Question for SRT guys about doctor selection

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reachout
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Date Joined May 2009
Total Posts : 725
   Posted 4/13/2011 10:16 AM (GMT -6)   
We all know the many discussions about the number of surgeries required to achieve competence in open or robotic procedures. That complicates the search for a good surgeon, but it's well worth the effort to ask around.

How about radiation doctors who do SRT? Is there a rule of thumb for how much experience they should have, or are they all pretty much just following the same standard procedures? I realize some, like Purgatory, had pretty bad SEs but not sure if that was just one of those unfortunate things that happens with even the best doctors.

Also, is IMRT the standard for SRT?

BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 4/13/2011 10:26 AM (GMT -6)   
Interesting topic, although I think that it has been discussed here before. I personally think that experience counts in everything. However, when selecting RO I went with a institution/facility as opposed to the Doctor. My comfort came from the fact that the facility was a teaching hospital. Honestly, my biggest concern was the techs.
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

English Alf
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Date Joined Oct 2009
Total Posts : 2215
   Posted 4/13/2011 12:28 PM (GMT -6)   
For my SRT I saw one doc to discuss things beforehand, but he was part of a team that decided on how to plan my treatment (and the planning meeting included one of the physician assistants from the surgeon's department too.) I have since seen four different RT docs so far during my check-ups, and have had no problems with this aspect.
Alf
Age dx 48
Apr 09 PSA 8.6
DRE neg
Biop 2/12 pos
Gleason 3+3
Jul 09 DaVinci AVL-NKI Amsterdam
6 Aug 09 Cath out
PostOp Gleason 3+4 Bladder neck & Left SVI -T3b
No perin’l No vasc invasion Clear margins
Dry at night
21 Sep 09 No pads daytime
Nov 09 PSA 0.1
Mar 10 PSA 0.4 sent to RT
13 Apr CT
RT 66Gy ends 11 Jun 10
Tired + weird BMs
Sep 10 PSA <0.1
Jan 11 PSA <0.1
Apr 11 PSA <0.1
Erection OK

BB_Fan
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Date Joined Jan 2010
Total Posts : 1011
   Posted 4/13/2011 12:56 PM (GMT -6)   
Reach, I had IMRT which I think is pretty common, but it isn't the standard for SRT. The type of RT one gets and the machines used is a hot topic here. I am by no means the expert. Others will probably weigh in.
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

Fairwind
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Date Joined Jul 2010
Total Posts : 3739
   Posted 4/13/2011 1:10 PM (GMT -6)   
BB_FAN brings up an excellent point.. It's the technicians that actually administer the treatment..Unless they have problems, the R-doc is not involved with that. Basically, he just writes a treatment plan, a computer program, which is loaded into the computer that controls the LINAC that is treating you...He shows up once a week to chat with you about any possible side-effects after his nurse has done the same thing...He decides on how many treatments, dose per treatment, total dose, and whether or not to include HT as part of the salvage operation..There are minor variations between patients but it's pretty much standard stuff. My R-doc prescribed 34 pelvic area treatments, 1.8Gy each. Then, at the end, the beam was narrowed and focused on the prostate bed for the last 6 treatments. This was called "Boost" and is a little unusual..It worried the techs and they called in the R-doc before starting two of those last 6 treatments..

I'm two months out and everything is back to "normal"...
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
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 0.0

John T
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Date Joined Nov 2008
Total Posts : 4223
   Posted 4/13/2011 1:16 PM (GMT -6)   
I saw an article from a radiation oncologist from UCLA a few months back. She said that the radiation team, radiologist and physicist, should have at least 250 procedures relating to prostate cancer.
Treating PC is tricky because of all the nearby organs and the irregular target. 250 is the experience level recommeded to get the optimum cancer control and limiting the side affects.
This was the only article I ever saw that delt with the experience necessary for prostate radiology. My oncologist told me that in his experience some radiologists consistantly get better results than others. This is akin to surgeons where experience and skill are formulas for successful outcomes.
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.

JNF
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Date Joined Dec 2010
Total Posts : 3744
   Posted 4/13/2011 2:06 PM (GMT -6)   
The radiation practice I used has been radiating prostates for more than 20 years with three generations of rad-oncs. My own is the youngest in the group and he has directed more than 1,000 men through the HDR/IMRT process plus many hundred through post surgery SRT. He and the other two rad-oncs are onboarding 4-6 new PCa patients each week. Thus a lot of experience and throughput. PCa is over half of their practice. Next would be breast cancer and head and neck cancer.

