HDR Brachy as Monotherapy?

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jmadrid
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Date Joined Sep 2017
Total Posts : 21
   Posted 9/21/2017 4:37 PM (GMT -6)   
After gathering more information, I realized that single fraction HDBT monotherapy is not a standard technique. Actually, nccn only recommends HDBT when combined with external radiation. Maybe I should consider some of the other radiation techniques available in the same center, even though they apparently have more SE.

(Edited to provide a title)

Post Edited By Moderator (Tudpock18) : 9/21/2017 6:01:27 PM (GMT-6)


Michael_T
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Date Joined Sep 2012
Total Posts : 2456
   Posted 9/21/2017 5:44 PM (GMT -6)   
I know lots of guys that have have HDR Brachy as a monotherapy. In fact, unless you're high risk, monotherapy is the standard treatment. For my part, I did have the combo radiation, but I was a Gleason 9.

Check out Dr Jeffrey Demanes's website for more info. He's considered one of the top HDR brachy guys in the US. http://www.cetmc.com/CETmedteam.html
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

Tall Allen
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Date Joined Jul 2012
Total Posts : 8601
   Posted 9/21/2017 6:20 PM (GMT -6)   
That's true that single-fraction HDRBT is not a standard protocol. It has been used experimentally. Here's an article about this single-dose technique:

/pcnrv.blogspot.com/2017/01/is-once-ever-enough.html

Is the facility the Hospital Universitario Central de Asturias, Oviedo, Spain? If so, you will see in that article a reference to a study (Prada et al.) done there. I'm sure if you prefer two to four treatments instead of a single treatment they would be happy to accommodate you.

There is no need for external beam along with HDRBT for men who are low or intermediate risk.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 21
   Posted 9/21/2017 11:56 PM (GMT -6)   
Thank you for very helpful answers.
Tall Allen, very useful references. I am particularly concerned after reading another publication by Prada et al. (not related with the Center I am in contact). In 2016, after a longer follow-up, they reported a 66% biochemical survival in their single-fraction monotherapy HDBT cohort. They claim it is less effective than LDBT. More fractions/implantations seem to me less convenient than SBRT.
(I am sorry I did not add a title to this thread by mistake; Actually I just was trying to add another reply to my old thread, but after the topic has been added I think it is better this way.)

Post Edited (jmadrid) : 9/22/2017 12:09:42 AM (GMT-6)


Tall Allen
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Date Joined Jul 2012
Total Posts : 8601
   Posted 9/22/2017 12:32 AM (GMT -6)   
You mean this one, I think:

www.thegreenjournal.com/article/S0167-8140(16)31040-4/fulltext

You see why I question whether a single dose is a good idea? There are radiobiological reasons why even doing it in 2 doses may have better outcomes compared to a single dose:

/pcnrv.blogspot.com/2016/08/is-there-optimal-treatment-schedule-for.html

As you can see, the cancer control when given in multiple fractions is excellent, close to 100%. There's no reason why you can't request multiple fractions. Even two fractions with a few hours in between seems to be enough, and it will only mean a single day in the hospital. Or you can split it a week apart, and have a much shorter stay each time. It doesn't seem to matter at all - same excellent results and low toxicity.

I am certainly a fan of SBRT also, having chosen it for myself. I found it very convenient, unintrusive, inexpensive, no anesthesia, low/transient side effects, and excellent retention of erectile function. I had the choice of both HDRBT and SBRT, and I really could have flipped a coin to decide. I opted for the convenience. I'm sure seeds (LDRBT) would be fine too if you have an experienced brachytherapist using the most modern techniques and adequate doses.

For a man with favorable risk prostate cancer, all therapies, including surgery have about the same excellent oncological outcome.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 21
   Posted 9/22/2017 4:37 AM (GMT -6)   
Very helpful remarks again Tall Allen. It is nice to have such a great quality advice and support here, otherwise I would be really get lost.
One more question showing my ignorance on these radiation techniques: SBRT and cyberknive are the same thing? (I understand cyberknive is a commencial brand of sbrt but not sure). In his explanation on radiation techniques they have available, this doctor mentioned cyberknive as their only five days treatment.
Also, he mentioned that I would need to wear a catheter for 5 days for cyberknive, but I am reading that the catheter is not usually employed. I think I should visit him again and ask about this and the several fractions HDBT issues.
Cyberknive and robotic RP are the only treatment not covered by my insurance, but I could consider any treatment that is less aggresive and at least similarly safe than the covered options.

