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Posted 8/11/2013 10:23 PM (GMT 0)

I will be starting IMRT tomorrow; the plan is for 25 treatments followed by LDR Brachytherapy.   I have been having second thoughts about the brachytherapy and may just go with the 40 IMRT treatments.  What is the benefit of having the combination of IMRT/brachytherapy over the 40 IMRT treatments? 

Moe

 

Age 63,  PSA 4.2 12/12/2012  7.1 7/24/13  T2a ,   L base 4+3=7 2%,  L mid 4+3=7 8%,  L apex 3+4=7 4%,  R base 3+4=7 30%,   R mid 3+4=7 100%,  R apex 4+3=7 100%

Post Edited (moeskeeter) : 8/11/2013 6:19:59 PM (GMT-6)

Posted 8/11/2013 10:54 PM (GMT 0)
Combo therapy is usually reserved for higher risk men, and has a great track record (combined with ADT) for that. The extra boost to the prostate can help destroy some of the more radio-resistant tumors.

IMHO, combo therapy is overkill for lower risk men for whom HDR brachy or LDR brachy or SBRT alone will provide the same oncological benefit with much reduced SEs.

What are your stats? Are you intermediate or high risk? Any adverse features, like ECE or PNI?

- Allen
Posted 8/11/2013 11:01 PM (GMT 0)
Allen - My RO told me the same thing - really depends on your current risk and how aggressive the cancer is.

At G7 they told me that IMRT alone would likely be enough so I got 26 treatments. If my PSA ever starts going up again my RO has suggested that Brachy would still be an option for me.

If you were G8 or more, I'd go for the combo. Below that, don't know.

One advantage of IMRT is that they can target the margins around the prostate better than they can with just brachy. Brachy is good because they can put the radiation right on the cancer and hit it with a strong dose without hitting to much of the surrounding tissues.

I am about 18 months out from IMRT and my PSA has dropped nicely so I am happy with my choice.

Andrew
Posted 8/11/2013 11:46 PM (GMT 0)
Not trying to hijack thread, but just curious; Andrew how did you get by with just 26 imrt treatments as a mono therapy ? Was each treatment given at a higher dose?
Posted 8/12/2013 1:02 AM (GMT 0)
I'm having IGRT with ADT as my primary therapy, as noted in my signature line. My RO has not been in favor of adding HDR for my specific case (high risk, locally advanced, etc.). This has been a discussion with him for weeks now, continually re-energized by inputs from this forum.

There are more side effects with HDR. How much additional side effect load, vs, how much more effective, has really bothered me. I've brought the studies linked by Tall Allen to his attention, and he's aware of them. He's said repeatedly that in my case, if he thought adding HDR would improve my chances enough to be worth the side effect load he'd do it.

This whole discussion stresses me out, to the extent I've considered just dropping out of this forum for a while to let it go.

Professional radiation oncologists at major institutions squabble with each other about this topic. People on this forum quote abstracts of studies that these ROs are already familiar with. Some of the studies seem to favor HDR + EBRT, some don't see much advantage to adding HDR. The devil seems to be in the details. What patients were specifically selected in these studies? What specific dosages were used? What technologies were used (LDR, HDR in what fractions, EBRT, IMRT, IGRT in what fractions, with what margins)? With ADT (2,3)? Truly comparing apples to apples is trickier than it seems.

There aren't randomized clinical trials to compare this stuff; there may never be. The freakin' professionals can't agree. Institutions that feature certain methodologies somehow generate studies that support those methodologies. How 'bout that? They're all competitive, trying to attract health care dollars.

I don't know, I don't know, I don't know! I wish I had complete confidence. As an engineer, I know how hard it is to develop truly solid data, and also how easy it is to succumb to confirmation bias. Once we think we have the right solution, we'll begin to ignore contrary data.

C**p. And of course, no matter what treatment series one selects, there will be second-guessing. If all goes great, and I end up on the "good" side of the percentages, it's all moot. If it goes badly, in my case it's much more likely it will be because the already micrometastatic cells are having a field day far away from the initial local treatment zone. If so, it wouldn't matter if the original site is 100% cleared or not, though that still is obviously the goal.

