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Case history

image A 65-year-old man attended the urology-oncology clinic. He had recently been diagnosed with Gleason 9 (4+5) adenocarcinoma of the prostate with bone metastases and pelvic lymphadenopathy and had been commenced on androgen deprivation therapy (ADT). His presenting prostate-specific antigen (PSA) level was 200 µg/l. He was symptomatic from his spinal metastases, reporting low back pain. He had tried paracetamol with minimal effect.

His comorbidities included type 2 diabetes and hypertension. He also had chronic kidney disease secondary to diabetic nephropathy; his normal baseline creatinine level was 140 µmol/l. A staging CT scan at diagnosis showed evidence of left-sided hydronephrosis secondary to extensive pelvic lymphadenopathy and acute kidney injury.

He was the main carer for his disabled wife and did not have any close family or friends in the area for support. He took her out every day to a small café in his neighbourhood.

The option for upfront chemotherapy with six cycles of docetaxel was discussed in clinic. He initially declined treatment, however, as he was concerned about leaving his wife alone while he was having chemotherapy. He was also worried about the risk of neutropenic sepsis, as if it was necessary to admit him to hospital there was no one else to care for his wife. In view of his concerns and social circumstances we made several modifications which enabled him to go ahead with chemotherapy.

We prescribed prophylactic granulocyte-colony stimulating factor (GCSF) to minimize the risk of febrile neutropenia with the aim to prevent hospital admissions.

We commenced his docetaxel chemotherapy at the recommended dose of 75 mg/m2 but monitored him closely for signs of neuropathy which might have impaired his ability to care for his wife.

We organized for his wife to be seen by a social worker and occupational therapist, and to have regular home care visits.

We arranged for hospital transport to take him and his wife to the chemotherapy appointments so he did not have to leave her at home.

The urology multidisciplinary team discussed the management of his ureteric obstruction and decided that he should have a temporary nephrostomy, with the plan to convert to a stent if he had a good response to chemotherapy and ADT.

The patient successfully completed six cycles of docetaxel with no adverse effects. He did not require any hospital admissions during his treatment. A CT scan at the end of treatment showed resolution of his pelvic lymphadenopathy and his PSA fell from 200 to 1.5 µg/l. He successfully underwent a metallic ureteric stent insertion and his renal function returned to baseline.

What was the goal of cancer treatment for this patient?

What is the evidence base for his treatment options?

How did his social issues affect the decision to give chemotherapy?

How do we manage ureteric obstruction in patients with malignancy?

What was the goal of cancer treatment for this patient?

The aim of upfront chemotherapy for this patient was ...

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