Newbie and strongly considering HDR monotherapy; need help

I used HDR but was high risk and it was not mono-therapy. I encourage you to pursue the HDR. The side effects will not limit your activities after three days or so.

The good thing about HDR is that it can be repeated. If the one procedure doesn't cure, then it is easy to do another. With G6 the low risk is on your side. As to only 30 procedures, it is all about the initial placement as the fine tuning is under a ct san to ensure accuracy. My docs had many times that, but they all have to start somewhere.

I had HDR brachy, although not as a mono-therapy. All is well with no SEs.

Re the travel, if you had the procedure now I would think the odds of having any SEs by December would be very low. I did have some increased urgency for a few months, although I was also having IMRT at the time so hard to say what was the cause.

Also, as a G6 you have lots of time so I could imagine that you could wait until after your trip. That said, I'd ask for your biopsy slides to be sent to Epstein at Johns Hopkins for a second read just to get confirmation on the G6. That's a good practice for anyone being diagnosed and it's cheap and easy.

I think it's great that you are open to experimental treatments like this, as long as you go in knowing that it is highly experimental. Early trials of one or two fractions have been encouraging in terms of acute toxicity, but there is no data beyond a couple of years that I am aware of. Sunnybrook (Toronto) is doing a randomized clinical trial of one vs two fractions. Demanes and Martinez have done very few patients with one or two fractions - for the most part, they do the same # of fractions they have been doing- 4 to 6.

There are many radiobiology issues. HDR brachy is delivered by a process called heterogeneous planning. That means that the volume around the catheter gets a much bigger dose, and the volume between catheters get much lower doses. When there are multiple catheter placements, they get a pretty good distribution throughout. But will there be "cold spots" if there is just one fraction?

There is a technical issue that has to do with cell cycles. Cells protect themselves by entering a stage that is relatively impervious to radiation. With recovery between doses, they cycle back. (Recovery takes only a couple of hours) Part of the logic of multiple fractions is that eventually the cancer cells will get hit while they are in a vulnerable cell cycle phase.

Another issue is hypoxia. Cancer cells can survive and thrive in low oxygenation (hypoxic) areas. Because radiation depends on oxygenation to work, hypoxia can protect cancer cells. One of the reasons for multiple fractions is that each dose eats away at the borders of the hypoxic areas, and eventually gets down to the core where the cancer cells are hiding. Can this be accomplished in one extreme dose? No one knows the answer to that yet.

The urethral and rectal dose is an issue too. With multiple placements, they can avoid giving the urethra or rectum too toxic a dose ("hot spots"), but with only one placement can they avoid toxicity while not frying the urethra or rectum? So far, it looks good for acute toxicity, but no one knows the effect on late-responding tissues - especially bowel tissue.

What it boils down to are the two questions:

• What is its long-term cancer control rate?
• What kind of late term toxicity effects can one expect?

As for the learning curve, well, no one has much experience with one or two fractions. It's highly experimental and should only be done within a clinical trial. The only way we ever learn the answers is if people like you volunteer for these trials. Please keep us apprised of your progress.

I remember there was a HW member named Mike who had SBRT done at Mercy Hospital in St. Louis and was very satisfied. You may want to explore that as well. I also hope you don't rule out Active Surveillance because of your youth. about half of the men in Klotz's trial were still untreated 20 years later. Every year one is on AS is a year without any side effects of treatment.

GOP, based on what I've read, HDR has fewer side effects than LDR.

To all who have replied, thank you!!!

I'm still in the info gathering stage with no final decision reached. Much to consider.

Tall Allen, as usual, you are a wealth of info. One of my questions is how they settled on 19 Gy for one and done, a dose that's less than the more traditional cumulative dosing for the HDR monotherapy (2-6 fractions).

I emailed UCLA yesterday and Dr. Kamrava replied today (Sunday!). He said he'd have his office call me on Tues to set up a phone consult. He also said: "we currently only offer a 2 fraction regimen as there is not enough data to support doing a one fraction regimen outside of a clinical trial". That suggests he's pretty certain about the 2 fraction.

I look forward to talking with him and feel like I'm now prepared to have an intelligent discussion about HDR, which I wasn't when I met with the local rad oncologist on Friday. I will try contacting some of the other docs who are doing 1 and 2 fraction HDR treatments to get their insights/thoughts.