I'll have to take solace in making a decent decision, with the best advice I could obtain at the time, from knowledgeable doctors, at a truly major teaching university hospital with major available resources. Could they still be wrong? Sure, but who knows? I'm sure I don't.

Heading into a dark day, it seems. Sigh....
Posted 8/12/2013 1:36 AM (GMT 0)

Redwing57 said...
I'm having IGRT with ADT as my primary therapy, as noted in my signature line. My RO has not been in favor of adding HDR for my specific case (high risk, locally advanced, etc.). This has been a discussion with him for weeks now, continually re-energized by inputs from this forum.

There are more side effects with HDR. How much additional side effect load, vs, how much more effective, has really bothered me. I've brought the studies linked by Tall Allen to his attention, and he's aware of them. He's said repeatedly that in my case, if he thought adding HDR would improve my chances enough to be worth the side effect load he'd do it.

This whole discussion stresses me out, to the extent I've considered just dropping out of this forum for a while to let it go.

Professional radiation oncologists at major institutions squabble with each other about this topic. People on this forum quote abstracts of studies that these ROs are already familiar with. Some of the studies seem to favor HDR + EBRT, some don't see much advantage to adding HDR. The devil seems to be in the details. What patients were specifically selected in these studies? What specific dosages were used? What technologies were used (LDR, HDR in what fractions, EBRT, IMRT, IGRT in what fractions, with what margins)? With ADT (2,3)? Truly comparing apples to apples is trickier than it seems.

There aren't randomized clinical trials to compare this stuff; there may never be. The freakin' professionals can't agree. Institutions that feature certain methodologies somehow generate studies that support those methodologies. How 'bout that? They're all competitive, trying to attract health care dollars.

I don't know, I don't know, I don't know! I wish I had complete confidence. As an engineer, I know how hard it is to develop truly solid data, and also how easy it is to succumb to confirmation bias. Once we think we have the right solution, we'll begin to ignore contrary data.

C**p. And of course, no matter what treatment series one selects, there will be second-guessing. If all goes great, and I end up on the "good" side of the percentages, it's all moot. If it goes badly, in my case it's much more likely it will be because the already micrometastatic cells are having a field day far away from the initial local treatment zone. If so, it wouldn't matter if the original site is 100% cleared or not, though that still is obviously the goal.

I'll have to take solace in making a decent decision, with the best advice I could obtain at the time, from knowledgeable doctors, at a truly major teaching university hospital with major available resources. Could they still be wrong? Sure, but who knows? I'm sure I don't.

Heading into a dark day, it seems. Sigh....

..Good Post Redwing, hang in there and stay vigilant. I am with you brother.. Appleseed......
Posted 8/12/2013 1:38 AM (GMT 0)
I think much of the treatment recommendations you hear comes from people who are comfortable doing one form of radiation treatment but not another form..Nobody is going to recommend a treatment they can not perform...Radiation Oncologists who are skilled at performing Brachytherapy are not as numerous as you might think..

Also, one can not ignore the fact that a 40 fraction treatment of IGRT is FAR more profitable than a brachy treatment...This MIGHT have something to do with the equation...

I think the combined treatment is the way to go...A much higher total dose is possible and the Brachy puts the radiation where it can do the most good (when performed by an expert) while minimizing exposure to healthy tissue...
Posted 8/12/2013 1:52 AM (GMT 0)
Redwing57,

I think you're bringing up an important point about research. All I or most of us know about is what's been published. There may be some great doctors out there getting phenomenal results that we don't know about because they haven't published. Not everyone does. The ones that do tend to be associated with major teaching hospitals, but even they don't all publish. But what about all the great results we don't get to read about?

This has been my frustration with proton therapy. On paper it looked great, but there has been almost a complete dearth of published results. The last major paper was from 2004 at Loma Linda and was based on patients treated before 1997. Although those published results are less than stellar by today's standards, I'm sure their techniques have improved since then. MD Anderson has been doing pencil beam proton for over 4 years now, and yet has published nothing. What gives?

