Radiation Dose..

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Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2200
   Posted 7/5/2010 10:52 PM (GMT -6)   
While researching various PC treatments, I stumbled across something interesting. With radiation treatment, any type of radiation treatment, the higher the dose they can give you, the better the outcome. The IDEAL dose, the most effective, seems to be in the 90 to 100 Gray range. (I could be wrong about that one).. But with external beam radiation, photon or proton, the administered dose is usually in the 70 to 80 Gy range, because the damage to the surrounding tissue and organs is just to great and you have reached the point of diminishing returns, the treatment doing more harm than good..EXCEPT...

Except when the combination of brachytherapy (seeds) and IMRT are used in combination. Then doses to 100Gy and beyond can be administered which improves outcomes substantially..

This treatment option seems to have the best overall survival rate which leaves me wondering why it's not used more often..
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. A "top" radiation oncologist here in Denver, equipped with the latest IMRT/IGRT/RapidArc machine says he can do better by me..


English Alf
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Date Joined Oct 2009
Total Posts : 2043
   Posted 7/6/2010 12:39 AM (GMT -6)   
Fairwind,

Interesting for me to read this having finished RT 4 weeks ago (66Gy in total)

Did you read about this on the web, if so then posting the address here would enable those interested to read it too.

RT is not only about balancing the need to damage the cancer enough without damaging the surrounding tissue too much, but also about not giving you so much radiation that the radiation ends up causing cancers further down the line. So the full details on those survival stats you mention would also be good to see.

I have also never heard of anyone having seeds and IMRT.
New thoughts on all treatments for PCa are always going to be welcome.

The nature of Proton beams means they can be better: they behave strangely so that the target receives a higher dose than the tissue between the skin and target. (I think it's something called the Bragg effect/peak where the strength of the beam reaches its maximum about four inches into tissue and then almost disappears altogether on the way out. Whereas Photon-beam/xrays gradually reduce in strength after they enter the body and also continue through the body after hitting the target area.)

Another way of reducing the dose to surrounding tissue is to aim in beams from several directions. Many folk here have had RT from three different directions so that with a dose of say 66Gy only 22Gy gets given down each of the three axis. For me however they used SEVEN beams so that each one only gave 9.5Gy to the surrounding tissue, which also has to be an improvement. (I can see how you might be able to give 100Gy by giving 10Gy down 10 separate axis)

I imagine we have all be following David/Purgatory's story about how his bladder neck has not been healing since he had RT, which while not really a case of too much Radiation, may well be one of too much in the wrong place so it makes me aware that the guiding principle behind treating cancer with RT has to be that too much radiation is a bad idea.

Alfred
Age at Dx 48 No Family history of Prostate Cancer
Married 25 years, and I cannot thank my wife enough for her support.
April 2009: PSA 8.6 DRE: negative. Tumour in 2 out of 12 cores. Gleason 3+3.
RALP (nerve-sparing) at AVL-NKI Hospital Amsterdam on 29th July 2009. Stay 1 night.
Partial erections on while catheter still in. Catheter out on 6th Aug 2009.
Dry at night after catheter came out
Post-op Gleason 3+4. Tumour mainly in left near neck of bladder.
Left Seminal Vesicle invaded, (=T3b!)
no perineraul invasion, no vascular invasion. clear margins,
Erection 100% on 15th Aug 2009, but lots of leaking of urine
Stopped wearing pads on 21st Sept 2009
Pre-op style intercourse on 24th Oct 2009 !! No use of tablets, jabs, VED etc. but...
Nov 17th 2009 PSA = 0.1
Can still get erections okay, and almost no leaking of urine, but since December 2009 I don't have orgasms, instead I just have intense pain in place where prostate used to be.
Mar 17th 2010 PSA = 0.4!!! referred to radiation therapist
April 13th 2010 CT scan.
April 28th 2010 Started Radiation Therapy (66Gy - 33 sessions)
June 11th 2010 finished RT - main side effect tiredness, but also the occasional small leak

Post Edited (English Alf) : 7/6/2010 12:46:28 AM (GMT-6)


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3114
   Posted 7/6/2010 5:44 AM (GMT -6)   
Seeds and IMRT: These are the most reknown for brachy seeds and IMRT
(alot of local hospitals have docs doing so now, look for expertise levels)

www.dattoli.com  (Florida Dr. Dattoli) (IMRT first then seeding)
www.rcog.com  (Radio therapy clinics of Georgia) (seeding first then IMRT)
(Doctor Blasko I think, Oregon? maybe another one in this arena)

These two have a disagreement or did so in the past about is it better to have seeds first or IMRT first. I like Dattoli's information on that, senergy effect with external radiation with seeds inside of you already (used by RCOG), might not be the best way, who knows?

