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Q: Stage IV Prostate Cancer ( Answered 4 out of 5 stars,   1 Comment )
Subject: Stage IV Prostate Cancer
Category: Health > Men's Health
Asked by: utah-ga
List Price: $25.00
Posted: 02 Aug 2005 00:52 PDT
Expires: 01 Sep 2005 00:52 PDT
Question ID: 550706
My father is 76 years old and is in Stage IV Prostate Cancer.  He has
hot spots in his skull, shoulder, ribs, hips and spine.  He had his
prostate removed approximately 10-years ago and has been through all
the treatments, except chemo. The pain in his shoulder and neck has
been out-of-control since March of this year, until just recently when
the pain management doctor prescribed 75 mg Fentanyl Patch along with
5 mg Oxycodon, 2 tablets every four hours and also something for the
vomiting (which isn't helping).  He has lost over 20 lbs since April
(before the vomiting started) and since the agressive treatment of
pain management started, the vomiting has worsened.  I am so grateful
that finally his pain has been managed but I am extremely worried
about his nutrition and prognosis.  Question 1:  How serious does it
have to get in order for the doctor to have him hospitalized?
Question 2:  When is it appropriate to call Hospice?  Question 3:
What's his prognosis at best?  Thank you for your time.
Subject: Re: Stage IV Prostate Cancer
Answered By: crabcakes-ga on 02 Aug 2005 19:43 PDT
Rated:4 out of 5 stars
Hello Utah,

   In metastatic (cancer that spreads) prostate cancer, the prostate
cancer is shedding cancerous cells that lodge in other parts of the
body, particularly the bones. At this point, one needs to think about
quality of life of the patient, in this case, your father. Each person
reacts differently to cancer and the treatments for it. Some
therapies, as you know can make the last days even more difficult. It
sounds as if you and your family may have decided that pain control is
most important, deciding to forgo any further therapy. When other
treatments fail, some doctors will turn to androgen-suppression
therapy. (More on this later in the answer). It sounds as if your
father is comfortable with the exception of the vomiting.

If he is vomiting often, and not eating well, he  may become
dehydrated and his electrolytes may become unbalanced. Try to keep him
drinking, water, juice, or Gatorade, etc. The ginger in ginger ale
often helps a nauseated stomach ? serve your dad some ginger ale on
ice, and have him sip it. The canned nutritional supplement drinks
such as Ensure or Boost may appeal to him, and get him some extra
proteins and other nutrients.

You don?t say what your father was given for vomiting, but there are
several different type of anti-emetics available, such as Medrol,
Zofran, as well as an effective rectal suppositories such as Phenergan
or Compazine. Keep a close eye on him to avoid dehydration.

?The most common signs and symptoms of dehydration include persistent
fatigue, lethargy, muscle weakness or cramps, headaches, dizziness,
nausea, forgetfulness, confusion, deep rapid breathing, or an
increased heart rate. Dehydration is a very serious condition, more
than most people realize. Since seniors often have a reduced sense of
thirst, dehydration is one of the most frequent causes of
hospitalization after age 65.
Other less common signs and symptoms of dehydration can include:
	Excessive loss of fluid through vomiting, urinating, stools or sweating
	Poor intake of fluids, "can't keep anything down"
	Sunken eyes
	Dry or sticky mucous membranes in the mouth
	Skin that lacks its normal elasticity and sags back into position
slowly when pinched up into a fold
	Decreased or absent urine output
	Decreased tears?

The same site lists foods with a high water content that will aid in
avoiding dehydration.

   Your doctor will decide when to hospitalize your dad, based on his
condition. The issue is, do you want to hospitalize him? Would you
like to keep him at home during his last days? Of course, if you are
unable to care for him, or he becomes severely dehydrated or
malnourished, he may require hospitalization. Your doctor will need to
evaluate his condition. Let  me add that some families have a home
nurse come by to  start and maintain IVs for electrolyte and fluid
balance, and lines for TPN (Total parenteral nutrition) for proteins
and vitamins. According to some reliable web sites, treatment with
hormone therapy may help your dad live a few more years. (This is also
discussed further down in the answer).

Have you spoken about going to the hospital or hospice with your
father? Studies show that a large percentage of cancer patients want
to be informed and make decisions about their own care. If and when
the time comes for your father to have hospice care, you and he should
make this decision together.

