PROTON THERAPY ~ A come back?

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Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 6/15/2011 12:34 AM (GMT -6)   
I know a few that would wonder about me posting positively about proton beam therapy (PBT). First I will say I will draw the line with evidence. We still for some unexplained reason lack head to head comparisons of PBT versus Xray based IMRT/Cyberknife/IGRT etc. therapies. This blog post from a Harvard based PBT expert show me that I am not on firm ground. While we lack the information needed to disprove the efficacy of PBT, we do have some direct head to head comparisons. And PBT compares well to combined IMRT and brachytherapy studies. The argument can be made that the cost of PBT outweighs the benefits. But from what I understand that cost is shrinking.

Do we have enough to say that this very expensive therapy (high enough to make Provenge look cheap at 93k per dosage) is effective enough to treat prostate cancer remains the core argument that Medicare and other insuring venues decry.

I don't know this answer. But it's worth a second look as these costs decline.

This is the reason I am reconsidering my stance...

networkedblogs.com/ja90r

Tony
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:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

Grinnell86
Regular Member


Date Joined Feb 2010
Total Posts : 265
   Posted 6/15/2011 4:07 AM (GMT -6)   
I looked at doing Proton therapy in Jacksonville instead of photon radiation. Blue Cross Blue Shield made my decision for me when they refused to cover the Proton Therapy.
Age 47
PSA 10/09=4.60
Biopsy 12/09
Left side benign
Rt side 3of 4 cores positive, 70%
Initial Gleason 3+4
DaVinci surgery 2/16/10
Catheter removed 2/27/10
Gleason 4+3
Tumor quantitation=10%
Pos margins right side
Staging T2C PNX PMX
Post surgery PSA 5/10 <.05, 8/10 .12, 9/10 .12, 12/10 .16, 1/11 .15,
02/11 .17
03//11 .19
Started SRT 4/28/11

Sagittarian
Veteran Member


Date Joined May 2011
Total Posts : 546
   Posted 6/15/2011 4:28 AM (GMT -6)   
My wife and I visited the Roberts Proton Therapy Center in Philadelphia.
It was my first choice before going with surgery.
 
Our daughters boyfriend (6 years, cmon guy) is a Physicist who
graduated from an Ivy league school.  I asked him what he thought
would be less damaging passing through normal tissue.  He paused
thought about it, then first gave me a disclaimer.  I am not a Dr or
understand how a living cell would react to any treatment.  However,
he guessed it would be proton over photon (standard radiation) because
the body is comprised of photons.  But the photon would need something
to push it since it is less forcefull than a photon.  I think that is the reason
for the particle acellerator.
 
He explained other stuff to me which I didn't grasp, yet.  I will get back to
you once he explains it in detail, so I can share the information.  He needs
to explain physics 101 to me first :>
 
Once again, I will share the science of proton & photon once I can
understand what he is saying :<
Glenn-AGE-53,NJ, PSA-4.2, FPSA-7%
4/09/2011 - Biopsy, 8 NEG, 4 POS (left), 2(3+3), 2(3+4)
5/23/2011 - Da-Vinci Surgery, Right Nerves Spared, Partial Left
5/25/2011 - PATH, pT2c, 4+3, 25% cancer,Confined, Margin-Lymph-Seminal NEG
5/31/2011 - Catheter Removed
6/01/2011 - UTI, CIPRO 500mg 2 a day for 10 Days
6/10/2011 - No ED, Stress Incontinence
7/12/2011 - First Post Surg-PSA test

SkeeterZX22v
Regular Member


Date Joined Apr 2011
Total Posts : 240
   Posted 6/15/2011 4:40 AM (GMT -6)   
When I was diagnosed, I had never heard of proton therapy, and thought my only real decision to make was whether to have open or DaDivinci (sic) surgery. I had even started researching Johns Hopkins and the Mayo Clinic to see which one I would go to. THEN a friend of my wife told her about her husband having been treated at Indiana University at Bloomington with proton therapy. I took a look at it, and found out several other people I knew from my area had also been treated there. I started to then investigate ALL available options for treatment. I interviewed several who had had surgery, brachytherapy, imrt, and proton therapy.

I decided on proton therapy, and both my urologist and my family doctor were in agreement.

Unfortunately, my insurance company was not, and I am now in the appeal process. Based on past precedent, I am hopeful that my appeal to an independent third party reviewer will be successful. If I am not successful in my appeal, I will go for some form of imrt. For me, the choice of external beam radiation, be it proton or photon, was the most appealing method of treatment.

