I had my initial consult with my second radiology oncologist on Tuesday afternoon. I've had a chance to process my thoughts and notes, and thought I should share (as I have for my uro and RO #1 consults). Here's the summary:
As “usual” for new patients, I first met with a nurse to complete the usual new patient forms, questionnaires, etc. In addition to all the data collected by the other RO’s office, Dr. H's office also collected and reviewed an extensive questionnaire regarding the patient’s psychological/emotional status. This information was elicited in a most compassionate manner, given the circumstances. The entire “administrative” portion of the visit lasted about
30 minutes, and left me with an impression similar to mine at the other RO’s office – that these people care about
their patients, not just their disease.
At this point, Dr. H entered the room. This is definitely a “type-A” lady. She is highly engaged, high energy, and highly, highly qualified. Just my opinion, but my research supports my conclusion (Northwestern undergrad and grad school, residency at MSKCC, assistant prof. at MSKCC, etc.).
Dr. H began her discussion by saying that she knows that I have “done my homework” about
my diagnosis so we don’t need to cover the basics of the disease itself. We got right down to the specifics of treatment. We briefly discussed my reasoning for choosing radiation over surgery, and the doctor accepts my logic. She did also mention that either surgery or radiation would be appropriate for my pathology, but that she agrees with me (and Dr. K) that the decision really is based upon the side effects of each treatment option and how I perceive that these side effects will impact my life.
Dr. H then began a discussion of the options generally available in radiology oncology. She indicated that the “gold standard” is still traditional EBRT, specifically now IMRT (Tomotherapy). This is given in 40+ fractions lasting about
10 minutes each, daily 5 days a week for 8 1/2 weeks. They find that they have a high cure rate for low/favorable intermediate risk patients using this protocol. For many patients, this is the treatment of choice. It is non-invasive (except for fiducials) and has good history of success over a fairly long time period (10+ years).
I then asked her about
LDR Brachytherapy (as was suggested by Dr. M as a backup plan). She expressed less confidence in LDRBT, stating that it is difficult to ensure proper placement of seeds and that it is difficult to know where a higher dose might be needed or a lower dose safer. She felt that the long term results would not be as good as IMRT. We did not discuss HDRBT.
Dr. H then went on to begin a discussion of a newer form of radiation system (CyberKnife). She knew that I am interested in CK, but felt that in all fairness she should present the case for both IMRT and CK objectively and let me decide then. She indicated that the actual type of radiation used in IMRT and CK is the same, but that the equipment used for CK is far more precise, faster, and allows a higher radiation dose to be applied to the target area than does IMRT. We briefly spoke about
the alpha/beta ratio of PCa and the potential higher efficacy of the high-dose hypofractionated radiation (CK) versus IMRT. All through this comparison of the two beam radiation delivery systems the doctor remained calm, objective and clinical.
This hospital has been using CK for PCa since 2011. They have treated about
200 cases in the past 4 years with very good results. No mention of any BCR cases yet. Their CK protocol is 5 treatments over 2 weeks, M-W-F; M-W. They require bowel prep (enema) prior to each treatment but there is no specific bladder preparation required. Fiducials (threaded) are implanted in the clinic (not OR) via trans-perineal access using oral Norco), topical (gel) and injected (lidocaine) pain management medication. The lidocaine stops short of being a complete nerve block, and there is some pain, but most tolerate it well. A course of Cipro is given before/after implant. No rectal culture or boost ABx needed, as the implant procedure does not breach the rectal wall. They chose to implant the fiducials through the perineum to afford better
location control, better ultrasound view and lower chance for infection. If I ask, they will prescribe tamsulosin (FloMax) to ensure normal urinary function after the implant procedure. about
a week after the fiducials are implanted, imaging scans are prepared for treatment planning. Typically both an MRI and CT scan are used. I raised the question about
my pacemaker not being MRI compliant. Dr. H indicated that for her this is really not a problem as she relies most heavily on the CT scan for planning and only uses the MRI for additional clarification. When I asked her if she ever has a patient whose CT scan was not clear enough for treatment planning she said “It could happen, but it has not happened here.” This is in contrast to Dr. M, who seems to rely more on MRI and indicated that if my CT was not clear enough we would have to go to LDRBT, which Dr. H felt was not as effective.
Then I changed course. I asked the doctor “With all of these advantages of CK over IMRT, why would any man NOT choose CK? At this point the doctor became highly animated, smiling and admitting “I really don’t know why they wouldn’t choose CK.” She then went on to say that some people were afraid of the higher radiation dosage over fewer fractions. Some were less confident of a newer delivery system and some had trouble getting insurance coverage. We agreed that there are, in my case, no reasons not to favor CK.
We discussed possible side effects of both IMRT and CK. The doctor said that the possible side effects were the same, but that their timing and intensity differs between the two systems. With IMRT, side effects may begin during treatment, and typically resolve by 4-6 weeks after the end of treatment. With CK, the side effects also may begin during treatment, often as soon as following the second or third treatment, but that they should resolve within a few weeks or a month. Both systems may have the typical urinary toxicities (nocturia, urgency, weak stream, burning sensation), and these side effects are usually tolerable or can be treated medically. When it comes to bowel toxicities, IMRT seems to have more impact, sometimes leading to diarrhea, urgency, etc., but that CK seems to have far fewer bowel toxicities.
We also discussed some of my general questions and items related to my specific pathology. Dr. H feels that the likelihood that my PCa has escaped the prostate is “very low.” She completed one of the MSKCC nomograms and calculated (IIRC) 23% likelihood of extension. She also indicated that she feels that my odds of BCR are very low, due to my pathology. She opined that most nomograms over-state the seriousness of my pathology using the single GS3+4 core. She felt that the majority of my positive cores being GS3+3 and the very low percentage involvement indicated that my cancer would behave more like low-risk than even favorable-intermediate-risk.
Dr. H indicated that post-treatment follow-up would be PSA and T testing at 6 weeks, 3 months, then at 6 month intervals for 3 years (longer if I prefer). She would coordinate follow-up with my urologist but suggested that I continue seeing him for non-cancer-related urology follow up.
We also discussed some related specifics of my own case. These are items that the other doctors (both male) have basically said "Medical protocol is XXXXX. Deal with it." I don't take well to that type of advice, even from doctors whom I respect. Dr. H not only listened to me, but she HEARD me. She offered to help me find a workable solution, even reaching out to a colleague at MSKCC for advice. THIS is the sort of doctor I want on my team.
A public shout-out to Tall Allen and 0311, thanking them for recommending that I see this wonderful doctor. I plan to call later this week to begin scheduling appointments and get this show on the road.
Age 68 at Dx
PSA history: 2000-2012 0.9-1.2; 06/2012 started T replacement
2013-2015 3.0-3.3 (new normal)
Biopsy: 12-core biopsy 07/2016; 3 cores G3+3, 5% or less; 1 core 3+4, 15%; 1 core HGPIN; 2% of gland involved. Summary G3+4.
Post Edited (Paxton) : 9/15/2016 7:20:17 AM (GMT-6)