They have track records and been doing this along time, many patients saying decent things about their treatment (fyi). cool    Had it been near Michigan I might have gone with them, I did contact both of them way back 2002 and did not include them in my 8 opinions as it was not face to face only phone and writtings.


Youth is wasted on the Young-(W.C. Fields)

Post Edited (zufus) : 7/6/2010 5:51:33 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 23571
   Posted 7/6/2010 8:18 AM (GMT -6)   
I could be wrong, but couldn't imagine most people being able to endure a 100 gy routine of radiation, no matter how it was distributed. My 72 gys as as salvage was considered a strong salvage dose. I know we have a few men that had RT as primary treatment that took around 80-84 gys, but that was distributed while they still had a prostate in place.

Not sure they mix Seeding and IMRT together, I think they use a differerent delivery method with that combo, but hopefully some of our seeded brothers will check in.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest:  7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped  9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12 ,Cath #11 - 21 days,  Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, 7/2 - Caths #18 & #19


zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3114
   Posted 7/6/2010 8:58 AM (GMT -6)   
Purg- you did not trust my post above yours on this seeding and brachy?
 
tongue  
Youth is wasted on the Young-(W.C. Fields)


Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2200
   Posted 7/6/2010 9:23 AM (GMT -6)   
My own surgeon, in a pre-surgery conference, warned me that I needed to start doing physical therapy NOW to strengthen my bladder muscles so I could rapidly regain continence after the operation..He said "should you need follow-up radiation treatment, the radiation will "freeze" my continence level right where it is and there will be no improvement after radiation is started..

I translated that to mean that the radiation will damage already damaged tissue and the healing process stops right there.. Purgatories experience would seem to support this.

What the research says:
Published research series have already demonstrated advantages of
IMRT over 3-D conformal radiation at higher dose levels. Meanwhile,
several recent studies have even demonstrated the lack of superiority of
protons over 3D conformal radiation. We are unaware of any proton
study series utilizing higher doses than 3D conformal radiation. The
preponderance of data suggests that higher doses equal higher cure
rates. It is not possible to safely escalate protons to doses as high as
those used with 4D IG-IMRT coupled with a Palladium-103
brachytherapy. It has been well documented that it requires far higher
doses of radiation to truly eradicate prostate cancer. This is
accomplished only with 4D IG-IMRT utilizing DART and Pd-103
brachytherapy, which also has the advantage of maximally sparing
adjacent normal tissues -- neither is achieved with protons.

http://www.prostateseedinstitute.com/treatmentcancer.aspx

http://www.cancernetwork.com/print-cme/article/10165/11...

Prostate cancer treatment, prostate cancer brachytherapy - dattoli.com
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. A "top" radiation oncologist here in Denver, equipped with the latest IMRT/IGRT/RapidArc machine says he can do better by me..

Post Edited (Fairwind) : 7/6/2010 9:39:43 AM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 23571
   Posted 7/6/2010 9:25 AM (GMT -6)   
Zufus ,actually, I didn't see it. Only remember seeing Alfs advice. Your advice was very sound, of course. I wonder if it wasn't posted yet when I posted mine, but the more advice the merrier, especially when opinions are in general agreement of the subject.

Alf - my SRT was delivered on 7 daily rotations of the Tomalis Machine. I use to keep my eyes closed and listen for the position changes each time
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest:  7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped  9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12 ,Cath #11 - 21 days,  Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, 7/2 - Caths #18 & #19


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 467
   Posted 7/6/2010 9:52 AM (GMT -6)   
Fairwind,  Several men on the HW forum have had seed implants followed by IMRT including the very knowledgeable JohnT.   You and Zufus are correct about the high doses used.  From the PCRI site,  "The doses delivered by implantation are significantly higher than those achievable by 3Dconformal/IMRT, external beam radiation therapy, or HDR brachytherapy. Typical doses for implants are 125-145 Gy. "  This is the link if interested:  http://www.prostate-cancer.org/pcricms/node/179.  For what it is worth dept., my former local uro recommended that I have the seed and IMRT combo.  It probably was the treatment of choice for me, but I had significant urinary issues with BPH and the local docs don't track their results.  I chose out of town surgery with an experienced surgeon that tracks his patients.   As zufus says, there are no easy choices.  Good luck.
 