As in anything, you pay your money and take your chances.
Age 61, psa 4.6, 30 days cipro, psa 4.3, biopsy 4/28/11, 2 of 12 cores positive, Gleason 6
T1c
Central Ky

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 6/15/2011 7:05 AM (GMT -6)   
Interesting, Tony. One's mind should always be willing to be changed based on evidence and facts.

Sag - will be looking for your followup on what you were talking about. I would like to know the same thing in laymen's term.
I have a brother who is an astrophysicist, and his discourse on how to change a light bulb is volumunous and over my head, lol
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 margin
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, 4/11 3.81, 6/11 5.8
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

FrackMe
Regular Member


Date Joined Jun 2011
Total Posts : 398
   Posted 6/15/2011 7:19 AM (GMT -6)   
I intend to look into proton beam therapy as well. Something about it just makes sense. As I understand it, the energy is released in the target area, with much less energy hitting tissue on the way in and almost none on the way out. MD anderson has a center and one is planned in NY in which Sloan Kettering will be participating. If the two top cancer hospitals in the country are doing this type of therapy, it must be good science.

axle
Regular Member


Date Joined Feb 2011
Total Posts : 35
   Posted 6/15/2011 9:38 AM (GMT -6)   
I am not totally familiar with the details on how a proton therapy machine or IMRT machine function but as a chemist, I can add this to the discussion.

Protons are particles that have mass. A proton's mass is equal to a neutron's mass. A hydrogen ion is a proton.

I do not know exactly which type of radiation IMRT uses but I assume it is either x-rays or gamma rays. Often this radiation is grouped in with photons because it is a type of electromagnetic radiation (EMR).

From my simple point of view, I would compare the two different types of radiation treatments as this. Proton therapy is like shooting small sub-atomic sized bullets (with mass) at the target (i.e. atomic shotgun). In this situation, the mass and velocity of the radiated projectiles impact the target mass (atoms) to disrupt it.

IMRT is like using a magnifying lens and the sun to burn up ants. In this situation, the frequency of the radiation (EMR) needs to match the absorbtion frequency of the target to disrupt it (i.e. microwave).

Both types of radiation trreatment can result in treatment success and/or collateral damage depending on beam accuracy, beam focus, beam intensity and total dosage.

Note that I am making these comments based on my chemistry interpretation. I really have no idea on the exact functionality of the radiation delivery machines.
Age 58 @ DX; da Vinci on 1/26/2011
PSA History: 10/2005 = 1.7; 10/2007 = 2.8; 10/2009 = 3.6; 10/2010 = 4.9
Abnormal DRE in 2009; Increasingly abnormal DRE in 2010
Thank you POPs!
Biopsy 11/2010: GS = 3+4; 5 of 12 cores pos @ 40%
Post-OP pathology: GS=3+4; tumor = 35%; pT3b; SVI+; EPE+ R. bladder neck; margins neg.
Post-OP PSA 4/13/11 = <0.1

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3149
   Posted 6/15/2011 9:58 AM (GMT -6)   
You would be amazed at the power differences and nuiances within radiation rays and what they could accomplish. (pages 118-127 Dr. Strum's book A Primer on Prostate Cancer). The power goes in this order : neutron rays, proton, photon, (then lesser like electron after the photon). All four of these are useful in PCa patients scenarios, the electron rays can be used as light duty radiation for you possible breast enlargement issues from PCa drugs used, to prevent them enlarging (this is a safe ray for that protocol) and I had it done in one session, usually done in 4 sessions, low exposure levels, however is not guaranteed on all patients to prevent such.

There is one facility operating right now on PCa using neutron rays(was 3 in USA) (super powerful and work differently than proton or photo, if you read about the differences), you need a cyclotron to do this (those are scarce and expensive) also the doc using such needs to be an expert, making errors with this would be really significant. I got 10 session of Neutron rays and then 24 sessions of Photon rays and the max. overall exposure you can get...as my primary treatment (I was refused surgery righteously by Dr. Menon). The doc I did have had a written article about his findings over the years, that using Neutron & then Photon rays had a significant difference in patients outcomes, measureable. So, that is why I chose it and my prostate was loaded to the max with PCa...not sure seeds would be completely doable and not wanting to travel to Florida or Georgia from Michigan. Maybe proton will prove out along the way, on its power differences. Not much written on neutron radiations for us to look at, but there is some.

Just so you know there are many ways to work on the dragon and even within those we have nuiances of newer radiation targeting and methodologies...getting complex as heck.