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2456
   Posted 9/22/2017 8:15 AM (GMT -6)   
I know the current regimen at UCLA for HDR brachy is to give two fractions in one day. When I had it in 2013, it was two fractions over two days, so you had an overnight in the hospital.
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

tde44
Regular Member


Date Joined Dec 2014
Total Posts : 56
   Posted 9/22/2017 8:56 AM (GMT -6)   
I had HDR as 4 fractions performed on different days with a shortest interval of 3 days and a longest interval of 10 days. My RO told me that this was the best way to ensure 100% coverage with minimal SE's.

At present my only long term SE has been urinary retention.

To be honest, if I had to do it over again I would have gone for surgery rather than go through this 4 times.
Bradycardia-dual lead pacemaker implanted 12/18/2015
Large hiatal hernia repair-Nissen fundo wrap 7/27/2015
Prostate Cancer@55. G3+3=6 T1C
PSA 2/2014: 5.5 7/2014: 7.00 11/2014 (6 weeks after HDR): 4.80
2/2015: 4.23 5/2015: 3.67 8/2015: 4.01 11/2015: 1.46 (Finasteride) 05/2016: 0.78 (Finasteride); 1/2017: 0.96
HDR mono-therapy (4 rounds)

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2456
   Posted 9/22/2017 9:11 AM (GMT -6)   
tde....all for fractions were on different days? So you had to undergo the procedure to insert the catheters and the procedure to remove the catheters four different times? Yeah, I'd have to say that wouldn't be much fun.
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8601
   Posted 9/22/2017 10:58 AM (GMT -6)   
jmadrid-

Your understanding is correct. SBRT is a generic name, CyberKnife is a brand name of Accuray's SBRT system. I was treated using a different system (Truebeam with RapidArc) which is a lot faster (each session took about 5 minutes vs. about 45 minutes for CyberKnife) but the effectiveness and side effects are the same.

Every SBRT RO has his own protocol for it. Mine never uses any catheters, enemas or dietary changes. I know that some use a catheter once for the MRI and CT that is used for planning. They say it helps them see the urethra better. Your RO might use it for each of the five sessions, but I couldn't explain why he would do that - it's a good question to ask him. They use fiducials or transponders for image guidance, not a catheter. There are usually 5 sessions, every other day, so with weekends off, the treatment takes 10 or 11 days. I can't imagine that they would leave a catheter in that whole time. One reason I decided on SBRT rather than surgery was because I hated thought of catheters.

With brachytherapy of either kind, the planning is done intraoperatively, and they use the catheter as a landmark. That helps them avoid inserting the implants through the urethra, and to keep the urethral dose within the dose constraints. Those who had brachytherapy, please correct me if I'm wrong, but I think the catheter is inserted and removed under anesthesia at the end of the procedure.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Dogdays
Regular Member


Date Joined Jan 2017
Total Posts : 98
   Posted 9/22/2017 11:27 AM (GMT -6)   
You are correct TA. For my brachy procedure, the catheter was inserted and removed while under anesthesia. Along with using the catheter to avoid the urethra, they also used it to flush through to the bladder to remove any clots or blood. And as for the SBRT, a catheter was inserted again during the simulation and planning phase and removed before I left MSK that day.
Age at Dx. 63
PSA 1/08 1.4, 12/16 12.17, 4/17 3.8, 7/17 1.05
GS 9 (4+5)
CT Scan and bone scan 1/17 both negative
2/2/17 prostate MRI.
2/27/17 pelvic bone biopsy done. No mets
3/7/17 Started HT. Degarelix, 4/17 lupron (1-2 years)
7/7/17 Brachy (Zelefsky MSK)
8/25/17 SHARP (SBRT) finished at MSK

Michael_T
Veteran Member


Date Joined Sep 2012
Total Posts : 2456
   Posted 9/22/2017 2:05 PM (GMT -6)   
My implant--the device that connects to the 17 catheters--was done under anesthesia, but not the removal. Something recently said here that the removal was the worst pain of his life. My removal didn't hurt at all the first time and was somewhat painful the second in kind of a "ripping off the band aid" type of pain.
Age 56, Diagnosed at 51
PSA 9.6, Gleason: 9 (5+4), three 7s (3+4)
Chose triple play of HDR brachy, IMRT and HT (Casodex, Lupron and Zytiga)
Completed HT (18 months) in April 2014
3/17: T = 167, PSA = 0.13