?Patients have variable preferences for information and involvement in
their cancer care, with predictive variables including age, sex,
education, and performance status. A survey of 1,012 Canadian women
with early breast cancer revealed that most of these women wanted
detailed information about their disease, that 22% wanted to select
their own treatment, that 44% wanted to select treatment
collaboratively with their doctor, and that 34% wanted their doctor to
select the treatment.5 A small study of 48 patients with colon cancer
reported that while these patients have similar information needs
compared with patients with breast cancer, they have strikingly lower
involvement preferences.6 Indeed, 78% wanted to play a passive role in
decision making and 80% perceived that they did so. Similarly, a study
of 57 men with prostate cancer found that the men wanted to be well
informed, though 58% preferred that their doctor make the final
treatment decision.7 Estimates of the proportion of cancer patients
who achieve their desired involvement in their treatment decision
making range from 34% to 42%.?

?Treatment decisions in advanced cancer are difficult. The uncertain
benefits of systemic anticancer treatment must be weighed against
likely toxicity, in a situation where the goal of treatment is not
cure. While many decision supports exist for early-stage cancer
patients, there are few for advanced cancer patients, who arguably
have a greater need for decision support.
The potential benefits of DAs include enhanced patient understanding,
reduced decisional conflict, enhanced harmonization between patient
values and treatment decisions, and greater patient involvement and
satisfaction with decision making. Two systematic reviews have been
reported regarding 18 randomized trials that studied the effects of
DAs on improving patient decision making and patient outcomes in
patients with early-stage cancer.

 These meta-analyses demonstrate that, compared with controls, most of
the DAs studied produced higher patient knowledge scores, lower
decisional-conflict scores, and more active patient participation in
decision making. No differences in anxiety or satisfaction with
decisions were seen.13 The effectiveness of these promising decision
support tools for advanced-stage cancer patients and their role in
current oncology practice should be better defined through additional
randomized trials. DAs and supports to facilitate decision making for
patients grappling with the diagnosis of advanced cancer can further
our goal of improving the quality of decision making and overall care
in advanced-stage cancer patients, through enhancing informed consent,
decision satisfaction, better harmonizing of treatment decisions at
the end of life with patient values, and potentially improving patient
well being.?

As far as hospice care, most hospice centers follow the following criteria:
Progressive disease 
	Worsening clinical signs ? see below 
	Decreasing functional status 
	Evidence of metastatic disease 
Clinical signs 
	Pain, nausea or vomiting 
	Thrombosis or DIC 
	Bone marrow involvement requiring transfusion 
Disease stage 
	Stage IV (any T,N,or M1) at initial diagnosis 
	Progression of an earlier stage of disease with either of the following: 
  ? Patient continues to decline despite definitive therapy 
  ? The patient is refractory or refuses further treatment 
Performance status 
	Karnofsky score of 50% or less
	Karnofsky score of 70% or less, if patient has progressive disease
on therapy, or declines therapy

The Karnofsy Score may be requested under certain diagnoses.
	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 work 
	60 -- Requires occasional assistance from others but able to care for most needs 
	50 -- Requires considerable assistance from others; frequent medical care 
	40 -- Disabled, requires special care and assistance 
	30 -- Severely disabled, hospitalization indicated; death not imminent 
	20 -- Very sick, hospitalization necessary, active supportive
treatment necessary
	10 -- Moribund
(Moribund signifies death is imminent or close at hand)

?It is appropriate to discuss all of the patient's care options at any
time during a life-limiting illness. The patient and family should
feel free to discuss hospice care at any time with their physician,
hospice professionals and other healthcare professionals, clergy or
friends. Most physicians are familiar with hospice, even if they
haven't worked directly with a hospice program. Hospice staff can also
help patients and families with questions about end-of-life care
planning and decision making. The decision to enter Hospice care
belongs solely to the patient.?

?Who makes the decision about entering hospice and when?
Ultimately the decision to enter hospice belongs to the patient. Any
time during a life-limiting illness, it is appropriate to discuss all
care options, including hospice. People are sometimes uncomfortable
with the idea of stopping aggressive efforts to cure their disease.
Hospice staff members are highly sensitive to these concerns and are
available to discuss them with the patient and family.

Can the patient stay at home while under hospice care?
Yes. Hospice is a philosophy and a concept, not a place, so it comes
to you. With hospice support, the majority of hospice patients are
cared for in their own homes surrounded by loved ones and friends.
Family and friends deliver most of the care under the watchful eye of
the hospice interdisciplinary team members who teach caregivers, visit
regularly to provide care, answer medical questions, and provide
support. Hospice of the Treasure Coast has a staff available 24 hours
a day to consult with the family and make additional day or night
visits as appropriate. Hospice designs the care to enable you to stay
at home if you desire to do so.

