best radiation for avoiding adt for unfav intermediate

Welcome Manticore-

You are right that brachy boost therapy probably doesn't need any ADT in unfavorable intermediate risk men:

/pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html

(I don't think it matters much which you do first. But if you do brachy first, allow some time for the swelling to subside before iMRT)

Your other choices that don't need adjuvant ADT are SBRT monotherapy and HDR brachytherapy monotherapy. Both have reported excellent cure rates in intermediate risk men and may be less toxic than a brachy boost. U Michigan now offers SBRT. you'd have to go to Alvaro Martinez in Detroit for HDR BT.

Sorry- I'm got confused because you mentioned an RO at UMich. The RO I know of at Duke is Dr Lee:
/scholars.duke.edu/display/per0826072

I think they do all of the ones I mentioned at Duke - let me know if they do.

Here's a nomogram so you can see the probability that men with your diagnosis will have the cancer wholly contained in the prostate:

/www.mskcc.org/nomograms/prostate/pre_op

I recall that Duke was experimenting with hyperthermia and will be interested to hear what they say about it. Both hyperthermia and hypothermia may work equally well in radiosensitizing the cancer. No, the nerves are not harmed by it, and its effects wear off after a few hours. Radiation doesn't harm nerves either. (btw-
I don't recommend reducing radiation dose if using hyperthermia - adequate dose is important and there's not enough clinical data on hyperthermia to support reducing dose. It may make the dose received more effective.) Cauterization used in surgery is very hot compared to the hyperthermia used with radiation.

I would talk to Dr Lee first - you can ask him what measures he takes to spare healthy tissue.

Saw RO at Duke. I asked, "Is there a way to responsibly avoid ADT?" he replied, "for unfavorable intermediate like you, No." I started to whip out the chart from your piece: /pcnrv.blogspot.com/2017/12/is-adt-still-needed-for-high-risk.html, but then I thought better of it.

I did have a very good discussion with the RO about potency preservation in surgery vs. radiation, he thinks the differences are not significant. He also talked about McLaughlin and the care he puts into placement of seeds. And also the results McLaughlin gets in potency preservation. I don't think it was the RO's intention but I became more interested in McLaughlin's ldrbt with dosage escalation via EBRT even if I have to go live somewhere for 5 or 6 weeks. We never made it to SBRT. It was not his recommendation which was LDRBT + EBRT + ADT (4 months)

I did find it very easy to talk with the RO. He is the only Doc I've seen who seemed to really take in my bout with severe Peyronie's disease 10+ years ago, and the very satisfying outcome I had. That has been my model for this encounter with PCa so having him recognize the unusual result felt good. Most docs say nothing.

Where does it leave me? Right now, McLaughlin's LDRBT with dosage escalation with EBRT and peripheral treatment with vessel sparing seems the best I have found, even if I have to go there for 5 or 6 weeks.

I would like to know the 3 most experienced SBRT people in the country you would recommend for SBRT with unfavorable intermediate risk.

I also want to know more about HDR mono brachytherapy vs. combination brachytherapy or brachy boost? I want to know more about the toxicity risks there.

I am also still tracking if the LDRBT can be temporary. I get conflicting answers from RO's. I know the HDR is often temporary. I prefer the temporary. I've seen the graphs of higher dosage and more ablation of cancer but I wonder why the higher dosage wouldn't also carry more risk of toxicity?

"I would like to know the 3 most experienced SBRT people in the country you would recommend for SBRT with unfavorable intermediate risk. "

That would include the RO who first used it in 2003- Chris King at UCLA. Probably Alan Katz in Flushing has treated more people and been doing it longer than just about anybody but Dr King. For third - maybe Debra Freeman in Tampa - she started soon after Dr King.

"I also want to know more about HDR mono brachytherapy vs. combination brachytherapy or brachy boost? I want to know more about the toxicity risks there. "

HDR-BT monotherapy would have a lower toxicity profile than any combination therapy, of course.
/pcnrv.blogspot.com/2016/08/hdr-brachy-boost-and-monotherapy-for.html

"I am also still tracking if the LDRBT can be temporary. I get conflicting answers from RO's. I know the HDR is often temporary. I prefer the temporary. I've seen the graphs of higher dosage and more ablation of cancer but I wonder why the higher dosage wouldn't also carry more risk of toxicity?"

