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Upcoming choice between IMRT/BT and just BT

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Posted 2/26/2015 12:17 PM (GMT 0)
For those who have provided their experiences and expertise - thank you!

After weeks of reading, I've finally joined! I need help from others who have faced this.

Almost decided but which treatment.... I've met with RO and we both believe all these treatment options will get positive results. His thought, the IMRT/BT combo and I agree. I then changed mind to BT.

I'm meeting with Surgeon tomorrow. I feel like that option too radical for my situation.

I've studied site posts and researched medical outcomes for IRMT and BT enough to understand SEs, survival and disease free outcomes. I'd like to glean your experience\bias for real life treatment thoughts. If you can offer that insight I'd appreciate it.
All of my choices are locally obtainable from my PPO.

P.S. - I am still working office job and have BC/BS. Wife and I are raising one grand child and have plenty of family locally with other grandkids. We are active with scuba dive, ride bike, hikes in mountains, regularly exercise and am in generally good health. I'm family orientated and very involved in their lives.
Posted 2/26/2015 1:21 PM (GMT 0)
Welcome Craig - it will help us, help you, if you could create a signature with all of your pertinent PCa stats. Good bunch of folks here to lean to.
Posted 2/26/2015 3:39 PM (GMT 0)
Welcome to HW, sorry you need to be here.

Here's the problem - either will likely work just fine, with the same SE, and possibility of cure. It's a bit of a numbers game. I am not a doctor but in your place, I'd be tempted with just the BT. Likely it would work just fine. If things didn't work out you could do the IMRT later as a secondary step.

You do need to talk to a surgeon - who will likely recommend surgery and possibly tell you the evils of RT.

However, BT offers the fastest recovery time and given your numbers a very high probability of cure. With BT you'll be off the job for a couple of days. IMRT is a slow grind - weeks of showing up at the clinic every day for the 15 minute treatment. Surgery will have you on your back for 2-4 weeks.

I didn't like the thought of surgery so I went with IMRT and it's worked fine for me. My older brother (numbers about the same as mine) went the BT only route and his PSA two years later is .4.

Hang in there and keep us updated on your progress,
Andrew
Posted 2/26/2015 4:19 PM (GMT 0)
I had HDR Brachytherapy alone and feel like I'm doing very well. (SE's:My Johnson has minor stinging sensation occasionally and I notice some urgency now).

If you choose this method, go ahead and get it done asap and you'll be ready for road-bike season a couple months later.

I've only had one follow-up and my PSA dropped from 4.6 pre-treatment to 1.7 at one month. My doc said they wanted to see < 2.0 so that was good.

My RO said I was a good candidate for LDR as well, but I did have (pretreatment) some leaking after urinating so we decided the HDR might be better for me, given the answers on the questionaire.

I won't go back through it, but my biggest issue in this whole thing was hemorrhoid pain from the biopsy. It took about 2 months to get past that and I'm still eating stool softeners, fibercons and using suppositories.
Posted 2/26/2015 4:29 PM (GMT 0)
I see many HW veterans who are expressing they think combo is an edge better. And, I agree with InTheShop that looking at the numbers this is a close to even decision.

I trust the ROs initial thoughts on IMRT/BT and that was my own gut conclusion but I waffle over to mono easily.

I didn't really think about IMRT later, but you seem to think it's a valid option. What are IMRT ramifications for my body if done a year out? I haven't seen any reporting on this.
Posted 2/26/2015 4:42 PM (GMT 0)
Hello, Craig and welcome. I had similar stats to yours and chose LDR Brachy as a mono- therapy. I do understand your dilemma, however, and there is no easy answer. I strongly considered the dual treatment option since it gave an extra bit of safety. However, at the end of the day, I was pretty well convinced that my Cancer was contained in the Prostate and that LDR alone would be curative - and it has been.

One thing you might consider in your decision making is to get another reading on your biopsy slides by an expert like Dr. Epatein ay JHU or Dr. Bostwick at Boswick Labs. A change up or down might affect your decision.

I understand your feeling about the radical nature of surgery and your rejection of it but it would likely provide a cure for your Cancer, albeit with a higher likelihood of onerous side effects. Nevertheless, reviewing this as an option is a good idea. I would also suggest you consider HDR Brachy and SBRT as they are also likely cures for your Cancer with lower chances of nasty SE's than surgery.

Good luck and please tell us how we can help.

