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Deciding between SBRT or HDR

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Posted 8/9/2014 11:37 PM (GMT 0)
Hi guys,

I've been lurking for awhile and appreciate all the useful info I've found here. My situation is at the point now where I'd appreciate your advice.

I've been on AS for the past year since DX. Recently I've consulted with Dr's Bahn, Scholz, Demanes, King, and Lam. Consensus is to end AS and begin treatment. Surgery is not an option due to proximity of tumor to external sphincter. I was very impressed with Demanes and King at UCLA and have pretty much decided on either HDR or SBRT as a monotherapy. Dr Lam feels that the SE with HDR could be less than with SBRT, particularly rectal issues. From my reading here on HW both SBRT and HDR sound equivalent in their effectiveness and SE.

Dr Lam recommends getting a MRI guided biopsy at UCLA before deciding on a treatment. His concern is that a new biopsy might show a higher Gleason than my G 3+3 from last August and then a monotherapy might not be the best course. But Demanes and King seemed willing to go based on the G6 biopsy.

Appreciate your thoughts on SBRT vs HDR, and whether or not to have another biopsy now.
Posted 8/10/2014 12:49 AM (GMT 0)
Have you talked to Tall Allen?

He is in LA and regularly points people top Dr Chris King.

Also have you had your biopsy rescored by Jonathan Epstein at Johns Hopkins?

pathology.jhu.edu/department/services/secondopinion.cfm

I too am trying to decide on SBRT versus IMRT/IGRT but for different reasons.

I am in FL and wife is not thrilled with 2 weeks at UCLA. Happy wife, happy life.

With you being in Southern Calif, not an issue for you.

We have a very good IMRT/IGRT guy only a few miles away her in Florida, but I dread having to go there Mon-Fri for 7-8 weeks when I could have it over and done with in 2 weeks by Dr King with only 5 very high dose fractions every other day.

I did not talk to Dr Jeffrey Demannes but know he is world renowned and that he and Dr. Chris King at UCLA collaborate on an HDR with a boost treatment.

So either way you go with those guys you are in good hands.

One thing Tall Allen put me on to was suspending my Zytiga in hopes of qualifying for Provenge to leverage the so-called abscopal effect. It takes two PSA increases at least 14 days apart to qualify for Provenge but so far my PSA is not cooperating. Not all bad having a PSA not increasing.

I have some time since I do not want to start my radiation, whatever flavor until after the last week of Sept GFMPH in Rochester.

LupronJim
Posted 8/10/2014 1:17 AM (GMT 0)
Boy, nearly a coin toss. You have done an excellent research job considering the best possibilities. I am a HDR pioneer and didn't know about SBRT. What would I do now four years later?........probably HDR. I used Demanes for research and local treatment that used the Martinez protocol. Happy as a lark with the treatment, minimum side effects and results.
Posted 8/10/2014 4:15 PM (GMT 0)
It was pretty much a coin toss for me. SBRT is modeled on HDR brachy and has very similar results - radiologically, oncologically and side effects. It came down to convenience - 5 visits where I lay on a bench for a few minutes vs 2 overnight hospital stays (he now does it in one as well) with anesthesia. Most guys I bring to see both have gone with King.

While I respect Scholz/Lam/Turner, you can't really expect them to be expert on the treatments - you have to ask the experts about that. Unless your PC is GS 8-10, it really won't matter what an mpMRI tells you - the treatment is the same. They will have to do a fused MRI/CT anyway when the fiducials are in place in order to do the treatment planning. That will enable them to precisely contour the radiation to the shape of your prostate, including any bulges that may be present.
Posted 8/10/2014 4:45 PM (GMT 0)
One thing I really liked about Dr. Chris King is when I asked him if my obesity would be a problem, he said it might actually protect my rectum and bladder from unwanted radiation.

So I guess I wait until after the treatment to lose the 50 pounds:}.

LupronJim
Posted 8/10/2014 7:36 PM (GMT 0)

LupronJim said...
Have you talked to Tall Allen?

He is in LA and regularly points people top Dr Chris King.


Yes, I've read his every post with interest.

LupronJim said...
Also have you had your biopsy rescored by Jonathan Epstein at Johns Hopkins?


Yes, Epstein downgraded the original G3+4 to G3+3.

LupronJim said...
We have a very good IMRT/IGRT guy only a few miles away her in Florida, but I dread having to go there Mon-Fri for 7-8 weeks when I could have it over and done with in 2 weeks by Dr King with only 5 very high dose fractions every other day.


I hear you on that, 7-8 weeks sounds like forever right now. Could you get a referral from King to an SBRT facility closer to you?