VMAT linacs like RapidArc and other traditional IMRT machines like Tomotherapy are now being used to deliver SBRT, so I'm sure they can do every bit as good a boost as HDR brachy, with as low toxicity and great oncological outcomes. We need more published results. My RO got so tired of my asking about his upcoming publications that he now sends me his early drafts to shut me up. Maybe we should all be asking our docs to publish more.

- Allen
Posted 8/12/2013 2:11 AM (GMT 0)
Thanks, guys. I hear ya, and appreciate the feedback. (moeskeeter, not trying to hijack your thread. This discussion should be pretty relevant.)

Appleseed, thanks. This is a real roller coaster ride!

Allen, to my RO's credit, he will have earnest discussions about all these things I bring in or send him. He's quite gracious about it. I've apparently intimidated his assistant though, by the level of discussion we have. Clearly, I'm not their typical patient with superficial questions. And absolutely, we don't know all that Vandy is doing that might not get published, or won't for a while. They have told me that Vandy is a major referral center for people dealing with serious complications of treatments from other institutions, and that may color their perception of the risks of these combo treatments.

Fairwind, the money side of this likely does loom large. I like to think that isn't controlling their treatment selections, but money is always important. It seems they could make a pretty penny with all of the factors involved in a couple of HDR sessions though, maybe more than a number of IGRT sessions. They're billing about $2000/session for the Varian Trilogy. Any idea what a couple sessions of HDR cost? Just curious. With anesthesia, operating theater (?), catheters, use of the HDR machine, and so on, it seems that could add up to a lot.
Posted 8/12/2013 2:38 AM (GMT 0)

Tall Allen said...
Combo therapy is usually reserved for higher risk men, and has a great track record (combined with ADT) for that. The extra boost to the prostate can help destroy some of the more radio-resistant tumors.

IMHO, combo therapy is overkill for lower risk men for whom HDR brachy or LDR brachy or SBRT alone will provide the same oncological benefit with much reduced SEs.

What are your stats? Are you intermediate or high risk? Any adverse features, like ECE or PNI?

- Allen

Age 63, PSA 4.2 12/12/2012 7.1 7/24/13 T2a , L base 4+3=7 2%, L mid 4+3=7 8%, L apex 3+4=7 4%, R base 3+4=7 30%, R mid 3+4=7 100%, R apex 4+3=7 100%

My RO is recommending the LDR Brachytherapy/SBRT and when I asked him about it he says he has no data that shows the combination therapy has any better results than SBRT alone.  But his gut feeling is that it is the best way to proceed.   I was told Brachytherapy alone was not option for me.

 

OOPS!  I meant IMRT not SBRT

Post Edited (moeskeeter) : 8/13/2013 8:30:43 PM (GMT-6)

Posted 8/12/2013 3:03 AM (GMT 0)
Hi moesteeter,

To answer your original post, I don't believe it's as simple as to say to you'll skip the brachytherapy and just have an additional 15 IMRT sessions. I could be wrong and if so, I'm sure the guys here that are smarter than I will jump in. But I presume it's a more complicated equation than just adding additional sessions when having IMRT as a mono therapy instead of combining it with brachytherapy.

Michael
Posted 8/12/2013 5:19 AM (GMT 0)

jym62 said...
Not trying to hijack thread, but just curious; Andrew how did you get by with just 26 imrt treatments as a mono therapy ? Was each treatment given at a higher dose?

Don't know but I did. PSA results tell that story. I didn't really ask how much radiation they used - could have, it's in the records but I went with "out of sight out of mind" thinking. My medical team's thought has been to use the lest amount of radiation needed. In the end I just trusted my RO's calculations and went it.

The option of doing seeds has always been there for me, if the first treatment failed. Happily, things are going my way for the moment.

