Gleason 4 + 5 -- need advice

TA
Great story! Many thanks. Looks more promising for high risk guys treated in the 2000's ! This deserves wider publication.
Bob

Another source is Radiotherapy Clinics of Georgia, with their ProstRcision procedure. They do seeds + IMRT, and rarely hormone therapy. Their clinical experience showed little improvement to outcomes for adding HT. I don't know what the conventional wisdom on this forum is about them, or whether it's even PC here to bring them up. I never see references to them or discussion about them, even though their radiation procedure is pretty similar to that part of the "triple play" so often discussed.

Anyway, they have a huge database of treated cases. You can contact them with your particulars, and they'll review your situation. They match it against their database to offer a projection of outcome for you by their treatment plan.

This was useful to me when deciding on treatments, since I was struggling with the whole "triple play" vs. only IGRT+HT. This forum was heavily in favor of the triple play idea, based on certain studies and experiences. My RO was not, based on Vanderbilt's Cancer Center clinical experiences, at least as of April 2013. Their assessment was that the side effect risk exceeded the potential enhanced disease control.

My interaction with RCOG became a little humorous. I figured they would be a high-pressure sales job, like "see us or else" kind of thing, but pursued it anyway. Quite the opposite! When they called me back, they had found that out of their (at that time) 14,000 member database, they found just 52 like me. 52. And, they further found that their success rate was only about 60% with that group (success = <0.2 PSA at 15 years, quite stringent). They actually said, "So, if you have a plan with a doctor you like there in Vanderbilt, we suggest you go ahead with that."!

That whole discussion supported to a fair degree my RO's contention that seeds+IMRT wasn't necessarily much more effective than IMRT alone, for me. (Both being further helped by HT, but that was a given anyway.) So, I ended up doing IGRT (dose escalation with fiducial markers) by IMRT with HT.

I get criticized here when I mention this, but I do it again for some balance. The study link Allen provided says the median EBRT radiation exposure was 76.5 Gy. That means half of those EBRT treatments were below that value, and it's been shown that lower doses are not sufficiently effective for high risk cases (mine was 79.2 Gy, some go as high as 81 Gy dose escalation). So, the study compares a known less-than-effective radiation dose group vs. BT enhancement to an effective level. Not sure how convincing that study is. It's directionally supportive of EBRT+BT anyway.

You pays your money and you takes your chance. That's about all we can do. I've had nearly zero side effects from the radiation therapy, for which I'm ever grateful. Disease control is TBD, and mine was a nearly over-the-brink case when detected, so we'll just have to see. I'm approaching 4 years since diagnosis, and my PSA is still only 0.5, so I'm provisionally optimistic. Time will tell.

RichardNY said...
Sr Sailor,
The triple attack, SBRT + IMRT + hormonal sounds interesting and it seems it to be working for you.
It does sound confusing since I thought that one did either SBRT or IMRT and not both.

You said SBRT was followed by IMRT. I thought that it was not possible to do that. Where did you have it done?

Am I reading your history correctly that you did hormonal before Cyberknife and then continued it after the radiation therapy? Was that done because you still had a high PSA after Cyberknife and IMRT?

I think your case was one step more severe than mine. I have had several recent digital rectal exams with no abnormalities detected. I think (not certain) that I was told that I was a T1C. I have to check this.

Did you get the hormonal therapy before or after the radiation therapy?

I have seen some of the studies that suggest G 9 cures post 5 years are much less successful than G 8.
Of course, that is not what we want to hear.

I am glad to hear that you seem to be doing OK. Especially since your case diagnosis was similar to mine.

There have been a great many good responses in the meantime, but let me answer your questions anyway.
After some 'research' I decided to follow the treatment plan proposed by Dr. Collins (Georgetown U Hosp and Med School). I was impressed by his 'academic approach' (many papers) and liked the somewhat experimental combined therapy he suggested. Moreover, that group had a lot of experience with the CyberKnife system. Dr Collins started me on Casodex, and then Lupron (pretty much standard for Gleason 9 patients). After a few weeks, three SBRT sessions followed by 25 IMRT sessions. I have seen other reports where it's done the other way around (IMRT first), but I don't know the pros and cons. Maybe there aren't any?

My main point though, was that for you some sort of combination therapy might be best. I was not advocating that the therapy that I received is the best. But, as you noted, it did work for me SO FAR. The medical science is moving on (a good thing) since I was helped, as exemplified by the many responses in this thread and a slightly different approach may be best for you. Just think it over.

Thank you everyone. Great information.
I have an appointment with a 2nd RO in 2 hours. Dr. Israel Deutsch at Columbia P&S in Manhattan.
I saw Dr. Jonathan Hass at Winthrop Cyberknife last Wednesday. Also in Manhattan.
I got the 2nd opinion on the biopsy from Dr. Epstein last Friday.
I hope to make a decision soon and will try to post again today.

The triple attack approach sounds interesting.
I have to re-read the papers and Tall Allens's reviews carefully again.

On first reading of one of results that TA posted, I though I read that if the a G9 cancer had not spread beyond the prostate, that the results were similar between RT only and RT + hormone therapy.

Did I misread that?
I intend to go back and re-read all the TA summary results and the papers. The technical information is often more understandable on second reading after having read other results.

Richard,

Richard said...
On first reading of one of results that TA posted, I though I read that if the a G9 cancer had not spread beyond the prostate, that the results were similar between RT only and RT + hormone therapy.

