Why no radiation failures on HW?

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Tudpock18
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   Posted 1/13/2011 1:21 PM (GMT -6)   
Given my bias toward radiation treatments I hope this question won't sound self serving as I mean it in all seriousness.  I have been wondering why we rarely see any men at HW who are experiencing BCR after choosing brachytherapy and/or IMRT as their initial treatment.  I have been coming here for 2 years and can only recall one (maybe there were others that I don't remember) man who had brachy that failed and who followed that up with a fairly disastrous surgery.
 
In trying to answer my own question, it may be that since surgery is more popular anyway we are just not big enough to get the numbers.  Or, the fact that it takes a lot longer with radiation to detect BCR may be part of the answer.
 
But honestly I'm wondering if, as JohnT postulates, modern radiation provides a better chance of killing the cancer around the edges.  If that is true, then the long term numbers at some point in time should show that radiation is superior to surgery as an initial treatment...not only for side effects but for cure. 
 
Any thoughts?
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

clocknut
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Date Joined Sep 2010
Total Posts : 2667
   Posted 1/13/2011 1:33 PM (GMT -6)   
I might have chosen brachy except for the fact that my prostate was, as I recall, 88cc, and I think the top limit for brachy is in the 50 cc range. I only know one guy personally who has had brachytherapy, and his was done I think 9 years ago. He has moved on and rarely seems to even think about PCa anymore.
Age 65
Dx in June 2010.
PSA gradually rising for 3 years to 6.2
Biopsy confirmed cancer in 6 of 12 cores, all on left side
Gleason 7 (3 + 4)
Bone scan, CT scan, rib x-rays negative.
DaVinci 8/20/10
Negative margins; negative seminal vesicles
5 brothers, ages 52-67 ; I'm the only one with PCa
Continence OK after 7 weeks. ED continues.
PSA 1/3/10: 0.01

Purgatory
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Date Joined Oct 2008
Total Posts : 25380
   Posted 1/13/2011 3:23 PM (GMT -6)   
Tud,

RT or Seeds as a primary treatment: not sure I have seen an out and out failure as a first line event.

We have had several failed Adjuvant and SRT as secondary treatments that didnt work.

David
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

BB_Fan
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Total Posts : 1011
   Posted 1/13/2011 4:18 PM (GMT -6)   
I'm starting to think that seeds with IMRT may be the way to go if you are a G8-10. Although everything I read seems to indicate outcomes are the same.
Dx PCa Dec 2008 at 56, PSA 3.4
Biopsy: T1c, Geason 7 (3+4) - 8 cores, 4 positive, 30% of all 4 cores.
Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%, nerves spared, no negitive side effects of surgery.
PSA's < .01, .01, .07, .28, .50. HT 5/10. IMRT 9/10.
PSA's post HT .01, < .01

Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 1/13/2011 4:28 PM (GMT -6)   
Tud,
You'll need to start looking a little closer. I have seen a few here and I have a few in my live group as well.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/13/2011 5:54 PM (GMT -6)   
Tudpock18 said...
Any thoughts?
 
 

I think there are several reasons why you perceive them to be less prevalent…

One reason is that brachytherapy tends to have “late-term effects”…stuff starts going wrong somewhere down the road (I read examples of 2 or 3 or 6 years later, after guys have “moved on” from HW).  The “effects profile” is opposite for surgery where essentially all the effects are immediate then reduce over time (usually within about a year), so guys are still hanging out at HW immediately after surgery but fade away as side effects diminish.

Another reason is that when guys start bleeding from their butt (here’s why, IMAGE), their brachy oncologist refers them to a proctologist for further treatment…it’s no longer an oncologist’s problem to treat.  These guys might generally be looking for other support pages

Also, as sexual function begins to diminish as another post-brachytherapy late-term effect, the patient thinks of this as an ED issue, not as a PC issue from several years before.  It seems like a natural diminished capability...although perhaps it happened sooner than it might have otherwise happened.  Further to that point but a little off your question, I think it’s clear that American society generally celebrates immediate gratification, and oncologists tend to describe the immediate effects of a PC therapies…perhaps understating the late-term effects of all types of radiation therapy.  Here’s a quote from the article titled:  “Management of Sexual Dysfunction After Prostate Brachytherapy”

The young patient who chooses radiation based solely on his desire to maintain sexual activity may be gaining very little in the long run, and may be choosing an inferior therapy based upon incomplete information. If the patient has a better chance of survival at 10, 15, or 20 years with radical prostatectomy, but chooses seed implantation to reduce the risk of erectile dysfunction, he may still find that there is a significant reduction in erectile function at 3 to 6 years posttherapy. The trade-off may not be worth it to him and his family, and they may ultimately believe the short-term gain was not worth the long-term pain.

