Most recent SBRT and HDR-BT experiences please

Hi,

My husband had HDR-BT this past May at UCLA with Dr. Jeff Demanes as a "boost" for his IMRT (my husband is a Gleason 9, treatment is the triple play...a combination of HT, IMRT (25 sessions) and the HDR-BT boost).

He had the brachy boost before the IMRT (some patients do it after. Dr. Demanes seemed to feel that the order didn't matter. We chose to do brachy first, as Dr. Demanes could place the fiducial markers for the IMRT treatments while he was in there doing the brachy).

My husband was on HT for about 2 months before the brachy boost. It was outpatient. Dr. Demanes only does one treatment now for the boost. We checked in early in the morning, they checked us in, prepped him, gave him a spinal block, he was under anesthesia but not general (no intubation), and placed the implant/ran a CT scan.

Then he woke up (implant in place, but no radiation had been given yet).

During this time, I was able to see him, he ate lunch (he'd had to fast for 24 hours or so prior), and this was when the doctors/dosimetrists "mapped" his treatment plan.

Then they kicked me out, wheeled him in, and delivered the dose of radiation.

After that, implant was removed, and they worked on getting him to stand, walk around, and urinate on his own. After a 6 am check in, we were released at 3pm.

By that evening, he had some pretty shocking burning with urination, but he took pyridium and flomax and it was tolerable. He took the day of the procedure off as well as the day after (but the day after the procedure, he was definitely up and around and working from home and keeping busy...he wasn't laid up in bed all day).

He's since had all 25 sessions of IMRT (finished July 10), and is still taking pyridium and flomax, but he doesn't expect to need the pyridium much longer.

As far as current research, I would defer to Tall Allen, but I recently completed my SBRT Tx at UCLA about 3 weeks ago and can share some of my experiences. You should be able to see my condition leading up to the procedure from my signature below and so far I am glad with the selection I made.

The procedure itself is painless. The most painful part was the inserting of the fiducials and compared to BT, it's probably insignificant. I was only given a local, three fiducials were implanted--I recall the ultrasound probe (used to guide the implantation) being inserted as more painful/uncomfortable. There was some blood/discoloration of semen I experienced which was probably due to the implantation process. As far as the radiation Tx, it took anywhere from 20-30 min. The most uncomfortable part was filling the bladder prior and holding it throughout the Tx (I usually had to rush to the bathroom afterwards).

As far as the recovery, I experienced some loose stools and then after modifying my diet, some constipation (although still feeling the urge to go several times a day). Compared to the side effects I have read about from other treatments though, this is relatively minor.

Probably not relevant to this thread but I had SBRT to femur met . Three fractions which took no more time than IMRT fractions. Same machine , Higher dose in same time frame. Amazing. No SEs .
Bob

If you look at my 'history' you will see that I had IMRT with an SBRT boost at Georgetown U Hospital, combined with hormone therapy (18 months). A triple play as some like to call it.
It appears that my numbers going into this radiation fest were a little worse than yours. And I am still around without complaints. Thanks Dr Collins!

I know you're looking for recent info and Wife of Pie can provide that much more than I can. But as a G9 graduate of HDR brachy + IMRT, I'm doing very well several years out. Low and steady PSA and my only real SE is that I don't pee as well as I used to, although a Rapiflo once a week seems to handle that. It's only three years since my HT, so I'm still knocking on wood-like surfaces, but so far, so good.

Good luck to you!

Notam-
I couldn't stand it, and I had to look on the website to see about the placement of the catheters...based on the description, it sounds like a mix of both template and optimization...they use a template with pre-drilled holes but then flexible "guides" to optimize the placement...check it out on Dr. Demanes's website (the link might not be clickable, sorry...might have to cut and paste):

http://radonc.ucla.edu/prostate-cancer-brachytherapy

WifeofPie-

Super, you have been incredibly helpful thanks! From the link, I would say they are very considerate of dosimetric constraints for organs at risk. Very interesting how they explain it and the images used. And they really poo-poo the standard, fixed template for catheter insertion. I guess each method finds supporters but they make a good case and I found these comments noteworthy: "The template is held in one hand, while the flexiguides are inserted with the other. Holding the template, rather than having it clamped to the table as in the fixed template technique, allows the physician to tip and angle the template, resulting in more control over where they can place the flexiguides. This is a major advantage as it allows the physician to flare the flexiguides to encompass larger prostates, extracapsular extension, or seminal vesicle involvement." and "The non-fixed template technique allows the physician to slightly lift the prostate away from the rectum, reducing rectal dose." Ability to better target EPE and seminal vesicles may be an important consideration.

