IMRT Procedure

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Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/30/2013 6:45 AM (GMT -6)   
Irmaly, if you are on, I am at the point of treatment planning. Do you recall the type of targeted guidance Dr. Lee uses at Duke? Some centers implant gold markers in the prostate while others utilize a CT for each IMRT treatment (process at Seby Jones) which is less efficient. I am very satisfied with Dr. Mack, the RO here, but want to compare process and equipment Dr. Lee uses. I would think Duke would have the most contemporary process.
 
Also, I know your husband had an MRI done at Wake Baptist but did Dr. Lee do any other scans/tests? I noticed your husband had an undetectable PSA after the IMRT treatment, and virtually no side effects (the first being rare for IMRT). Do you attribute that to the process and equipment Dr. Lee utilizes?
 
I have decided on IMRT and initially wanted it done here so I don't have to leave my wife alone for most of 7 - 8 weeks. She is still tired from her IMRT. However, if there is a big difference in process etc. here vs. Duke, I may change. I have an email ready to send to Dr. Lee.
  
Thanks,
Robert   
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/30/2013 2:09 PM (GMT -6)   
I emailed Dr. Lee and got a quick answer. He said Duke does the gold implants in the prostate for beam guidance but some centers use a low-dose computed tomography (CT) scan right before each treatment to verify prostate position. The tomography method is done at the Seby Jones center here. Duke also does an MRI before treatment planning. Other centers do not....they just do a CT.
 
Wonder what other members who have had IMRT experienced regarding the IGRT imaging process? I am not real excited about 38+ CT scans even though low dose, however, IMRT will be a lot more rads.
 
Btw, I met with the RO here yesterday. We discussed the Seattle Study Review that I took with me due to my control issues. She said that if she was still doing seed implants, she would do seeds plus IMRT for my 4+3 but was fine with IMRT alone. Not so sure she wasn't trying to do what I had wanted earlier. Dr. Lee at Duke still maintains IMRT alone that he says is equivalent today as Irmaly relayed so that's what I'm going to do, just had questions on IMRT technique here vs. Duke.  
 
Robert  
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Tall Allen
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Date Joined Jul 2012
Total Posts : 2122
   Posted 5/30/2013 3:50 PM (GMT -6)   
Robert,

There are two ways that prostate motion is tracked inter-fractionally -- only once at the beginning of each session. Often that's done with cone-beam CTs. The other way is intra-fractionally -- continually throughout each treatment. Intra-fractional tracking is more precise and gives fewer SEs. Both of these are called "IGRT" - image guided radiation therapy.

Image guidance is achieved in one of 3 ways:
- tracking the position of gold fiducials with X-rays (cone beam CT or stereo X-rays)
- radio transponders (Calypso)
- continuous CT scanning (Tomotherapy)

I just read that the cone beam CTs can add up to 1 Gy on an 80 Gy treatment. Probably not enough to worry about.

As for your other question about whether combo therapy (BT+IMRT) is better than dose-escalated IMRT for intermediate risk PC...

In a recently completed randomized prospective trial, the only one ever done that I know of, they found in an interim unpublished analysis that there were superior outcomes with combination of EBRT plus brachy boost as compared with EBRT alone.

Retrospective analyses are unclear. At Sloan Kettering they found that an HDR brachy boost+IMRT had better results than ultrahigh dose-escalated (86 Gy) IMRT:
Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT.

However a retrospective analysis from UC Irvine found no difference between HDR brachy boost+IMRT compared to high dose IMRT alone:
Preliminary results in prostate cancer patients treated with high-dose-rate brachytherapy and intensity modulated radiation therapy (IMRT) vs. IMRT alone.

Both HDR brachy and SBRT have been used as monotherapies for intermediate risk with excellent results:
High dose brachytherapy as monotherapy for intermediate risk prostate cancer.
Intermediate-Risk Patients With Organ-Confined Prostate Cancer Have High Cancer-Free Survival Rate After Stereotactic Body Radiation Therapy


It seems like you have several good choices.