Lastly, regarding cancer control itself, patients considered for intersititial brachytherapy are generally those classified as low risk, more specifically, those with stage T1c–T2a (tumor confined to the prostate gland), PSA less than 10 ng/ml, and Gleason score of six or less.  (REFERENCE)  These guys pretty much do well in cancer control with any of the major treatments.

Hope this helps answer your question...


Tudpock18
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Date Joined Sep 2008
Total Posts : 4157
   Posted 1/13/2011 6:03 PM (GMT -6)   
Casey, your answers were interesting...it's just that they were answers to a different question than the one I posed.  You talked about side effects and I was asking about recurrance....and not just from brachy but also from brachy/IMRT.   Any thoughts on the original question?
 
Tudpock (Jim)

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/13/2011 6:05 PM (GMT -6)   
Amazing, this criteria at the end of the post above, was right in line why it was reccomended to me at the time of my primary treatment decision process, not to do seeding as I had desired. I didn't seem to meet any of the acceptable criteria.
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/13/2011 6:07 PM (GMT -6)   
Tudpock18 said...
Any thoughts on the original question?
 
 
You're right...I answered the more broad question about long-term brachy patients not being present in larger numbers here at HW and discussing their problems.  Sorry, I drifted...
 
 
More directly to your original question:

Lastly, regarding cancer control itself, patients considered for intersititial brachytherapy are generally those classified as low risk, more specifically, those with stage T1c–T2a (tumor confined to the prostate gland), PSA less than 10 ng/ml, and Gleason score of six or less.  (REFERENCE)  These guys pretty much do well in cancer control with any of the major treatments.

Hope this helps answer your question...

 

The other point, which was also Tony's, is that they are here...but I agree with you not so many.


F8
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   Posted 1/13/2011 6:16 PM (GMT -6)   
im a gleason 7 with intermediate risk.  you can see my treatment in my profile, and i saw other similar cases at the radiation clinic.  my urologist and his associate, both surgeons, did not like to operate as a primary treatment when there was a good chance that the disease had jumped the capsule.  of course they would operate if you prefered or did not qualify for BT.
 
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

F8
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Date Joined Feb 2010
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   Posted 1/13/2011 6:24 PM (GMT -6)   
but i do agree that choosing BT as an only treatment would not be my first choice unless i was convinced that the cancer was in its early stages.

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

Fairwind
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Date Joined Jul 2010
Total Posts : 3748
   Posted 1/13/2011 6:31 PM (GMT -6)   
"Why no radiation failures on HW? "

Well, there is the obvious answer...

Tudpock18
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Date Joined Sep 2008
Total Posts : 4157
   Posted 1/13/2011 6:45 PM (GMT -6)   
Casey, that does of course help re brachy only.  But, once again, I'll refer you back to my original question which was brachy and/or IMRT.  Do you have thoughts on the original question?
 
Tudpock (Jim)

142
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Date Joined Jan 2010
Total Posts : 6949
   Posted 1/13/2011 6:45 PM (GMT -6)   
I asked at two major centers about seeds, but having a complete coverage of 4+3 and 4+4 biopsies (9 of 12 positive, 3 quadrants of the prostate had two 4+4, one had three), no one would do anything but suggest I was not a good candidate.
 
Hey, I tried.
DaVinci 10/2009
My IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808

Willie B
Regular Member


Date Joined Jul 2010
Total Posts : 155
   Posted 1/13/2011 7:05 PM (GMT -6)   
Hi Mary here,

We had a friend, diagnosed in 2004, G6, chose Brachy.

Last September he was found to have cancer in his kidney, not an uncommon problem after Brachy, then it spread to his lung and he died in December.

He was 57 years old.

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 1/13/2011 7:15 PM (GMT -6)   
Tud,  I would hazard a guess that most of the Brachy and IMRT folks have good outcomes and don't bother to post.  At age 74 I have many friends and acquiantances that had trouble free brachy and IMRT.  They are in disbelief that I chose surgery.  Here is a sample report from Schiffler Cancer Center.  I don't know if this is typical but it surely makes me question my decision.
 
"What did they find?
Based on a median follow-up for the entire population of 58.6 months they projected that 98.2% of the low-risk men would survive progression-free after 8 years as measured by PSA levels. Among the intermediate-risk group they estimated that 98.4% would survive progression-free after 8 years, and 88.2% of the high-risk group would survive that long without PSA progression.

At last follow-up, only 5 patients (0.8%) had died of metastatic prostate cancer. When they analyzed multiple factors they found that Gleason score, percentage of biopsy samples that were positive for cancer, and ADT predicted PSA progression in high-risk patients. In low- and intermediate-risk patients, none of the evaluated variables predicted PSA progression."
 
