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IMRT 40 treatments vs hypofractionated IMRT

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Posted 3/13/2017 5:21 PM (GMT 0)
Hi All,

So my first RO consultation has passed (he is local on Cape Cod and I'm planning on getting a second opinion in Boston) and he recommends a course of 40 IRMT treatments over 8 weeks.

Have any of you had hypofractionated IRMT? What opinions are there of hypofractionated IRMT vs the standard course?

Thank you,
Tim
Posted 3/13/2017 6:13 PM (GMT 0)
With the data that's come in over the last couple of years, there is no advantage to 40-44 treatments in either toxicity or oncological outcomes:

/pcnrv.blogspot.com/2016/09/hypofractionated-radiation-therapy.html
/pcnrv.blogspot.com/2016/10/sexual-function-was-no-worse-when-fewer.html

Oncological outcomes may be better with a brachy boost, so that is something you should investigate too. SBRT may be used experimentally for high risk.
Posted 3/13/2017 7:03 PM (GMT 0)
Hi Allen,

Thank you for those links. Great information (again!).

All,

Has anybody gone the "hypo" route with IMRT? If so, how was your outcome... side effects?

Thank you,
Tim
Posted 3/13/2017 7:25 PM (GMT 0)
mine was done in 26 fractions.

Made my hemorrhoids worse and gave me a interest in writing poetry.

Other than that, worked fine. 5 years later, still have a low PSA.

Andrew
Posted 3/13/2017 7:25 PM (GMT 0)
You may be interested in the following article that explains the radiobiological differences between conventional fractionation, moderate hypofractionation, and extreme hypofractionation.

/pcnrv.blogspot.com/2016/12/sbrt-vs-moderate-hypofractionation-same.html
Posted 3/13/2017 7:33 PM (GMT 0)
Hi Allen,

Very interesting indeed. I'm still on the learning curve but is the only difference between SBRT and IMRT the number of fractions? I thought the basic technology was different somehow.

I guess I'm asking if this is an apples and oranges comparison?

Thank you,
Tim
Posted 3/13/2017 7:48 PM (GMT 0)
The article explains the differences.
Posted 3/13/2017 7:59 PM (GMT 0)
Hi Allen,

Yes... I see it now. It answers the question I was asking. I'm glad to have this information before going up to Brigham and Woman's.

Thank you,
Tim
Posted 3/13/2017 9:07 PM (GMT 0)
Wonder why EUA (Europe) seems more cautious in their guidelines for radiotherapy for localised PCa than seen here and in the articles by Allen. Are we too cautious in Europe?

EUA Guidelines said...
Taking into account the published results and the uncertainties of the correct α/β ratio, moderate HFX plus dose escalation should be done by experienced teams, accompanied by meticulous RT quality assessment and close attention to organ at risk dose-constraints until long-term data are available. For extreme HFX, it seems prudent to restrict this therapy to prospective clinical trials and to inform patients on the uncertainties of the long-term outcome.


HFX = Hypofractionation, extreme HFX = SBRT
Posted 3/13/2017 10:43 PM (GMT 0)
In fact, the main impetus for hypofractionation came from the CHHiP trial in the UK and the HYPRO trial in the Netherlands. You may be looking at old guidelines.
Posted 3/14/2017 1:51 PM (GMT 0)

Tall Allen said...
In fact, the main impetus for hypofractionation came from the CHHiP trial in the UK and the HYPRO trial in the Netherlands. You may be looking at old guidelines.

No it is not old it is in the latest published guidelines (2016) from European Association of Urology

uroweb.org/guideline/prostate-cancer

see chapter 6.3.3.2.Hypofractionation (HFX)
Posted 3/14/2017 4:31 PM (GMT 0)
I guess the US counterparts are further along. For both moderately fractionated IMRT and extreme fractionation (SBRT), NCCN writes "They can be considered as an alternative to conventionally fractionated regimens when clinically indicated." ASTRO has endorsed both as options and is working on detailed practice guidelines.
Posted 3/14/2017 4:32 PM (GMT 0)
Well I'm in my 3rd week of IMRT and have 6 weeks to go. The side effects I am experiencing is urgency with going to the bathroom and difficulty urinating. I was given a drug called ALFUZOSIN to help with that and it has BUT not much and if it gets worse as I go along that will become alarming to me. I keep marching forward.

Thanks
Jay
Posted 3/19/2017 3:32 PM (GMT 0)
Hi Jay,

So you went with the "full fractions" (or however it is said)... I sent and email to the doctor I'm going to see up at Brigham and Woman's asking if they offer hypofractions or SBRT. I didn't get any answer back. Which I guess I will have to wait and see what they say on 3/29 when I trek up there.

