Treatment after Radiation as Primary Therapy.

We often counsel newly diagnosed men and their wives that they should not believe a surgeon or anyone else who states "you can have radiation if surgery doesn't cure you, but not the other way around." And certainly that is not a true statement from a literal point of view.

However, I've been thinking about this, and looking at the issue from a practical, utilitarian point of view, I'd like to hear what the options are, if SBRT, EBRT, or Brachytherapy ultimately fail as primary treatment.

---Of course, we know that surgery is possible. But we also know it's very difficult after radiation and more likely leads to side effects very detrimental to quality of life.
---There's cryotherapy, but I wonder how often that's used and to what extent it is usually curative.
---There's hormone therapy, but that would be step #3 in the course of treatment, if done after both surgery and SRT/ART fail, besides which it's not curative. So is that really a good answer?
There's more radiation. But I would think that SRT after radiation as primary therapy could leave one with an awful lot of damage.

So I'm just curious, if you had Radiation in one of its forms as primary therapy and it failed, what would you do, or what would you advise someone to do, or what did you choose, as an option that would be potentially CURATIVE.

Not trying to stir the pot. Just curious, and I do think we need to take care to give clarity on the side effects that come with treatments available after primary radiation fail, if we are to give a newbie advice.

Ken there are many treatments including HDR brachytherapy, HIFU, cryo, NanoKnife, ADT, and for some limited number surgery.

Radiation rarely fails locally. Thus there is rarely a need for additional local treatment. Most failures are because the cancer was already outside of the radiation field. For them no initial treatment including surgery would have been curative. Then it is ADT, second line ADT, immunotherapy, chemo therapy and such.

The table at the end offers a good summary of salvage treatments after radiation failure:

/pcnrv.blogspot.com/2017/09/focal-salvage-ablation-for-radio.html

Q: Treatment [surgery] after Radiation as Primary Therapy?

A: While surgery may be doable, good luck finding a surgeon willing to get into that mess (they are out there, but many will decline). The side effects will be awful...but if you have no other choice, it's indeed doable. Bad idea to count on going this route for anything but a last resort.

The words of Dr. Anthony D’Amico are always on my mind. While discussing my concerns about the side effects of ADT, he said I should be more concerned about the long term effects of radiation.

This coming from a world class radiologist. A moment of medical honesty in a sea of unknowns, I think.

garyi said...
While discussing my concerns about the side effects of ADT, he said I should be more concerned about the long term effects of radiation.

Agreed.


Actually, I think the proper technical term is radiation “late-term” effects.

garyi said...
The words of Dr. Anthony D’Amico are always on my mind. While discussing my concerns about the side effects of ADT, he said I should be more concerned about the long term effects of radiation.

This coming from a world class radiologist. A moment of medical honesty in a sea of unknowns, I think.

Thank you for citing Dr. D'Amico. There are are videos of his formal presentations on YouTube, and he is an impressive speaker with strong slide and citation displays.

As to your above quote, did you hear this, first-person, in a conversation with him? I could not find a reference to such a suggestion, on the internet.

Prat-

In the table I provided, outcomes are from 2-5 years. Since we know from the ProtecT RCT that there is no change after the first couple of years, this seems adequate.

"it may not be a concern based on science, but I'd call it a concern based on logic, not emotion."

Reason/Logic can't get anyone to knowledge of medical science. You can think about it until your head smokes, and you still can't get to the same understanding that a randomized controlled trial can. We've known this since Francis Bacon in the 17th century. What you call "logic" has nothing to do with medical science. Only empirical observation, not what you call logic, can get to the truth of it.

"I've talked to guys who've had radiation as primary tho, who've told me about issues 6, 7 8 9 years later such as strictures. So it seems logical to me that radiation ON TOP OF primary radiation, is , let's say, less than ideal."

Again, this is where science is useful. Anecdotal evidence is not evidence at all - just hypothesis generating. When you get to 9 years, age effects overwhelm the effects of radiation. Remember that the average age of someone getting primary radiation is about 70. How many men of 79+ are fully potent or fully continent? To see an elegant approach to sorting through this problem, see:

/pcnrv.blogspot.com/2016/08/half-of-long-term-erectile-function-ef.html

Tall Allen— I’ve heard from doctors and read online that instances of brachytherapy side effects are less common than they were years ago. That improvements have been made. Do you agree with this, based on the data you have? Or is it too early to judge what late term effects will be for more recent radiation patients?

Not that we have much choice about treatment at this point. At 50, my husband would be living with problems for a long time, if he’s lucky. I think he’s most concerned about ED, but I know that increases with age anyway. The issue that concerns me most is bowel disfunction. Not sure how one manages that while trying to work and remain active.