When I made my decision, I down played the incontinence side effects because I thought they were aberrations.  Now I realize that my uneventful surgery was the aberration.  Most of my surgery friends are incontinent, have ED and one had a rectal fistula. 
 
I'm throwing in the towel.  You and John T win.  I'm a full convert to brachy and IMRT.
 
Carlos 

Dx 2/2008, age 71, PSA 9.1, G8,T1c. daVinci surgery 5/2008, G8(5+3), pT2c. LFPF, good QOL. PSA <0.1 for 2 yrs. PSA rose to .2 at 30 months, started SRT 12/15/2010.

Post Edited (Carlos) : 1/13/2011 10:25:55 PM (GMT-7)


F8
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   Posted 1/13/2011 7:16 PM (GMT -6)   
>>not an uncommon problem after Brachy<<
 
do you mean it's not uncommon to die of something else or that BT was the cause of the kidney cancer?
 
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

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/13/2011 7:25 PM (GMT -6)   

The brachy plus IMRT doesn’t have much history yet; combined treatment was largely experimental before the 2000’s…it has ramped up in the later part of the decade.  Few early reports exist.  In the early 1990’s, brachytherapy alone was considered investigational, but no longer so.  Even at the 2007 ASCO Prostate Cancer Symposium, researchers were writing that “The role of supplemental EBRT in brachytherapy is controversial.”  A number of the early studies showed no statistical difference in the prostate cancer specific mortality of seeds vs. seeds+IMRT; recently, some studies have shown differences (probably as they are continuing to tweak the radiation doses). 

The reports out there generally end with a statement like this example from 2009:  Longer followup will help to determine the role of HDR brachytherapy and IMRT in the treatment of early stage prostate cancer.  For the  somewhat limited set of patients eligible for seeds + IMRT the BCR results look positive...I suspect that this will probably continue to hold true over time, or continue to improve, with respect to the original question on cancer control.



F8
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Date Joined Feb 2010
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   Posted 1/13/2011 7:33 PM (GMT -6)   
>>The brachy plus IMRT doesn’t have much history yet...<<
 
here's a story that's about 15 years old.
 
 
andy grove defied the gold standard of surgery and had combination radiation therapy and HT. grove has remained cancer free tho he was diagnosed with parkinson's a couple of years later.
 
 
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

JNF
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Date Joined Dec 2010
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   Posted 1/13/2011 7:37 PM (GMT -6)   
My urologist and two others said that I was a bit high risk for surgery. G7 and T2b with a high PSA. They all said they would expect positive margins that would then require RT. They were all straight with me that PC surgery is tough...one of the most difficult, complex, and inherently fraught with complications with nerves and vessels. Nothing as simple as my wife's breast cancer surgery or even most brain surgeries!. It was posited that I would likely be facing rt anyway so why not start there without the problems of surgery. I feel I spoke with three very honest urologists. I asked each whether Walsh would operate on me and they laughed saying I would screw up his statistics.

I chose HDR brachytherapy over permanent brachytherapy as it is far more focussed, more accurate, and with fewer side effects. My research included the pre-eminent permanent brachytherapy center (in Atlanta...you can do the research) and I was convinced that permanent seeds was the way to go in the last century, but HRD is the way to go now. As was mentioned before, they were able to radiate the gland, a 5-10mm margin, the seminal vessicles, amd the lymph nodes. Can't do that with surgery and still be able to function.

I figure my primary treatment can't fail in the same way surgery can. If down the road I have increasing PSA it means that the cancer was already in the distant nodes or bones and that neither radiation nor surgery would have been sole cure. By definition, surgery fails if there are positive margins or something is left behind to spare nerves, vessels, or non-prostate tissues.

My brother's brother-in-law had RP seven years ago. He was T2, G9, and PSA of less then 2. He only consulted an urologist and wasn't even given the choice or RT. Since then he has done SRT and one round of HT (but didn't know about ADT3) and is looking at his second round of HT as his PSA has continually increased. Obviously, in retrospect, his surgery was not appropriate and his mild incontinence (two pads a day isn't bad after 7 years!!!) and ed should not have been inflicted upon him.

My take is that if you are T1, G6, and PSA<6, than surgery or RT will do you well and you are likely to make the 10 year mark at <0.20......cured. But so would HDR or LDR without the RP side effects. But when I look at the signatures....I don't find many in that range. Thus I think most of us are higher risk than we would like to admit and the intermediate and higher risk just are not good candidates for surgery. I think in the future we will see more urologists partnering with rad-oncs to use RT and get better with HT rather than jumping at surgery and then trying to explain why it failed and we need RT...and HT.... and Chemo....and....

My urologist and I and my wife all agreed that, being realistic, I am looking at long term management, not cure. Much like someone with diabetes or rheumatoid arthritis. I am 60, in great shape and hopefully will make it to 75 or so and living life accordingly. My dad just died at 93, but I don't expect that span so I want to pursue treatment that is life prolonging but doesn't include knives.

