Posted 1/6/2016 6:50 AM (GMT -7)
Tall Allen has compiled some excellent questions for patients to ask if they are consulting with doctors about HDR Brachytherapy, LDR Brachytherapy and SBRT. These questions are presented below. Thank you Allen! (just added the other questions that Allen prepared)
Jim
SBRT doctor questions
1. How many have you performed?
2. How has your practice of SBRT changed over the years?
3. What is your 5-yr freedom from recurrence rate for patients at my risk level? What proportion of your recurrences were local?
4. What kind of urinary and rectal reactions can I expect? How long can I expect them to last? What medications or interventions do you typically give for that? Should I expect those symptoms to recur later?
5. What is your rate of serious (Grade 3) adverse events? Do you see urinary strictures? Urinary retention requiring catheterization? Fistulas? Rectal bleeding requiring argon plasma or other interventions?
6. What is the margin you will treat around the prostate? Is it less on the rectal side?
7. What is the prescribed dose to the planned target volume?
8. Do you work off a fused MRI/CT scan?
9. What machine do you use (e.g., VMAT, CyberKnife, step-and-shoot, Tomotherapy, etc.)?
• If CyberKnife: Do you use the IRIS or a new multileaf collimator?
• Do you set a limit on “hot spots”?
10. Do you use fiducials or Calypso transponders? Do you do transperineal placement of them?
o What system do you use for inter-fractional tracking?
o What system do you use for intra-fractional tracking?
11. In my treatment plan, what do you identify as “organs at risk” and what dose constraints do you put on them?
o What dose will my penile bulb receive?
12. How long does each treatment take?
13. How will I be immobilized during each treatment?
14. Are there any bowel prep or dietary requirements?
15. Should I avoid taking antioxidant supplements during treatment?
16. In your practice, among men who were fully potent, what percent remained fully potent 3-5 years later?
o Have any men retained some ability to produce semen?
o What is your opinion of taking Viagra preventatively?
17. Do you monitor side effects with the EPIC questionnaire?
o In your practice, what percent of men experience acute urinary side effects?
o In your practice, what percent of men experience acute rectal side effects?
o In your practice, what percent of men experience late term urinary side effects?
o In your practice, what percent of men experience late term rectal side effects?
18. What kind of PSA pattern should I expect following treatment?
19. What is the median PSA nadir you are seeing in your practice, and how long does it take to reach that, on the average?
20. In your practice, what percent of men experience biochemical recurrence?
o What % of those have been local?
o If there should be a biochemical (PSA) recurrence, what would the next steps be?
o Have you ever used SBRT, brachy, or cryo for salvage after a local SBRT failure, and was that focal or whole gland?
21. Are you open to email communications between us?
HDR Brachy monotherapies doctor questions
1. I assume we are talking about monotherapy only, without external beam radiation or hormone therapy – is that correct for my case?
2. How many monotherapies have you performed? How many combined with external beam?
3. How has your practice of HDR brachy changed over the years?
4. What is your 5-yr freedom from recurrence rate for patients at my risk level? What proportion of your recurrences were local?
5. What kind of urinary and rectal reactions can I expect? How long can I expect them to last? What medications or interventions do you typically give for that? Should I expect those symptoms to recur later?
6. What is your rate of serious (Grade 3) adverse events? Do you see urinary strictures? Urinary retention requiring catheterization? Fistulas? Rectal bleeding requiring argon plasma or other interventions?
7. What is the margin you will treat around the prostate? Is it less on the rectal side?
8. What is the prescribed dose to the planned target volume?
9. What is your treatment protocol? Number of insertions? Number of fractions? Dose per fraction? Can we vary those for convenience?
10. What kind of imaging do you use for planning? MRI? CT? US?
11. Do you increase dwell times in areas of known cancer?
12. Do you use fiducials or Calypso transponders?
13. In my treatment plan, what do you identify as “organs at risk” and what dose constraints do you put on them?
o What dose will my penile bulb receive?
o How do you limit urethral dose? (e.g., catheter)
14. How long does each treatment take?
15. How will I be immobilized/anesthetized during each treatment? What kind of analgesia is used?
16. Are there any bowel prep or dietary requirements?
17. Should I avoid taking antioxidant supplements?
18. In your practice, among men who were fully potent, what percent remained fully potent 3-5 years later?
o Have any men retained some ability to produce semen?
o What is your opinion of taking Viagra preventatively?
19. Do you monitor side effects with the EPIC questionnaire?
o In your practice, what percent of men experience acute urinary side effects?
o In your practice, what percent of men experience acute rectal side effects?
o In your practice, what percent of men experience late term urinary side effects?
o In your practice, what percent of men experience late term rectal side effects?
20. What kind of PSA pattern should I expect following treatment?
21. What is the median PSA nadir you are seeing in your practice, and how long does it take to reach that, on the average?
22. In your practice, what percent of men experience biochemical recurrence?
o What % of those have been local?
o If there should be a biochemical (PSA) recurrence, what would the next steps be?
o Have you ever used SBRT, brachy, or cryo for salvage after a local HDR brachy failure, and was that focal or whole gland?
23. Are you open to email communications between us?
Questions for LDR brachytherapists
1. How many have you performed?
2. How has your practice of brachytherapy changed over the years?
3. What is your 5-yr freedom from recurrence rate for patients at my risk level? What proportion of your recurrences were local?