The good news is that I don't feel rushed into making a decision. While AS would be nice, the universal advice so far has been to submit to treatment sooner rather than later, and the oncologist I consulted has 35 years of experience and is a friend of mine with no agenda. In my case, he said he fears genetics more than the disease. But for my strong family history, he'd urge AS.

Stay tuned.

Meanwhile, if there are others who have HDR monotherapy stories to share, I'm all ears.

I had HDR mono-therapy treatment from Dr. Demanes at UCLA last October. I had to choose between 2 single fractions of 10.5 Gy each, spaced one week apart or 2 X 3 fractions of 7.25 Gy each, also spaced a week apart. I decided on the "tried and true" 6 fraction treatment even though that involved 2 over night stays in the hospital with the implants. I went with the 2 X 3 fraction method for many of the same reasons that Tall Allen mentioned in his reply. It just made sense to me that having 6 opportunities to hit all of the cancer cells made for better odds than only 2 shots.

In addition to the learning curve for the doctor, I think the pain management will be better in a facility where they have a long track record in doing HDR for PCa. The folks at UCLA were great, they do 3 to 4 HDR treatments for PCa per week. The team there has been together for many years, and I felt like I was in very good hands the whole time I was there.

I'm not so sure of there being more side effects with LDR.

Of course I had HDR, but in reviewing my options the only thing I learned that distinguished the two, in my particular case, was the time it took for urinary functions to return to normal.

I had a little dripping prior to my diagnosis and based on the questionnaire he said HDR might be better in that regard. Interestingly, I have no more dripping issues and rarely ever get up in the middle of the night to pee. My urgency (which was a SE) was gone for six months but oddly I've felt some during this past week.

I'm happy with HDR but I've heard many good stories from those with LDR treatment as well. For some reason, I didn't want to have a foreign objects in me down there. I don't know if they show up on airport scans but I kept thinking of that.

Mary, thanks for the note. I have been "chatting" with John on that thread. Very helpful info.

Mary,
Thanks for the 10-year update - looks great! I look forward to reading the full text sometime. I'm eager to see results broken down by risk group.

It seems to me the only real advantage to fewer fractions is to get it all done quicker. I'm surprised that J had to come in for a second visit a week later and go through the whole procedure again. Normally, they only have to wait a few hours between fractions for healthy tissue to recover. What is Kamrava's reasoning for splitting the 2 fractions a week apart?

- Allen

Allen and Mary, I spoke with Dr. Alvero Martinez yesterday via a cold call and he had several interesting things to say.

First, in my case, he is recommending 2 fraction HDR instead of one due to my strong family history and the fact that one fraction treatment is still experimental. He thought one fraction would be "too aggressive" in my case.

Second, when doing 2 fractions, he separates the treatment by two weeks, explaining that allows time for the urethra, bladder and rectum to better recover, leading to fewer acute issues. He used to do the 2 fraction treatment on back to back days but experience led him away from that.

As you know, Dr. Martinez, along with Dr. Demanes, was the HDR 2 fraction pioneer and it was extremely nice of him to talk with me. He was very helpful and friendly.

No one in St. Louis is doing the two fraction treatment. Thus, if I want to do it as opposed to the one fraction, which is offered here, I will have to travel out of town.

In that regard, I will be having a phone consult with Dr. Kamrava on October 2.

Neither Dr. Hsu nor Dr. Santosh Yajniik in Chicago ,who is also doing 2 fraction treatment but apparently on back to back days, will do phone consults.

Mary, what has been J's follow up HDR treatment? Presumably it did not require traveling back to LA?

Tall Allen,

Another advantage of a single fraction per insertion is that needle displacement is not a concern. I think it takes an experienced technician to accurately re-position the catheters after the patient has been waiting for 6 or more hours with the inserts in place.

www.aapm.org/meetings/04AM/pdf/14-1325-69992.pdf

Hi All,

Dcd, you asked about J's follow-up. Really, it's been almost nothing so far. He had a phone consult with Kamrava about a week after we returned home. He will see a local urologist and get a PSA reading this month, and I'm pretty sure he'll have a phone consult with UCLA at that time, too, as they want to follow him. Otherwise, that's been it. If by chance you do end up traveling to LA, definitely check out whether or not you can get into the Tiverton House. It was a perfect place to stay, it was inexpensive, convenient for groceries, free parking, etc., etc. I can't say enough good things about it. We also got to hang out with Allen a couple of times, which was really great! :)

Feel free to ask anything and I'll respond to the best of my ability, and I'm sure J would feel the same.

Take care everyone,

Mary