John T
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   Posted 1/13/2011 7:56 PM (GMT -6)   
Tud,
I'm on the prostatepointers seed and ERBT forum. There are some radiation failures and some nasty side affects, mostly relating to rectal bleeding. Very few posts relating to either incontinence or ED. Compared to the amount of failures and side affects posted on healing well (about 50% of all posts) there are relatively few regarding negative consequences from radiation, even fewer for brachy.
Radiation reoccurrances occur on an average of about 5 years later than reoccurrances from surgery. This could play a part in why so few posts on radiation failure.
I keep hearing references to side affects from radiation occurring 5 or 6 years later, this may have come from the older ERBT treatments. All the radiation oncologists I have talked to say that the side affects you have in 2 years are what you will most likely have; it doesn't get better or worse from there.
There is a huge difference in both brachy and external radiation from the procedures 10 years ago. A lot of what we hear about are the older ERBT treatments. Most of the radiation posts I read are about the lack of side affects and low and stable psas.
From everything I have read in the past two years brings me to the conslusion that radiation, especially brachy combined with IMRT has a slightly better cure rate than surgery across all gleason grades and in general has less side affects with many more patients having no side affects at all, especially for brachy.
JohnT
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.

Purgatory
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Date Joined Oct 2008
Total Posts : 25380
   Posted 1/13/2011 8:41 PM (GMT -6)   
John, you bring up some good points, as usual.

So weird for me, as when I had neck & throat radiation, in the year 2000, it was old school EBRT. The side effects and long term damage potential were well spelled out for me, and there really wasn't any surprises. It was a tough way to get 70 gys in such a small area at the time. Took a long time to recover from it too, but again, the negative side was well known.

This time, in 2009, I am told over and over, that the IMRT I had was well focused, very safe, virtually no side effects, etc, etc, and yet it went terribly wrong at 72 gys. And, old story now, but left me with perm. bladder damage and bladder neck damage.

At least with the old radiation, I knew what to expect, there weren't any surprises. With the new radiation, the whole negative side took me by complete surprise ,because I beleived what the radiation oncologist and radiation clinic told me. Boy, was I ever wrong.

David
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Julietinthewoods
Regular Member


Date Joined Sep 2010
Total Posts : 309
   Posted 1/13/2011 9:59 PM (GMT -6)   
Carlos, thanks for posting that. John T, your posts always encourage me. My husband is a gleason 7, and is undergoing 45 sessions of IMRT after gold marker implantation. We can only hope for the best.

I know this post is about recurrence, not side effects, but I wanted to say (to encourage others who may be reading and hoping for answers) that Carter has had not a single side effect....no fatigue, no bladder symptoms, no loose stools, no irritated skin, absolutely nothing. He has nine sessions left, and I hope that means that if they were going to appear, they would have by now. I also hope it is some kind of omen for the future, because of course what matters most is the cure rate. Needless to say, the fact that this has turned out to be a relatively easy treatment choice has bolstered him so much, and given him a hopeful and positive outlook.

That said, quality of life right now mattered greatly to him for personal reasons related to a need to reach the retirement finish line. People just have different needs and different circumstances. It isn't necessarily 'wrong' to care more about even the next two years than eight years out.

Purgatory, you have earned the right to hate the very word 'radiation', and I don't blame you a bit. I would feel exactly the same way.

JoeFL
Regular Member


Date Joined Oct 2009
Total Posts : 420
   Posted 1/14/2011 11:52 AM (GMT -6)   
Tud,
 
Thanks for asking the question. After visiting HW for over a year, I wondered the same thing myself. I agree with the point someone made that the BT and/or IGRT guys tend to have lower Gleasons (less risk of reoccurance) and very little need to seek advice on side effects. I can't recall a seed/IGRT poster who has had any serious issues. Most probably just move on....if something happens 5 or 6 years down the road they must not be coming back to report.
 
The reason I stick around is to be sure we encourage the newbies who qualify to carefully explore their options. You are not the only one with a bias for this treatment. That said, I would never question anyone who chooses surgery after doing their due diligence.
 
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 as of 12/9/10 - 0.1

Willie B
Regular Member


Date Joined Jul 2010
Total Posts : 155
   Posted 1/14/2011 4:10 PM (GMT -6)   
Hi Mary here,

Ed (F8), I believe that was the phrase used by his doctor and our friend took it to mean that the kidney was possibly cancerous due to the proximity of the brachy therapy that he'd had years ago.

ie it was as a result of having radiation seeds within the urinary tract.

Brachy has such a good success rate and maybe if/when it fails, it's prone to being in the same body system?

Hope that helps.
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