HDR Brachy

Hello -

Had a phone consult with Dr. Scholz and he recommended HDR Brachy.

Effectiveness of HDR Brachytherapy at UCLA: http://radonc.ucla.edu/site.cfm?id=470

"Conclusion - HDR brachytherapy and EBRT is a safe and effective treatment for all risk groups of patients with prostate cancer. Unlike the randomized trials that use EBRT without brachytherapy, the outcome stratified by risk group was not improved by the use of androgen deprivation therapy (ADT). Long term follow up of the CET HDR brachytherapy and EBRT patients shows the PSA progression free survival for low and intermediate risk group patients to be excellent. High risk group patients also have good control rates compared to other treatment approaches. Lack of randomization in the study means that some degree of case selection bias cannot be excluded, but our results suggest further study of ADT with HDR will be required to demonstrate which risk groups of patients, if any, will benefit from ADT."

I'm hoping to talk with UCLA today, but are there other providers that you would recommend?

I've done some searching on the internet but have not come up with many good results yet.

I'll do whatever it takes - I can go to LA for the brachy, but if external radiation is required in addition (likely) I'm not sure I'd want to stay for many weeks.

Thanks,

Walt

Hi Walt,

I'm a graduate of UCLA's HDR brachy program and also did my IMRT at UCLA. I'm about 18 months out from finishing the last of the IMRT and so far so good, although it's still a bit on the early side.

I agree with JNF that you can do the IMRT locally. If I had one disappointment in my treatment it was that I felt there was no special coordination between the brachy program and the IMRT programs at UCLA. (Or so it seemed...perhaps they were really coordinated behind the scenes.) No matter where you go for your IMRT, I would work hard to make sure there's good coordination going on.

There are several other active folks here that had HDR brachy at UCLA so I'm sure you'll be able to get any questions you have answered. All the best with your treatment.

Walton,

Where are you located?

Walton,

I'm having the HDR brachy done at UCLA later this week. I still am not sure if I will be doing the HDR mono-therapy, or the combination HDR/EBRT. I have an MRI at UCLA before we start the HDR treatment, and I hope the decision is easy to make based on the MRI results. If I do the external radiation, I can do that closer to my home.

I'll post updates as I proceed.

Today I set an appt. to speak with Dr. Demanes at UCLA on the 7th. Another option is Alvaro Martinez at 21st Century in Detroit (previously recommended).

I'm in southern Arkansas and I cannot the only major cities that are reasonably close to me are Dallas at 4.5 hrs and Houston at about 7. Do not see a provider in Little Rock. It doesn't look like MD Anderson offers HD Brachy and I haven't found one in Dallas.

I'm not sure I'll want to drive back after the treatment from Chicago @12-13 hrs or Atlanta @10. If flying, most major cities are about equal. We do have some family in LA, and in November/December it wins out over the Windy City.

Best locations for me the second course of action (IMRT or SBRT?)
Bay Area, CA (UCSF?) or Sacramento, CA (UC Davis?)
Detroit, MI
Florida - Ft. Myers

I will call Dr. Mantz in Ft. Myers - I likely have a place I could stay there at a reasonable cost, but need to learn more about SBRT. Does SBRT = Cyberknife? I'm behind in my studies, too much to learn and working too many hours.

The next question is will I need ADT - Allen's post demonstrates the upside, but the study quoted in in my OP indicates it may not always add value with HD brachy, even with high risk cases like mine. http://radonc.ucla.edu/site.cfm?id=470. But it looks like the standard care for my condition usually includes ADT.

I've got to decide this in the next month and get as much treatment as possible scheduled and completed this year both for health and financial reasons. My insurance plan has an obscene deductible and then a 35% co-pay until my out of pocket is met:
OOP = (3) * (obscene co-pay).

Thanks again to all for the suggestions and helping me work through this.

JNF,

Demanes has been offering the 2 single HDR procedures a week apart for almost a year now. I need to decide whether to go with his new regime, or his old tried and true 3 fraction x 2 sessions protocol. I haven't yet heard what the pros and cons are, only that the 1 X 2 method involves a shorter hospital stay and similar results. Do you know how long Martinez has been doing the 1 X 2 method?

Hawaii-Guy,

It was four years ago that I went through the HDR and Martinez was performing the two sessions a week apart. Thanks for the update on Demanes, I wasn't aware that he was also offering the two sessions without a hospitalization.

Both of my sessions were outpatient. I was only actually in the hospital for a couple of hours. The catheter insertion was done in the operating room and took about 45 minutes. I was then transported to my radiologist's clinic for the radiation procedure. Start to finish I walked into the hospital at 11:30 am and walked out of the radiology center at 4:30 pm.

super max said...