Carlos

Diagnosed 2/2008 at age 71, Gleason score 5+3=8, stage T1c, PSA 9.1. 
Robotic surgery 5/2008, nerves spared, stg. pT2c, N0, MX, R0, Gleason 5+3=8 
PSA <0.1 at 20 months and each test since surgery.


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3541
   Posted 7/6/2010 10:45 AM (GMT -6)   
To set the story straight and help to sort through the misinformation about radiation.
The normal ERBT dose was about 65gy for years. The newer radiation devices like IMRT and IGRT have allowed standard doses of about 81gy. Proton still uses about 65 to 71 gy because of scatter.
The normal dose of brachytherapy is about 100gy depending on the size of prostate and planning data. The normal dose for a combination therapy of seeds and IMRT is between 120 gy and 150 gy about twice the dose of proton and ERBT. The delivery methods have improved so much in the last few years that higher doses can be safely given with fewer side affects. It is a well established fact that higher doses equate to higher cure rates. Cure rates go up significantly with just a small rise in dose. There is a very small cahance that secondary cancers can appear years down the road, but your chances of getting another unrelated cancer, a reoccurrance or dieing from something else is hundreds of times higher, so I choose to worry about real dangers, not imagined ones that have a small chance of ever occuring. The Prostate Cancer Study Group concluded that a combination of Brachy and IMRT had the best cure rate over all grades of PC than any other method. There are many long term studies over 15 years from Seattle, Chicago Prostate Institute, RCOG and Dattolli that support this. Newer studies also show that delayed radiation affects rarely occur later than 2 years out, so what you have at the 2 year mark you will most likely have for life.
I had 85 gy of seeds and 45gy of IMRT for a total of 130 gy, with absolutely no side affects and 1 year out my psa is 0.1 down from 40. I don't know why it isn't used more, but I think it is because many doctors and patients are so fixiated of surgery they don't look any futher. Radiation works best with small prostates, under 60mm and where the tumor volume is not excessive. The newer forms of radiation and planning have gone a long way to reduce dead spots and damage to surrounding organs from the older ERBT resulting in higher cure rates than surgery and much less side affects.

JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


SubicSquid
Regular Member


Date Joined Oct 2009
Total Posts : 252
   Posted 7/6/2010 11:13 AM (GMT -6)   
Since I no longer have a prostate, I guess seeds wouldn't help much. For men deciding on initial treatment the seed/IGRT combination sounds like something to consider. According to my radiologist, there are two schools of thought on how much radiation for salvage. Old school is 66 gys. New school is 70-72 gys. The newer machines make delivery more accurate with less collateral damage. The stronger dose helps kill the cancer. I am getting 39 treatments for a total of 70 gys. I get seven zaps at each treatment as the maching rotates around my body. I count them down each day and know where the machine weill stop each time. Only 15 treatments left!!!!! Like most radiologists, mine feels that if I had come to him first I would have been better off than having surgery. Who knows. Squid.
*Age 63, PSA July 2009 5.66
*Diagnosed July 2009, Biopsy: 2 of 12 cores positive, Gleason 3 + 5 = 8
*MRI and Bone Scan Negative.
*open Surgery October 22, 2009
*Prostate, both nerve bundles, seminal vessels, and lymph nodes removed during surgery.
*Post surgery Biopsy, Gleason 4 + 3; 2 positive margins
*ED - Yes 
*30 day PSA (ultra-sensitive) .07
*90 day PSA (standard) <0.15
*01/10 - bladder neck stricture. opened during cysto exam. Cath #2 in for 5 days.
*03/01 - bladder neck stricture. Dilated during cysto exam. Cath #3 in place.
*03/11 - Bladder neck surgery. Cath #4 in place.
*03/15 - Cath #4 out. Great urine stream. Unfortunately, incontinence back to post surgery level.
*04/14 - Six month PSA .21.
*05/15 - Incontinence basically under control.  99% dry.  Wear pad daily at work "just in case".
*06/10 - Started IGRT.   39 treatments scheduled.
 

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