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 6/15/2011 10:10 AM (GMT -6)   
I investigated proton beam as a treatment. Spoke to both Loma Linda and Shands in Jacksonville. FL. The cost was pretty outrageous and almost 2.5 times the cost of the photon not to mention the travel costs. I am uninsured so this was a major factor in my decision. I did find some research that indicated no difference in efficacy for proton vs. photon. This was in 2007. However, patient responses to inquiries on another board seemed to indicater fewer ED and bowel problems with the proton therapy. Given my stats I would have wound up having a combination proton/photon so I went with the photon only.
 
For those who are interested there is a book by Robert Marckini "You Can Beat Prostate Cancer" subtitled "And you don't need surgery to do it". It is fairly biased towards proton therapy but is informative. If you make an iquiry to Loma Linda they will send you the book.
 
Don

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4149
   Posted 6/15/2011 10:32 AM (GMT -6)   
Tony, interesting link and thanks for sharing.   However the science outlined in this blog is not particularly new and, indeed, is pretty much the same as what I was presented by Shands when I considered PBT in 2008.  This sounded (and sounds) "great" but the problem that I had with making this choice was that almost all of the curative and SE data that I could find was anecdotal.  You have been a big proponent of seeing long term data before making decisions...I could find 10-15 year data on brachytherapy, external radiation and surgery but was unable to find the same on PBT.  You referenced some head to head studies and I'm just not familiar with these.  Are they long term and, if so, could you please find the time to share them?
 
Thanks,
 
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

flippin out
Regular Member


Date Joined Mar 2006
Total Posts : 137
   Posted 6/15/2011 11:09 AM (GMT -6)   
Target area would be of significant importance in my particular insistence as having both Da Vinci surgery & Proton radiation, now I am considered for IMRT radiation of the lymph nodes this time along with hormone treatments as a final objective for a cure.
As told by the radiologist at Loma Linda medical center radiation is radiation of course the option of Proton as I understand it was more direct to the effected/targeted area and less to surrounding tissue I am wondering if it is too direct and had missed the cells left over from surgery? All I know is here we go again!
54Yr Cancer Detected 2005
PSA 8.0+ Gleason 7
55Yr DaVinci City Of Hope California
57Yr Cancer rise in successive PSA's
57Yr Proton Radiation Loma Linda Medical Center California
59Yr 2010 ^ Rising PSA 2011 Feb .18 May .26 June .3
Lymph node radiation suggested with hormone drugs
Diabetic T2

Sagittarian
Veteran Member


Date Joined May 2011
Total Posts : 546
   Posted 6/15/2011 11:16 AM (GMT -6)   
 
10 Year study for PBT.
 
Disclaimer:  It is from a PBT center.

dkob131
Regular Member


Date Joined Apr 2008
Total Posts : 364
   Posted 6/15/2011 11:19 AM (GMT -6)   
Ahhhh, the brotherhood of the baloon, I didn't have proton but I did receive the endorectal baloon for my SRT IMRT, it was interesting to say the least. I read a few studies that said good  things about it.
 
I don't believe its an option with proton, you do the balloon or find another treatment.  Maybe someone can confirm this or not.
 
David

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4149
   Posted 6/15/2011 12:12 PM (GMT -6)   
Sagittarian, thanks.  But, I think I recall seeing this one before and discounted it because:
 
1.  The mean and median follow up was only about 5 years.
 
2.  Only a small number out of 1200+ patients had ten year results.
 
3.  Over half of the patients were treated with both photon and proton.
 
So, unless I'm missing something, I still haven't seen long term data on PBT therapy results and SE's.  But, I really would like to believe this is a good choice...just need some data!
 
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

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 6/15/2011 1:03 PM (GMT -6)   
I'm only aware of two head to head studies comparing Proton treatment. The ICER 2009 report and the Prostate Cancer Study Group. Both of these indicated Proton was not as effective as other types of radiation.
From everything I have read Proton is very effective for small cancers in hard to get at places such as the brain and neck. To amortise the high cost of the machines they started treating the more common cancers such as prostate. The large area of the prostate and the irregular shape make it more difficult for Proton treatment than other types of radiation. The last I heard is that they were working on newer ways to shape the beam to make it more effective for PC. If I had brain cancer I wouldn't hesitate to use Proton, but have yet to see evidence that it is more effective than conventional treatments, especially in Intermediate or high risk cases of prostate cancer. I would love to see another option that his minimal side affects and I hope that one day changes to proton will make it more effective for PC.
JohnT
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. 2 years of psa's all at 0.1.

