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Julietinthewoods
Regular Member


Date Joined Sep 2010
Total Posts : 309
   Posted 10/4/2010 9:33 PM (GMT -6)   
Hello all,

We had a consultation with the radiation oncologist today. He seemed quite knowledgeable, and low pressure. Quite experienced. He suggested that Carter, with his small prostate, PSA of 6.7, stage T1C and Gleason of 3+4=7, would be a good candidate for either EBRT alone for 9 weeks, or a combination of EBRT for 5 weeks, followed by LDR Brachytherapy. He said LDR Brachy alone would not be an option for a Gleason 7, which we already knew.

I guess I was surprised that EBRT alone was an option, though. Carter would definitely prefer it for the sake of convenience (EBRT can be done in our town, on his way to work) and got the impression that adding the seeding would just be a way to cut the therapy time down. I think, though, that I have read here that a combination of the two leads to better results.

Would love to have your opinions.

Juliet

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 10/4/2010 10:01 PM (GMT -6)   
with a gleason 7, would not want to trust ebrt alone. in my opinion, i would go for the combo with the seeding.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

F8
Veteran Member


Date Joined Feb 2010
Total Posts : 3987
   Posted 10/4/2010 10:19 PM (GMT -6)   

Juliet -- my numbers are similar.  you can see in my signature that i had HT, BT and IGRT. 

ed


age: 55
PSA on 12/09: 6.8
no symptoms, no prostate enlargement
12/12 cores positive....gleason 3+4 = 7
HT, BT and IGRT
received 3rd and last lupron shot 9/14/10

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 10/4/2010 11:52 PM (GMT -6)   
Juliet,
IMRT alone would be fine with a small tumor, small prostate even with a G7. I also believe that brachytherapy alone would also be fine unless it was identified that the tumor was near the margin. Radiation's effectiveness is directly related to dose, anything above 81 greys should kill any cancer in the prostate and with a margin to the bed. A combination of brachy and IMRT could give a dose of 140-150 greys because the seed dose can be placed more accurrately. A dose of 150 greys of IMRT alone would cause serious damage to surrounding tissue. A dose of seeds only is about 100gy. The primary reason for the combination is to get a higher dose for larger tumors and to hit the prostate bed with a comfortable margin. Also the PC cells have a much harder time adapting to two different types of radiation. PC cells hate change and the more change you throw at them the faster they die before finding a way to adapt.

JT
65 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, no side affects and psa .1 at 1.5 years.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3887
   Posted 10/5/2010 12:06 AM (GMT -6)   
Juliet, the advantage with the combo treatment, they can get the total dose up to about 150Gy and as you might expect, that works considerably better than the 80 Gy limit with EBRT alone..The seeds can deliver powerful, concentrated dose right in the tumor without damaging the surrounding tissue. The external beam (IGRT?) can then deliver a lower dose to the surrounding tissue and still get the job done.

I looked very closely at this but I would have had to travel "out of network" to get it done and I had dallied too long already...

A friend of mine, older than me, he was about 75 when he had the combo done at a community hospital in El Paso, TX about 11 years ago..He died suddenly of a heart attack at the age of 83...He suffered no side effects from his treatment...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP performed Sept 3 2010, pos margin, one pos vesicle nodes neg

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 10/5/2010 7:13 AM (GMT -6)   
Liked John T's assessment on this which is about that same as I have witnessed such in my own case and other patients travels. I believe you meant EBRT as being IMRT, in todays radiations at minimum make sure it is IMRT (photon rays), and of the old EBRT or EBRT-3D as more possibilities to having collateral damages (inferior in comparison). Some patients can do fine on IMRT alone or seeds alone, the combo is more potent method and depending upon patients biology of disease level, would dictate which method(s) to use. This is why you go get opinions from the top radiologist vs. the average radiologists....there is a difference.

I met with 3 radiation oncologists in getting my own 8 opinions, glad I did and glad I fired one of them prior to starting proceedure and found a much more experienced reknown type doc and with more a potent radiation protocol, of which my stats warranted throwing the kitchen sink at this disease...and that is what I did and was necessary. I also had correspondence with Dattoli and RCOG as considerations for treatments, since I didn't see them face to face, did not include them in my count of 8 opinions. Those two are known for brachy seeds and IMRT, but can do either and have alot of experience in doing such.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

Post Edited (zufus) : 10/5/2010 6:16:27 AM (GMT-6)


