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Feedback on HDR Brachytherapy as a monotherapy

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Posted 5/28/2018 1:33 PM (GMT 0)
I have spent the last three months researching options for treating my specific Prostate Cancer case (see below). I have met with two surgeons (one with 600 robotic surgeries and one with 3,000 open surgeries) and two ROs that specialize in brachy (one with LDR permanent seeds and one with HDR temporary seeds). I have a visit scheduled with Emory in Atlanta this week with their multi-disciplinary team. I am also considering reaching out for a consultation with Doctor Freeman in Tampa to discuss SBRT. I am leaning toward HDR brachytherapy as a monotherapy with a high volume doctor in Atlanta recommended by one of the veteran board members on this site. I have spent many hours combing thru the threads on this site looking for members that have had HDR as a monotherapy. I have found several members that have had HDR in combination with external radiation and or hormone therapy. However I am struggling to find members that have had HDR brachytherapy as a monotherapy. I am looking for any feedback I can find from board members that have had HDR as a monotherapy or feedback from experts on why or why not they would recommend moving forward with this option. Thanks in advance for your help - regards MJ
Posted 5/28/2018 2:52 PM (GMT 0)
There are many guys here that have had it had HDR brachy as a monotherapy--I'm sure they'll be along. Off the top of my head, Subdenis had it fairly recently and has commented often.
Posted 5/28/2018 5:26 PM (GMT 0)
Also, Works Out and pjr64
Posted 5/28/2018 6:54 PM (GMT 0)
Tall Allen - how would you decide between HDR Monotherapy and SBRT? Also did you recommend Dr Freeman in Tampa for SBRT to another board member? Seem to remember seeing that but can’t find the thread - thanks MJ
Posted 5/28/2018 7:40 PM (GMT 0)
Linda Freeman has be recommended many times, and enjoys a seller reputation down here. She is most generous with her time and expertise. I've had several extended conversations with her.

Take a close look at how HDR Mono is accomplished. It is surgery, and catheters are inserted into your perineum. Dr. Matt Biagioli, at Florida Hospital in Orlando, is one of the most experienced physicians in the state with HDR.

Both are good choices; SBRT has been around longer and has many more satisfied patients.
Posted 5/28/2018 8:12 PM (GMT 0)

MJ1961 said...
Tall Allen - how would you decide between HDR Monotherapy and SBRT? Also did you recommend Dr Freeman in Tampa for SBRT to another board member? Seem to remember seeing that but can’t find the thread - thanks MJ

Check out posts from 19tarpon47. Just put "19tarpon47" and "Freeman" in the search bar.

It was a very tough decision for me, especially because I had the pioneering practitioners of each therapy (King and Demanes) within a 10 minute drive from home. I think both are excellent, and had a hard time deciding between them. They were designed to be radiobiologically identical. One places the highly radioactive source within the prostate and the X-rays emit outwards in all directions. The other starts from a large number of outside points and only reach a cancer-killing effect at the points in which the beams converge in the prostate. Both have very low toxicity outside of the prostate - the dose/volume histograms, which show the amount of radiation absorbed by organs near the prostate are pretty much identical. Both are extremely hypofractionated - which we now know has greater prostate cancer killing power and lower healthy cell killing power (because of the reduced total dose) than conventional fractionation. They both have a very low amount of ED - 70-80% of men retain potency. They both have near certain probability of reducing or eliminating ejaculate.

HDR-BT has the longer track record, it has been used as a monotherapy since 1995. SBRT has been used for prostate cancer since 2003.

HDRBT involved 2 overnight hospital stays (they've since reduced it so the two treatments can be done without an overnight stay). It also involved anesthesia and is intrusive. SBRT took only five 5-10 minute treatments. Dr King does not require any bowel prep or special diets because he uses a very fast machine. (Some machines take 45 minutes to an hour for each treatment and involve bowel prep and low-gas diets). SBRT also costs a lot less than HDR-BT, so if you pay a co-pay, that is a consideration. In the end, I chose SBRT because it was easier and cheaper.

I have had some fairly mild irritative side effects along the way, but they were transient, as is most often the case. Currently, I have no side effects, no ED whatever, but also no ejaculate. I am very pleased with my choice. I'm pretty sure I would have been equally pleased with HDR-BT.
Posted 5/28/2018 8:43 PM (GMT 0)
I'm three years out from treatment and can recommend HDR-BT as a monotherapy. In my research of how best to treat I fairly quickly eliminated surgery, as I thought in comparison to surgery that radiation therapy would be less invasive, would have comparable efficacy and would have reduced incidence/likelihood of side effects.