Jim
Posted 2/26/2015 4:43 PM (GMT 0)
Hi Dewayne. My RO mentioned the patient experience is more difficult and most patients complain about the delivery time span. Your signature has HDR Brachy 12/2 & 12/16/14. My RO discussed that but on consecutive days. What radio did they use?
Posted 2/26/2015 5:01 PM (GMT 0)
I had the BT/IMRT combo (with HT thrown in since I'm a masochist), but I was a G9 and hence high risk. You are favorable intermediate risk so I believe that BT monotherapy would be the norm. I think that the suggestion above to get your biopsy slides confirmed is a good one just to make sure you are still G7. (And heck, you may get downgraded to G6...)

Good luck to you. Treatment decision is really difficult.
Posted 2/26/2015 5:09 PM (GMT 0)
CraigG,

My RO, Dr. Rossi at Winship Cancer Institute (Emory) in Atlanta, recommended or performs the HDR Brachytherapy on two different days - one to two weeks apart.

After the first treatment on Dec. 2, I was at a school board meeting at 5 p.m. and then at my firm's Christmas dinner at 6:30 p.m., actually feeling fine. I went in to work at 10 a.m. the next day.

After the second treatment on Dec. 16, the RO scolded me, at my wife's urging, and "ordered" me to take it easy for 48 hours. I could have went to work normal (I come from a mom who didn't believe in missing anything unless you're a risk to others) the following day, but I intentionally took it easy for a couple of weeks. I took a 4 p.m. nap daily for a week or so.

My only complaint was the urgency; but it never kept me up at night or anything like that. It's a lot better now, even though it wasn't all that bad to begin with. I don't like the no ejaculate all that much but I guess every option causes that?

Good luck. I'll be happy to tell you, or anyone, more about my experience.
Posted 2/26/2015 5:13 PM (GMT 0)
Honestly, I'd rather have the two procedures a couple weeks apart.

My first procedure was more difficult during the procedure itself, but I recovered very quickly. That cathetar was driving me crazy during that first one. I would've probably killed someone if I had to keep it in for 24 hours.

However, the second procedure it hardly bothered me. It was remarkable the difference in pain levels from my first to second procedure. You can "Search" and find my account given on the day of each. I think it was titled "HDR Brachytherapy Round 1" and then round 2.
Posted 2/26/2015 5:14 PM (GMT 0)
Thanks for updating your signature Craig, helps a lot to know you better.

Reading your signature I almost felt like I was reading my own. Very similar, other than your PSA readings were higher (keeping in mind PSA is merely a predictor whereas the biopsy tells you) and also I had much more cancer present.

Initially I too had briefly considered the combination treatment approach; I eventually settled on LDR/BT/Mono as similarly to Tudpock, I felt my cancer was contained - and that by going to "one of the best" practitioners I had the confidence the mono approach would be successful.

I agree with the other guys that have stated with your PCa stats, any of the current treatment approaches will likely kick the cancer down and out, beyond that it gets into potential side effects related to those different modalities, and your own internal psyche.

If you're interested I'd be happy to share with you a litany of data, reports, studies, etc. that I gathered and used towards my own decision making process - you can shoot me an e-mail by clicking on the envelope in the upper right hand corner of this post, under my handle "A Yooper."

Hang in there, no need to panic or rush. Get out there and gather as much information and knowledge as you can towards your decision.

Best to you.
Posted 2/26/2015 5:18 PM (GMT 0)
Here's a copy of my post on the night of my first procedure:

Posted 12/2/2014 8:21 PM (GMT -7) VIEW IMAGE
Had my procedure at Emory-St. Joseph's at 7:30 a.m. this morning.

I'm feeling good right now, at 10 p.m., but for the board I wanted to give an account of my procedure:

Monday - liquid diet all day, plus a bottle of magnesium citrate in the afternoon and a fleet enema at 9 p.m. Nothing to drink or eat after midnight.

Tuesday. -Checked in at 5:30 a.m. Undressed all the way into a robe and wheeled to the pre surgery area for prep, IV, etc.

-Wheeled into the surgery room right on time. All I remember is talking to a couple of guys and then putting on the anesthesia mask.

- Woke up at some point with a catheter in and 16 needles that had been implanted through my scrotum and into my prostate. The pressure was pretty intense. The feeling of needing to urinate was strong.

- At some point I started getting some bladder spasms that hurt, like a 7 on a 10 scale.

- Went into a nice waiting room with a tv where I had some delicious saltine crackers and orange juice AND a perkiset.. (sp?).

- Rolled down to radiation, where the nurse and physicist made the plan, along with Dr. Rossi.

-The radiation machine was hooked up to the wires implanted in my scrotum. There was a piece sutured to my scrotum holding the needles. I felt some vibrating with the radiation but no pain.

