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Most recent SBRT and HDR-BT experiences please

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Posted 8/29/2017 8:02 PM (GMT 0)
I had HDR monotherapy with Dr. Demanes at UCLA in February. Just before the implant, I had a PSA level of 20.1, and it was going up very fast. At that time, we were quite worried that I would not be cured from the monotherapy since my PSA was above 20. But, we did do the mono, and 3 months later, my PSA level was down to 2.9, a stunning decrease.
So, I am really happy I had the mono. I wanted the mono so that I had a better chance at an erection, and I felt any additional radiation would only harm the chances of that. I didn't want ADT for the same reason.
I had a total of 35 grays of radiation over 2 doses. That is a really small amount of radiation compared to what it would have been with external beam, or even LDR.
So, bottom line, I think I cured the cancer with a very small amount of radiation. I am not out of the woods on the erection side, but do take Cialis, and can get one, although it does burn a bit, and is certainly is not the same as before
Posted 8/30/2017 4:09 PM (GMT 0)
I chose HDR-BT monotherapy at FCCC with Eric Horwitz in Feb 2016. Two implants a week apart, a single 13.5Gy fraction during each implant (Feb 17 and Feb 24). If you are concerned about travel to this location, for anyone over 60 miles away, there's a free cancer center hotel just down the street that you will stay in the night before, and I'm sure if you have any concerns you can stay there the day after as well. It's been 1 1/2 years for me, but I can say I don't think I would want to drive several hours same day of the procedure right after discharge. I felt every bump in the road driving the 65 miles home it seemed. It's a very nice benefit having the hotel right down the street for anyone traveling to FCCC for treatment.

Eric Horwitz still does most of the HDR-BT implant procedures himself. You will also have a dedicated urologist assigned to you from FCCC that will work directly with Dr Horwitz during catheter insertion to ensure proper catheter placements and that no bladder punctures occur, all via imaging along with a video camera inserted into your bladder during the procedure. Four eyes are better than two type thing. You are not moved at all during or after the implant - you stay in the same radiation shielded room the entire time. I believe they use TRUS imaging for the implant procedure, along with the video camera in your bladder. You are asleep for the entire procedure at FCCC. You will wake up in the recovery area. I believe FCCC is now also doing single implant, single fraction 19Gy for HDR-BT monotherapy as well.

I could be wrong but I think what TA is getting at bigger picture is that overtreatment for PCa still remains one of the biggest challenges to overcome today. Over-treatment as a problem is getting much better, but it's still an issue. It's a major part of the reason why having PSA tests done was scaled way back by the national healthcare organizations a couple years ago. They have since revisited the initial recommendations on scaling back and have republished updated recommendations, but the goal of the new testing regs is to scale back over-treatment of PCa from what I understand.

I agree with you it's a bit tougher of a call given you are intermediate risk (whether favorable or unfavorable). You are in that somewhat gray area where the choices aren't as clear at least in some respects. This is partly why there have been recent changes to PCa Gleason scoring model to move toward a more straightforward 1-5 grade scale as opposed to the somewhat confusing 3+4/4+3 scoring model that both score as 7. You certainly seem to be doing the required due diligence for your case, all the best as you navigate the world of PCa. I'm sure you will come to a decision that is best for your specific case. Anything we can do to help along the way, we're all here for you! cool
Posted 8/31/2017 1:19 AM (GMT 0)
HDR Monotherapy patient here. Very pleased at two years post treatment. It came down to SBRT or HDR-BT for me and I chose HDR in part because I was warned by more than one doctor that SBRT was not going to be automatically approved by my Blue Cross health plan.

Will second Tall Allen's skepticism that Dr. Zelefsky would do an HDR brachy for you. I met with him and was told that he has very rarely done HDR as a monotherapy.

Tall Allen said...

SBRT can treat any pre-specified margin outside of the prostate. So can HDR brachytherapy. Their precision at doing this is one of their greatest strengths. It sounds like you should be talking to a different specialist if they misinformed you about this.

Let me know if Zelefsky does HDR brachy on you. I would be very much surprised.