- Allen

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/30/2013 4:41 PM (GMT -6)   
Thanks TA. You have a lot of knowledge here. Did you have IMRT? All I know so far is I will have continuous CT scanning (Tomotherapy) for guidance. Did not know about the inter and intra tracking IGRT. I have a treatment plan meeting next Wednesday so anticipate will get answer on this then. Sometimes, it seems hard to get the full story from doctors early on. You really have to know what to ask.

Even though unpublished, do you have any written info on the randomized prospective trial for IMRT + brachy?

Robert

Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 2122
   Posted 5/30/2013 6:58 PM (GMT -6)   
Here's the info on the randomized prospective trial, called the ASCENDE-RT trial:

Androgen Suppression Combined With Elective Nodal and Dose Escalated Radiation Therapy

and this link has all I know about the results:

www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Genitourinary/Prostate/Brachytherapy.htm

the authors said...

In November of 2002, BCCA opened a randomized control phase II trial (accrued 41), which was further expanded to a randomized phase III trial in October 2004 (accrued 357) (ASCENDE RT), to compare the efficacy and toxicity of dose escalated radiating using EBRT vs. EBRT plus brachytherapy. Eligibility criteria included patients with ≤ Clinical stage (CS) T3a, any Gleason score (GS) and an initial PSA (iPSA) ≤40 ng/mL. All patients received 12 months ADT (8 months neoadjuvant) and elective pelvic nodal irradiation (46Gy/23 fractions 4 field conformal). Randomization was between high dose conformal EBRT (78Gy total dose to prostate) vs. a brachytherapy boost (115Gy, I125 Permanent Prostate Implant)(19). Trial was closed Dec 1, 2011. Results are pending publication. An interim analysis of ASCENDE-RT phases II-III (including all patients started on LHRH injections on or before Aug 31, 2006 N=161 pts) showed superior outcomes with combination of EBRT with brachytherapy boost as compared with an EBRT alone.


I agree that you have to know what to ask, and it helps to speak in their language (Medicalese). Also, a given doctor may not pay a lot of attention to things outside his specialty. The way I have handled some discussions is that I print out (or email in advance, even better) abstracts or articles from peer-reviewed journals. I usually lead off by saying, "You've probably already seen this, but I wanted to get your perspective on this research..." My experience has been that my doctors sometimes haven't seen it and are very interested (I looked for doctors who are research mavens). As long as the source is good, they are happy to talk about it -- they live and breathe this stuff and have devoted their lives to it after all.

- Allen

gardenz
Regular Member


Date Joined May 2013
Total Posts : 43
   Posted 5/30/2013 7:38 PM (GMT -6)   
Time101, have you asked about SBRT? That is what Tall Allen did instead of IMRT. Its five sessions instead of 8 weeks. I'm looking into it right now.

http://www.healingwell.com/community/default.aspx?f=35&m=2745278

irmaly
Regular Member


Date Joined May 2012
Total Posts : 73
   Posted 5/30/2013 8:04 PM (GMT -6)   
Hey, Time. Looks like you already got your answers. My husband had the gold markers, and I think his undedectable PSA was because of the lupron.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 2122
   Posted 5/30/2013 8:11 PM (GMT -6)   
I know Dr. Lee at Duke treats PC with SBRT, and possibly Wake Forest as well. According to the following, Dr. Lee is accepting GS7s if the other risk factors are low:

Stereotactic Body Radiotherapy (SBRT) for Prostate Cancer (SMART) - Duke University

Not everyone treats GS4+3 with SBRT. Georgetown U. has published their results with intermediate risk so far, as has Dr. Meier in Seattle, and Dr. Katz in Flushing, NY.

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/31/2013 5:58 AM (GMT -6)   
Allen,

I wouldn't be a candidate for that trial since I am on 6 months HT. The gy's look low? When I was at Duke, Dr. Lee mentioned a trial he was doing on high dose IMRT for 5 weeks but I missed the start and couldn't get in. Regarding Brachy + IMRT, Dr. Lee siad he was concerned about toxicity in my case. I emailed him yesterday, and he again said he still recommended IMRT alone for me.