- The pain at this point was all about the pressure from those needles and the catheter. It was getting fairly unbearable by the end of the 40 minutes of radiation.

- After finishing, the doctor said he was going to take the needles out. They got me to relax and he jerked the needles out fast and all at once. I believe this was the most intense pain I have ever felt in my 48 years. It was awful, and the nurse had to keep pressure on it for 10 minutes.

- When I settled down, the nurse took (jerked) the catheter out. This pain might make my top 10 all-time pain.

- On the way home I got a little sick and almost puked. It's an hour drive for me and my wife isn't the smoothest driver.

- I took a two hour nap and felt pretty fair afterwards. I went to a school board meeting (my term ends this month) and an office Christmas party. I actually felt very good from 8 pm on.

- when I urinate, it feels like pissing razor blades. Seems to be getting better, but the first three or four times to pee is awful.

I'm feeling good about my choice, but not looking forward to doing it all again Dec. 16.

My doctor said this would "do significant damage to the cancer cells" today, when I asked if it was killed over time sine they can't multiply.
Posted 2/26/2015 5:22 PM (GMT 0)
Here's a copy of my post, on the night right after my second procedure:

Today.

I let them know about the couple of instances of unpleasant pain in the first session, and I'm proud to report the second sessions was much better.

Not really painful taking out high dose radiation pins or the catheter at all. I wouldn't call it pleasant, but there wasn't much to it.

I came home and took a four hour nap. The doc suggested 48 hours of rest/recliner/remote.

I haven't taken any pain meds so far and almost feel guilty with lack of pain. He said my perenium might be more sore after second session.

I've felt pretty 'high' all day though... tongue

Posted 2/26/2015 5:26 PM (GMT 0)
Craig,
I had LDR and IMRT for a G4+3 and a psa of 40 about 6 years ago. My psa is now <.1 and I have no side effects from the treatment. Never had any ED and urinary frequency and urgency lasted about 4 weeks after Brachy. The IMRT had really no additional side effects except for some loose stools for a few months. All side effects were very tolerable and none kept me from my daily activities from day 2 on.
The reason I chose the combo treatment was that I had a large volume tumor and wanted a higher dose as well as wider margins. The use of two different radiation isotopes was a plus as I believe that cancer doesn't react well to change and the more different things you throw at it at the same time ( two different radiations, small amount of Casodex and Proscar, and radical diet change) don't enable the cancer cells to have time to adapt to treatment.

JT
Posted 2/26/2015 5:28 PM (GMT 0)
Thanks Jim. I appreciated reviewing your journey and found it helpful.
Posted 2/26/2015 5:38 PM (GMT 0)
JT, I don't know my tumor volume. Did the longer term worries from wider margins or spillover beam to rectal/bladder area concern you much? That concerns me but not as much as leaving something untreated.
Posted 2/26/2015 5:57 PM (GMT 0)
Craig - I had some concerns about the margins so my RO widened the beam a bit to get more of that. Getting all the nasty PC cells was top priority - spillover to healthy areas a concern but overridden by wanting to only treat once.

Remember that with IMRT that they reduce the beam strength as it passes through structure like the rectum to minimize the damage there.

I'd thing the only reason to do the combo is if you have concerns about margins that the BT wouldn't cover.

Andrew
Posted 2/26/2015 8:05 PM (GMT 0)
Craig,

I am exactly four weeks post-treatment, HDR Brachy Mono using the MSK protocol of 2 consecutive days of treatment. My RO in Chicago trained at MSK so he uses that particular protocol as opposed to HDR Brachy (mono) done one day... then a week separation.... then second course completed.

HDR BRACHY (mono) using the one-week separation between treatments is the protocol at centers in LA, Detroit and Atlanta as far as I know.

HDR BRACHY (mono) protocol completed in 2 consecutive days is the technique used @ MSK (NYC) and in Chicago.

My treatment completed in 2-consecutive days was not comfortable but not painful as I was under local spinal anesthesia for the placement of the 20 needle catheters (via the perineum) as well as epidural and other associated pain meds throughout the 2 day procedure. I was in the hospital for 2 1/2 days--- the 1/2 day was to ensure I could urinate appropriately without the foley catheter before they would release me.

You have to stay absolutely in one position with your legs situated in stirrups positioning for the entire 2 days of the procedure. This ensures that the metal needle template that is sewn to your perineum is not moved. Before each of the four HDR ZAPPINGS they will run a CT scan to again, check the precise positioning of the placement of each needle catheter into the prostate. They only had to do one slight adjustment on me before the first session of the second day. Again no pain, eat normal full meals during my stay at the hospital. Even had my own pain pump ... didn't really need it... but heck ... why waste all that fun medicine?