Good luck with your therapy. Keep us posted.

Thank you,
Tim
Posted 3/20/2017 7:57 PM (GMT 0)
Hi,

So I talked to the Nurse up at Dana-Farber (Brigham and Woman's). She said that the course of treatment they use there is very similar to what the local Cape Cod R.O. recommended. That is IMRT with 42 to 44 fractions plus 6 months of hormone therabpy. She said that since I'm more than 40 miles from the hospital I can get free housing at the Hope Lodge. So that eliminates the unreasonable commute issue. She did say that Beth Israel does offer hypofractions.

If I do decide to go with the 40+ fractions, I'm leaning towards going the Boston route. I realize the machines are probably the same, but it is the people behind the machines that make the difference. So... my question for the forum... how do you feel about this? It will be a much more major life disruption to go to Boston. Is that the right decision or do you think the local Cape Cod Hospital can do a perfectly fine job?

Thank you,
Tim
Posted 3/20/2017 8:12 PM (GMT 0)
There is absolutely no reason to endure 40-44 IMRT treatments anymore. Irving Kaplan at Beth Israel Deaconess does SBRT or hypofractionated IMRT.
Posted 3/21/2017 7:05 PM (GMT 0)
Hi Allen,

I'm going to see Anthony D'Amico tomorrow and I just made an appointment to see Irvan Kaplan on Friday 3/31. I pretty much know what D'Amico is going to recommend based upon what his Nurse told me.

I wish I could see Kaplan sooner but these guys are all very busy.

Thank you,
Tim
Posted 3/21/2017 9:59 PM (GMT 0)
I have great respect for Dr D'Amico, but I honestly don't understand his reluctance to go with hypofractionation. As you can see in the following study, Zietman (at Mass General) and Kaplan (at Beth Israel) both seemed to get onboard with extreme fractionation, while D'Amico's name doesn't appear:

www.thegreenjournal.com/article/S0167-8140(16)34355-9/abstract

What's more, in 2015 James Yu advised caution based on Medicare claims and D'Amico supported that. Since then, James Yu (at Yale) has become a true believer.

www.thegreenjournal.com/article/S0167-8140(16)34355-9/abstract

I actually wish I could join you at the meeting with D'Amico as I would love to hear what he has to say about it (and on a number of other topics as well).
Posted 3/22/2017 10:48 PM (GMT 0)
Hi Allen,

I'm back from seeing Dr. D'Amico. Very impressive. He said that specifically for someone like me that already has issues with frequent urination, the tried-and-true standard fractionation is the way to go. He pointed me to this article:

https://www.nytimes.com/2017/03/20/health/prostate-cancer-sbrt-radiation-therapy.html?_r=0

Thank you,
Tim
Posted 3/22/2017 11:06 PM (GMT 0)
Yeah- saw that misinformative article. That's why mainstream media is not a good source of info. No increase in urinary frequency, as you can see for yourself, with hypofractionation.
Posted 3/23/2017 4:36 PM (GMT 0)
Hi Allen,

I asked for the technical definition of the issues Dr. D'Amico was concerned about with hyprofractionation so I could do some more research. He said:

"With both forms of hypofx there is the possibility of late (after 5 yrs)

Urethral stricture
Bladder neck contracture
RT cystitis (i.e. hematuria)"

I'm still researching...

Thank you,
Tim
Posted 3/23/2017 4:46 PM (GMT 0)
Hi Allen,

This seems to buttress his argument about men who already experience urinary issues before treatment:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805927/

"Conclusion:

The hypofractionation regimen did not result in a significant reduction in BCDF; however, it is delivered in 2.5 fewer weeks. Men with compromised urinary function before treatment may not be ideal candidates for this approach."

Thank you,
Tim
Posted 3/23/2017 4:48 PM (GMT 0)
Hi Timoz,

Do these longterm side effects that you speak of below also include the 43 treatments with IRMT? just curious because I am in my 4th week of these treatments.

"With both forms of hypofx there is the possibility of late (after 5 yrs)

Urethral stricture
Bladder neck contracture
RT cystitis (i.e. hematuria)"

Thanks
Jay
Posted 3/23/2017 4:54 PM (GMT 0)
Hi Jay,

No... he was specifically speaking of hypofx (hypofractionation)... so, by both methods he was speaking to the shorter course of IMRT and SBRT (cyberknife).

And this was in context to someone, like myself, that has compromised urinary function before therapy begins.

Thank you,
Tim
Posted 3/23/2017 5:52 PM (GMT 0)
Thanks Tim!
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