PAX, Max and searchinginla-

Really good reports for SBRT treatments, great data points and I am so happy for you guys. Man, if I could just get away with SBRT only I think I would be willing to fly across country. So PAX, did you also have 5 fractions delivered over a week and a half?

SrSailor-

You have a different treatment path with the SBRT Boost but it sure seems like it worked well for you. If a SBRT Boost to IMRT works as well as the HDR-BT Boost, I think that sounds a lot better than a bottom full of catheter needles. I would even put up with the fiducials and CyberKnife for one or two fractions.

All great info and much appreciated. Hoping to find some experiences with the east coast facilities too.

Notam, as you see I had HDR and IMRT a few years ago. My contribution to you can be the longer term experience aspects of postitive cancer control and for me no negative tretment side effects.

In my research I leaned on both Demanes and Martinez for information, but my procedures were done here in Atlanta. I had two excellent clinics to choose from. At that time both had adopted the Martinez protocol of two fractions separated by a week. At that time Demanes was also doing two fractions but on consecutive days requiring and overnight stay in the hospital. I understand that in the last few years Demanes no longer includes the overnight stay.

My clinic has also started doing higher radiation fractions for some men and requiring only one procedure. I remember Martinez also offering this to selected men.

I have also read some recent updates on the 21st Century Oncology issues. It was reported that their operations are being managed by a Chicago firm that specializes in running medical operations in such situations. I have not found anything to indicate that the day to day operations of Martinez are in any way compromised by the issues. Remember that Chapter 11 doesn't mean going out of business.

Notam,

I had some of the same travel concerns, somewhat magnified because I was traveling from Hawaii. Because of this Dr King structured a treatment plan whereby I could complete the treatment within a little over a week and half.

The fiducial implants and CT mapping was done the first day-Mon (actually the next morning, since I arrived in LA in the evening). Then a break for a couple days for Dr King and his staff to map out the radiation treatments. On Thurs I had my first SBRT session, then again on Fri, took a break for the weekend, then completed the reminder of my sessions on consecutive days (M, Tue, Wed). I flew home on Thurs. Looking back, this was an ambitious schedule and didn't allow for anything going wrong--like it almost did when the machine went down...luckily they were able to repair it prior to my scheduled session. Oh, and as far as the PSA monitoring (every 3 mo), Dr King noted that I could just get the test done locally and send him the results.

Hope this info helps...let me know if you have any more questions.

Notam said...
I still feel as if this is all somewhat of a guessing game, but that's what each of the surgical and radiation oncs are saying given the info they have now. Every one of them has suggested an aggressive treatment plan for this Dx at my age.

Sorry, I don't understand. What is a guessing game? If you mean your risk level, you appear to be favorable intermediate risk. I don't really understand why you are trying to make yourself higher risk than you are. I would point out that there is no advantage to the kind of multimodal therapy you seem to want. But if you are willing to endure the extra SEs and feel it affords better insurance, there is no debating feelings.

/pcnrv.blogspot.com/2017/05/brachy-boost-therapy-should-be-reserved.html

Notam said...
hence my insistence on the 3T MRI to help quantify any EPE they maintain is an issue.

MRI won't help you. It's sensitivity for EPE is only 57% - not much better than a coin toss. Some have advocated biopsy cores through the suspicious area, but there's not a lot of data. A nomogram and judgment are still your best bets. Of course, it doesn't matter if you're pursuing radiation.

Notam said...
Katz uses CyberKnife, my least favorable SBRT delivery system due to the fraction duration...Zelefsky on the other hand is a noted HDR-BT and SBRT guy

Katz uses the IRIS with CyberKnife which he says is faster. Yes, 40 minutes can be tiresome, but you only do it 5 times. Zelefsky is not an HDR-BT guy. His background is LDR-BT. He started doing SBRT a few years ago.

Notam said...
Then there are the 1,3,6,12 month followups...

Live follow-ups are not really necessary.