My team, and HDR BRACHY is a team, did a great job of providing great care while I was in the hospital and the associated cancer center. Not so much after I was discharged.

SE Situation Upon my release

1. No real pain, they did provide me with Vicodin, but did not need it, used Tylenol PLUS

2. No incontinence

2.5 No bowel problems (I was/am taking, Colace 2 a day)

3. Urination has been problematic and painful.....for the entire month. I had to up my FLOMAX to 2 a day and take 4 capsules of URIBEL (which turns your pee blue/green) and is supposed to help with the pain. Didn't seem to work well for me. It has been consistently challenging as far as pain during the urgency/ release phase of urination...... until yesterday when things started to improve... I moved from Tylenol to normal aspirin as I think that helps with any ongoing swelling which impacts the urethra. Again this has been a surprise to me... this length of the urination problem, but I have to be patient and I now feel it is improving... Also note, that for the first three and one half weeks post, I have been waking up 4-6 times a night with urgency/pain issues. Therefore, no real sleep exacerbates all the problems. This has also quieted down and I sense I am improving. Slept well last night!!

4.No ED issues... this seems to be working fairly well.... ejaculate is different and that was expected, but all seems to be fairly good in the erector-set department (relieved).

This has been my experience with the one month post-HDR BRACHY MONO treatment. I see my RO for the first time next week.

Best to you

BENSAM



Posted 2/26/2015 9:09 PM (GMT 0)
Bensam,

My RO practiced years ago in Chicago. The differences are reasonable once you explained it. In terms of outcomes the HDR seems good. The RO stated for mono LDR BT there would be approx. 144 Gy and with HDR it would be approx. 35-40 Gy but at a higher rate. Honestly, I don't think I dumb or anything but can someone explain the difference to me? This is the part that is unclear to me. The RO can't seem to get this through to me or I can't grasp the Gy world.

My RO isn't doing HDR any longer. I was told patients complained a lot, so his nurse says. Very uncomfortable to endure. I don't know if it's something I could do. I'm guessing if I could I'd have to go somewhere else.
Posted 2/26/2015 10:24 PM (GMT 0)
I can explain that. I'll try without the math. A Gy is not a Gy - it depends on thehow the radiation is given. Radiobiologically, HDR brachy and LDR brachy are at opposite ends of the spectrum. HDR brachy gives you a few very intense doses of radiation. LDR brachy is a very slow steady continuous onslaught of radiation, starting high, dwindling to practically nothing. They both kill the cancer, but do so in different ways.

It's the same kind of difference with IMRT - which is 80 Gy over 40 treatments - vs SBRT - which is 35-40 Gy over 5 treatments. (SBRT was radiologically modelled on HDR brachy and is nearly identical in every respect except the direction the X rays are coming from).

The reason these very intense doses work so well in just a few treatments is because prostate cancer has a uniquely low "alpha/beta ratio." This means it is killed more efficiently by a few intense doses. It also means that healthy tissue, which has a much higher alpha/beta ratio, is killed much less effectively by the more intense doses.

To put things on an equal footing, radiologists speak of a "biologically effective dose (BED)" which incorporates the alpha/beta ratio. So my SBRT dose of 40 Gy is actually equivalent to an IMRT dose of 109 Gy in its cancer-killing power (35% greater), but as far as healthy tissue is concerned, it is only equivalent to a 60 Gy IMRT dose (25% less), which makes it more sparing of healthy tissue. It also opens up greater possibility for retreatment after SBRT because the total nominal dose was only half as big.

The differences between HDR and LDR are similar to the above, although calculating the BED for LDR is a lot more complicated (you have to include the initial dose rate, the radioactive decay constant, its half life, and the tissue repair rate constant). In general, the LDR brachy dose is a bit less than the equivalent to an IMRT dose, but is much more sparing of healthy tissue. Because it's less, it may be fine as a monotherapy for low risk cancer, but has to be amped up for higher risk cancers with additional IMRT.