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8601
   Posted 9/22/2017 2:28 PM (GMT -6)   
In HDRBT, "catheter" is the term used for the tube that goes up the penis and for the 15 or so tubes that are inserted transperineally to stake the prostate and through which the radioactive implants are inserted and removed. The OP was concerned about the transurethral catheter.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

tde44
Regular Member


Date Joined Dec 2014
Total Posts : 56
   Posted 9/22/2017 2:52 PM (GMT -6)   
Yeah my fractions were all done on different days so I was put under each time and spent the day on my back, multiple CT scans each time, etc. Had 17 of those &^*( catheters each time.

Would have to check in to ambulatory care @ the hospital by 5:30 AM and was released by 3 or 4 PM.

To make things even worse, it was when the "affordable" health care act first came into being the nearest uro & ro that I could see were 2 hours away so we had to book hotels for the night before and after and also put the dogs into kennels each time.
Bradycardia-dual lead pacemaker implanted 12/18/2015
Large hiatal hernia repair-Nissen fundo wrap 7/27/2015
Prostate Cancer@55. G3+3=6 T1C
PSA 2/2014: 5.5 7/2014: 7.00 11/2014 (6 weeks after HDR): 4.80
2/2015: 4.23 5/2015: 3.67 8/2015: 4.01 11/2015: 1.46 (Finasteride) 05/2016: 0.78 (Finasteride); 1/2017: 0.96
HDR mono-therapy (4 rounds)

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 21
   Posted 9/28/2017 6:09 AM (GMT -6)   
Today, I came back to be to the radiotherapist. His level of empathy and communication are just the opposite of the well-reputed urologist-surgeon that I visited a couple of days as reported in my thread about surgery.
I asked him about the paper I read about a HDBT single fraction monotherapy cohort elsewhere here in Spain that showed poor progression survival. His reply was that he instead uses two fractions implants at 6 hours interval. He showed me his patient statistics, private or included in congress seminars and planned publications (it is very rare in this country that any doctor discusses or gives that information). In seven years he has treated about 170 low and intermediate risk patients and has had a single case failure. This single case received salvage surgery and the pathological report revealed a G10 focus. (This patient seems to be all right now).
I understand that HDBT as monotherapy still has some experimental flavor and that treatment failure data takes some time to mature after radiation but, anyway, I am very impressed with his statistics.
I asked him also about SBRT. He confirmed me that in their protocol the patients have a cathether for five days. He has appointed me with the doctor that uses cyberknive in their Center. It is not covered by my insurance but the cost is not as high as I imagined.
Up to this point, I think I have been doing everything it is required to take an informed treatment decision but I am still doubtful about what it will be. Sometimes I have the challenging thought that if I finally do not follow the conventional choice (surgery) will be not because of my research but because it frightens me too much. Right now, it seems I have PCa and a big headache confused
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5 with a couple of high peaks (up to 9.1).
May 2017: 6.1; July 2017: 7.6
mpMRI, July 2017: left medial apex posterior PIRAD5 5 with some capsule abuts.
Dx August 2017,Gleason 3+3, two cores, left 5%, right 3%, greater tumor length: 3.5 mm., left.
Prostate size 2017: TRUS: 71 c.c.; mri: 98 c.c.
DRE: increased consistency left side, september 2017.

Post Edited (jmadrid) : 9/28/2017 7:48:00 AM (GMT-6)


Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8601
   Posted 9/28/2017 10:36 AM (GMT -6)   
You are doing exactly what an ideally empowered patient should be doing - gathering information without deciding. It is actually hard not to decide. We all want closure and feel uncomfortable having things open ended. But in the end you will be happier that you did it. After you have met with all the doctors, take an extra couple of weeks where you try not to think about it at all. Let your mind work "behind the scenes." That will also help overcome the natural bias towards the last thing we heard.

