently, be it a man treated for prostate cancer or a woman treated with hormone ablation for breast cancer. My experience has been that most of the time the concern about recurrence or progression of the malignancy overrides the side effects of the therapy, but occasionally I see a patient such as this.

I don’t yet know how I will resolve this other than to make sure the patient understands the implications of discontinuing appropriate treatment of his prostate cancer and have a long discussion with his urologist and oncologist.

My patient’s thinking was that, at 85, quality of life trumps life expectancy. That is no doubt true but he has fortunately yet to experience life with skeletal metastases and is less likely to on his current therapy. I don’t want to be the one responsible for putting him in that situation.