Thanks for your advice Jim
Posted 8/10/2014 7:53 PM (GMT 0)
Lupron Jim,

I think super max raises an interesting possibility for you. Dr King has a colleague in Tampa, Dr. Freeman, who has treated a couple of guys I know, and they give her rave reviews. Dr. King has great respect for her as well, and they have co-authored studies. I don't know if Tampa is really more convenient for you, however. I also don't know if she is willing and able to follow Dr. King's new high risk protocol (she uses a different linac).

BTW - fiducial placement can be done locally. Dr. King doesn't do that himself anyway. A local urologist would just follow his placement prescription.

- Allen
Posted 8/10/2014 8:26 PM (GMT 0)

Tall Allen said...
It was pretty much a coin toss for me. SBRT is modeled on HDR brachy and has very similar results - radiologically, oncologically and side effects. It came down to convenience - 5 visits where I lay on a bench for a few minutes vs 2 overnight hospital stays (he now does it in one as well) with anesthesia. Most guys I bring to see both have gone with King.


Thanks Allen, that helps.

I was reading the HDR "Before Surgery" and "Home Care Instructions" last night. No question that SBRT has the convenience advantage. The fasting and enema before each of the two HDR sessions isn't something I look forward to. And logistically I may have a problem getting released after each session since I'm driving myself and 60 miles from home.

HDR has some appeal to my engineering brain since the radiation originates from within the prostate and doesn't have to travel through surrounding tissue to get there. I asked Dr King about that and he said the "spillover" radiation to other tissues is about the same whether SBRT or HDR.

I also wonder about whether HDR is more precise than SBRT in conforming to the target area, but sounds like both are capable of sub-millimeter accuracy.

This is literally a once in a lifetime decision (hopefully) so I'm trying not to be over influenced by the convenience factor and only concentrate on the longterm results in deciding which way to go.
Posted 8/10/2014 9:18 PM (GMT 0)
There really is no radiological advantage to one over the other. X-rays travel through tissue, whether from the inside outward or the outside inward matters not. There will always be some dose to organs at risk (bladder, rectum). What the RO does is create a treatment plan that minimizes the dose to the organs at risk. The computer program that calculates that comes up with a Dose-Volume Histogram that shows the percent of tissue in each organ (volume) that is subjected to each dose level of Xrays. It is highly dependent on individual anatomy. It is pretty much the same for SBRT or HDR brachy.

A potential confounder would be intra-fractional prostate motion. SBRT deals with it by tracking it continually during treatment. HDR brachy deals with it by immobilizing the prostate with catheters during treatment. They both calibrate the location of the fiducials inter-fractionally as well.

They both are highly conformal to the shape of the target. SBRT (as Dr Kings uses it) uses intensity modulation and multileaf collimators to accomplish that, while HDR brachy uses the number and placement of catheters, and the dwell time along them to accomplish the same thing. Both have sub-millimeter accuracy.

Dose to the prostate is nearly identical, and, more importantly, the biological effective dose is the same (and in both cases greater than IMRT). However, as you probably know, the nominal dose is only about half of what the IMRT dose would be, which is why they are both more effective than IMRT while having fewer toxic side effects.

The biggest difference between the two treatment plans is in dose homogeneity. SBRT delivers a very homogeneous dose throughout the prostate, with few hot spots or cold spots. Because HDR brachy is constrained to the catheters and the dwell time along the catheters, the dose is very heterogeneous - there are hotter areas and colder areas. It is unclear that either approach is better or worse than the other. Dr. Fuller in San Diego is using SBRT to mimic heterogeneous dosing in a clinical trial.

- Allen
Posted 8/10/2014 10:35 PM (GMT 0)

Tall Allen said...
Lupron Jim,

I think super max raises an interesting possibility for you. Dr King has a colleague in Tampa, Dr. Freeman, who has treated a couple of guys I know, and they give her rave reviews. Dr. King has great respect for her as well, and they have co-authored studies. I don't know if Tampa is really more convenient for you, however. I also don't know if she is willing and able to follow Dr. King's new high risk protocol (she uses a different linac).

BTW - fiducial placement can be done locally. Dr. King doesn't do that himself anyway. A local urologist would just follow his placement prescription.

- Allen

Thanks as I say to you so often Allen.

Yes, Tampa is no further South of me than Gainesville is NE of me, about an hour and a half.

In fact, I am looking in to the local RO doing the gold fiducial placement here on Sept 18. However I thought they tend to do the CT Scan and fusion with MRI at the same time, the MRI having been taken in advance, in my case a 1.5T MRI with coil this coming Tuesday.