Why would terminally ill patients choose hospice care?
Hospice care focuses on patient comfort and quality of life; helping
individuals with life-limiting illnesses live their final days
pain-free and with dignity. Making the choice to begin palliative care
through Hospice of the Treasure Coast allows the patient and family to
remain together in the comfort and security of their home or, in the
case of resident care, in a home-like setting. Hospice care is
available anywhere the patient lives; at home, in an independent
living complex, assisted living or skilled nursing facility, or even
in the hospital. The intensity and range of hospice and palliative
interventions may increase as illness progresses and the complexity of
care and needs of the patient and their families increase. Care
priorities shift to focus on end-of-life decision-making and to
support physical comfort and a death consistent with the values and
expressed desires of the patient.

Hospice and palliative care guide patients and families as they
address issues of life completion and closure. Hospice care does not
replace the family, in caring for a loved one, but provides the
primary caregiver with well-trained support staff that is skilled in
caring for patients and families coping with a life-limiting illness.?

According to Cancer Consultants Stage IV prostate cancer is complex
and hard to treat.
?Prostate cancer diagnosed in this stage is often difficult to cure,
although patients may live for several years with effective

?A variety of factors ultimately influence a patient's decision to
receive treatment of cancer. The purpose of receiving cancer treatment
may be to improve symptoms through local control of the cancer,
increase a patient's chance of cure, or prolong a patient's survival.
The potential benefits of receiving cancer treatment must be carefully
balanced with the potential risks of receiving cancer treatment.?

?Prostate cancer that has spread to distant organs and bones is
treatable, but not curable with current standard therapies. Hormonal
therapy has been the standard treatment of metastatic prostate cancer
for many years. Metastatic prostate cancer usually can be controlled
with hormone therapy for a period of time, often several years.
Eventually, however, most prostate cancers are able to grow despite
the hormone therapy.?

?Patients with advanced prostate cancer can have cancer cells  that
have spread to their bones, called bone metastases.  Bone metastases
commonly cause pain, increase the risk of fractures, and lead to a
life-threatening condition characterized by an increased amount of
calcium in the blood called hypercalcemia.  Treatments for bone
complications may include bisphosphonate drugs or radiation therapy.?
Because of copyright restrictions, I am unable to post the entire
contents of this page. Please read the information on bisphosphonate

?Treatment selection depends on age, coexisting medical illnesses,
symptoms, and the presence of distant metastases (most often bone) or
regional lymph node involvement only. The most common symptoms
originate from the urinary tract or from bone metastases. Palliation
of symptoms from the urinary tract with transurethral resection or
radiation therapy and palliation of symptoms from bone metastases with
radiation therapy or hormonal therapy are an important part of the
management of these patients. Bisphosphonates are also under clinical
evaluation for the management of bone metastases.?

?Prostate cancer usually is a disease of older men. Bone scans may be
used to discover metastatic prostate cancer, which often appears in
bones. Other tests that may be used to determine the extent of
metastatic prostate cancer include computed tomography (CT) and
magnetic resonance imaging (MRI).
Treatment for metastatic prostate cancer focuses on relieving symptoms
and slowing the rate of cancer spread. Treatment may include hormone
therapy, radiation therapy, surgery, and chemotherapy. In some cases,
participation in a clinical trial of a new treatment may be an

?Prostate cancer has been shown to metastasize by following the venous
drainage system through the lower paravertebral plexus, or Batson's
plexus.4,9 Although hematogenous spread of other malignancies is most
commonly to the lungs and liver, 90 percent of prostatic metastases
involve the spine, with the lumbar spine affected three times more
often than the cervical spine. Prostate cancer also spreads to the
lungs in about 50 percent of patients with metastatic disease, and to
the liver in about 25 percent of those with metastases.?

?Can I help prevent prostate cancer metastasis? 
Because the cause of prostate cancer and its metastases is not known,
doctors do not know how to prevent it. In the hope of early diagnosis
leading to longer life and fewer complications, all men, and
especially men over 40, should have a doctor examine the prostate
every year.?