I don't remember writing that, and I'm not sure what you are reading, could you quote it and show the source please?

There is a list of commonly used abbreviations on this site:www.healingwell.com/community/default.aspx?f=35&m=1019612

The other sticky for the newly diagnosed explains the concepts like Gleason score, staging, etc. that it is important to understand:www.healingwell.com/community/default.aspx?f=35&m=2652250

Richard-

That comment was made specifically for Dr. Katz's SBRT and not for any other kind of radiation. It is definitely not true for IMRT, where ADT has been found to add greatly to its efficacy in high risk patients. Not all RTs are alike.

This thread just shows how desperate us G niners are for evidence that there are treatments which will save us from this miserable disease. Wouldn't it be wonderful if there were a specific formula to treat every permutation of this beast for every guy with his unique set of genes?? Unfortunately this is not a simple disease wherein one treatment fits all. We can just hope we're like the " median" guy in the trials. This study brightened up my day.
Bob

Break60: Hello, my stats are very similar to yours. Given the nature of Mr. Tall Allens study regarding the "triple play", I had a question about your remarks. You had RP followed by SRT, etc. Given the study was referring to a different tx mode, what is it about that study that made u feel better or brightened up your day? Just wondering if I missed something. Thank u, AJA

Post Edited (Michiganman16) : 2/2/2017 2:14:02 PM (GMT-7)

Here is an update.
I have not yet reached a conclusion about the treatment that I will pursue.

I saw the radiation oncologist at Columbia P&S last Monday.
His facility does a variety of radiation treatments: brachiatherapy, IMRT, SBRT.

His suggestion for me (Gleason 4 +5 etc.) was an extended treatment in this sequence.
He said this would be the current best practice
1. a month of ADT
2. 4 weeks of lower dosage IMRT to pelvic region
3. 5 weeks of higher dosage IMRT to prostate
4. 2 years of ADT

Having had this discussion, I set up another consultation with the Winthrop radiation oncologist for tomorrow to ask him more questions. Especially about ADT.

Clearly the 5 day CyberKnife with no ADT is an easier process. My key concern is if the longer treatment produces a significantly better outcome that would justify the ADT side effects. I have been reading research study papers that seem to say that the outcomes are similar. The papers are not easy to interpret because their patient samples have different risk factors.

Please stay tuned. I hope to make a decision soon.
I may wait until the updated Katz results are announced at the GU conference next week. gucasym.org/

I am currently experiencing the side effects of reading too many research studies.
Anxiety, insomnia, obsessive/compulsive reading disorders.

Michael_T,
I just checked my notes vs my memory.
He might have said that phase 2 radiation would be a boost to prostate.
I am not sure now if he said IMRT or SBRT for each phase of radiation.
Both my notes and my memory might be a little garbled.

He definitely said 2 months ADT before and wait for PSA to drop. He also definitely said ADT during and for 2 years after.

Listen to Redwing on the IMRT info and not me...I didn't realize when done as a mono-therapy for high-risk guys that it's nine weeks. (For some reason, I had 7 weeks in mind and I had 5 weeks of IMRT in conjunction with my brachytherapy.)

WARNING: this may confuse RichardNY some more, but I hope that the following response will be useful in the long run.

As mentioned earlier, the therapy that I received was a combination of IMRT + SBRT boost (+ 18 months of ADT). But the combination of HDR brachy + IMRT as a therapy for high-risk patients has been studied extensively and has good outcomes (see Tall Allen's earlier post in this thread). In fact, we know that the parameters for SBRT are based on HDR brachytherapy
To elaborate further, the urologist who discovered my Gleason 9 cancers proposed conventional brachy (he would do that), followed by IMRT (45 sessions as I recall) by a RO. He explained that the brachy would mostly hit the cancers within my prostate and that the IMRT would have a wider field, hitting adjacent tissues (where cells might have escaped to) as well. This all made sense. But I choose the SBRT + IMRT approach used by the Georgetown U group for various reasons. Recent data from that group (Mercado et al. 2016) are pretty hopeful. They reported on 59 high-risk patients, and a 3 yr follow-up showed 90% biochemical control.
But they are not the only group studying this kind of combination (IMRT + SBRT) therapy. Anwar et al (2016) used 45 Gy of external beam radiation combined with 2 SBRT sessions (~10 Gy each). Biochemical control was around 90% after five years. Note however that this group included intermediate-risk patients!

Tall Allen said...
Anwar had a high rate of late urinary toxicity. A group in Taiwan published an all high risk trial of SBRT boost with 4-yr bRFS of 92%, that had no late term toxicity.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4215618/

However, they all had whole-pelvic radiation, and they almost all had long-term ADT, so it's hard to compare to a group like Katz's that did not.

This kind of boost therapy is discussed here:

/pcnrv.blogspot.com/2016/08/sbrt-boost-therapy.html

But if one is going to have whole pelvic treatment anyway, why not just do it during the same 5 SBRT treatments? Anyone would prefer 5 treatments to 25. The only objection would be if toxicity is higher. I would guess that it isn't any higher because SBRT (tracking intra-fractional motion) is more precise than IMRT (tracking only inter-fractional motion). We won't have to guess because next week King is presenting his early toxicity results at the GU Conference. Then we can at least compare the toxicity outcomes to historical controls.

That study had 41 high-risk patients who received 45 Gy to the pelvis (IMRT) and had 3 SBRT sessions (7 Gy each). The biochemical failure free survival was 92%. Promising, as is the report of Mercado et al. to which I referred earlier.