I will have another PSA read right after that to see if my PSA can get up to 0.04 which is not only an increase from most recent 0.03, but also an increase from last month's <0.04. If a coil placed next to my prostate does not cause a PSA increase, forget about what they say about bike riding causing an increase.

Next time you talk to Dr.King, please try to find out more about Dr Freeman and I will do the same from this end.

fullcircle-pr.com/cyberknife-centers-tampa-bays-dr-debra-freeman-featured-healthcare-news/

So far I have found that she has done some low risk CyberKnife, but have not found any high risk cases like mine, albeit locally advanced. Will give her a call tomorrow.

www.cyberknifetampabay.org/docs/MonotherapyProstateCancer.pdf

Two weeks instead of 7-8 would be great if it could be done in Tampa instead of LA, but I understand she may not be a card carrying member of the SBRT high risk protocol.

It's funny, my initial reaction before I read Allen's reply was that this procedure is only being done at UCLA, in Toronto, and possibly at MSK. Then I read earlier about someone having it done in Colorado. So gaining popularity.

LupronJim
Posted 8/10/2014 11:42 PM (GMT 0)
Jim-
I don't think you can use an MRI with endorectal coil for treatment planning. It distorts the shape of your prostate. Did Dr King tell you to do that? Also, I thought that they have to do the CT and MRI at the same time and after the fiducials are placed, but if Dr King told you you can do that, he would certainly know better than me.

Yes I know that everyone does low & intermediate risk SBRT. What I'm suggesting is that if you want to you can ask Dr King if he can collaborate with Dr Freeman to suit you. He may not be able to as she uses a CyberKnife machine and he uses Varian Truebeam w/ RapidArc. I know the treatment time is much longer on the CK machine. I don't know what other constraints there may be for whole pelvic treatment.

You are right that only a few places are using SBRT for high risk cases.

- Allen
Posted 8/11/2014 2:31 AM (GMT 0)
Allen, the 1.5 T MRI followed by a CT scan and gold fiducials is the protocol the local RO is suggesting for IMRT/IGRT, not something Dr King recommended.

Good to know though in case Dr. Freeman requires a different type of MRI to superimpose with the CT Scan and gold fiducial markers, unless she has the very high end equipment like UF & Shands does that does not require gold fiducials to calibrate.

I sent an email to Dr King asking if he knew whether Dr Freeman does high risk SBRT/Cyberknife, and copied you on it.

LupronJim
Posted 8/11/2014 5:26 AM (GMT 0)
Jim-
It's starting to look like you have too many doctors, all following different protocols, which will interfere with one another and may cause insurance payment issues. If I were you, I'd be making some decisions about which doctor's protocol you're going to follow before you have anymore imaging or other procedures done.

- Allen
Posted 8/11/2014 5:08 PM (GMT 0)
phahn - Thanks for the reply, much appreciated. I'm at the point of shopping for RO's and each has a different technology that they endorse. I could comfortably go with Demanes/HDR or King/SBRT with confidence in getting the best possible treatment.

Your comment about "doing nothing" is still my other option and I'm thinking about it too, that is continuing on AS. What I may do now is get an MRI guided biopsy at UCLA to confirm the G3+3 of original biopsy. Although the original biopsy of 8/13 was ultrasound guided, apparently only one of the seven cores was from the left apex where the tumor was found. Maybe mores samples of that area would confirm the G6 and not something more aggressive.
Posted 8/11/2014 8:18 PM (GMT 0)
Hi supermax,

I was in a similar situation as you 8-12 months ago although my numbers were more advanced than yours. Dr. Bahn thought my cancer looked more aggressive and could have penetrated the capsule. A 3T MRI at UCLA later confirmed it, so I had to go with the kitchen sink treatment (HDR BT + IMRT + HT). Sholtz, Lam, Turner have been my oncos, Dr. Demanes did my HDR BT, and Dr. King did my follow up 5 weeks of IMRT. All have been excellent.

If I were in your shoes, I would consider the HDR BT. Personally, I found it to be a very minor operation and Dr. Demanes is great. The catheters allow planning so that there is maximum dose where needed and minimum where wanted, so that SEs are among the lowest of all treatments, especially under Dr. Demanes. Plus, he now can do it as an outpatient procedure which, although requires more visits, may be less strenuous.

Dr. King is the best at what he does, and, intellectually, I was very attracted to SBRT at first. I also believe that if you have a clean bowel, no gas, and the right amount of fullness in your bladder when you have the 5 SBRT treatments, you will probably come through with minimal SEs. It is true that it may be less invasive than BT, but I wouldn't give so much weight to that, especially considering how minor the HDR BT procedure really is.