LupronJim said...
Hawaii-Guy and super max - My 5 SBRT fractions at UCLA start on Monday Oct 6 at 1:45 every other day and end on Wed Oct 15. I will also be at Scholz/Lam/Tuner offices in Marina delk Rey CA on Oct 6 and on Oct 20 for my Provenge Infusions.

If our session times overlap, would love to meet you in person.

Hi Jim,

I was hoping to meet you at PCRI but didn't happen. My appointment in MDR is Oct 22, close to yours but not close enough this time.

Yes, I commented on the PCRI form that they should on the name tag, let us show our usernames from HealingWell or from Us Too Inspire.com.

I wrote "LupronJim" in and we likely crossed paths at some point but your name tag had your real name rather than super max.

I can see the other side though as lots of guys do not participate in forums and had to wonder why "LupronJim" was hand written.

The guys on Inspire.com organized a Friday luncheon to meet one another.

LupronJim

Jim,

I sent you an email with my contact info. I spent 8 hours at UCLA today in preparation for my upcoming brachy sessions- TRUS, MRI along with lengthy discussions with the medical staff.

Hi Walt,

I originally wanted to do SBRT with Dr. King at UCLA, but when imaging showed probable ECE, he recommended HDR BT with Dr. Demanes along with IMRT. He said he could incorporate the lymph nodes and SVs into the SBRT but only under a trial.

My onc, Dr. Scholz, strongly suggested the HDR BT route, so that is the way I went. Dr. King did the IMRT on the same machine he does the SBRT.

It is more important that you have an expert do the HDR BT. It is my understanding that as long as the equipment is good and the RO competent, the IMRT follow-up can be done anywhere.

If I am not mistaken, I believe HDR BT can treat the SV but not the lymph nodes.

Hope this helps.

Walton said...
Still want to know more about how it compares to HD Brachy on effectiveness and SE's.

There's never been a randomized comparison. You can expect the SEs and effectiveness to be pretty much identical because SBRT planning is based on HDR brachy monotherapy. I've seen treatment plans for both and they are very similar. You can see the SBRT results in the link in my signature.

I think Dr. Mantz uses Tomotherapy to do SBRT, which should be amazingly precise. With Tomo, it tracks prostate movement continuously using the excess CT X-rays.

Walton said...
Is it the case with both SBRT and HD Brachy that if SV's or lymph nodes require treatment you need additional RT in a different form?

Seminal vesicles are easily included with both SBRT or HDR monotherapy. Seminal vesicles will be treated if your biopsy or imaging show a significant risk of SVI.

LNs are treated during the same 5 treatments for SBRT. However, LNs are out of the range where catheters can be inserted for HDR brachy monotherapy, so they would have to be treated with about 5 weeks of IMRT. LNs are only included if you are at high risk for LN invasion. That depends on your PSA and Gleason score.

Well, I finished up my 2nd and final HDR brachy session this week with Dr. Demanes. I had 2 implants, spaced 6 days apart, and had 3 fractions per implant. I had the option of going with a single fraction per implant, but decided to go with the multiple fractions, since UCLA has 10 year data showing the effectiveness of this method. The only advantage to the single fraction would have been to avoid the 2 over night stays in the hospital.

I also had to make the tough decision on whether to go with HDR mono-therapy or to follow up the HDR treatment with 4 to 5 weeks of external radiation. Supposedly, my HDR treatment took care of the SVs and a 5 mm margin around the prostate. The only real benefit to the external radiation would be to treat the lymph nodes, and it is a bit controversial as to how successful the external radiation is in treating LNs. According to the Partin tables, my risk for LN invasion is only about 6%, so I decided on the mono-therapy, only time will tell if that was the right decision or not. According to the Roach formula, my risk is much higher, but the Roach formula awards the same risk factor to both forms of GS 7 (3+4 and 4+3 are given the same risk factor in the formula), so I think my risk is somewhat overstated by the formula. Also, my Prolaris score of -0.8 helped tip the scales towards mono-therapy for me.

The whole experience at UCLA was better than I had anticipated, with much less pain than I had imagined. Dr. Demanes' entire team is excellent, some of his staff have been with him for over 20 years. They were always concerned about how I was doing, and took great care to explain everything to me as we went along.

Today is the 2nd day after my last implant, and the side effects are not too bad. I do have some tenderness, and have to position myself carefully when sitting down. The worst SE so far is frequent night time urination, and reduced urine flow at night. These SEs are supposedly temporary, and should subside over the next week or two.

Walt, or anyone else considering HDR brachy as an option, feel free to ask me about any aspect of this type of treatment.

Hawaii-Guy-

Pelvic LN treatment is certainly controversial and there's no clear treatment choice. Did you ask whether you can come back and treat the pelvic LNs, perhaps with 5 treatments of SBRT, if you should ever detect a failure there (let's hope not!)? I imagine your bowel dose was low enough to not preclude that.

- Allen