And in which radiation procedure to go with I eventually eliminated LDR-BT from consideration, leaving HDR-BT and SBRT. And I might have gone with SBRT, except that I was warned I could expect difficulty having my health care plan approve SBRT. By now, with more study results in, my health care provider may be more easily approving SBRT than they were then.

I'm pleased with results to date. Life goes on as before and my quality of life is undiminished.

I wanted to be treated at a center that had performed thousands of HDRs and specialized in it, and needed to travel for that. You do have an experienced provider in Atlanta (think there may actually be a couple of them).

Different centers may use different treatment protocols - some centers may offer options to you. I had two separate treatments spaced one week apart and did not have any overnights.
Posted 5/29/2018 1:56 AM (GMT 0)
Works Out - thanks for the feedback. Can you share the protocol used ( was it 2 days and 2 fractions per day) and who did your procedure? Were Gleason 7 (3+4) also? thanks MJ
Posted 5/29/2018 1:59 AM (GMT 0)
Garyi - thanks for the feedback on Doctor Freeman - regards MJ
Posted 5/29/2018 2:05 AM (GMT 0)
Tall Allen - thanks for sharing your decision making process and the other feedback. Truly appreciate your support. In your opinion do you believe that Dr. Freeman could provide a similar result to Dr. King? Tampa would be significantly easier for me than traveling to LA. However, I would go to LA if it resulted in a potentially better outcome. regards MJ
Posted 5/29/2018 4:18 AM (GMT 0)
Drs King and Freeman are colleagues - I doubt that their treatments are give different results, although they use different platforms.
Posted 5/29/2018 9:23 AM (GMT 0)
I had HDR BT in February. The procedure was a piece of cake. And the post-treatment was a non-event. I played golf the next day after each treatment. I had some urinary urgency for a week, had urinary burning for a few days but AZO fixed that. My first post-procedure PSA I dropped from a 5.7 to a 1.3. If you would like to talk about it send me a message and I will share my phone number. Denis
Posted 5/29/2018 3:40 PM (GMT 0)
I had HDR-BT monotherapy in Feb 2016, so a little more than two years out now. PSA at 0.8 and falling. See sig for details and a link to my thread. Feel free to ask questions. Two procedures a week apart, Feb 17 and Feb 24, a single 13.1 Gy fraction each procedure IIRC. Under anesthesia for each entire procedure. Have had some minor SE's similar to TA, transient here and there, nothing permanent/long lasting. I have had periodic irritation problems in my perineum area a few times now where the catheters were inserted, that's about the only SE that has proven bothersome for me that comes readily to mind.

Erectile function is not quite as firm as my pre-treatment days, but still plenty good enough for penetrative sex. Like TA it was a difficult decision for me between SBRT and HDR-BT, but HDR-BT has been around a bit longer, and therefore has a bit more post treatment statistical data available over a longer time period. That said, it's not nearly as popular as it once was given higher procedure costs and invasiveness when compared to more modern hypo-fractionated targeted beam treatments like SBRT. I think HDR-BT also requires more surgical experience to deliver as compared to SBRT. Best guess is provided SBRT continues to show statistical cure rate equivalence to HDR-BT outcomes (which has been the case so far), HDR-BT will gradually fade into the limelight.
Posted 5/29/2018 5:42 PM (GMT 0)
Excellent analysis and evaluation HitchHiker.

May your PCa, just like HDR-BT, continue to fade away.
Posted 5/29/2018 8:07 PM (GMT 0)
MJ

I was also a Gleason 7 (3 + 4). I was treated at UCLA by Dr. Demanes and had 1 fraction per day done twice - one week apart

If I had the option of two smaller fractions done during a day, and then duplicated the following week, I probably would've chosen that, but that wasn't an option. Could've done three fractions over the course of two days (requires an overnite stay) with a repeat the following week, and decided against that. Think Hawaii Guy who posts here did that shortly before me at UCLA.