I know Dr. Bahn and Scholz are big Demanes proponents and not big on SBRT at all, so you may want to ask them why if you haven't already.

Either of these procedures will still ablate the prostate which has its own set of SEs. If at all possible, you should try to keep as much of it as long as you can. Have you looked at focal therapies? Otherwise, you are smart to consider continuing AS if all looks good. Have you seen Dr. Bahn recently? My wife works in radiology at UCLA and was there when Dr. Bahn did his CDUS as well as when I got my MRIs at UCLA, and she was very impressed with Dr. Bahn's insight. I know he doesn't take insurance, in which case Dr. Scholz could do a CDUS, but, as he will admit, he doesn't have Dr. Bahn's same level of skill.

MY BT and IMRT treatments were nothing compared to the ongoing misery of HT, so feel lucky you don't have to experience that.

In any case, good luck!
Posted 8/12/2014 1:23 AM (GMT 0)
Hi Jack,

Thanks for the reply.

jacknsan said...
Dr. Bahn thought my cancer looked more aggressive and could have penetrated the capsule. A 3T MRI at UCLA later confirmed it, so I had to go with the kitchen sink treatment (HDR BT + IMRT + HT

I have the same report from Dr Bahn, possible T3a, although my other docs have dismissed that. So confusing.

jacknsan said...
If I were in your shoes, I would consider the HDR BT.

At the top of my list. I've never been more impressed with any doctor than Dr Demanes.

But let me ask you, had you needed only mono therapy would HDR still have been your choice over SBRT?

jacknsan said...
I know Dr. Bahn and Scholz are big Demanes proponents and not big on SBRT at all, so you may want to ask them why if you haven't already.

I figured that out from other doctor's comments. Dr King is Stanford educated and considered "old school" for not putting much faith in imaging for PC (MRI, CDUS). Both Bahn and Scholz are all about imaging, that's the issue as I understand it, not specific to SBRT.

jacknsan said...
Either of these procedures will still ablate the prostate which has its own set of SEs. If at all possible, you should try to keep as much of it as long as you can. Have you looked at focal therapies?

I'm not eligible for focal because of proximity of tumor to the external sphincter, or so I'm told. And as someone pointed out in a PC support group, "if you can do focal treatment then you can do AS".

jacknsan said...
Have you seen Dr. Bahn recently? My wife works in radiology at UCLA and was there when Dr. Bahn did his CDUS as well as when I got my MRIs at UCLA, and she was very impressed with Dr. Bahn's insight. I know he doesn't take insurance, in which case Dr. Scholz could do a CDUS, but, as he will admit, he doesn't have Dr. Bahn's same level of skill.

I'm walking distance from Dr Bahn's office and just saw him for a followup CDUS. He recommends treatment and suggests T3a.

My current plan is an MRI guided biopsy at UCLA to confirm what I'm dealing with and then make a decision on treatment. Doing lots of reading and coming to to the conclusion that I'm not really a candidate for AS, as much as I would like to be.
Posted 8/12/2014 1:58 AM (GMT 0)
Hi Max,

I think you are doing all the right things. For me, the diagnosis by Dr. Bahn was the hinge pin for all of my decisions, even though I wanted to believe all those who dismissed it. Dr. Scholz convinced me to take it to heart and treat it as T3A and throw the kitchen sink at it. Dr. Demanes was on the fence.

I was hoping to do SBRT with Dr. King as a monotherapy or along with a short course of HT. After the 3T MRI and the T3a confirmation, even Dr. King suggested the HDR BT with HT and follow up IMRT. So if you asked me before the MRI, I would have said I prefer the SBRT, but now that I have had all the treatments, I would have to say the HDR BT, especially if you have a lesion so close to the rectum and if you were to do it as a monotherapy.

Dr. Scholz also helped my decision when he told me he had Cyberknife patients with rectal burns, but that could have been with older machines.

I realize you have the travel issue. Although I would never recommend driving unaccompanied after such a procedure, I would say that when I did not hit the pain button so much and asked for Ibuprofen instead, I was in much less pain, less nauseous, and much more alert upon dismissal.

You are in that grey area just as I was, so the decision is difficult. I feel for you, but it sounds like you are on your way to the making the right decision.
Posted 8/12/2014 5:24 AM (GMT 0)
I just visited Kaiser LA with a friend today. Bahn had Dx'd him with extracapsular extension. Kaiser did a T2 and DCE MRI and found it was fully contained with no hint of ECE. Even I could see that on the DVD, while the CDUS image was ambiguous. Recent data suggests that mpMRIs are more accurate than CDUS.