4. What kind of urinary and rectal reactions can I expect? How long can I expect them to last? What medications or interventions do you typically give for that? Should I expect those symptoms to recur later?
5. What is your rate of serious (Grade 3) adverse events? Do you see urinary strictures? Urinary retention requiring catheterization? Fistulas? Rectal bleeding requiring argon plasma or other interventions?
6. For how long should I refrain from sex with a partner?
7. For how long should I refrain from close contact with people and pets?
8. Among men who are previously potent, what percent of your patients return to baseline?
9. Do you recommend ED meds as protective?
10. What kind of dose with which isotope do you use? Would adjuvant IMRT be given with that? Would hormone therapy be given with that?
11. How do you prevent seed migration?
12. Do you use “intra-operative planning” or some other technique to guide placement and assure adequate seed distribution? Do you use a template with ultrasound guidance, cone-beam CT or some other method?
13. What do you set as dose limits for organs at risk? How do you assure that urinary sphincters, the urethra, and the rectum are spared?
14. Do you do a follow-up CT or MRI after a month? How often do you find you have to go in again to treat cold spots?
15. How will we monitor PSA? What kind of PSA pattern can I expect?
16. What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects, and for how long? Will you regularly monitor my urinary and erectile recovery progress with validated questionnaires like EPIC and IPSS?
17. In your practice, what percent of men experience biochemical recurrence?
o What % of those have been local?
o If there should be a biochemical (PSA) recurrence, what would the next steps be?
o Have you ever used SBRT, brachy, or cryo for salvage after a local LDR brachy failure, and was that focal or whole gland?
18. Are you open to email communications between us?
Questions for surgeons
1. How many of that technique (whether robotic, laparoscopic or open) have you performed? (1000+ would be a good answer)
2. In the last year, what was your positive surgical margin rate? (Should be close to 10% in total, less among men with stage pT2)
3. What is your "trifecta" rate? (tricky because you don't want cherry-picked patients)
4. What is your estimate of my risk for lasting incontinence; i.e., a pad or more after a year?
5. What about lasting stress incontinence? climacturia? penile shrinkage? inguinal hernia?
6. What kind of anastomosis technique do you use? (total - not just anterior)
7. Will the bladder neck be spared? How will you maximize the urethral sparing?
8. Will you take frozen sections and have a pathologist standing by to determine margins and how much of neurovascular bundles can be spared?
9. What measures will you take to assure the integrity of the neurovascular bundles?
10. What kind of penile rehab do you suggest?
11. Will you sample lymph nodes (PLND) or take extended lymph nodes (ePLND), or does it seem unnecessary for my risk level? If so, how will you find them (fluorescent dye)? How will you minimize risk of lymphocele and lymphedema?
12. What kind of aftercare (including sexual rehab) will you provide, and how will we monitor side effects, and for how long? Will you regularly monitor my urinary and erectile recovery progress with validated questionnaires like EPIC and IPSS.
Questions for a Salvage Radiation Interview.
1. What is the probability that I need salvage treatment? Do you calculate that from a nomogram?
2. Do you think I should get a Decipher test to find my probability of metastasis in the next 5 years? Do you know if my insurance covers it?
3. How large a dose do you propose for the prostate bed? (should be near 70 Gy)
4. Do I need concurrent or adjuvant ADT?
a. Why?
b. What's the evidence that it's useful?
5. How do you decide whether to treat the pelvic lymph nodes?
a. If so, at what dose? (50 Gy)
b. How do you plan to prevent bowel toxicity?
c. How will you account for the separate movement of that area and the prostate bed?
6. What do you think of doing this in fewer treatments (hypofractionation)?
7. What kind of machine do you use? (e.g., RapidArc, Tomotherapy, Vero, etc.) Why do you prefer that one?
8. What is the actual treatment time for each treatment? (faster is better)
9. What kind of image guidance do you propose? fiducials in the prostate bed? Using the fixed bones only?
10. How will inter- and intra-fractional motion be compensated for?
11. What measures do you propose to spare the bladder and rectum?
12. What side effects can I reasonably expect?
13. What probability of a cure can I reasonably expect, given my stats? Is there a nomogram you use to come up with that?
14. How will we monitor my progress afterwards, both oncological and quality of life?
15. What's the best way for us to communicate if I have a question or issue?
Questions for yourself
• Do I need to see a pathology report to tell me how contained it was?
• If I choose radiation, can I live with the fact that PSA goes down over a number of years, with bounces along the way, and never becomes undetectable?
• If the pathology is adverse and PSA does not become undetectable, am I prepared to undergo adjuvant radiation with all the potential side effects that entails? (Your doctor has hopefully run a nomogram showing the probability of this happening)
• If the radiation doesn't work, am I prepared to have a biopsy and possible focal brachy re-treatment?
• Which bothers me more - the potential for incontinence and ED after surgery or the potential for retention and irritative effects after radiation? (given the probabilities of those side effects)
• Do I understand the other possible side effects of surgery? (e.g., infection, hernia, climacturia, penile shrinkage, stress incontinence, etc.) Am I prepared to take on penile rehab?
• Do I understand the other possible side effects of radiation? (e.g., fatigue, proctitis, hemorrhoids, frequency, urgency, burning while peeing, ED).
• Am I prepared to undergo 8 weeks of radiation (5 weeks with combo therapy)?
• Am I prepared to undergo surgery and its recovery?