Posted 8/31/2017 12:24 PM (GMT 0)
@GDS- It would appear your PSA has the glide path of a brick, sure hope that continues! When you say "it does burn a bit" are you referring to achieving and/or maintaining an erection, ejaculation or urination? Thanks

@CJ- Finding someone with recent experience at Fox Chase is a big deal, certainly not a lot of top HDR-BT facility choices up here in the NE particularly for monotherapy. I also read your original thread and it details the differences in FCCC vs. UCLA protocol quite nicely for anyone interested. I would definitely check out FCCC if I was after HDR-BT monotherapy. Hope your checkup at FCCC last week was all good, were you ever able to confirm that your post-op uro problems were related to infection?
Posted 8/31/2017 1:51 PM (GMT 0)
@Works Out-

I think the point TA was trying to make about Zelefsky is exactly what you say, that he does do HDR-BT but primarily for combo rather than mono therapies. That all does square with my brief conversation with Bonnie. I know he's given the impression that I want mono therapy from Zelefsky but I do not. Here's what I said with regard to Zelefsy: "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?" Basically, all combo therapies because I am primarily checking around for someone/someplace to do the HDR-BT portion if I follow my local RO's recommendation of IMRT w/ HDR-BT boost. Since the actual procedure is pretty much the same regardless how you employ it, I obviously want to seek out the most experience providers of HDR-BT and MSK/Zelefsky certainly fits the list.

The reality is, my health ins plan will not cover HDR-BT monotherapy or SBRT when given as a boost. So those two Tx options are pretty much out for me. However, for my Dx they do cover LDR-BT seeds as a monotherapy. As well as both Brachys "in conjunction with EBRT". On that point, it's important to note that a.) it's described as a combo therapy rather than a single definitive treatment; b.) the policy does not specifically restrict Brachy as a boost to EBRT, and; c.) does not define EBRT as IGRT or IMRT only. Therefore, I wondered if I might utilize the latest, greatest form of EBRT (ie. SBRT) in conjunction w/ HDR-BT with the benefit of some creative coding by the providers.

Now on that coding point, I fully expect that to open another can of crap but I've seen mention by other HW posters that this 'strategy' is utilized by some physicians as a tool to provide services to patients they feel beneficial and streamline the subsequent billing process. No idea if that is common practice or something worth pursuing, just investigating all the options.

Thanks for your input, I wish you continued success!
Posted 8/31/2017 4:29 PM (GMT 0)

Tall Allen said...
Of course you can use additional risk factors as an aid to judgment. I'm just saying that research studies are designed with a very specific set of risk factors, and it is inappropriate to reinterpret them. You are also free to go beyond the medical evidence if you want to - that's every patient's prerogative.


Good. Nowhere have I said otherwise. Enough already, end of discussion please.

Tall Allen said...
SBRT can treat any pre-specified margin outside of the prostate. So can HDR brachytherapy. Their precision at doing this is one of their greatest strengths. It sounds like you should be talking to a different specialist if they misinformed you about this.


I do not think I was misinformed. Far from it, actually. The context of the discussion I referenced focused on SBRT treatment for clinically localized prostate cancer in intermediate and high risk patients, including the use of SBRT boost to the prostate after more regional IMRT radiation. Ie., is SBRT a viable alternative RT technique to HDR brachytherapy for boost delivery... in my case... which up to this point may be either fav or unfav intermediate risk depending on who you talk to and why (yeah, yeah, please do your best to let that comment go). As well as reported potential SE's and QOL issues which help me determine whether any particular treatment carries unacceptable risk in the event 'aggressive' treatment actually does become 'over' treatment. The discussion was prompted by a Georgetown study which I quote in part:

https://doi.org/10.3389/fonc.2016.00114 said...
Until recently, there were limited data supporting the safety and efficacy of such SBRT monotherapy in the intermediate-risk population. Current publications by multiple single institutions used SBRT monotherapy regimens of 35–40 Gy, delivered to the prostate in four to five fractions, for intermediate-risk patients. Additionally, a pooled analysis from a multi-institutional consortium has shown a favorable 5-year biochemical disease-free survival of 84% in intermediate-risk patients (33, 34). Following the publication, these papers and the analysis of our own results, it is now our policy to treat intermediate-risk patients with SBRT alone.