Kongo
Regular Member


Date Joined May 2010
Total Posts : 36
   Posted 10/5/2010 7:56 AM (GMT -6)   
Hi, Julie. If you're considering radiation there is a twist on the suggestions you have been given so far that you may wish to check out on your own. In June I received stereotactic body radiation (SBRT) via the CyberKnife system to treat my 3+3=6, T1c, 1 of 12 cores positive with 15% involvement PCa. SBRT is similar to IMRT and different at the same time. SBRT delivers a hypofractionated dose to the prostate that achieves a biological equivelent dosage of about 95 Gy. I received five fractions (five sessions) of treatment each about 45 minutes in length. The SBRT delivery systems use hundreds of shaped radiation beams to deliver an extremely accurate dosage to the prostate while minimizing radiation to surrounding organs and tissue. A big advantage of CK is that it has the ability to track prostate movement in real time and make adjustments to dosage. Two of the most popular delivery systems for SBRT are CyberKnife and Varian. IMRT typically adjusts for prostate position once a session. Three months out from treatment I have had zero side effects and my PSA has dropped to 1.35. A variation on SBRT which might be appropriate for a Gleason 7 is a combination of IMRT with a SBRT boost which is designed to replace the dosage you would receive from seeds. My radiologist indicated to me that they do this quite frequently with excellent resuls. Yet another procedure you may wish to consider is HDR (high dose rate) brachy with MRT. With HDR they insert radioactive wires into the prostate for pre-determined periods of time to deliver high dosage internally to the prostate. I don't know if the size of your husband's prostate would be an issue there or not but HDR with IMRT has an excellent success rate with relatively low incidence of side effects.

A couple of papers you might wish to look at:


This is the latest paper on what CyberKnife SBRT does: http://www.tcrt.org///mc_images/category/4309/04-katz_tcrt_9_5.pdf


This is a study out of Georgetown where they are using a CK boost with IMRT:

Monday, 27 September 2010
Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA.

Clinical data suggest that large radiation fractions are biologically superior to smaller fraction sizes in prostate cancer radiotherapy. The CyberKnife is an appealing delivery system for hypofractionated radiosurgery due to its ability to deliver highly conformal radiation and to track and adjust for prostate motion in real-time. We report our early experience using the CyberKnife to deliver a hypofractionated stereotactic body radiation therapy (SBRT) boost to patients with intermediate- to high-risk prostate cancer. Twenty-four patients were treated with hypofractionated SBRT and supplemental external radiation therapy plus or minus androgen deprivation therapy (ADT). Patients were treated with SBRT to a dose of 19.5 Gy in 3 fractions followed by intensity modulated radiation therapy (IMRT) to a dose of 50.4 Gy in 28 fractions. Quality of life data were collected with American Urological Association (AUA) symptom score and Expanded Prostate Cancer Index Composite (EPIC) questionnaires before and after treatment. PSA responses were monitored; acute urinary and rectal toxicities were assessed using Common Toxicity Criteria (CTC) v3. All 24 patients completed the planned treatment with an average follow-up of 9.3 months. For patients who did not receive ADT, the median pre-treatment PSA was 10.6 ng/ml and decreased in all patients to a median of 1.5 ng/ml by 6 months post-treatment. Acute effects associated with treatment included Grade 2 urinary and gastrointestinal toxicity but no patient experienced acute Grade 3 or greater toxicity. AUA and EPIC scores returned to baseline by six months post-treatment. Hypofractionated SBRT combined with IMRT offers radiobiological benefits of a large fraction boost for dose escalation and is a well tolerated treatment option for men with intermediate- to high-risk prostate cancer. Early results are encouraging with biochemical response and acceptable toxicity. These data provide a basis for the design of a phase II clinical trial.

Written by:
Oermann EK, Slack RS, Hanscom HN, Lei S, Suy S, Park HU, Kim JS, Sherer BA, Collins BT, Satinsky AN, Harter KW, Batipps GP, Constantinople NL, Dejter SW, Maxted WC, Regan JB, Pahira JJ, McGeagh KG, Jha RC, Dawson NA, Dritschilo A, Lynch JH, Collins SP.

Reference: Technol Cancer Res Treat. 2010 Oct;9(5):453-62.

PubMed Abstract
PMID: 20815416

Good luck to you as you sort out your many options.
============================
Age:  59
Dx:  March 2010
PSA @ Dx:  4.3 (Latest PSA = 2.8 after elimination of dairy)
Gleason:  3+3=6 (confirmed by second pathologist)
Biopsy:  1 of 12 cores contained adenocarcinoma at 15% involvement and no evidence of perineural invasion
DRE: Normal
Stage:  T1c
Bone scan and chest x-rays:  Negative
Prostate Volume: 47 cc
PSA Velocity:  0.19 ng/ml/yr
PSA Density:  0.092 ng/ml/ccm
PSA Doubling Time:  > 10 Years
Treatment Decision:  CyberKnife radiation treatment in June 2010.  Side effects:  None
 
 
 

Julietinthewoods
Regular Member


Date Joined Sep 2010
Total Posts : 309
   Posted 10/5/2010 8:45 AM (GMT -6)   
Wow. Sounds like you are all in agreement that external radiation alone is probably not the best choice. Thanks so much for the feedback, and for the article posted. So much to consider.

The doctor never used the term IMRT, just 'external beam', so first thing we will do is make sure he is talking about IMRT. Then we could ask about the SBRT 'boost' procedure. Is it commonly done, or hard to find? We can also make an appt. with the doctor in a nearby city who would be responsible for the brachytherapy part and get his opinion. This doctor was not big on HDR, and said he thought there was a more reliable track record for LDR, but he doesn't do it.