?Treatments for cancer that has recurred after initial therapy is not
always clear-cut. If the cancer recurs locally, cure may still be
	Surgery and androgen-suppression therapy may be considered for
patients who were first treated with radiation receive.
	For patients who were initially treated with surgery, radiation or
androgen-suppression therapy are both options.
If the disease has already spread or if the physician suspects that it
may have spread, the patient is typically given androgen-suppression
therapy. Chemotherapy agents in combination with hormonal agents are
being investigated for patients who fail surgery or radiation.
Androgen-Suppression Therapy. Treatments that block or suppress
androgens (male hormones) are often the appropriate response to rising
PSA levels after treatment failure. There has been some debate over
whether to start this therapy as soon as PSA levels rise or wait until
symptoms develop. Some studies indicate there is no increased survival
from early treatment, and patients have a better quality of life if
therapy is started only after symptoms have occurred. A major analysis
in 2002, however, reported that early intervention prolonged survival
over a 10-year period.?

?Hormonal treatment is the mainstay of therapy for distant metastatic
(stage D2) prostate cancer. Cure is rarely, if ever, possible, but
striking subjective or objective responses to treatment occur in the
majority of patients. Initial results from a randomized study of
immediate hormonal treatment (orchiectomy or LHRH analogue) versus
deferred treatment (watchful waiting with hormonal therapy at
progression) in men with locally advanced or asymptomatic metastatic
prostate cancer showed better overall survival and prostate
cancer-specific survival with the immediate treatment. The incidence
of pathologic fractures, spinal cord compression, and ureteric
obstruction were also lower in the immediate treatment arm.?

?Prostate cancer cells require androgens in order to grow. Androgens
can be testicular or adrenal in origin.
The secretion of testosterone is stimulated by the direct action of
luteinising hormone (LH) on receptors located on specialised cells
(Leydig cells) found in the testes. LH itself is stimulated by
luteinising hormone-releasing hormone (LHRH) produced by the
pituitary. Thus LHRH indirectly regulates the secretion of
testosterone from the testes.
The adrenals secrete precursors, which are converted into androgens in
the peripheral tissues and in the prostate itself. Removing Androgens
may be an effective way of temporarily reducing the tumour bulk and
delaying growth.?
The following page does not allow copying, but scroll down to Page 3,
and look for Hormone Therapy. It recommends androgen-suppression
(anti-androgen hormone) therapy. Low doses of corticosteroids may help
alleviate bone pain as well.

Consider too, getting your dad a thick memory foam mattress pad to
make resting and sleeping more comfortable on his aching bones.

I hope this has answered your questions adequately. If not, please
request an Answer Clarification, before rating. This will allow me to
assist your further, if possible.

I wish you and your father well.
Sincerely, Crabcakes

Search Terms
prostate cancer metastasized
Metastatic prostate cancer
signs dehydration
Stage IV prostate cancer
Hospice criteria

Request for Answer Clarification by utah-ga on 03 Aug 2005 02:54 PDT
Thank you for the detailed and very informative response.  Yesterday,
my father was admitted to the hospital.  There is a great deal of
comfort in knowing he is getting the proper care and treatment.  He
was so weak yesterday morning that he could hardly get out of bed.  My
father has refused chemo treatments at this time.  His approach was
for "quality" of life rather than the possibility of prolonging his
life. We know he is scared....we all are but one thing is certain,
keeping him comfortable is the most important thing to all of us.  The
information you have provided will certainly assist us in making the
best choices with and for my father.  Thank you!

Clarification of Answer by crabcakes-ga on 03 Aug 2005 09:55 PDT
Hello Utah,

   Thank you for the generous tip. I know this is a difficult time for
all of you. Don't be afraid to ask for the care your dad deserves in
the hospital. You can also take in a memory foam mattress if the
hospital does not provide a comfortable mattress. Most hospitals allow
you to bring in family pictures, and a favorite blanket. Bring a
picture of your father before he was ill, to remind staff that your
father is a human being, and not just a "case"

   All the best, Crabcakes
utah-ga rated this answer:4 out of 5 stars and gave an additional tip of: $10.00
Information provided was very informative and detailed.  Thank you!

Subject: Re: Stage IV Prostate Cancer
From: hovattar-ga on 23 Jul 2006 12:14 PDT
Dear Utah,

A really good, quality memory foam mattress and pillow can help so
much increase the quality of life with older people or people who need
to spend time in bed due to illness. You can find a memory foam
mattress at They also carry memory
foam mattress protectors that help prevent any liquid from damaging
the mattress.

Hoping this helps,


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