Case Study: Mr. Aquino

Case Study: 63 year old male with advanced prostate cancer

Author of case study: VJ Periyakoil, MD.

Initial Diagnosis

Carlos Aquino, a 63 year old Filipino male with hormone-refractory prostate cancer is your clinic patient. Mr. Aquino was diagnosed with benign prostatic hypertrophy (BPH) several years ago and was taking alpha blockers for this condition.

A year ago, his BPH symptoms worsened despite maximal therapy. At that time you performed a digital rectal exam and noted that he had a new hard nodule (1cm x 1cm) in the right lobe of his prostate and a PSA of 2.4 (PSA in the year prior to that was 2.2). A prostate biopsy revealed high-grade adenocarcinoma in 5/5 R lobe biopsy specimens with Gleason’s score of 4+5, and 2/5 of L lobe biopsies. A bone scan showed a small focal abnormality in the lumbar spine at the level of the L2 vertebra. The prostate cancer was staged as T2b.

Past Medical History

  • Hormone-refractory metastatic prostate cancer per HPI
  • Severe Gastro Esophageal Reflux Disease
  • Coronary artery disease status post myocardial infarction two years ago with a history of left circumflex percutaneous transluminal coronary angioplasty
  • Pulmonary nodules 2mm , stable per CT  for the last 5 years
  • Hypertension
  • History of depression
  • Current tobacco abuse
  • Hyperlipidemia

Social History

The patient was born and raised in Manila, Phillipines. He completed high school, and worked in the Phillipines. A few years ago he immigrated to the US ( sponsored by his sister who is in the US).

He has been married to his wife for 35 years and has three adult children .

At time of diagnosis

Patient seen by Oncology and then by radiation oncology. Their recommendation was for the patient to undergo radiation therapy (external beam Intensity Modulated Radiation Therapy) followed by hormonal therapy and possible Taxotere trial.

Six months post cancer diagnosis

Mr. Aquino was treated with radiation therapy (external beam Intensity Modulated Radiation Therapy) to his prostate and pelvic lymph nodes and placed on hormonal therapy and a Taxotere trial. He complained of increasing low back pain. An MRI scan showed bony metastasis to the L2 and L3 spine. The PSA was increasing at 18.6. He received radiation therapy to the spine.

Nine months post cancer diagnosis

Mr. Aquino complained of escalating back, flank, rib, and leg pain. A second course of Taxotere was initiated. Later that month, a bone scan demonstrated increased uptake throughout skull, ribs, and thoracic and lumbar spine, as well as a slightly increased uptake in the proximal L femur. PSA was noted to be 48.4. The patient was seen by uro-oncology and treated with two courses of mitoxantrone and prednisone. His pain was initially controlled with a hydromorphone patient controlled anesthesia and currently on methadone 80 mg every eight hours.

Today (eleven months post cancer diagnosis)

Patient is here with his wife to see you for routine follow-up. He reports moderate pain control on his current pain regimen. He also states that his appetite is poor and that he tires easily. He is independent in his ADLs and IADLs, and even working occasionally on his good days. You note that he has lost 2 pounds since his last clinic visit 2 months ago. (BMI= 25.6).He is alert and oriented. His recent labs show a PSA = 70.7

You elicit an interval history (wt loss, fatigue, Taxotere, etc). The patient lies down on the table and you do a routine exam.

Patient is looking anxious and asks: “Doc , how much time do I have”

Formulating a prognosis for this prostate cancer patient:

Mr. Aquino is a 63 year old male with hormone refractory prostate cancer, KPS = 70%, anorexia, weight loss, increasing pain and fatigue. His PSA is increasing despite multi-modal therapy. He is alert and oriented. He has no other reported symptoms.

You note that patients with hormone refractory prostate cancer who have indices similar to Mr. Aquino (age 63, PSA 70.8, Albumin 2.6, Alkaline Phosphatase 219, Hgb 11.5, LDH 680), who are tracked through database at Memorial Sloan Kettering Cancer Center, show a median survival of 3 months at a Karnofsky Performance Scale of 70 (which is Mr. Aquino’s KPS score at the present time) and a 1yr survival probability of 2% with 2-yr survival probability of < 1%. (These estimates don’t directly consider presence or extent of metastases, PSA doubling time or patient ethnicity). Memorial Sloan-Kettering Cancer Center Prostate Nomogram

Karnofsky Performance Scale
%
Description — Level of Functional Capacity
100
Normal, no complaints, no evidence of disease
90
Able to carry on normal activity, minor signs or symptoms of disease
80
Normal activity with effort, some signs or symptoms of disease
70
Cares for self, unable to carry on normal activity or to do active work
60
Requires occasional assistance, but is able to care for most needs
50
Requires considerale assistance and frequent medical care
40
Disabled, requires special care and assistance
30
Severely disabled, hospitalization is indicated although death is not imminent
20
Hospitalization is necessary, very sick, active supportive treatment necessary
10
Moribund, fatal processes progressing rapidly
0
Dead
Source: Karnofsky, DA, Burchenal, JH. The Clinical Evaluation of Chemotherapeutic Agents in Cancer. Pg. 196. IN: MacLeod CM (Ed), Evaluation of Chemotherapeutic Agents. Columbia Univ Press, 1949.

Additional Patient Information

As for the patient’s health care goals, his primary objective is to remain pain free. He realizes that despite his young age, metastatic prostate cancer is an uncurable disease with treatments being primarily palliative with rather modest survival benefit at the current stage.

Though his wishes are to continue considering available chemotherapy/radiation, Mr. Aquino’s primary goal is to be pain free, and to be able to spend quality time with his family, and to stay active. Though he would prefer to have CPR and intubation as treatments for acute issues, he would not like prolonged life support and would wish to have them withdrawn if they only served to prolong his life artificially.

 

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