I know Carter will want to have the IMRT done at this doctor's office because it is close to work, and it was a huge burden lifted for him to think he could undergo radiation and show up a bit late to work for a couple of months. He also jumped at the idea of just having the external beam, non-invasive procedure (he has never had any kind of surgery!) and forgoing anything more. He was so much happier yesterday afternoon after this appt., thinking maybe there was hope for this being less of an issue with work than he had been so worried about. I can understand that, but I want him to live!! Ultimately, the choice will be his.

I'll keep you posted, and again...thanks so much.

JoeFL
Regular Member


Date Joined Oct 2009
Total Posts : 420
   Posted 10/5/2010 10:32 AM (GMT -6)   
Julie,
 
Here's another vote for the combo of seeds and IGRT (or IMRT). I probably did not need to do both with a Gleason 6 but my rad. onco. told me my success rate would go up 5-8% if I did since the IGRT hits the margins. And just for info, I asked him why he did the BT first followed by the IGRT treatments rather than the other way around. His answer was that he (and his other partners in his clinic) have done it both ways and their collective experience is that their patients seem to have milder side effects in that sequence.
 
In either sequence, I belive your husband would tolerate the BT very well. If I weren't retired, I could have gone back to work on the second day after the BT procedure.
 
Best wishes with your decision.
 
Joe
 
 
Age 67 PSA 4.5 Biopsy 9/4/09 Bostwick Labs 5 of 8 sections (5 of 11 cores) positive-Gleason 3+3=6 Stage T1
BT on 12/11/09 (84 seeds of Palladium 103) Home same day/no catheter. Some burning, frequency, urgency for 6 weeks. No incontinence, mild ED. Normal activity within 3 days. 25 IGRT sessions ending 3/22/10 - some fatigue until 30 days after last treatment. PSA on 5/26 - 0.1 PSA on 9/1 - 0.1

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3887
   Posted 10/5/2010 10:53 AM (GMT -6)   
Radiation can be very expensive..Be sure to get "pre-approval" from your insurance company, your doctor can handle that..Also find out what your co-pays will be...

Also, the equipment that is used to deliver RT is being improved and upgraded at a rapid pace..The treatments Kongo touched on use this new equipment. Only the largest treatment centers can afford it as the costs can be staggering..Lots of marketing and salesmanship get stirred into this pot..Denver Cyberknife ran radio spots during Rockies baseball games...

corman
New Member


Date Joined Aug 2010
Total Posts : 7
   Posted 10/5/2010 11:56 PM (GMT -6)   

I had IMRT alone about five years ago. I know that advancements have been made in the last five years. I was a gleason 7.……….3+4 and was staged T1C. The biopsy did not find much cancer. I remember the Radiation doctor telling me that seeds alone were not out of the question but that if one was not placed next to a cancerous cell, I would probably get poor results because of the small field of radiation of the seed . I now guess they would have saturated the prostate with seeds but he felt that IMRT with the BAT for locating the prostate was a good bet. They also hit the ducts and such. The surgeon that I went to did not push me towards surgery, but stated that if it were him he would have external beam radiation….IMRT……..very odd that a surgeon who had done operations for probably 25 years did not steer me to the operating room. I have had amazing results so far but Fairwind is right it was expensive. IMRT five years ago cost me almost 3000 out of pocket and the insurance company was billed just over 65,000 dollars and this was for IMRT alone. I can only imagine what it would cost today in the Cincinnati area. I know they are now using the GPS Type markers. On my last visit I asked about the markers and he said by going to them they could raise the dose a little higher.. I was told by the financial person in the rad office that some insurance companies would have questioned my decision because of my age and the cost. I was 59 at treatment. I have had no side effects to speak of. I would not be afraid of IMRT alone. In the last 5 years I have read hundreds of reports many of them very technical. However, that said look at all treatment options, only you can decide which is best for yourself. The selling factor for me was the cancer treatment center was only 3 miles from my house. I was in at eleven and out by 11:30 but it went on for nine weeks! My major concern was incontinence. I wanted to stay as far away from incontinence as possible. I remember the surgeon telling me that I would probably have some degree of incontinence if I went the operation route…………..it might be very, very slight ,only when lifting or coughing. With the results I have had I have no regrets but every six months I do suffer PSA anxiety .


Julietinthewoods
Regular Member


Date Joined Sep 2010
Total Posts : 309
   Posted 10/6/2010 12:21 PM (GMT -6)   
Corman, so good to hear that someone had success with the IMRT alone. Five years sounds very encouraging to me.

Money is a big issue, and thanks for the reminder to check on insurance coverage. The SBRT boost intrigues me, but I can't find much more information about it. I doubt seriously, then, that our insurance would cover it. I understand Medicare does not pay for it in my state, so the chances that private insurance will seems slim. I assume it would be one session of Cyberknife? It would be so much easier to go through than the seeding procedure! I'm still reading....

I'm trying to find out now the difference in cost between nine weeks of IMRT, and the IMRT/LDR brachy combo. I think Carter will not do HDR if he can do LDR with similar results.

Next: Carter will contact the radiology office and ask them how many greys he will receive if he goes the IMRT or IGRT route vs. combo.

The people on this forum are so helpful!

Juliet
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