I'm in Metro NY and would've had good providers locally for any other procedure I might've chosen. But there wasn't a comparable center near here for HDR, and once I decided to go with HDR and travel I figured it didn't make much difference how far I traveled, and we made the week between the two procedures kind of a vacation

MJ1961 said...
Works Out - thanks for the feedback. Can you share the protocol used ( was it 2 days and 2 fractions per day) and who did your procedure? Were Gleason 7 (3+4) also? thanks MJ

Posted 5/30/2018 12:37 AM (GMT 0)
Works Out - thanks for the feedback, happy to hear your thoughts about 2 fractions vs 1 fraction per day. The local HDR guy in Atlanta recommended by a fellow board member is 2 days 2 fractions per day morning and afternoon with one week between treatments. I feel very positive about moving forward with HDR option but still need to decide if I want to checkout SBRT before making final decision. thanks MJ
Posted 5/30/2018 12:41 AM (GMT 0)
Hitchhiker - thanks for sharing your experience with HDR. The positive feedback from you and fellow board members is confirming my belief that HDR would be an excellent choice for my treatment. thanks MJ
Posted 5/30/2018 12:46 AM (GMT 0)
Sub Dennis - thanks for the offer to talk. I did not see your email in your profile. If you can email me your phone number and a good time to talk, I will give you a call. My email address should be available in my profile. If not, let me know. thanks MJ
Posted 5/30/2018 8:54 AM (GMT 0)
I sent you an email with my contact info. I will look at my profile and see why it is not available, thanks,
Posted 5/30/2018 2:44 PM (GMT 0)

MJ1961 said...
Hitchhiker - thanks for sharing your experience with HDR. The positive feedback from you and fellow board members is confirming my belief that HDR would be an excellent choice for my treatment. thanks MJ

Sure thing, feel free to click on the email icon and message me privately if you need anything. The decision making process IME is the most prolonged and difficult part of this endeavor. Are you candidate for AS given you have only a single core of 3+4? Your single core 80% is high but with only 10% G4 you may still be eligible for certain AS programs. Just a thought. All the best as you navigate the decision making process.
Posted 5/30/2018 3:27 PM (GMT 0)
Hitchhiker - thanks for your suggestion on AS. I was not eligible for the AS program at Johns Hopkins because of being higher than G6 and because of my prostate density. I have a consultation with Emory in Atlanta this afternoon and I plan to ask about their AS program along with HDR and SBRT during my visit. I have eliminated surgery and LDR brachy as options but HDR brachy, SBRT and AS are still on the table. - regards MJ
Posted 5/30/2018 9:32 PM (GMT 0)

MJ1961 said...
Hitchhiker - thanks for your suggestion on AS. I was not eligible for the AS program at Johns Hopkins because of being higher than G6 and because of my prostate density. I have a consultation with Emory in Atlanta this afternoon and I plan to ask about their AS program along with HDR and SBRT during my visit. I have eliminated surgery and LDR brachy as options but HDR brachy, SBRT and AS are still on the table. - regards MJ

Got it, hope the consultation today went well! Sounds like you have everything well in hand and are taking all of the required steps.
Posted 5/30/2018 9:46 PM (GMT 0)
I don't peruse studies in detail - Tall Allen is your guy for that - but the best I can tell is that there is really no consensus that any particular protocol is better than another - other than having it all done in one fraction seems more likely to lead to short term urinary issues. And maybe that was from a single study.

Best of luck.


MJ1961 said...
Works Out - thanks for the feedback, happy to hear your thoughts about 2 fractions vs 1 fraction per day. The local HDR guy in Atlanta recommended by a fellow board member is 2 days 2 fractions per day morning and afternoon with one week between treatments. I feel very positive about moving forward with HDR option but still need to decide if I want to checkout SBRT before making final decision. thanks MJ

Posted 6/2/2018 10:36 AM (GMT 0)
Hello All,

I'm sorry to be late in posting to the forum -- traveling these days. My husband had HDR mono at UCLA. The procedure itself was okay -- not really too many side-effects to speak of. Now, he has almost no side effects at all, except for no ejaculate (of course). From the partner's perspective, at least, this is an upside! smile

I hope my signature comes through, as you will be able to see that he has really bounced around a lot since then, with one point being really pretty nerve-wracking. He's due for another PSA check when we get back to the US (in about a week). Though all of this time, it's been really helpful to read about bounces, slowly declining PSAs, etc.

I'm very willing to talk with you if you want, as is my partner. This forum is always a god-send, and TA is helpful beyond measure.

Yours,

Mary
Posted 6/3/2018 4:35 AM (GMT 0)
Mary - thanks for the response, it is encouraging to hear all of the positive feedback around the HDR brachy monotherapy. I am very close to making my final decision to move forward with HDR option. Good luck to you and your partner on your next PSA test and a continued trend down. - regards MJ
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