In your post above, you mentioned: "I just read that the cone beam CTs can add up to 1 Gy on an 80 Gy treatment. Probably not enough to worry about". I don't know if it is cone beam that I will have for guidance. I was told that it involves a CT just before each treatment to make sure beams are correctly placed. So, is that cone beam? I will not have the gold implants like at Duke.

Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

81GyGuy
Veteran Member


Date Joined Oct 2012
Total Posts : 987
   Posted 5/31/2013 9:14 AM (GMT -6)   
Tall Allen wrote:

"I just read that the cone beam CTs can add up to 1 Gy on an 80 Gy treatment. Probably not enough to worry about."

Exactly. That's how I wound up as "81GyGuy."
Age: 67
Chronic prostatitis (age 60 on)
BPH w/ urinary obstruction, 6/2011
TURP, 7/2011
Ongoing high PSA, 7/2011-12/2011
Biopsy, 12/2011: positive 3/12 (90%, 70%, 5%)
Gleason 6, T1c
No mets, PCa likely still contained
IMRT w/ HT (Lupron), 4/2012-6/2012
PSA (8/3/2012): 0.1
PSA (12/7/2012): 0.1
PSA (4/11/2013): 0.1

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/31/2013 9:55 AM (GMT -6)   
Yep, just varified mine will be the cone beam so I'll get another Gy. Don't know total Gys yet but will know at planning session next Wed. RO may also do 7 to 8 pelvic lymph nodes to be safe. I asked her about doing them all so she is thinking. There is no indication of LN involvement, but why not play it safe. I can't have a combidex and MRI/CT won't show PC cells.
Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Squirm
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Date Joined Sep 2008
Total Posts : 691
   Posted 5/31/2013 10:02 AM (GMT -6)   
Alan,
You're a mountain of info, I enjoy learning from your postings.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 2122
   Posted 5/31/2013 10:12 AM (GMT -6)   
Robert,

I'm a little confused...
Robert said...
All I know so far is I will have continuous CT scanning (Tomotherapy) for guidance.

Robert said...
I was told that it involves a CT just before each treatment to make sure beams are correctly placed.


Tomotherapy uses the wasted X-rays of your treatment, the ones not absorbed by your body, to provide continuous CT scanning (not cone beam) throughout the treatment (intra-fractional).

Inter-fractional guidance can be done without fiducials too. They can just do a CT scan (usually cone beam) and adjust the position based on where your bones and tattoos (dots they put on your belly) line up that day. They can put a balloon up your rectum to restrict organ motion -- they do that when they give proton therapy. I had semi-permanent tattoos (they came off with alcohol when I was done) that were sighted by lasers, and that was used to position the bench that I lay on at the start of each treatment.

Tall Allen
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Date Joined Jul 2012
Total Posts : 2122
   Posted 5/31/2013 10:16 AM (GMT -6)   
Robert,

There can be consequences to zapping a lot of lymph nodes. Lymphedema can be a very serious consequence. Usually they look for at least some sign that lymph nodes are enlarged before zapping them.

Thanks, Squirm :-)
Allen
•3rd biopsy (4/2010):
PSA=7.3, prostate volume=55cc, 8 of 17 cores G6 5-35% involvement
•SBRT (5x8Gy) at UCLA, 10/2010 at age 57
•PSA since treatment:
+3 mos:3.9 +4 mos:3.5 +7 mos:3.0 +10 mos:3.7 +13 mos:3.6 +19 mos:1.18 +23 mos:1.29 +29 mos:.37
• Side Effects of treatment:
+2 wks: Grade 1 urinary & rectal last 1 wk
+1 yr: Grade 1 urinary last 2 months
no ED

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/31/2013 11:10 AM (GMT -6)   
Allen,

No, I'm the one who is confused. Got a call this morning to schedule planning and the RO's scheduler said I would have a low dose cone beam CT when I mentioned I was concerned about a daily CT before each treatment. Apparently, I used the wrong term -Tommograpy. So, it's a one time CT just before each treatment to line up with the tattoos they will do in planning/simulation.