Among the things that impressed me was that early in our relationship he introduced me to the two more senior rad-oncs for a general discussion and I experienced their collaberation of opinions regarding my situation. Though I was working directly with the one rad-onc, I was getting the benefit of the overall braintrust.

Several times during the two months of treatment the senior partner visited with me to see how I was progressing. This also gave me confidence that if for any reason my rad-onc couldn't procede, i would have a seamless transition to another within the practice whom I had met.

I concur that experience is very important with each specialist......the urologist, the rad-onc, and the med-onc. And it helps to have them communicate on your behalf.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard shot and daily Jalyn started on 10-7-2010.
IMRT to prostate and lymph nodes 25 fractions started on 11-8-2010, HDR Brachytherapy 12-6 and 13-2010.
PSA <.1 and T 23 on 2-3-2011.

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/13/2011 3:58 PM (GMT -6)   
Good Question Reachout,

There are two factors involved. The planning by the Radiation Oncologist and the experience level of the technicians at the machine. If the technicians get behind and don't properly align your body against to the original mapping scan, then the radiation will hit the wrong places.

Even after overlaying the scans, they still have to adjust the table in millimeters to make sure the proper radation zones are targeted.

A hurried technician that isn't exact and careful can make the best radiation oncologist look bad. Likewise, a technician can't make up for a bad mapping done by the oncologist.

In the overall scheme, having lots of experience in both areas is important. Seeking the best oncologist usually will result in the best technicians. They seem to go hand in hand, but there are exceptions.
You are beating back cancer, so hold your head up with dignity

Les

Robotic Surgery Sept 2008
PSA increasing since January 2009
Current PSA .44
PSA Doubling time approx. 6 months
Clinical Trial - Control Arm SRT begins 3/01/11

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 4/14/2011 6:19 AM (GMT -6)   
Thanks for all of the replies. This board is, as usual, very helpful. So if I have to go this route, besides finding an experienced RO, I'll be extra nice to the techs.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 4/14/2011 7:28 AM (GMT -6)   
I current post regarding treatment in July got me a bit concerned. I had my SRT in August and September. Since I had traement at a teaching hospital, I think that I would have addressed the experience and superision of the techs had I know that this is the time period in which the are normally rotated in there assignments.
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 RP March 2009
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes - tumor volume 9%, nerves spared, no negitive side effects.
PSA's < .01, .01, .07, .28, .50. ADT 3 5/10. IMRT 7/10.
PSA's post HT .01, < .01

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3739
   Posted 4/14/2011 11:08 AM (GMT -6)   
The newest LINAC's, like the Varian RapidArc, have built in safeguards to make sure you are positioned correctly and your rectum and bladder are in their proper positions before the beam is energized..

The hospital where I was treated had 15 minutes of slack time built-in between patients to give the techs a buffer should there be a problem..Twice during my 40 treatments, the techs delayed the treatment for a few minutes until a doctor was in the control room because of positioning problems. Once, I had to get off the table and "clear my bowels" before treatment could proceed..

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7203
   Posted 4/14/2011 11:42 AM (GMT -6)   
Bottom line: It seems much harder to get a fix on the competence of an RO and staff. It really is.
 
I met with the RO twice and eventually I just went with my gut feeling and also tempered by the fact that my local facility is THE MAJOR facility in mid-Michigan and they do use the Varian Trilogy RapidArc. Still, who knows...
 
I was much more confident on the surgery side as I was getting done by, for sure, one of the top people in the country.
 
If SRT fails, I will most assuredly be seeking out a top medical oncologist specializing only in PC. As of now, my thinking is Dr. Hussein at Umich and probably also a consult with Dr. Scholz in LA
 
Mel

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 4/14/2011 12:45 PM (GMT -6)   
I agree with Mel, I interviewed and heavily grilled 3 different radiation oncologists before my SRT, chose the one that appeared the most qualified and experienced, and it got me no where. She was the one responsible for destroying my bladder and bladder neck, put me into a year of extreme pain, and forced me to have a urostomy. And that's after I spent much time researching. Much easier to check out a surgeon in my opinion
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 2/11 1.24
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 9/10,
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