Answer: ADT docetaxel if PS improves on ADT

I would probably start this man on hormonal therapy and observe him to determine whether his functional status improved, and I would have a discussion with him about the risks and benefits of docetaxel. Certainly no difference is known to exist in the efficacy of these therapies between younger and older patients. The key issues are tolerability and the ability to receive a full dose on schedule without marrow suppression, neuropathy, fatigue, et cetera that will be more challenging in older patients. So I give these patients an opportunity to try chemotherapy, but I would be inclined to dose reduce docetaxel more quickly for an older man and I would certainly consider preemptive growth factor support.

If I had free access to all the drugs, I would start thinking about enzalutamide and abiraterone for this type of patient, but I would still use goserelin and bicalutamide as a standard and discuss the addition of docetaxel as an option.

Answer: ADT docetaxel if PS improves on ADT

This patient’s symptoms are related to his tumor load, which needs to be reduced. So I would administer ADT and docetaxel. Some doubt does arise because this patient is 80 years old and frail and his life expectancy is likely to be short, so the benefit from chemotherapy may be less robust than it would be in a younger patient. That doesn’t imply that I would refrain from chemotherapy, but I would be more inclined to initiate the ADT and wait 4 to 8 weeks to see what happened. Perhaps his performance status will improve and increase the feasibility of administering docetaxel.

This patient may not be the optimal candidate for chemotherapy, based on his performance status and symptoms. I may want to administer standard hormonal therapy to see what kind of response he experiences, what happens with his pain and whether his performance status improves. Many patients who respond to hormone therapy have a dramatic turnaround, and this could make him eligible for chemotherapy later. You have to use reasonable caution and good clinical judgment and not induce more debilitation than the disease has already caused. I believe that the data support the administration of bone-targeted therapy for patients with extensive bone metastases.

He would receive ADT regardless, but for an 80-year-old with a PS of 2, I might be inclined to try the every-other-week regimen for docetaxel. It’s gentler and better tolerated in a fragile patient. I would administer denosumab as well.

Answer: ADT docetaxel if PS improves on ADT

This scenario would give me a little more pause. I would probably administer ADT alone to an 80-year-old with PS 2 to see how he’d respond. I may consider adding docetaxel later if he fared well with ADT alone.

Answer: ADT docetaxel if PS improves on ADT

If you go back and evaluate the TAX-327 and SWOG trials that led to approval of docetaxel for castration-resistant disease, you find a substantial palliative effect of chemotherapy with ADT for all of these issues. I believe that’s the current standard, whether the patient is symptomatic or not.

The judgment here would be whether PS 2 would preclude chemotherapy. Because I don’t personally administer chemotherapy, I can’t make that judgment. I would rely on my medical oncologist to judge whether or not this patient could tolerate chemotherapy. But I’d predict that if the patient were hormone-naïve we’d start him on hormone therapy and maybe some steroids, and many of these issues would resolve relatively quickly and then I would reassess him.

If his performance status improved, then we’d start him on chemotherapy. If his performance status didn’t improve, then I would have a frank discussion with the patient and family and say, “We’re into palliative therapy only. What symptoms do you have? We’ll treat your symptoms appropriately.”

If he had focal bone pain in 1 or 2 spots even though he might have more extensive disease, you could administer spot radiation. If he had more extensive painful metastases, you might need to start him on narcotics and then perhaps radium-223.

Answer: ADT docetaxel if PS improves on ADT

I would administer ADT to this 80-year-old patient with extensive bony metastases and determine how he fared. My goal would be to get the patient on the full dose of chemotherapy once the performance status improved. However, tolerability is less predictable in older patients. Pharmacokinetics are variable in these patients. I have administered chemotherapy to some patients in their nineties who have fared well, but these patients are physiologically in their seventies. You have to select your patient carefully. I would consider growth factor support for older patients and monitor their blood counts frequently.

Answer: ADT docetaxel if PS improves on ADT

I would start this patient on ADT and then reassess his performance status, which often improves after hormonal therapy. In the CHAARTED trial, docetaxel was administered within 4 months of ADT, so I have about 120 days within which I can initiate chemotherapy. If his performance status improved, I would consider administering docetaxel at 60 mg/m² and then escalating to the full dose.

Answer: ADT docetaxel if PS improves on ADT

For this 80-year-old patient with extensive bone metastases and PS 2, I would initiate ADT immediately and hope to see improvement in his performance status with time due to remission of his disease, particularly the bone lesions. Then I would consider starting him on docetaxel. If I had concerns regarding the patient’s overall performance status and tolerance to chemotherapy, I might consider reducing the dose of docetaxel. I would start therapy with a lower dose of docetaxel, recognizing that the survival data are consistent with the higher dose of 75 mg/m². I would initiate chemotherapy between 1 and 3 months and consider the PSA nadir, which is an important prognostic factor in terms of disease progression and survival. I would also be more liberal in recommending growth factors for an elderly patient.