We go to UCSD on Friday for appt with RO. We are hoping we like this referral because we found out he coincidentally subcontracts with Kaiser, so we may have some coverage. Any connection to Kaiser makes me a little nervous at this point. But I believe UCSD radiation oncology has a good reputation. ?

garyi said...
Better than anything before or since....YES. But hard scientific fact....NO. Just like, IMHO, many studies. Getting us closer, but not fact. i’ve read the studies and conclusions until I’m blue in the face. Most of what is portrayed as fact, is really just educated guesses.

Educated guess. An educated guess which uses well-understood "levels of evidence." ("Proof" in not in the lexicon of medicine, but we do have "levels of evidence.") As a great illustrative example, it's fascinating to realize that a medical diagnosis is nothing more than a primitive doppelgänger search based on similar cases seen or read about by a doctor.

I recently read the book "Everybody lies. Big data. New data. And what the internet can tell us about who we really are" and one very interesting discussion was about the potential power and impact of big data in medicine, but it also challenges our thoughts on individual privacy and ethics. Here's a real, live example: Early detection of pancreatic cancer makes a powerful difference in outcomes (unlike some other cancer types). If the pattern of one's internet searches—made in the privacy of your home—revealed that you were a likely candidate for early pancreatic cancer diagnosis, would you want to be individually notified by "someone" or "some computer program" that you should go get checked out? The book cites examples of how this potential life-saver has been demonstrated.

The book would make a good Book Club read. It's a new book (May 2017); anyone else read it already?

Post Edited (NKinney) : 4/9/2018 10:13:47 AM (GMT-6)

Prat-

Tools like mpMRI, advanced PET scans and biopsies have changed how quickly we can assess effectiveness. You don't seem to understand the process, so let me take you through what would happen in a typical case of a 70 yo man with a suspected recurrence after IMRT 4 years ago:
1. PSA rises over nadir +2 and remains elevated or increases.
2. An Axumin scan shows a site of recurrence within the prostate, and no detectable distant metastases
3. An mpMRI-targeted biopsy confirms the cancer
4. An HDR brachytherapist determines that based on location, time since last radiation, and amount of last radiation, that the recurrence can be safely treated. His plan includes that data and shows the radiation exposure to organs at risk. He sets dose constraints and finds they can be achieved.
5. Patient fills out baseline questionnaire on urinary, sexual, rectal function, and health status. other than needing ED meds, all functions are good.
6. After treatment, patient reported outcomes are tracked every 3 months along with PSA
7. After, say 18 months, patient receives another Axumin scan - no metabolically active sites
8. They do a follow-up biopsy and find no cancer
9. Tracking of patient reported outcomes shows an initial deterioration in urinary and rectal function with a return to baseline within a year.
10. Erectile function continues to deteriorate.
11. PSA falls within 2 years to below 0.5 ng/ml

This is a successful case, as about 50-70% are. I expect that number will go up after PSMA PET scans get approved. High grade urinary and rectal SEs are rare, in spite of what you call "reason."

Statistics are our best guess at what will occur in the individual case. If you have the emotional expectation that results will be different for you, that is unarguable, but recognize it for what it is - an emotional guess. For most people, I'd hope that what you call "logic" would give way to empirical information. Who needs all these expensive clinical trials when we have your "logic" to rely on?

Garyi-

I have no idea what you mean by "fact."

David Hume in the 18th century pointed out a flaw in all scientific reasoning - that it is all based on inductive reasoning. Thus, having observed an apple fall from apple trees to the ground hundreds of times, Newton induced that there is a force of attraction that we call gravity, and that it will pull all objects with mass towards all other objects with mass. But that requires a belief that it will always be observed. It was a grand leap of faith on Newton's part (Newton was a man of faith, after all), that has proved useful. All of what we believe to be true about the "laws" of the universe are just beliefs. So you can adopt Hume's skepticism, and believe none of it is objectively true, or you can adopt the POV that probability of truth is good enough.

Tall Allen said...


Garyi-

I have no idea what you mean by "fact."

So you can adopt Hume's skepticism, and believe none of it is objectively true, or you can adopt the POV that probability of truth is good enough.

TA, dear man, what ANY ONE of us accept as “fact” is the issue, isn’t it? With PCa it almost invariably requires a leap of faith. We could use David Hume around here. A highly researched probability of fact and truth is more than good enough for me. 🤗

Thank you for your always well thought out observations👍
Gary

I do think it is important to explain to new patients the difference between our "opinions" vs standards of care. In my experience as a health care provider, inexperienced patients are extremely vulnerable to anecdotal reports from other patients.

Paul