As you can see in the following, two fractions seems to work about the same as more fractions:

/pcnrv.blogspot.com/2016/08/is-there-optimal-treatment-schedule-for.html

HDR-BT monotherapy is not new -- it has been done since 1995:

/pcnrv.blogspot.com/2016/08/high-dose-rate-brachytherapy-hdrbt.html

I remembered that I had seen a Spanish study comparing quality of life in patients receiving surgery, LDR-BT, and 3D-CRT (an older form of external beam radiotherapy not often used anymore in the US). Then, a US SBRT RO compared his outcomes with those of the Spaniards who had surgery. None of the comparisons were randomized (as patients were in the ProtecT study), so for what it's worth:

/ro-journal.biomedcentral.com/articles/10.1186/1748-717X-7-194
www.redjournal.org/article/S0360-3016(07)04764-5/fulltext
/pcnrv.blogspot.com/2016/09/patient-reported-outcomes-from-protect.html

I will be very interested to hear about the catheter.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 21
   Posted 9/28/2017 4:42 PM (GMT -6)   
Thank you TA, I will follow your advice,
I have been randomly gathering information during the 5 years I have been in the grey zone before Dx. But I have never seriously considered radiation for me, even though my atypical HIFU urologist always mentioned it as a good option. It has been after I asked here for help and discarded AS that I have realized it can be such a good alternative to surgery.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5 with a couple of high peaks (up to 9.1).
May 2017: 6.1; July 2017: 7.6
mpMRI, July 2017: left medial apex posterior PIRAD5 5 with some capsule abuts.
Dx August 2017,Gleason 3+3, two cores, left 5%, right 3%, greater tumor length: 3.5 mm., left.
Prostate size 2017: TRUS: 71 c.c.; mri: 98 c.c.
DRE: increased consistency left side, september 2017.

jmadrid
Regular Member


Date Joined Sep 2017
Total Posts : 21
   Posted 10/6/2017 8:39 AM (GMT -6)   
I visited today the SBRT (cyberknive) radiologist.
Another nice person giving explaining all options in detail (great difference with the surgeon).
about the 5-day catheter: It is to be sure the bladder is full and fixed. He will fill it every day. Also, it helps to localize the urethra during the procedure. No bag attached, just a stopper to be removed when needed. Maybe he does not want to insert it five times. He added that if the urethra is too thin it would not be placed but then I would have to follow some strict drinking recommendations (I guess that as in any urologic ecography). He also inserts another catheter in the rectum (not permanent, every day). This way not special diet requiments are needed. He has treated about 300 pacients with a BR of about 95% in "5-8 years". Low SE.
He finally added that any option I can choose will be allright.
Any comment will be appreciated.
Still aprehensive about going away from the standard path here. I do not know (in person) anybody that has been radiated as primary treatment.
I will decide next week.
67 years old.
PSA: 2008:2.8; 2012-2016: 4.5-5.5 with a couple of high peaks (up to 9.1).
May 2017: 6.1; July 2017: 7.6
mpMRI, July 2017: left medial apex posterior PIRAD5 5 with some capsule abuts.
Dx August 2017,Gleason 3+3, two cores, left 5%, right 3%, greater tumor length: 3.5 mm., left.
Prostate size 2017: TRUS: 71 c.c.; mri: 98 c.c.
DRE: increased consistency left side, september 2017.

HitchHiker
Regular Member


Date Joined Nov 2015
Total Posts : 171
   Posted 10/6/2017 3:01 PM (GMT -6)   
Tall Allen said...
With brachytherapy of either kind, the planning is done intraoperatively, and they use the catheter as a landmark. That helps them avoid inserting the implants through the urethra, and to keep the urethral dose within the dose constraints. Those who had brachytherapy, please correct me if I'm wrong, but I think the catheter is inserted and removed under anesthesia at the end of the procedure.


I had two implants a week apart, one fraction during each implant. The urinary catheter was inserted under anesthesia, but removed in the post op area after I was awake. It definitely wakes you up when they remove it but it's not so much painful, just a set of intense sensations you probably never experienced before. cool

In my case, at FCCC, the urologist participates in the surgical implant procedure, and the urinary catheter inserted has a camera that allows the urologist to check visually for any punctures in the urinary tract, in addition to the scanning equipment being used to guide implant catheter insertion.
Warm Regards-CJ-age 45

Dx 11/13@42YO - PSA 5.8, -DRE, GS6, MPMRI G-Bx@JH - 1/12 cores+@<5% - AS started
11/14@43YO - NIH T3 ERC-MPMRI, PSA 5.84, PSA-D 0.127
5/15@43YO - Bx, -DRE, PSA 6.41, 6/18 cores+, unilateral all G6@<5-75%
2/16 - HDB-m@FCCC, PSA 6.6, stage T1C
PSA - 6.6 2/16, 6.0 8/16, 2.0 2/17

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