LDRBT (seeds) is ONLY permanent - once placed, they cannot be removed. HDRBT is ONLY temporary. HDR means high dose RATE, not higher dose. The nominal dose for seeds is usually about 145 Gy, while the nominal dose for HDR-BT monotherapy is about 45 Gy. But because of radiobiology, the biologically effective dose of HDRBT is much higher for cancer killing, while it is lower for healthy tissue toxicity.

Dear JNF, thanks for the link to learn more about brachy and HDR and Dr. Demanes. Also thanks for the encouragement not to be overly fearful about ADT.

Let me say more about ADT. Sure there is some fear, but always I try to differentiate legitimate fear from irrational fear. If I am in a new city and I get lost and make a wrong turn and fear comes, it may be telling me quite legitimately to "watch out". .... or not.

So when I asked Tall Allen about ways to avoid ADT for my unfavorable intermediate risk category, I was delighted that he gave me 8 studies with 6 of them showing no effect from ADT meaning those methods were probably sound without ADT.

When I first looked into ADT, I was surprised to find how many things it affected and how many very slight risks it opens. Cardio, bone, cognition, mental health and more, not just threatening sexuality, are involved.

In dealing with disease, I like to take the generality of things and have it interact with me in particular. I have some vulnerability to osteoporosis and discomforting pain, I have some vulnerability to irritability. So for me in particular, ADT may not be such a wise way to go IF THERE ARE LEGITIMATE ways around it.

Also, in dealing with disease, I like to notice theoretical discrepancies which have not yet been integrated fully in the literature. So A. Morgenthaler's work has been pretty strong in challenging the notion that testosterone is a 'bad guy' in prostate cancer, 'like pouring gasoline on a fire.' That old concept sustains despite his empirical work challenging that. A new concept explaining why ADT helps but that testosterone is not at all bad, rather a basic building block of health it is, is yet to be fully fleshed out.

So when I see these places of insufficient theoretical integration, it is a signal to look for 'my way'. I ask myself, "Is there a responsible way to carve out a slightly different path here with ADT?"

It may turn out that my answer becomes no, like my recent RO appointment when I began with that same question. He answered with a flat out "No". If he had answered "No, there are some studies that indicate 'yes' but those studies aren't strong enough for me." I would have felt better.

These little places actually become a help for finding my personalized path in a place where there are many paths and many contradictory perspectives. Sometimes it feels like I am in a little boat in a stormy sea trying to find my way. But if I can sustain through that chaos, I can find pointers to my path. So this discussion list, and every response is helpful for sorting out my decision.

Dear Tall Allen,
I am exploring SBRT further and have made contact with Freeman's office in Tampa. Thanks for that suggestion.

In terms of long-term rates (percentages) of biochemical recurrence-free survival (bRFS) how does SBRT do for Unfavorable Intermediate Risk--my category?

Thanks, Manticore

Dear Allen,
I am looking for a top HDR brachy RO. Someone suggested looking for a protege of Dr. Alvaro Martinez indicating that he was a top 3 researcher/practitioner for HDR and that there were a couple of very strong HDR RO's in their own right who had developed with Martinez. Would you know names of the strongest HDR docs at Beaumont Hospital besides Dr. Martinez?

Manticore

I have decided on SBRT. I've chosen a practitioner who specializes in that and whom I feel very confident in.

I am working on setting dates for the procedure and accomplishing the preliminaries. I am aware that I have a commitment to teach an important workshop in Germany about 3 months after the SBRT completes. I've also read that post-radiation effects are more intense in the first few months. Should I be concerned about the Germany trip? Would it better to take the earliest available SBRT time and have the full 3 months before I go or not important if I schedule the SBRT treatment a little later than the earliest possible?

I also have short trips--1.5 hour flight--which are NOT critical to work in the first month after the treatment so unsure whether to just wait and see or definitely cancel or???

My SEs started about a week after treatment and lasted about 10 days. Think of it as a sunburn on the inside. They were mild and did not interfere at all with work or work outs.