Sorry for confusion...I'm new at all this particularly radiation. It's done different by doctors and centers, as you know.

The RO mentioned she typically does only 7 - 8 lymph nodes only if needed when I asked about it. She said they do a 2mm slice CT scan in the planning step to look for any swollen nodes. No scan shows cancer cells other than combidex that I have read about. So, guess my point was to hit some close by nodes rather than wait until there is a possible problem. Even though I have a small amount of cancer based only on the needle biopsy, the 4+3=7 acts like an 8. Anyway, I'm going to just let the RO do what needs to be done and try to keep my anxiousness and need for excessive control under control LOL. My wife just recently finished treatments recently for BC so I am overly cautious about all this.

Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Redwing57
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Date Joined Apr 2013
Total Posts : 899
   Posted 5/31/2013 11:38 AM (GMT -6)   
Vanderbilt uses gold fiducials for daily alignment (I have 3 implanted). I don't think they do intrafractional guidance, but they have the RapidArc Varian IMRT machine so the actual treatment exposure is pretty quick (less than 10 minutes I understand), so intrafractional movement should be pretty small.

My RO is planning to treat my pelvic lymph nodes too, and I think it's all of them due to my very high risk situation. Dr. Mack Roach talks about that, saying it's important to hit them all. He said targeting related lymph nodes is common to virtually all other cancers, so why does the prostate cancer community seem to think this one is unique?

With my situation, I think the risk of lymphedema is probably warranted, but it's sure something to consider. They call it "whole pelvic", but I imagine it really means targeting the areas where lymph nodes reside.

My simulation appointment is June 13, and I plan to ask about all that.
IGRT by 3D-IMRT to start 7/1/13: 40-50 Gy pelvic field, 79.2 Gy to prostate (81?)
Lupron started for 2 yrs, 1st 6 mo on 5/1/13
3T MRI shows extraprostatic extension, SV+LN "normal"
Age 55, Dx 4/16/13, Bx w/12, one side G9=5+4 (80%, 60%), 4+5 (2 at 100%, 80%, 10%), PNI
Date PSA fPSA
3/13 5.2 12% PCA3=31
9/12 4.1 15%
history... as far back as 2002 elevated PSAs and 3 negative biopsie

Tall Allen
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Date Joined Jul 2012
Total Posts : 2122
   Posted 5/31/2013 12:10 PM (GMT -6)   
Robert - ah - that explains it -- the words all sound alike - it is very confusing. I think the marketers at Accuray called their machine Tomotherapy because it uses Computed Tomography (CT). But lots of IGRT machines use CT too.

Redwing57 - I was treated on a RapidArc machine too, but it was rigged up with stereoscopic X-rays that they used to line up my fiducials with the plan MRI/CT image. They did that before each of the four half arcs, and the entire treatment took only 5 minutes, including the realignment time. Varian's new TrueBeam machine is twice as fast! You're right - not much time for much movement with that. My treatment was SBRT -- only 5 treatments at about 8 Gy each. SBRT is more typically done with Accuray's CyberKnife machine. When they're delivering that kind of radiation intensity, they have to be extremely accurate and account for intra-fractional motion. When they're only delivering 2 Gy per treatment, there is less of a need to be that precise.

Only about 100 men in the US with high risk PC have been treated with SBRT. My RO, Dr.King, is just starting to expand to high risk patients. So far, the early results look very promising. They are treating a wider margin (except near the rectum) and are increasing the dose to anyplace where imaging suggests there is more cancer. I'm happy to see all these innovations occurring.

- Allen

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/31/2013 6:09 PM (GMT -6)   
Allen and Redwing57,

I have read about the RapidArc machine. My RO says my treatments will take about 15 to 20 minutes each due to the cone beam CT that has to run at the start of each treatment to check alignment. But, even though I would be on the table 15 to 20 minutes, I won't be getting constant radiation will I? The RO here is very accomplished with 21+ years experience and highly recommended by Dr. Robert Lee at Duke. She also has a high patient rating. However, after reading you guys comments about RapidArc etc., I wonder if I should just go to Duke with Dr. Lee. They do an MRI as std. protocol, use the gold implants, and I'm sure they have RapidArc. Below is a short description of our local Seby Jones Cancer Center's radiation program. Am I missing anything about the Varian part etc.?