SkeeterZX22v
Regular Member


Date Joined Apr 2011
Total Posts : 240
   Posted 6/15/2011 2:24 PM (GMT -6)   
Interesting how any discussion of proton therapy treatment brings out such strong opinion about the appropriateness or not of this type of treatment. Inasmuch as the supporters of PBT are often taken to task for being "cheerleaders," the same could be said for those who challenge PBT with nothing more than their opinion. Frankly, reading this forum for the past couple of months has done more to convince me that surgery is one of the least desirable options for treatment of PCa. I simply cannot believe that such respected cancer centers as M D Anderson would use PBT to treat PCa if it were not a viable and effective way of doing so. Likewise, I cannot believe that so many other major hospital facilities would be in the process of adding PBT to their arsenal of treatment options.

Everything that I have read indicates that PBT is indeed a very effective treatment for PCa. The only criticism that I have found is really the cost of the treatment, and whether for PCa it is justified in comparison to other radiation options. That is fair debate, I suppose. But to say it isn't an effective treatment is a statement that I would disagree with.
Age 61, psa 4.6, 30 days cipro, psa 4.3, biopsy 4/28/11, 2 of 12 cores positive, Gleason 6
T1c
Central Ky

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 6/15/2011 4:00 PM (GMT -6)   
Skeeter,
Most center are adding Proton for other cancers, not for PC. PC is being used to increase the utilization of the costly equipment. No one ever said that Proton is not effective; it is effective for low grade PC. It's effectiveness in treating the higher grades of PC are questionable. It just hasn't been proven to be more effective, and when total costs are considered it's effectiveness for treating PC drops dramatically.
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. 2 years of psa's all at 0.1.

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4149
   Posted 6/15/2011 4:22 PM (GMT -6)   
Skeeter, I didn't see anyone give an opinion on this thread that PBT was ineffective.  JohnT referenced a couple of published articles and I hope you didn't take my questions as statements that I thought PBT was ineffective.  In fact I would very much like to believe that it is a VERY effective treatment and that the SE's are minimal...after all, that's what most of us want.  All I'm saying is that when I was looking at PBT as an option I was unable to find substantive long term data about either it's effectiveness or side effects.  Tony stated that PBT compares well with IMRT and brachytherapy studies...I'm just asking for these to be shared by him (or anyone) since I was unable to find such data.  I hope it exists.
 
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

mr bill
Veteran Member


Date Joined Sep 2010
Total Posts : 688
   Posted 6/15/2011 5:46 PM (GMT -6)   
From what I have heard John T. is correct. I Believe M D Anderson will not consider patients for Proton if Gleason is an 8 or 9 and PSA is over 20.  Not 100% sure but pretty close. So it makes sense that they to believe it may not be successful treating advanced PCa.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 6/15/2011 6:48 PM (GMT -6)   
I would like to point out that because we lack level 1 studies on the efficacy of proton beam therapy, this would still not be the choice i would have chosen. For me, the decision to go with surgery was the best choice as I felt most secure with it and I had access to a very good doctor who had history in our family (not prostate cancer related) and who would do the procedure at a reputable location. My surgical morbidities are far less than many others have experienced so I am happy with the choice and because of my choice I had the opportunity to look at adjuvant therapies.

My biggest concern with any form of radiation was long term side effects which today are still poorly documented for a man that was just 44 years old. But because I was 44 and had locally advanced disease I believed that most of the long term morbidity associated with radiation therapies were outweighed by my stage, Gleason sum, and age (life expectancy). I felt I needed to keep damming the torpedoes and attacking the cancer.

My friend who is a Harvard trained radiation oncologist released this post on his website and I thought it was appropriate to share. I do believe that PBT can be effective for many men of all stages. It is more likely to succeed than to fail by a large margin. I think that is important to say for most radiation options. With the median age at diagnosis at 67yo, we do have good radiation data for that patient.

Tony
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:
Da Vinci Surgery ~ 2/16/2007
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.
Undetectable PSA.

Blog: www.caringbridge.org/visit/tonycrispino

Sagittarian
Veteran Member


Date Joined May 2011
Total Posts : 546
   Posted 6/17/2011 6:24 AM (GMT -6)   
I spoke with the Physicist, and before I can pose the correct questions
he is taking me down a long road.  
The link below is to give you an idea of where he is leading me.
The basics of an atom is where I am starting.
 
 
http://www.khanacademy.org
Glenn-AGE-53,NJ, PSA-4.2, FPSA-7%
4/09/2011 - Biopsy, 8 NEG, 4 POS (left), 2(3+3), 2(3+4)
5/23/2011 - Da-Vinci Surgery, Right Nerves Spared, Partial Left
5/25/2011 - PATH, pT2c, 4+3, 25% cancer,Confined, Margin-Lymph-Seminal NEG
5/31/2011 - Catheter Removed
6/01/2011 - UTI, CIPRO 500mg 2 a day for 10 Days
6/10/2011 - No ED, Stress Incontinence
7/12/2011 - First Post Surg-PSA test
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