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Combo radiation hdr brachytherapy and 25 ebrt

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Posted 5/25/2018 6:18 PM (GMT -8)
Hi all read a lot of good things on here about brachytherapy...my story 57 diagnosed back in January ..PSA 7.2 3 out of 12 cores pos. 3+3. 3+4. 70 % volume 10% #4 3+4 same as other ...been to Stanford and been to UCSF ...Stanford ehhh surgeon pushing surgury hard ..Stanford radiology saying combo treatment would give me over 90% chsnce at cure ....UCSF top surgeon over 6000 RPs. Decided to do genomic testing glad he did ..everyone thought just your average 3-4 ..some said I could watch it ....well genomic saying hi risk as well as UCSF Pathology..so no waiting ...bone scan clear t3 mri clear seems to be fully contained ...so surgeon at UCSF says I can go either way ..no difference in results both short and long ..of course he suggests I take it out...but it’s up to me ...great ,.nit to fond of surgery ..UCSF radiologist bee their 23 years ..is extremely confident I can be cured ...his failure rate is less than 10% ....also I bit of knowledge ..I have been doing tonnnnnnnssss or research .....yes at UCSF u can have the Prostate removed after radition ..u can also re radiate if need be . There are options after radiation at least at UCSFthere r ...I’m leaning g combo treatment just nit comfortable with surgury...I mean it seemed like the surgeon talked more about radiation than he did the surgery....any thoughts I want the best chance fir a cure and I have been reading a lot about the combo treatment and great outcomes
Posted 5/25/2018 8:24 PM (GMT -8)
Welcome to HW.

Brachy will work just fine. If brachy fails, they can do follow up beam radiation. No need to think about surgery if primary RT fails.

UCSF is a good place to me.

Andrew
Posted 5/26/2018 2:51 AM (GMT -8)
Welcome to our club--it sounds like you're doing the research you need to be doing, asking the right questions.

Here's the deal, with 3+3 and 3+4, you are 'low-intermediate risk', and combo treatment might be a case of going after a cat with an elephant gun. Monotherapy, whether you go brachy, SBRT, EBRT, or surgery is likely to cure you with a lot less fuss. Most places don't do the combo therapies until the patient is G8 or 9.

Pay attention to your docs....they have a good rep out there...but it's ok to ask if you really need HT at G7?
Posted 5/26/2018 4:15 AM (GMT -8)
Thanks feeling better about it now ...doing the combo because the cancer is of high risk ...apoarsntky cribifirm festures ..want to make sure so doing the most aggressive treatment so I’m doing that ..they are more confident than but once I start I will be ok ..it’s tough to swallow
Posted 5/26/2018 4:21 AM (GMT -8)
Oh and combo is both IRB and EBR no HT thanks .....sounds like a lot to do but the hospital is very close by ......just want it done one way or another ..anxiety is kicking in ...thanks
Posted 5/26/2018 5:56 AM (GMT -8)
Also I haven’t clearly made up my mind yetttt...almost got about a week to decide ..granted they both have side effects ....radition takes a long time ...fatigue urinary issues etc...hopefully no rectal problems ....
Surgery ..it’s over in a few hours ...a lot of what if’s with positive margins so on ...ED problems ..incontinsnce as well....oh and losing length as well.. ...oh yeh wearing the catheter for 10days as welll.
So if all goes well with surgery u r home the next day..family take care of youn..once catheters is out everything should be good ...
My dilemma ...surgury. I don’t care about ED at all my surgeon says loss of control would be about 7% and I should regain that ..he is confident it will be a suceesful sugary ........the big one is while in there he will take out nodes as a precaution and maybe therapeutic as well in case some leaked out and lsnded in the nodes....kinda like that idea ....but afraid of being put under for some reason never hsve been that’s really holding me back ....sounds silly but we all have reasons fir not wanting surgury

Radiation drains you and I fir one have to keep working and my job is physical ohh and I don’t sleep well as it is ..never have ...anxiety issues ...between fatigue and getting up 4-5 times s night I don’t know how I will handle it wonder if I could go on state disability fir a while if need be ..
Also if it comes back and it’s in the modes then HT ..wow I don’t see how I could work with no sleep at all
From all those side affects

Any thoughts

Post Edited (Stan1961) : 5/26/2018 7:59:15 AM (GMT-6)

Posted 5/26/2018 6:14 AM (GMT -8)
The fatigue from RT doesn't hit everyone and exercise while doing the treatment minimizes the effect. Most guys do RT and are able to work without much problem. I ended up taking a couple of sick days near the end of treatment - but that was it.

Andrew
Posted 5/26/2018 7:16 AM (GMT -8)
I'm not an expert on this, but I don't think a genomic test alone can change you from intermediate to high-risk. I do suppose it can suggest that there's a higher grade cancer that the biopsy missed. Still, I would be cautious of having the combo treatment with brachytherapy alone could cure you. Certainly something to discuss with your radiation oncologist.

