When Age is a Relative Thing

I remember when I was a medical student and an elderly patient would be admitted to the surgical service through the emergency room with a bowel obstruction, or a lung cancer, or blockage in the coronary arteries so severe that only a coronary bypass could save him.   The students and residents would gather around the attending, and debate the merits of operating on the patient, or “keeping him comfortable”, ensuring certain death.  One of the things I remember hearing, typically from the mouths of those advocating for aggressive management was always, “But he’s a GOOD ninety!”  Meaning, the patient may have been ninety years old, but he looked younger, and had no competing medical problems, and had been living independently and enjoying life.  As I grew in my radiation oncology career, and medical students and residents would debate the same with me, one of the things I always try to remind them is, “There’s nothing like radiation and chemotherapy to turn a GOOD ninety into a BAD ninety really fast.”  It’s the truth.

So when I returned from my mini-vacation at the dog show in Palm Springs at the beginning of last week, the first thing I did was check my schedule to see if any of the patients who were seen in my absence were on the simulation list for treatment planning so I could review their history and physical exams.  I found one unfamiliar name, so I picked up his chart.  It turns out, this man is an 86 year old retired figure skater, still active as an international figure skating judge, who had recently been diagnosed with an early stage intermediate risk prostate cancer, Gleason grade of 3+4=7, PSA of 9.  He had come in under duress to see one of my partners because, you see, he didn’t WANT radiation therapy.  He wanted a prostatectomy.  Now, in my world, and in the world of my referring urologists, 86 year old men do not get prostatectomies, robotic or otherwise.  There is too much risk of fluctuation of blood pressure and bleeding, and consequently heart attack and stroke. Dr. Donald Skinner, retired Chairman of Urology at the University of Southern California used to say, “I won’t even operate on a 70 year old man, unless he brings his 90 year old father to the consultation with him.”  This patient’s choices were watchful waiting, now known as “active surveillance”, hormonal therapy, or radiation.  After a long discussion with my partner, he chose radiation therapy.

When I walked in the exam room to get the patient to sign a consent before we started, I was fully prepared to try to convince him that at his age, it wasn’t likely to make a difference in his overall life span to be treated for this early stage prostate cancer.  What I wasn’t prepared for was a man who looked twenty years younger than his stated age, in great condition, holding hands with his equally attractive wife, also a retired skater.  My speech about the treatment being unnecessary “at your age” went unsaid.  Instead, I gawked and said, “Ice dancing or pairs?”  From then the discussion veered from the upcoming Winter Olympics, and then to the fact that he grew up in Seattle and came to San Diego on vacation, whereupon he discovered that there was a place where it didn’t rain every day and decided to stay. He was twenty when he met his fifteen year old bride to be at a skating rink in Orange County.  He was tall, with an elegant physique. She was petite and a beginner. He smiled at her as he told me the story of the “best pick up line EVER!”  He found himself next to her at the edge of the rink and said, “What are you doing there, standing in a HOLE?”

Perhaps it was not the best pick up line ever. But his vivacity, vitality and joie de vivre certainly bought him a definitive course of intensity modulated radiation therapy.  After all, he’s a GOOD eighty six.