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Posted 11/10/2016 4:07 PM (GMT 0)
As a update, I have been continuing my research in to the most effective treatments and am leaning strongly towards SBRT. It's been difficult trying to learn about all the technical details about radiation therapy ("Bragg Peak", 3DCRT, VMAT, etc) and trying to cross off treatments that might not be suitable for me due to side effects and effectiveness. It seems the more I look into the different forms of treatment, the more complicated things get. Hence I was wondering if I could get some feedback from members here. It seems with SBRT and to some degree IMRT, effectiveness and decreased side effects rely on having an accurate targeting system in place--is this true and what is recommended? I also just saw a presentation by Peter Grimm, D.O. regarding his findings/recommendations ("...Imapact of ASCENDE trial") regarding use of brachytherapy boost and was wondering if that could be used after SBRT treatment?
Posted 11/10/2016 5:09 PM (GMT 0)
Targeting is everything. You want to make sure that you only target PC and avoid healthy tissue as much as possible. That's the magic that makes current RT methods work.

I am aware of these alignment methods used (sometimes all at once):
tattoos on the body to align the patient's body with the machine
fiducial markers places in the prostate
CT scan just before the treatment session - the scan locates the markers and/or prostate and adjusts the machine's position so the beam hits the desired area.

Andrew
Posted 11/10/2016 5:14 PM (GMT 0)
Hi PAX, I think the guy who is more in line technically is Tall Allen who is normally off for the month of November for writing. I went through HDR Brachy and IMRT. I didn't have any issues following Brachy at UCLA. My issues came when I had IMRT locally but I am apparently in that small percentage who is having chronic issues (longer than a few months). I have heard great things about SBRT and that it used as a monotherapy, especially for G6 PCa. Good luck on your research and getting your answers. -JR
Posted 11/10/2016 6:17 PM (GMT 0)
I used HDR with IMRT and had absolutely no problems at the time or now some six years following treatment. I was much higher risk than you so I needed more aggressive treatment.

To me you look like a candidate for either HDR mono-therapy or SBRT. I think I recall TallAllen advising that SBRT isn't done in conjunction with brachytherapy, either HDR or seeds. To combine brachytherapy and external beam for you looks to be more aggressive than a low risk status (G6 and PSA <10) would indicate.

If you choose external beam, clearly SBRT would be to your advantage. I think five fractions rather than 30 or more for IMRT. In other words one week and done versus nearly two months. If you choose brachytherapy then HDR is better than seeds. Better use of technology, more conformal to the cancer and away from good tissue, no chance of seed migration, and a more powerful treatment.

The main reason that HDR and SBRT are so good compared to IMRT/IGRT/Proton and seeds is that unlike most other cancers, PCa responds better to more powerful and shorter duration radiation. This is termed hypofractionated radiation where fewer, but more powerful fractions (treatments) are used. HDR and SBRT are hypofractionated treatments. In SBRT you get the required amount of radiation in 5 or 6 fractions compared to 30-45 fractions for IMRT/IGRT/Proton. In HDR you get as much radiation in 15-30 minutes of treatments that seeds deliver in 60-90 days.
Posted 11/10/2016 8:17 PM (GMT 0)
PAX - All of the SBRT platforms I've read about use some form of implanted markers to target the radiation. I'm starting CyberKnife next week and they use a set of 4 gold fiducial markers implanted into the prostate. They perform a "planning" scan (sometimes CT, sometimes adding MRI and fusing them together) to program the system, then at and during each treatment the machine constantly tracks the location of the markers and keeps the radiation beams tightly focused only where they belong, thus minimizing the collateral damage to surrounding tissue.

For primary monotherapy the current standard is to deliver 36.25 Gy in 5 fractions of 7.25 Gy each. Most centers now do the therapy over 5 sessions spread over 2 weeks. They have found that having an "off day" between treatments reduces the damage to surrounding tissue. With the tight focus of the beams, this has the same biologically equivalent dose as HDR brachy, which should contribute to better cure rates - especially for the low-risk group.

If you search for any of Tall Allen's posts, look at the studies linked in his signature section for 9-year oncological results and 7-year toxicity results. These are very encouraging, as they are as good as any other similar treatment, with many fewer visits to the clinic.
Posted 11/10/2016 8:50 PM (GMT 0)
You could avoid any side effects by choosing active surveillance. Many people with Gleason 6 do that.