- Allen
Posted 8/12/2014 8:21 PM (GMT 0)
Hi Allen,

I probably had an MRI with the same machine back in October if it was the one at Kaiser Sunset. They concluded mine was contained as well with no evidence of ECE. 2 3T MP MRIs at UCLA (one with ER coil, one without) later diagnosed it as ECE. I realize my PCa is not your friend's and am only relating the story as it pertains to my experience.

Dr. Bahn reads the blood flow and the edges of the lesion which show up much better in real time on the CDUS monitor than in the print-out he gives. The image I saw that day on Dr. Bahn's machine showed me more than all the MRI slices I poured over.

I would have preferred that the Kaiser MRI was correct and that Dr. Bahn was in error. I may have been over treated as a result, but I made my decision to err on the side of caution. Dr. Scholz and Dr. King were very adamant in their support of that decision. Dr. Demanes said it was a difficult choice but he respected the others' advice.

Also, I think reading all the signatures of 3+4 guys having RPs and their pathology upgrading them to 4+3, 4+4 (or 5) with ECE, and their subsequent followup with SRT and ADT, helped me decide as I did.

Your friend saw his prostate on Dr. Bahn's monitor so he may have a good "feel" for what is likely. Had I not changed insurances so I could get the 3T MRI and see Dr. King and Demanes, I would have stayed with Kaiser LA and maybe had the LDR BT monotherapy as Dr. Goy had advised. Perhaps I would have been better off... but perhaps not.

Your friend's journey sound interesting and I wish him well.
Jack
Posted 8/12/2014 11:05 PM (GMT 0)
I was actually with Dr. Bahn myself as he did two CDUS (a year apart) on my friend. I can see why there are so few experts. I've gotta say, I saw nothing clearly, and Dr. Bahn kept pointing to a couple of black dots (and there were many other black dots throughout) saying , "See! See!" My friend only has a small amount of GS 6. On the other hand, the MRI picture was clear and the dense region was far - well over a centimeter - from the edge. He would have just stayed on Active Surveillance, but I thought that since he hasn't had a confirming biopsy in 3 years, it would be a good idea to check for grade progression. If there's no grade progression, he can probably go another 5 years without further checking (his PSA is low and stable).

- Allen
Posted 8/13/2014 6:34 PM (GMT 0)
Allen,

I think if I were in your friend's shoes I would be doing the same. The question about checking for grade progression makes me wonder how that would be done... A blind biopsy at Kaiser or an out of pocket targeted one with Dr. Bahn? Or something else?
Posted 8/13/2014 6:53 PM (GMT 0)
Dr. Bahn felt comfortable having Kaiser do it. He felt that it is covered there and it would be OK as long as additional cores are taken in the suspicious areas. The identified lesion is pretty small but his prostate is small as well, so it shouldn't be much of a problem hitting it. The biopsy urologist has both the CDUS and the MRI to work off of, and is happy to have all that. Of course, he will take random cores from all the other sextants as well.
Posted 8/13/2014 7:31 PM (GMT 0)

jacknsan said...
The question about checking for grade progression makes me wonder how that would be done... A blind biopsy at Kaiser or an out of pocket targeted one with Dr. Bahn? Or something else?

I'm about to get an MRI targeted biopsy at UCLA to confirm Dr Bahn's original biopsy. When I called UCLA to schedule, I first had to submit a CD of the previous MRI images (non-UCLA) for review. Apparently UCLA may use the earlier MRI for targeting instead of repeating the MRI. I hope that's the best way to proceed.
Posted 8/13/2014 11:17 PM (GMT 0)
super max-

Since you have favorable risk PC and you are down to a choice between HDR brachy or SBRT, I can't see how an mpMRI can change anything, so your regular MRI would seem to be sufficient. If you were still considering Active Surveillance, and you seem to be a perfect candidate for that, an mpMRI-targeted biopsy might be more useful. I would be especially reassured by that very low Prolaris score - how much did that cost?

- Allen
Posted 8/14/2014 1:44 AM (GMT 0)
Allen-

I'm still at a point of confusion re: AS vs treatment. Every doctor I've seen has recommended treatment but also delineated a path for AS. I am hoping that the UCLA biopsy will give me a clue about what to do. Maybe continue AS if still G6 but treat if any G7. So I'd like this UCLA biopsy to be mpMRI-targeted if that would give more information for possible AS.

My Prolaris score of +0.3 is actually unfavorable according to Scholz and Lam. I don't have the report in front of me but +0.3 was not a good number. There was no cost for the Prolaris test as part of a clinical trial with Dr Scholz, which may still be ongoing.
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