HDR Brachy as Monotherapy?

After gathering more information, I realized that single fraction HDBT monotherapy is not a standard technique. Actually, nccn only recommends HDBT when combined with external radiation. Maybe I should consider some of the other radiation techniques available in the same center, even though they apparently have more SE.

(Edited to provide a title)

Post Edited By Moderator (Tudpock18) : 9/21/2017 6:01:27 PM (GMT-6)

That's true that single-fraction HDRBT is not a standard protocol. It has been used experimentally. Here's an article about this single-dose technique:

/pcnrv.blogspot.com/2017/01/is-once-ever-enough.html

Is the facility the Hospital Universitario Central de Asturias, Oviedo, Spain? If so, you will see in that article a reference to a study (Prada et al.) done there. I'm sure if you prefer two to four treatments instead of a single treatment they would be happy to accommodate you.

There is no need for external beam along with HDRBT for men who are low or intermediate risk.

You mean this one, I think:

www.thegreenjournal.com/article/S0167-8140(16)31040-4/fulltext

You see why I question whether a single dose is a good idea? There are radiobiological reasons why even doing it in 2 doses may have better outcomes compared to a single dose:

/pcnrv.blogspot.com/2016/08/is-there-optimal-treatment-schedule-for.html

As you can see, the cancer control when given in multiple fractions is excellent, close to 100%. There's no reason why you can't request multiple fractions. Even two fractions with a few hours in between seems to be enough, and it will only mean a single day in the hospital. Or you can split it a week apart, and have a much shorter stay each time. It doesn't seem to matter at all - same excellent results and low toxicity.

I am certainly a fan of SBRT also, having chosen it for myself. I found it very convenient, unintrusive, inexpensive, no anesthesia, low/transient side effects, and excellent retention of erectile function. I had the choice of both HDRBT and SBRT, and I really could have flipped a coin to decide. I opted for the convenience. I'm sure seeds (LDRBT) would be fine too if you have an experienced brachytherapist using the most modern techniques and adequate doses.

For a man with favorable risk prostate cancer, all therapies, including surgery have about the same excellent oncological outcome.

I know the current regimen at UCLA for HDR brachy is to give two fractions in one day. When I had it in 2013, it was two fractions over two days, so you had an overnight in the hospital.

tde....all for fractions were on different days? So you had to undergo the procedure to insert the catheters and the procedure to remove the catheters four different times? Yeah, I'd have to say that wouldn't be much fun.

You are correct TA. For my brachy procedure, the catheter was inserted and removed while under anesthesia. Along with using the catheter to avoid the urethra, they also used it to flush through to the bladder to remove any clots or blood. And as for the SBRT, a catheter was inserted again during the simulation and planning phase and removed before I left MSK that day.

In HDRBT, "catheter" is the term used for the tube that goes up the penis and for the 15 or so tubes that are inserted transperineally to stake the prostate and through which the radioactive implants are inserted and removed. The OP was concerned about the transurethral catheter.

Today, I came back to be to the radiotherapist. His level of empathy and communication are just the opposite of the well-reputed urologist-surgeon that I visited a couple of days as reported in my thread about surgery.
I asked him about the paper I read about a HDBT single fraction monotherapy cohort elsewhere here in Spain that showed poor progression survival. His reply was that he instead uses two fractions implants at 6 hours interval. He showed me his patient statistics, private or included in congress seminars and planned publications (it is very rare in this country that any doctor discusses or gives that information). In seven years he has treated about 170 low and intermediate risk patients and has had a single case failure. This single case received salvage surgery and the pathological report revealed a G10 focus. (This patient seems to be all right now).
I understand that HDBT as monotherapy still has some experimental flavor and that treatment failure data takes some time to mature after radiation but, anyway, I am very impressed with his statistics.
I asked him also about SBRT. He confirmed me that in their protocol the patients have a cathether for five days. He has appointed me with the doctor that uses cyberknive in their Center. It is not covered by my insurance but the cost is not as high as I imagined.
Up to this point, I think I have been doing everything it is required to take an informed treatment decision but I am still doubtful about what it will be. Sometimes I have the challenging thought that if I finally do not follow the conventional choice (surgery) will be not because of my research but because it frightens me too much. Right now, it seems I have PCa and a big headache

Thank you TA, I will follow your advice,
I have been randomly gathering information during the 5 years I have been in the grey zone before Dx. But I have never seriously considered radiation for me, even though my atypical HIFU urologist always mentioned it as a good option. It has been after I asked here for help and discarded AS that I have realized it can be such a good alternative to surgery.

Tall Allen said...
With brachytherapy of either kind, the planning is done intraoperatively, and they use the catheter as a landmark. That helps them avoid inserting the implants through the urethra, and to keep the urethral dose within the dose constraints. Those who had brachytherapy, please correct me if I'm wrong, but I think the catheter is inserted and removed under anesthesia at the end of the procedure.

I had two implants a week apart, one fraction during each implant. The urinary catheter was inserted under anesthesia, but removed in the post op area after I was awake. It definitely wakes you up when they remove it but it's not so much painful, just a set of intense sensations you probably never experienced before.

In my case, at FCCC, the urologist participates in the surgical implant procedure, and the urinary catheter inserted has a camera that allows the urologist to check visually for any punctures in the urinary tract, in addition to the scanning equipment being used to guide implant catheter insertion.