- Allen
Posted 2/26/2015 11:45 PM (GMT 0)
I had four sessions of 9.5 GY for 7.5 minutes each spread over a 2 day period
Posted 2/27/2015 1:02 AM (GMT 0)
I don't necessarily want to tout HDR brachy over LDR brachy, but I very much doubt the reason it was no longer offered by your RO was that patients complained it was uncomfortable.
Posted 2/27/2015 1:43 AM (GMT 0)
CraigG: Much like Yoop, your stats mirror miine accept for your higher PSA readings. I listened to a lot of folks including Uro and local RO but ultimately let prominent specialist in the BT field make the choice of LDR monothearapy. I am glad for that decision because the research indicates less SEs which, fortunately has been the case for me.
Posted 2/27/2015 1:52 AM (GMT 0)

Michael_T said...
I don't necessarily want to tout HDR brachy over LDR brachy, but I very much doubt the reason it was no longer offered by your RO was that patients complained it was uncomfortable.

+1

If you read my posts after HDR, you'll see I "felt guilty" that the pain was so minor.

He probably didn't have the demand or wanted to specialize.
Posted 2/27/2015 12:49 PM (GMT 0)
Hi Craig,

To give you an idea of what LDR BT/Mono looks like, here's is what I wrote after I got home from my treatment:

"Hi everyone - I'm back after my LDR Brachytherapy today. Right off the top, I feel, incredible - physically and mentally! Here's the rundown of my day:

Arrived at the Chicago Prostate Center in Westmont, IL at 11:00 a.m. Was given the paperwork to read and sign in the waiting room, and then Dr. Moran came out to welcome us and bring us in.

Nancy the pre-op nurse took all the vitals and so forth, and explained what would be happening. She then hooked up the three-mix cocktail I.V. and we waited for Dr. Moran to come back in. Dr. Moran then also explained what would be happening and as always reassured me that everything would be fine; he also engaged in small talk that was very calming overall - and as I have come to know is simply what he is all about.

At 12:30 I was wheeled into the OR where a full staff including the anesthesiologist, nurses and technicians (including Michael and Sonia!) and of course Dr. Moran. I'm not sure but less than 10 minutes later I was in ga-ga land. Next thing I know I'm looking up and asking the staff what time it was - 1:20 p.m.! I was given a total of 61 Iodine 125 seeds at 0.382 mCi per, for a total seed activity of 23.30 mCi.

After coming back around for about 10 minutes the urologist / Jane took me down to radiology to perform a cystoscopy to ensure correct placement and quantity of seeds - but first I was shown to the men's room and asked to pee in a bottle so they could observe that I could pee o.k. and also review the volume and color. My first pee after procedure was totally normal - no frequency, burning or uncomfort at all; my results were almost 500 cc's and light, which was my "get out card." The cystoscopy was quick, some scans on my back and more on my side. Jane showed me both views and explained things to me, everything good and as expected. I requested a copy of the scans and she gave me one on the spot, pretty cool stuff.

At 1:40 I was taken over to the recovery room and hooked up with my wife and friend who had accompanied me today. Post Op nurse Susan spent a significant amount of time with us, explaining everything that had occurred, what to expect today, tomorrow, two weeks and answering the "50-questions" I posed. We of course were given copies of everything. I was also given post-op meds that included Medrol 4mg (steroid to help in reducing the swelling of the prostate from procedure) - 21 tablets that start out at three a day and over the course of 12 days is weaned down to 1 per day; Rapaflo 8mg - 1 tablet daily to assist in urinary function, and even though my initial post-procedure pee was uneventful I'm still going to take this one as cheap insurance. It is supposedly the newest version of Flomax and Susan was good enough to give me a one month supply; Cipro 500 mg - antibiotic 2 per day for 2 days. Dr. Moran gave me his home phone and cell phone and told me to call at anytime with any questions or concerns. I will get a follow-up call on Monday and then the next visit will be in about 12 weeks for a follow up with Dr. Moran and a PSA draw.

After all the explanations were given I decided to pee again before leaving, this time about 275 cc's and light colored and again no issues. On the way out I signed out and then asked the receptionist Lili for copies of all of my records to date for my files, which she printed out for me on the spot.

So then I guess in summary - qualifying this with I do not yet know how this will all come out - I am beyond appreciation for how this entire process went today with Dr. Moran and his staff. You may have noticed I used everyone's name in this summary - it's because that is exactly how they make you feel, incredibly comfortable both in the professionalism and experience each of them provide for this process as well as how they treat/interact with you.

As we left we decided to stop next door at Pappadeaux's Seafood Kitchen, which is essentially next door to the Chicago Prostate Center. Had an awesome dinner of fresh grilled fish-kabob and other than some very minor dull pain in the perineum it was like any other out to dinner. . . . some 2 hours post procedure.

Thanks to all for your thoughts and prayers leading up to this. For all of you that have followed me along these past several weeks you know I have made a commitment to both "Pay Back" and "Pay Forward" - this summary is meant to be a small part of that promise.

Peace to all."
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