George

www.uptodate.com/contents/active-surveillance-for-men-with-low-risk-clinically-localized-prostate-cancer
Posted 11/10/2016 11:52 PM (GMT 0)
I had SBRT at the Cleveland Clinic in April of this year. One planning session and five treatments. Minimal side affects that cleared up in about a month. PSA has dropped from 8.64 to 1.56 seven months. Dr. Stephans was the RO. It seems to be working for me.
Posted 11/11/2016 6:34 PM (GMT 0)
Thanks for all the responses so far. The facility which I am thinking of doing the SBRT Tx at is advertising things like: TomoTherapy; Elekta Infinity, Dual-Energy Varian Multi-Leaf 2100C, and Tomo- Therapy HiArt system; 4-D gating; Radiaonics Xknife for Stereotactic Radiosurgery (SRS); 3-D CT imaging, real time motion tracking, and 5mm multi-leaf collimator; volumetric intensity modulated arc therapy (VMAT). I tried googling some of this stuff, but much of the results are just as confusing and not always relate to P-ca. This is some of the difficulty I am facing in researching radiation Tx's--a lot of the stuff seems so highly technical. Any assistance anyone can provide with deciphering some of these technical terms would be greatly appreciated.
Posted 11/11/2016 7:32 PM (GMT 0)
Pax
I agree with George active surveillance might be the way to go unless there is a reason to think Gleason 6 is something the Dr think needs attention now
Jack
Posted 11/11/2016 7:36 PM (GMT 0)
Pax...we have someone here that is an expert on SBRT, but he's not very active on HW this month since he devotes his Novembers to writing. His name is Tall Allen if you do a search. You might also want to post a separate thread asking for SBRT info--in case he does quickly get on HW that might attract his attention more than the general title of this post.
Posted 11/12/2016 10:35 AM (GMT 0)
Pax,

in general there is IMRT radiation and SBRT radiation (plus Proton). IMRT is used more often since it is an improved version of the radiation that has been done in the past. If the RO has an old machine he will replace it with an IMRT machine. SBRT allows to do a more targeted radiation and radiate smaller areas. This is an advantage if you just want to radiate the gland, the prostate bed or a few metastases. This will have less side effects. If you want to do a salvage radiation to the pelvis without knowing where and if there are micrometastases, IMRT is better. An RO with an IMRT machine will point out additional advantages. I am on the SBRT side.

I think you better go to the facility you have in mind for a consultation and not try to figure out the differences between the various manufacturers with Google. You just have to decide between SBRT and IMRT and in your case, if active surveillance is not an option for you, I would definitely choose SBRT.

Still I would like to point out active surveillance. It says here: "A new study revealing 91% of very low-risk and 74% of low-risk prostate cancer patients in Sweden choose active surveillance should be a benchmark for the use of the management strategy in the U.S. and elsewhere in the world, according to study authors."

Why not give active surveillance a try for a year or two, you can always have the PCa treated later when you want that done. Tall Allen stated that a Gleason 6 PCa cannot cause metastases. So if this is true, there is no risk here.

George

Post Edited (George_) : 11/12/2016 3:44:28 AM (GMT-7)

Posted 11/12/2016 1:48 PM (GMT 0)
Your attempt to learn all the technical marketing terms of equipment will do nothing to help you choose the treatment. The single most important factor is the radiation oncologist. Find those that do a lot of prostate work. Find one that does SBRT, and one that does HDR Brachytherapy, and one that does permanent seeds, and one that does Proton (very limited as there are only about 15 sights in the USA). And please do not let one specialist speak for the others. Do not let the urologist tell you the best radiation treatment any more than you would listen to your dog's vet. You must speak to each specialist directly about that specific treatment.

Any really good rad onc that does a lot of PCa work will have the proper equipment and well functioning clinical staff. If you think you will find the rad onc that does it all and then decide because his machine does or does not have a flux capacitor or super alloy muffler bearings, then you are barking up the wrong tree.

Please check out Active Surveillance seriously. How I wish I could have been dealt your hand. I could have avoided a boatload of radiation and hormone treatment and saved thousands of dollars and lived a much more normal life because I know I would not have treated a low risk G6 until it absolutely told me it needed treating. And for many that is a lifetime of treatment avoidance. Remember, the prostate cancer that is the easiest to cure will never hurt you and did not need to be treated or cured. Don't fall into the overtreatment trap for what appears to be very low grade and risk cellular anomaly.
Posted 11/12/2016 3:55 PM (GMT 0)

JNF said...
Your attempt to learn all the technical marketing terms of equipment will do nothing to help you choose the treatment. The single most important factor is the radiation oncologist. Find those that do a lot of prostate work. Find one that does SBRT, and one that does HDR Brachytherapy, and one that does permanent seeds, and one that does Proton (very limited as there are only about 15 sights in the USA). And please do not let one specialist speak for the others. Do not let the urologist tell you the best radiation treatment any more than you would listen to your dog's vet. You must speak to each specialist directly about that specific treatment.