Thanks Paxton, another great testimonial for SBRT monotherapy. I like SBRT on so many levels, but I am getting mixed signals for monotherapy as some restrict it's use focused to tumors contained in the prostate only, preferring IMRT if the odds of localized EPE are high. SBRT as a boost to IMRT or HDR-BT and targeting prostate only is also on my radar.

Tall Allen said...
Sorry, I don't understand. What is a guessing game? If you mean your risk level, you appear to be favorable intermediate risk. I don't really understand why you are trying to make yourself higher risk than you are.

TA, to be clear, I am not trying to make myself anything. Every Surgical and Radiation Onc I have met with face to face has told me that I do not appear to be favorable intermediate risk due to the tertiary factors. All recommend treating me as unfavorable intermediate risk. It is not my choice they put me in a different box than might better meet a textbook definition (maybe they're all just anti-establishment rebels because they also refuse to use DRE only for clinical staging as AJCC is advocating, but that's another matter). In any event, Dx is subjective so I am not as hung up on it as you appear to be. Only sharing their professional opinions and taking them at face value. Are they right? Without post RP pathology certainty I'll never know, but they obviously have reason to say what they did and I feel there is value in their consensus. What I clearly do know is that many of the combo therapies showing the best results for unfav int risk show little to no benefit for fav int risk. So yes, when put somewhere between fav vs. unfav int risk by the professionals, I find my treatment decision entails a whole lot of guessing and second-guessing the trade-offs, and perhaps even more so than usual at that. No way to know definitively which is potentially more harmful TO ME... failing to treat aggressively enough or over treating? Forced to choose between an even higher possibility of biochemical recurrence vs. an even greater increase in SE's than usual? Tough call and YMMV on that one.

Tall Allen said...
I would point out that there is no advantage to the kind of multimodal therapy you seem to want. But if you are willing to endure the extra SEs and feel it affords better insurance, there is no debating feelings.

Well, I have no idea which combination therapy you think I want. I have attempted to identify which treatment options are appropriate to either favorable or unfavorable intermediate risk, and to clarify, focus on and prioritize those of special interest to me pending the MRI results. The standard 'If this -> Then that' exercise stuff, but with twice the info. A lot to process but I'm an info junkie and need detail. I've found plenty to support both mono and combination therapies within each of those two risk strata, certainly some are of greater interest than others but I obviously don't feel like I can make a good decision yet. It doesn't help at all when two RadOncs claim the same Tx is not appropriate to the same risk level... HaHa, go directly back to square one in the treatment 'guessing game', Do Not Pass Go and Do Not Collect $200. Are you kidding me? If selecting a PCa treatment option isn't some sort of twisted guessing game I surely don't know what is.

Tall Allen said...
MRI won't help you. It's sensitivity for EPE is only 57% - not much better than a coin toss. Some have advocated biopsy cores through the suspicious area, but there's not a lot of data. A nomogram and judgment are still your best bets. Of course, it doesn't matter if you're pursuing radiation.

Yes, I know exactly what my nomograms suggest and, IMO, it's a large part why the Dr's recommend what they do. If a 3T MRI has potential to help clarify, I'll use it. I recognize the limitations but if it confirms EPE, I can rule out the Tx options that target prostate only. If not, I will still have to decide whether sticking to a more aggressive treatment targeting beyond the prostate to the other pelvic areas is advisable and/or desirable. At least the MRI images will be available for image fusion if that is beneficial in any eventual treatment.

Tall Allen said...
Zelefsky is not an HDR-BT guy. His background is LDR-BT. He started doing SBRT a few years ago.

Actually he does both Brachys, see his MSK Bio: "For patients with advanced or aggressive prostate cancer, I have significant expertise using high-dose-rate brachytherapy and temporary brachytherapy, in which patients receive several high-dose treatments either as a boost or as the sole treatment." I am aware of MSK's SBRT w/ LDR-BT Boost trial for intermediate risk but Zelefsky also participated in a dose escalating retrospective study of HDR-BT w/IMRT combo vs. CF IMRT for intermediate risk with Zumsteg. The questions I have are, does he do HDR-BT as a boost to either hypo frac IMRT or SBRT? Or SBRT boost using HDR-BT mimicking dosimetry to the prostate after primary HDR-BT targeting the prostrate and any local involvement? So many possible combos. I will call to see what they currently offer when I have MRI results and images.