Except for the hemorrhoids, ED and urgency...
Posted 8/12/2013 8:51 AM (GMT 0)

moeskeeter said...
My RO is recommending the LDR Brachytherapy/SBRT and when I asked him about it he says he has no data that shows the combination therapy has any better results than SBRT alone. But his gut feeling is that it is the best way to proceed. I was told Brachytherapy alone was not option for me.

I know it's like alphabet soup and I'm the worst at throwing around all these initials. He is recommending LDR brachy/IMRT not LDR brachy/SBRT. SBRT is a very quick intense precise form of radiation, much like brachy. IMRT is what they use to treat a wider area. So brachy and SBRT are like rifle shots at your prostate, while IMRT is like a shotgun to the local area. To make it more confusing, some ROs are now giving an SBRT boost to the prostate with an IMRT to the local area.

He's right that for intermediate risk there's no convincing data that brachy+IMRT is more effective than brachy alone, but looking at the results below, the results are more consistent with combo therapy. I think a lot depends on how proficient he is at brachy. The Seattle docs are known for their spectacular results. I don't know of any randomized controlled trials directly comparing brachy+IMRT to brachy alone. But here are some biochemical (PSA) recurrence-free survival numbers for intermediate risk men from my files:

For intermediate risk men receiving LDR only:

Taira, et al - UW Seattle - 12 yrs - 97%
Kollmeier et al - MSK - 8 yrs- 94%
Prada, et al - Asturias, Spain- 10 yrs- 84%
Stone et al. - Mt Sinai, NYC- 12 yrs -79%
Sylvester, et al. - Swedish Hospital, Seattle (early yrs) -15 yrs - 80%
Henry et al - St. James, Leeds,UK - 10 yrs- 74%
Hinnan et al - Utrecht, Holland - 10 yrs- 61%

As you can see, results vary a lot from one hospital to another, and even over time -- there seems to be a sharp learning curve for LDR.(range 61%-97%)

HDR brachy monotherapy for intermediate risk does very well too:

Rogers et al - GammaWest, SLC, Utah - 5 yrs - 94%

HDR brachy+IMRT gets consistently very good results for intermediate risk:(range 87%-98%)

Morton et al - Sunnybrook, Toronto, ON - 6yrs -98%
Deutsch et al - MSK - NYC -5 yrs -98%
Bachand et al - Laval, Quebec - 8 yr -96%
Cury et al - McGill, Montreal, Quebec - 5 yr -91%
Marina et al- Wm Beaumont, MI -8 yrs -91%
Demanes et al - UCLA - 10 yr - 87%

LDR brachy+IMRT got the following results among intermediate risk patients:(range 82%-90%)

Sylvester et al - Swedish Hospital, Seattle - 10 yrs- 90%
[url=http://www.ncbi.nlm.nih.gov/pubmed/22330999]Lawton et al - Wisconsin Medical, Milwaukee- 8 yr- 82%
[url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3338200/]Hurwitz et al- 7 institutions-6 yr -85%

Post Edited (Tall Allen) : 8/12/2013 10:45:44 AM (GMT-6)

Posted 8/12/2013 11:00 AM (GMT 0)
moeskeeter,
As I understand you need at least 70-75 gy to effectively treat the PCa through radiation. That is about the maximum you can tolerate through IMRT. To get a greater amount of tolerablr radiation, brachytherapy is added to the mix. You have planned 25 IMRT treatments (same as I had). Each will be about 1.5-1.7 gy so that alone will not deliver enough killing power. That is why you are using a combination with LDR brachytherapy. You will get as much or more radiation from the seeds as you will from 25 fractions of IMRT. If you only want to use the IMRT you will need to have at least 35-40 IMRT fractions. This is what my brother-in-law did last year. He was relatively low risk and at age 75 they docs decided that 35 IMRT fractions would be good. I, like you, was mainly G7. All my consults with different urologists, radiologists, and a medical oncologist agreed that the IMRT and brachytherapy was the way to go, but that I could not do monotherapy.

If you are serious ablut not having seeds your rad onc needs to know that now so he can make the significant changes in the IMRT doseage and schedule.