Any really good rad onc that does a lot of PCa work will have the proper equipment and well functioning clinical staff. If you think you will find the rad onc that does it all and then decide because his machine does or does not have a flux capacitor or super alloy muffler bearings, then you are barking up the wrong tree.

Please check out Active Surveillance seriously. How I wish I could have been dealt your hand. I could have avoided a boatload of radiation and hormone treatment and saved thousands of dollars and lived a much more normal life because I know I would not have treated a low risk G6 until it absolutely told me it needed treating. And for many that is a lifetime of treatment avoidance. Remember, the prostate cancer that is the easiest to cure will never hurt you and did not need to be treated or cured. Don't fall into the overtreatment trap for what appears to be very low grade and risk cellular anomaly.

Very good points. In fact, with respect to SBRT, you don't just choose the radiation oncologist (RO); you are choosing a team of professionals, including the physicist and the technicians (the RO is largely out of the picture after the initial set-up). You want to ask how many procedures they have done. If they have published, so much the better. And if they are associated with academic centers of excellence, so much the better.

I am not advocating SBRT, but if you choose that option, ask for their results for the low-risk patients they have treated. Biochemical failures after 5 years should be quite low (consult the Alan J Katz papers for details)

Post Edited (Sr Sailor) : 11/12/2016 9:10:58 AM (GMT-7)

Posted 11/16/2016 6:08 AM (GMT 0)
Sorry for the late reply, but thank you for all your responses. With regard to Active Surveillance, this is something I discussed with my Internist and Urologist and both were pushing me to get Tx'd via surgery (RALP). They did not feel that AS was appropriate for me due to my age, family Hx and # of cores affected as shown via my Bx. I on the other had did not want to struggle with SE for the rest of my life and was investigating other available Tx's. This was partly why I was looking into SBRT, due to the low side effects and studies showing its effectiveness in Tx P-ca. I still plan to pursue AS as I continue to research into a Tx which I would be most comfortable with, and if you saw my posts on another thread, would know that I hit a dead end with SBRT since my health insurance will probably not pay for it. Right now looking into HDR Brachy.
Posted 11/16/2016 2:25 PM (GMT 0)
Have you actually consulted your insurance company regarding SBRT? What makes you think they won't cover it? I suggest it is time to start "knowing" rather than "thinking". Seek out a few different radiation oncologists and have a consult with each regarding their specialties including one each for HDR, SBRT and seeds. At the same time seek out an urology group that truly manages a formal AS program for their advice.

That should take all of three to four weeks and then you will "know" who the specialists are, get their assessment, consult your insurance company specifically for any restrictions, and make decisions. You can have all this done before the new year. After y diagnosis and initial treatment assessment and advice from my urologist I saw two other urologists, two radiation oncologists, and a medical oncologist within three weeks. Thankfully, you have no need for a medical oncologist due to your apparent low risk status. Plus we are entering the holiday season when many people cancel appointments so you should be able to get in to see the docs.

Best wishes
Posted 11/16/2016 4:38 PM (GMT 0)
It's been a long (and frustrating, at times) road, but I have seen 2 Urologists and will be seeing my second RO tomorrow I also plan to see a Medical Oncologist to get a more unbiased opinion. It seems each doc is primarily pushing the Tx each specializes in--especially the Urologists. I am told that they gotta pay for that expensive Da Vinci machine they use.

With regard to the insurance payment, the first RO noted that he didn't do SBRT, even though I specifically asked my Urologist for a referral to one that did. While at the MD Anderson affiliated hospital, I met with a "patient navigator" and she had me speak with the clerk who does the insurance claims. This is how I found out that other claims to the insurance carrier I subscribe to had been rejected for SBRT for P-ca. I had planned to possibly go to UCLA for the Tx if it wasn't available in Hawaii, but this new info put these plans to a screeching halt. I have gone directly to my health insurance company in the past to inquire about coverages, but they would just tell me to have to the doc submit a request for prior approval and see if it gets accepted or rejected. When I see the second RO tomorrow, I will try pursuing this route. The struggle continues....
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