The Cancer Center was among the first few North Carolina facilities to offer a new treatment modality called intensity modulated radiation therapy or IMRT. This unique form of treatment is the most advanced method available to deliver high dose radiation to destroy cancer cells while minimizing risk to normal tissues. IGRT (image guided radiation therapy) is the added component of a high quality x-ray system or "on-board" imager that allows quick and precise adjustments of a patient's target volume for greater accuracy. Examples of sensitive tissues that can now be "sculpted" around include the prostate, spinal cord, optic nerve and salivary glands.

Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 2122
   Posted 5/31/2013 7:03 PM (GMT -6)   
Robert,
I'm not sure that there's any advantage to one machine over another for IMRT (other than speed), especially with the wide spray you seem to be getting. There was a report recently that IMRT had no real advantage over 3DCRT, an older technique.

The important part is the treatment plan -- making sure you get an adequate dose to the treatment area, and that you don't get too much dose to organs at risk. As I said, SBRT uses very intense dosing so that tracking intra-fractional motion becomes very important. On the CyberKnife version, a free-moving robot moves around the patient, constantly checking position before every beam. My friend in Florida just had it done, and each treatment took about 50 minutes. With IMRT, interfractional tracking may be adequate.

Maybe you will feel more confident if you can ask your RO to go over the treatment plan with you. I found it interesting to see the "isodose curves" (a contour map connecting the points that get the same dose) and the "dose-volume histogram" (showing what percent of each organ-at-risk (e.g., bladder, rectum, penile bulb) gets what dose).

After the initial positioning, you will be getting the radiation. I don't know how the multileaf collimator on your machine works. It's the device that shapes the beam to the shape of your prostate. On some machines the X-rays stop while it re-adjusts. There's usually a mold you lie in that keeps you in position, and there's probably something that pauses everything if you move too much. You can ask your RO what kind of controls are in place for that particular machine.
Allen
•3rd biopsy (4/2010):
PSA=7.3, prostate volume=55cc, 8 of 17 cores G6 5-35% involvement
•SBRT (5x8Gy) at UCLA, 10/2010 at age 57
•PSA since treatment:
+3 mos:3.9 +4 mos:3.5 +7 mos:3.0 +10 mos:3.7 +13 mos:3.6 +19 mos:1.18 +23 mos:1.29 +29 mos:.37
• Side Effects of treatment:
+2 wks: Grade 1 urinary & rectal last 1 wk
+1 yr: Grade 1 urinary last 2 months
no ED

Time101
Regular Member


Date Joined Dec 2012
Total Posts : 149
   Posted 5/31/2013 10:04 PM (GMT -6)   
Allen,
 
Thanks for all your help on this treatment. I am sure I will learn a lot at planning next Wednesday. The RO did mention that most patients have immediate ED lasting for a while and some permanent because of the samll blood vessels involved. That scared me, but she said you can use Viagra, if that happens. She said she tells all the guys this so there are no suprises. What I read is ED is possible 35% of the time - better than surgery.
 
Robert
Current age: 67
8/1/06 PSA 1.1
2/26/08 PSA 2.1
7/30/08 PSA 1.3
9/19/09 PSA 1.5
10/28/10 PSA 2.2
5/4/11 PSA 2.3
1/10/13 PSA 6.6
1/28/13 PSA 5.3
(Was using 1mg finasteride a few years)
Dx'd 2/27/13, 2 of 12 pos., GS6 (3+3) 1.0% 0.5mm, and GS7(4+3) 10% 5.5mm
DRE neg., 39cc, 1-month Eilgard, 4 mos. Lupron. IMRT scheduled June 2013.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 2122
   Posted 5/31/2013 10:27 PM (GMT -6)   
Robert,
The combination of androgen deprivation and radiation over a wide area can be bad for erectile function. I hope she avoids the penile bulb as much as possible. Low dose Viagra taken for 6 months starting at the beginning of IMRT helped prevent ED in a recent study. However, that was not with androgen deprivation as well. She is right that the problem with radiation is damage and subsequent fibrosis of blood vessels (especially the penile artery that connects by way of the prostate) rather than the nerve damage caused by surgery.