For high-risk patients (a category which in newer studies may include unfav int risk patients) there remains a concern that the tight clinical margins required to limit the normal tissue doses to the rectum with SBRT may not be adequate to treat the extent of ECE. While the planned posterior margin for SBRT is 3 mm, the actually treated posterior margin is commonly limited to 2 mm or less to maintain rectal tolerance (1 cc < 36 Gy) (7, 22). In these patients, the risk of ECE beyond 2 mm is approximately 40–70% (35). In many high-risk patients, the SVI extends beyond the proximal seminal vesicles (36) and distal seminal vesicle motion cannot be accounted for by intraprostatic fiducials (37). Thus, we await the mature results of ongoing trials treating high-risk patients with SBRT alone prior to recommending it for all but well selected high-risk patients (38).

Currently, it is our policy to not include pelvic node irradiation in the treatment of high-risk patients. Two randomized trials have been published questioning the benefit of treating pelvic lymph nodes in these patients (39, 40). A prior study with SBRT plus or minus conventional pelvic RT has shown significantly higher bowel toxicity associated with pelvic node treatment (41). Whether the use of pelvic IMRT can reduce bowel toxicity and improve the therapeutic ratio in select patients is an area of current investigation (13).


All of questionable value pending my MRI results and actual face-to-face consults with the top dogs, but I'm trying to get more than a perfunctory education so I can discuss my treatment options in some level of detail or intelligently question a recommendation given at these consults. In any event it's good info to know IMHO, even if SBRT is capable of tighter margins than mentioned in the article.
Posted 8/31/2017 7:18 PM (GMT 0)
Notam

In my case it seemed pretty clear that a monotherapy alone was indicated. And I had made a narrow choice to go with HDR over LDR, after deciding not to go though the process of trying to get an SBRT approval from Blue Cross. If I had decided to go with LDR or to push for an SBRT approval I probably would have elected to go with Dr. Zelefsky.

And once I decided to go with HDR I decided to go with a center that specialized in it as a monotherapy. And when I was researching options 2 1/2 yrs ago for some reason Fox Chase never came up at this forum or elsewhere. Fox Chase would have been the most convenient for me, but other than UCLA the only other places I found that specialized in HDR were in Michigan and Atlanta. And I decided that if I was going to travel for this
it didn't matter much how far I traveled and I chose UCLA.

Best of luck,



Notam said...
@Works Out-

I think the point TA was trying to make about Zelefsky is exactly what you say, that he does do HDR-BT but primarily for combo rather than mono therapies. That all does square with my brief conversation with Bonnie. I know he's given the impression that I want mono therapy from Zelefsky but I do not. Here's what I said with regard to Zelefsy: "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?" Basically, all combo therapies because I am primarily checking around for someone/someplace to do the HDR-BT portion if I follow my local RO's recommendation of IMRT w/ HDR-BT boost. Since the actual procedure is pretty much the same regardless how you employ it, I obviously want to seek out the most experience providers of HDR-BT and MSK/Zelefsky certainly fits the list.

The reality is, my health ins plan will not cover HDR-BT monotherapy or SBRT when given as a boost. So those two Tx options are pretty much out for me. However, for my Dx they do cover LDR-BT seeds as a monotherapy. As well as both Brachys "in conjunction with EBRT". On that point, it's important to note that a.) it's described as a combo therapy rather than a single definitive treatment; b.) the policy does not specifically restrict Brachy as a boost to EBRT, and; c.) does not define EBRT as IGRT or IMRT only. Therefore, I wondered if I might utilize the latest, greatest form of EBRT (ie. SBRT) in conjunction w/ HDR-BT with the benefit of some creative coding by the providers.

Now on that coding point, I fully expect that to open another can of crap but I've seen mention by other HW posters that this 'strategy' is utilized by some physicians as a tool to provide services to patients they feel beneficial and streamline the subsequent billing process. No idea if that is common practice or something worth pursuing, just investigating all the options.

Thanks for your input, I wish you continued success!

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