BTW, if you are truly high risk, a radiation oncologist would be recommending hormone therapy as part of your treatment, but that doesn't seem to be the case for you.
Posted 5/26/2018 7:52 AM (GMT -8)
ok I will clear this up....ucsf path report reported all the same 3-3 3-4 3-4 but their fining was the gleason 4 was of fused crib form which makes it a higher risk tumor ...meaning I should seek treatment and not wait so yes i am on the low end of intermediate but the tumor is of high risk which I am glad they found out because mono alone may have worked but may not have ..genomic report confirmed it....so they want to do the most conservative approach now to make sure....its kinda scarey ..here at UCSF the dr who has been there 22 years and is a so called expert Is extremely confident I will do well even with that cribiform... he doesn't seem too concerned as I am......just don't want to make the wrong decision...I flat out asked the radiologist what are my chances of llvivng another 10 15 years with this and he said absolutely and he was going to cure me that's the goal ...I hope soooo after seeing mri ct scan and ultrasound psa level steady at 7.1 limited volume chances are very good ..I should consider my self blessed ..justa tough decision...
Posted 5/26/2018 8:00 AM (GMT -8)
you're going to die of something, but not PC.

with your DX, you have every expectation of a cure.
Posted 5/26/2018 9:53 AM (GMT -8)
thanks brother for the confidence...I guess what troubles me is that there are twice as many RP out there that rad patients...even though I hear over the years the % are about equal...used to be 70% surgery 30% rad 20% watching now I hear its about 40 40 20 ....anyone hear the same..i like going with the majority
Posted 5/26/2018 10:00 AM (GMT -8)
surgery is on the decline as RT methods improve and as patients become more informed of their choices.

and the majority isn't always right.

Surgery is often selected because the URO (a surgeon) generally gives the biopsy results and says something like, "I can fix that with surgery, have an opening next Thursday." and guys take it without looking at alternitives.

Andrew
Posted 5/26/2018 11:14 AM (GMT -8)
Well , I am in the 2nd part of the Brachy / comb treatment as you are considering I too did all the research I was a 4+3 - 3+3 My Dr said we are going at it aggressively to give you the best chance of cure. as I have had some friends who just had the Brachy and are fine .. I do not want to take any risk so now I am on day 5 of my 25 IMRT sessions … so far I have had some urinary issues but that is due to my extremely large prostate which almost knocked me out of Brachy. I don't think you will make a bad decision going this route . as Surgery as most have said is a last thought for many including me . Wishing you the best of luck you will be fine there are many here like you and me who need help and reassurance .. so we all are here to help .

John


Age 64 Diagnosed Aug 2017
Gleason 4+3 =7 3+3 biopsy 11-17 , PSA13 , Brachy 1-31-18 88seeds PSA10, PSA 4-10 3.21 IMRT Started May 22,18
Posted 5/26/2018 11:41 AM (GMT -8)
I too think that brachy boost treatment is overkill. There was actually a study about that you may want to look at:

/pcnrv.blogspot.com/2017/05/brachy-boost-therapy-should-be-reserved.html

If it were me, I would be looking at monotherapies - brachytherapy and SBRT. Why have extra side effects if you don't need them?

But whatever treatment you decide upon, UCSF is a great place to have it.
Posted 5/26/2018 3:39 PM (GMT -8)
well I guess I don't qualify 7,2 psa 3-4 stage t2a but volume is 70 and 90- % darn oh well better safe than sorry

Post Edited (Stan1961) : 5/26/2018 5:42:00 PM (GMT-6)

Posted 5/26/2018 3:48 PM (GMT -8)
Hi Allen for me I was a Gleason 4+3 + 3+3 and a PSA 13 and from reading that report I fall in the Boost Category, I wasn't crazy about having the IMRT but im less crazy of having PC come back .. so im 5 treatments in so 20 more to go I was almost going to forgo the boost but My Dr who I have a lot of confidence in, said I would be the right thing to do to kill the cancer based on the numbers so Im doing it everyone is different. As you know I have had to deal with some urinary SE but , im learning how to deal with it and from looking at Stan he would probably fall in the Brachy not sure about the boost unless they are being aggressive with it .
Posted 5/26/2018 4:30 PM (GMT -8)
Doesn't the presents of 'cribriform' bump up Stan1961's risk?
Posted 5/26/2018 5:58 PM (GMT -8)
hi yes it does bump me up only for treatment purposes they say...right now hopefully all is still the same actually PSA went down from 8.2 in sept to 7.1 in may...biopsy done in dec......believe it or not I saw7 drs...surgeons and radiologists all said everything is ok bla bla bla ...but I wanted to see this one surgeon at UCSF the best they have ..32 years 6000 surgeries..anyway he was the only one who wanted UCSF to look at the slide and have genomic decifer testing done glad I waited because UCSF pathology differed fron Stanford saying the #4 is of cribiform..and decifer agreed....meaning that I should get treated and not watch it which I was being told I could do ..I didn't want to do that anyway ....I was going to do mono brachytherapy until I heard this ,,that is why we are doing more aggressive ...cribiform mean that it can grow faster than the average cancer...but recent psa and mri and sonogram looks still hopefully to be still contained and of intermediate risk.....but being treated aggressively it.....hope its the right choice
Posted 5/26/2018 8:00 PM (GMT -8)
Stan-
Perhaps you can explain more about this for me. My understanding of the cribriform pattern comes from the ISUP Consensus on Gleason Grading:

2014 ISUP Consensus Statement said...
A major point of divergence from the original Gleason system is with the assignment of grade to cribriform glands. Within Gleason’s original illustrations of his cribriform pattern 3, he depicts large cribriform glands.Cases graded prior to 2005 as Gleason pattern 3 included large cribriform glands that today would uniformly be called Gleason pattern 4. It was agreed in the 2005 consensus that the vast majority of cribriform patterns be diagnosed as Gleason pattern 4, with only rare cribriform lesions satisfying diagnostic criteria for cribriform pattern 3. However, at the 2005 conference, when various images of these rare candidates for cribriform Gleason pattern 3 were shown to the participants of the consensus meeting, almost none of them were uniformly accepted as cribriform pattern 3 based on subtle features. A subsequent study, led by one of the current authors and published in 2008, found that even in a highly selected set of images thought to be the best candidates for cribriform pattern 3, most experts interpreted the cribriform patterns as pattern 4.The authors of this study concluded that all cribriform structures should be interpreted as Gleason pattern 4 and not pattern 3. This was formally accepted in the 2014 consensus conference, based both on the poor interobserver reproducibility of experts in diagnosing cribriform Gleason pattern 3 cancer and subsequent numerous studies demonstrating that cribriform glands, regardless of morphology, were associat- ed with an adverse prognosis.

So, I understood from this that cribriform patterns were moved from Grade 3 to Grade 4 since 2005. This makes both Grade 3 and Grade 4 less risky than they were before 2005 (this is called the Will Rogers Effect). In other words, before 2005, your GS 3+4 cores might have been graded as GS 3+3. But now, because they are cribriform, they are deemed as GS 3+4 instead. Your cancer isn't more risky, it's less risky.
Posted 5/27/2018 4:22 AM (GMT -8)
No it’s saying that the Gleason 3 should be considered Gleason 4 as well ...drs dint seem to be as worried as me ...that’s why I m thinking maybe surgery would be better ...but even the surgeon says no it wouldn’t matter either is a fine choice it’s up to me. To decide
Posted 5/27/2018 8:24 AM (GMT -8)
No. Since 2005, Gleason 3 with cribriform pattern has been designated as Gleason 4. Your Gleason 3s remain Gleason 3s. So when you got a diagnosis of GS 3+4, that means the majority of the cancer in that core were Gleason 3, and a minority were Gleason 4. Before 2005, that core would have been labeled as GS 3+3. The change was that Gleason 3 with cribriform pattern is now called Gleason 4.
Posted 5/27/2018 5:55 PM (GMT -8)
so what u r saying is most of the gleason 3 in the tumor looks normal and some of it doesn't it looks like cribiform so they consider it gleason 4 the part that looks unusual does this seem rational to say this is odd to me Stanford looked at the original pathology report and agreed witht the original...3 cores positive 3-3 3-4 3-4 nothing mentioned about cribiform...then UCSF looked at it and said all the same except they said the 4 seemed to be of cribiform.. this is important in decidintg treatment plan...makes me wonder how Stanford could miss something like that ...kinda pisses me off....I was considering watching it for a while because at 48 years old my psa was 5.0 and hovered there until I turned 56 ..then over a 2.5 year period it went to 8.2 and now down to 7.0 ....if I had not waited to see this one dr...I would not have known about cribiform and watching for a few more years would have been a bad mistake ..
Posted 5/27/2018 7:22 PM (GMT -8)
If there is any doubt, just get a second opinion from Epstein at Johns Hopkins - he literally wrote the book and is the gold standard. No one doubts his analysis. Cost is $250
Posted 5/27/2018 10:13 PM (GMT -8)
Even the very best surgeons are still surgeons. So they want to do surgery on you. You will be very unhappy with the Side effects of surgery.
Posted 5/30/2018 8:12 AM (GMT -8)
I will tell all of you the decifer test saying I’m of high risk has me worried even the surgeon and radiologist don’t see it as a problem ..they say it’s just mainly fir treatment options ...has anyone done the combo that was or is of high risk....just worried about it thanks

Post Edited (Stan1961) : 5/30/2018 12:24:44 PM (GMT-6)

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