Tall Allen said...

Live follow-ups are not really necessary.

All of the out of state facilities I spoke to 'encouraged' personal followups, but recognized the logistical realities for travellers. I think all they really required was a copy of your periodic PSA test results. Don't know exactly what would happen in the event you saw an actionable bump in PSA though.

Tall Allen said...
When a clinical trial uses a precisely defined risk category definition, it only shows it for that specific definition and not for any qualitative assessment you and your doctor may wish to add for it. The clinical trials that segmented on "favorable intermediate risk" included men with your disease characteristics.

Oh come now, no one is attempting to redefine any trial or risk definition therein. And no one is insisting that my characteristics are NOT considered favorable intermediate risk by definition in whichever risk stratification system you want to choose. My point is not about what constitutes a particular level of risk as defined by any of the current or past risk stratification systems. It's about whether any risk factor not included in those risk stratification systems can be a valuable and independent predictor or not and, if so, when and how it may be appropriate to use them while formulating your own treatment plan.

I suspect you know full well there are a lot more than three risk factors that have demonstrated accurate and consistent predictive qualities and are recognized by PCa Dr's worldwide. The oncs I spoke with all consider risk associated with PNI, Cribrifom, tumor % of cores, age etc. very important when formulating customized treatment plans. They say these tertiary risk factors matter and won't dismiss them as worthless simply because they are not one of the standard 'big 3' risk factors. They will treat a GS-7 with all my collective risk factors more aggressively than a GS-7 without them. Now that both GS-7 and Intermediate Risk have been further sub-categorized, that makes even more sense to me. You can question the approach but to my simple mind that logic seems both rational and reasonable when supporting data is available.

And lets be clear, a more aggressive treatment might simply entail adding 6mo of ADT to EBRT. Which would hardly stir a raucous debate as it is still considered by many to be standard protocol according to NCCN Prostate Cancer Treatment Guidelines for intermediate risk patients... even though evidence has shown different response after sub-categorizing into fav/unfav int risk groups which I do personally want to consider as well. Now if their recommendations seemed more appropriate to a GS-9 than a GS-(4+3)=7 according to NCCN Guidelines, you can bet your arse I would have a different opinion.

Admittedly my mistake for originally saying they consider me an unfavorable intermediate risk because they believe I will benefit from a treatment plan more closely geared to unfavorable rather than favorable intermediate risk protocol. Perhaps a better use of words might have been they proposed a more aggressive treatment plan for my favorable intermediate risk Dx because of my additional risk factors. Words matter and clearly it opened a can of crap. I'll try to parse my words more carefully in the future but see no need to debate or address this ad nauseam. If you insist that 'intermediate risk factors' has a single definition, is limited to three factors only or can't understand the context I've used by now, it is pointless.

Tall Allen said...
You seem to have an incorrect impression that radiation treatments do not treat areas outside of the prostate. The only one that doesn't is LDR brachy - all others do.

Of course they do, not exactly sure how I gave you that impression. But I also realize each of those radiation modalities are best suited for use in specific circumstances, ie. not all of the radiation treatments used outside the prostate are appropriate for every application or area outside the prostate. Ex., regarding SBRT when used as monotherapy for PCa, I am told it is limited almost exclusively to localized treatment of the gland itself and to tumors contained within the capsule. In limited instances, only a very small margin outside the capsule to include the base of seminal vesicles and never LNs. That info from the PA/CNP to a busy RadOnc who does a lot of prostate SBRT. In a real live conversation. Not an assumption. Not from reading. But I also understand it may be their belief and experience with SBRT while others do differently. If anyone feels that is not a 100% accurate description, particularly by personal experience, please feel free to chime in. PCa education is a continous process.

Tall Allen said...
Zelefsky does not do HDR brachy, or at least not very much, in spite of what you read. Ask him.

TA, I don't know how you quantify "not very much". But I can tell you that I have already spoken to Zelefsky's office directly and told they have performed over 100 HDR-BT treatments this year, some single but most with multiple fractions. And many, many more LDR-BT treatments. I left with the impression Zelefsky participated in a higher percentage of the HDR Brachys than LDR but could not get a definitive number for either during my call. If I decide HDR-BT is something I wish to pursue, I will get more details and report my findings.

Thanks for the input!