Radiation options

I was diagnosed with prostate cancer in April 2016, as a result of a standard biopsy showing one positive core, Gleason six ( 3+3 ). Both my local urologist and my urologist at MSKCC agreed I was a candidate for active surveillance . However, my Prolaris test showed my cancer was above normal in aggressiveness. As a result I had a saturation biopsy several weeks ago. Eight of 31 samples showed cancer. All were Gleason 6 except one which was Gleason seven ( 3+4 ).
My doctor at MSKCC believes I am no longer a candidate for AS. He is a surgeon and recommends that I also consult with a radiation oncologist. I have assumed that I was a better candidate for surgery due to my urinary frequency. Over the last several years, I've gotten up four or more times per night. In January 2017, I start Flomax and as a result, I am down one or two visits a night to the bathroom

First question: do my urinary problems alone rule out radiation as an option? If not is CyberKnife a viable alternative? What about IG – IMRT offered at MSKCC. Is there a difference between CyberKnife and SBRT also offered by MSKCC .
With CyberKnife, SBRT and IG-IMRT, how important is the physician ( as opposed to the technology ) . I ask this because there is a CyberKnife unit at a small hospital one hour from home ( MSKCC is 10 hours away ). Is there a difference in CyberKnife models? UPMC seems to talk about the new CyberKnife model. Any input you might offer is welcomed. I'm 68 years old with my most recent PSA being 3.16. I am otherwise in good health. Thanks

Hi, Fogo1. I'm another Post-Toastie, having completed CyberKnife treatment for G3+4=7 PCa last November.

I can answer a few of your questions, but maybe not all. Is there a difference between CyberKnife and other varieties of SBRT? Probably not, as CyberKnife is the brand name used by Accuray for their SBRT platform. I sincerely doubt that there is much difference, but the various machines that can be used to deliver SBRT treatment may differ in their levels of accuracy, precision, intensity of treatment, etc. Arre these differences significant? I doubt it, as most of the standard SBRT protocols now use a 36.25 Gy total dose level, spread over 5 treatments within about a two-week period.

SBRT is different than IGRT, as the IGRT systems I've seen are all traditional radiation machines, utilizing a dose level that spreads the treatments over 8 or 9 weeks, or in the case of the "moderately hypofractionated" plans, perhaps 5 weeks.

The major difference between SBRT and IGRT has been that the SBRT systems have much tighter beam focus, thus are able to deliver much higher radiation doses to the specific target areas while sparing the surrounding tissue to a greater degree than with IGRT.

There has also been research done that seems to prove that the higher dose levels and fewer treatments given with SBRT actually can have better disease control than can traditional delivery systems like IGRT. In theory, this is true. In actuality, we'll probably know in a few years, when the comparative study results are published.

As for the nighttime visits to the can, talk with your SBRT/CyberKnife RO. I typically was getting up twice nightly and mentioned this to my RO. She felt that there was a small risk that this might get worse, but it was by no means a given. I am now just over 4 months out from my last treatment, and I've been back to "baseline" of 1-2 trips nightly for the past month or two. I take no meds for urinary issues (I did take Flomax during treatment and for the first month or so after, but stopped it.) and I'm now doing as well as I did before treatment.

My biggest after-effect has been on intestinal function. I had, for many years, suffered from IBS (irritable bowel syndrome). I discussed this with my RO, and she advised me that some patients with IBS choose surgery, to avoid potential worsening of their symptoms after radiation. I chose radiation, as I did not feel that another major surgery was a good thing for me (almost 70 years old, previous open-heart surgery, cardiac issues/complications, past hernias. . . frequent flyer in the OR). My RO felt that this was a reasonable trade-off. I'm managing through it all, and it is still somewhat soon to draw any conclusions about long-term side effects. If this is as good as it gets, I'm fine here.

As for disease control - I believe that CyberKnife/SBRT is as good as its research results indicate. My pre-treatment PSA was 5.69. Now, 4 months post-toastie, it is 3.03. As long as the trend continues, I feel like a winner.

Good Morning, I went thru SBRT in Nov 2016. Like you I have had to make 3-4 trips to bathroom at night for a number of years I am also on Flomax. The SBRT hasn't changed that, I still go about the same as before treatment. I would think that like most other things the more experienced your team is the better the outcome. Cyberknife is a brand name my treatment was with a Varian Edge machine and the whole process took less than 15min per treatment. I have experienced very few SE's and if it wasn't for the HT (lupron for 6mo) I believe I would have had no real side effects of course time will tell if that changes. It appears you have several options for curative treatment just educate yourself on all available options and press on.
Good luck
Perry

Thanks to each of you for your excellenct advice. Any recommendations for radiation oncologist for SBRT ( CyberKnife) in Kentucky , WV, Ohio, western Pennsylvania, Virginia or Denver ( I have family in Denver ). Thanks

This is a very helpful thread.

I wondered whether it is technically possible to put together a radiation types flow diagram.

RT:

----- BRACHY
--------------HIGH DOSE
--------------LOW DOSE

------ EXTERNAL BEAM
-------------- IMAGE GUIDED
---------------------- IMRT
----------------------- SBRT

Etc. Not sure this is even right so far.

Just a thought.

D

Post Edited (Delta2) : 4/12/2017 6:16:13 PM (GMT-6)

TA: A very interesting link you posted above Allen. Continuing the out of the box theme, what about this:

Let's say a tumour is seen some time post prostatectomy in the pelvic bed on a patient's scan, maybe a consequence of a positive margin. Let's also assume lymph nodes appear clear, etc - so we are dealing with a defined, tumour in a known place in the pelvic bed.

In short, some focal treatment is desirable, I would think.

Why couldn't such a bulb with an X-ray emitter be inserted laparoscopically into the patient to irradiate just the tumour?

What other focal therapies might be appropriate in such a case?

Thank you, D

Go to as many doctors as you can. I went to a surgeon, an external radiation specialist and two separate proton therapy centers. I was very happy with one of the proton centers.