If ED meds don't work, there's always injections. Sometimes hyperbaric oxygen therapy can reverse the fibrosis if it sets in.

The best thing I know of to prevent the damage to blood vessels and all healthy tissues is exercise - plenty of it. It helps fight fatigue that may occur with IMRT. And it actually helps the radiation kill more cancer cells.

- Allen

Fairwind
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Date Joined Jul 2010
Total Posts : 2354
   Posted 6/1/2013 12:39 AM (GMT -6)   
I went out of my way to be treated on a Varian Rapid-Arc LINAC..That machine, still state of the art, was considerably more advanced in it's abilities than the older equipment some institutions are still using...With this new equipment, the RO can develop a much more advanced and accurate treatment plan, pinpointing the cancer while greatly limiting the damage done to healthy tissue..

Time will tell whether 40 gray delivered in 5 fractions is just as effective and safe as 80 Gray delivered in 40 fractions...

And lets not forget the combination of brachy and IMRT which can deliver 145 Gray with excellent results and acceptable side-effect risk..
Age 70
PSA age 55: 3.5, DRE normal.
age 58: 4.5
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA <0.1 10/'11, <0.1 2/12, <0.1, 4/12 <0.1, 9/12, 0.8 3/13, 0.5

PeterDisAbelard.
Forum Moderator


Date Joined Jul 2012
Total Posts : 3870
   Posted 6/1/2013 10:00 AM (GMT -6)   
Robert,

I was going to sit this one out since the conversation has passed my level of expertise and I am in learning mode here. But since you sent me an email asking me to comment, a few thoughts.

I had my ART treatment at the Cancer Centers of North Carolina in Raleigh. I am not sure of the exact model of IMRT machine they use. They used CT scans and xrays for planning and weekly xrays and daily ultrasound to make fine adjustments. They made a mold of my feet from the knees down which was used to position me on the table and they lined me up with laser lines and tattoos and then verified the location of my prostate bed with an ultrasound device that communicated with the room's 3-D positioning system. Since I was doing ART and not primary treatment the dose was slightly lower (66.6 gy total) and since I no longer had a prostate there was nothing in particular to aim at -- although there were things to avoid. They were radiating the general area around the surgical margin and no phenomenal accuracy was required.

Tall probably has some numbers for this but my impression is that the differences between the options you are looking at are small in terms of the percentages of negative outcomes. The reality is that the difference in the risks are small compared to the risk themselves and you can probably allow yourself the luxury of considering such things as convenience. Pulling numbers out of the air here, if your chances of developing ED as a result of treatment are 36 percent in Boone but only 34 percent in Durham then it is seventeen times as important to be lucky as it is to make the right choice.

You've done your homework. You've done the extra credit exercise. It's time to kiss your lucky rabbits foot, decide on an option, and get 'er done.

My Advice, for what it's worth.
60
Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012:
1)neg (some inflammation),
2)neg,
3)positive 1 of 14 GS6(3+3) 3-4%, 2nd opinion GS7(3+4)
4)neg.
Mild Pre-op ED
DaVinci RRP 6/14/12. left nerve spared
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
Start 24 mo ADT3 7/26/12
Adjuvant IMRT 66.6 Gy 10/17/12 - 12/13/12
Leaky but better, Trimix, VED
Forum Moderator - Not a Medical Professional

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3733
   Posted 6/1/2013 2:53 PM (GMT -6)   
Allen, I believe the study on IMRT vs CRT was for salvage radiation not primary.
Robert, one key is to keep your bladder full as you are getting radiated. I drank 32 oz right before each treatment and I thank that helped in not having SEs. You may have to keep a bottle in your car to pee in because if you have a drive longer than 10 min you will be using it.
JT
66 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, 4 weeks of urinary frequency and urgency; no side affects since then. 3 years of psa's all at 0.1.
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