The advantage of using both forms is that you get much better radiation coverage than either can provide on its own. TallAllen's rifle and shotgun analogy was excellent. With you being G7 you are in the intermediate risk area. However you really have to look at the fact that you have a good amount of G4 in the mix. This is the stuff that has to be stopped and given the significant and fast rise in PSA would indicate to me that you should be treated aggressively. I am a bit surprised that you aren't also getting 6-9 months of HT to go along with the radiation.
Posted 8/12/2013 2:51 PM (GMT 0)
moeskeeter,

I agree with pretty much everything JNF just said, including wondering why there isn't some ADT thrown in to make the radiation more effective. Your 100 percent G7(4+3) core from the right apex would seem to me to put you fairly high in the intermediate risk category and I would be tempted to treat it aggressively.
Posted 8/12/2013 3:20 PM (GMT 0)
"I was told Brachytherapy alone was not option for me."

Maybe get a second opinion on that before you pull the trigger?
Posted 8/12/2013 4:23 PM (GMT 0)

I repeatedly asked my RO about both IMRT along with the both IMRT and Brachy.  After all if I’m not high risk, who is??? Both her and the lead RO thought it would be overtreatment and my cause more damage in later years!!

So far so good,  but time will tell.  Who am I to second guess the experts.  I hope they are right. I guess I am.

And Redwing, I too am an engineer and it’s so hard to think in these gray terms. 

To me “The bridge is up, or the bridge is down” 

Good comments by all.

Good luck moskeeter

bertb

Posted 8/12/2013 4:25 PM (GMT 0)
I agree with PDA that you have a lot of invasive Gleason 4 cells. I'm wondering if your biopsy path report mentioned any perineural invasion, or if you've had a follow up MRI to look for extracapsular extension?
Posted 8/12/2013 4:57 PM (GMT 0)
Looking back at your original question, I realized I didn't address why your doctor is probably not recommending IMRT alone.

At Memorial Sloan Kettering, arguably the best for this kind of treatment, they were treating intermediate risk men with IMRT alone. Their 10-yr freedom from PSA recurrence was 78%. Compare this to the best results that brachy and combo therapy were getting, and you could see why it may not be enough. The 5-yr freedom from PSA recurrence for intermediate risk men getting SBRT therapy was 93%.

So let's sum up from my list the best and the median of each therapy in terms of freedom from PSA recurrence in intermediate risk men:

Combo (HDR brachy+IMRT) - 6 yrs - 98% (median 93.5%)
HDR brachy monotherapy - 5 yrs - 94% (1 hospital)
Combo (LDR brachy+IMRT) - 10 yrs - 90% (median 85%)
LDR brachy monotherapy - 12 yrs - 97% (median 80%)
IMRT monotherapy - 10 yrs -78% (1 hospital)
SBRT monotherapy - 5 yrs- 93% (avg of 8 hospitals)
Posted 8/14/2013 3:19 AM (GMT 0)
All of the surgeons and RO's I have seen have said brachytherapy alone would not be enough. The RO that is doing the IMRT suggested ADT but that is not a path I want to take at this time and he is ok with that. The RO that will be doing the brachytherapy does not think it is needed.   I got a little more clarification on the IMRT, 25 treatments followed by brachytherapy or if I decide against that there will be 19 addition treatments at higher dose that is concentrated on the prostate itself.   They told me today I need to decide soon so they can start the planning.   The brachytherapy will be done at another location.   I appreciate the input, thanks   Moe  
Posted 8/11/2018 3:20 AM (GMT 0)
This is my opinion and mine only ..I regret doing radiation ...the radiation had turned me upside down.if u have urinsry problems they will be way worse ..and yes you will hsve bowel problems as well ....totally sucks for me but everyone is different ...
Posted 8/11/2018 3:33 AM (GMT 0)
You know you're posting on a 5 year old thread ...
Posted 8/11/2018 10:39 PM (GMT 0)
Apparently, I was only 52 when I posted on this thread! (And interestingly, I still don't know if what I posted is accurate or not...)
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