IMRT then LDR-BT or LDR-BT then IMRT?

Greetings to All!

This particular topic of treatment coordination (or scheduling) of radiation events continues to trouble me somewhat. As many of you already know, my RO has proposed a three-pronged (so-called 'triple-play'), approach to my treatment, involving ADT+LDR-BT+IMRT, and he has proposed that they be performed in that specific order (i.e., LDR-brachytherapy 'before' IMRT, not after). And unfortunately, though there appear to be several detailed studies currently underway or scheduled for the near future, I've been largely unable to locate anything in the literature that focused specifically on this subject of treatment coordination (i.e., before vs. after, etc.).

However, a superficial review of published (peer reviewed) literature on the subject, as well as anecdotal evidence from sources like this (and other) on-line discussion groups, indicates that the vast majority of 'triple-play' patients are subjected to treatment in the reverse order (i.e., ADT+IMRT+LDR-BT). In fact, the very term "boost" that is often applied to brachytherapy would seem to imply that it is/was intended to 'follow' IMRT (not precede it). And if one digs even further into published books on the subject, like Dr. Michael Dattoli's text entitled "Brachytherapy and IMRT: A Primer on Seed Implants & IMRT for Informed Patients", you quickly discover two apparent reasons why most practitioners feel that IMRT followed by LDR-BT, is the preferred approach:

1) Conducting the 5-6 week long IMRT sessions PRIOR to LDR-BT can essentially sterilize the tissues before the implantation of seeds, thereby minimizing the prospects of cancerous prostate cells being released into the general bloodstream by needles used in the implantation process (an argument I've often seen used against biopsies in related discussions).

2) Since the radioactive emissions from the Pd-103 seeds last for several months (not days or weeks), conducting the IMRT sessions PRIOR to LDR-BT reduces the potential for adverse side effects from excess radiation to non-target tissues (e.g., seminal vesicles, bladder and/or rectum), by way of real-time combined (or overlapping) 'double-dosing', which is difficult to regulate or define in pre-planning stages.

Needless to say, I've asked my RO why he seems to prefer doing LDR-BT before IMRT, rather than the more common (IMRT then LDR-BT) approach, but unfortunately, his answer fell a bit short for me. All he said was . . . "we'll be happy to rearrange the treatment sequence if there are any personal or family scheduling issues." In other words, he didn't offer any technical or scientific rationale for either approach.

I hate to second guess the professionals or to question authority, but at this point, I'm inclined to request a reversal of treatment sequence, based upon everything I've learned and discussed here, but before I do so, I thought I'd open-up the topic for discussion here on the forum, in hopes of gaining some added perspective(s). Basically, I don't want to seem unreasonable in making such a request, so any additional information or opinions that I can gain on the subject, will help to insure me (and him), that such a request has merit.

Thanks for listening!

Michael_T said...
I've seen it both orders and when I asked about it I was told it didn't matter. That indeed seems unhelpful, but I suppose that also could be the truth. BTW, I had my brachy (HDR, not LDR) first, which is the typical protocol at UCLA...

Michael,

Thank you for that! That is most interesting. Are you aware of anyone else (like you), who may have had the BT first? In particular, are you aware of anyone else like you who was treated with IMRT at UCLA, but with LDR- (rather than HDR) preceding it? As of this moment, I think you're the very first that I've discovered on either score. Literally every one else that I've encountered has had their IMRT sessions followed by BT.

I'll say this much . . . I'm by no means a radiation expert, but to some extent, I can understand how having 'HDR'-BT before IMRT 'might' make more sense than having LDR-BT before IMRT, simply because the exposure duration of HDR is hotter, but much-much shorter. Theroretically, that would eliminate the risk of Item #2 (justification #2), in my above posting.

Oh well! We'll see. It might not happen, but I'm hoping that someone might come along here who has actually had LDR-BT 'before' IMRT, but thanks again for responding!

Yeah, I'm sure he'll see this at some point, and I'm hoping he'll respond. He's definitely very knowledgable about it.

I think I already said (several times) that the order didn't matter - you're worrying about something that doesn't matter. You are incorrect that the term boost means follows - it means adds more radiation. There is no "preferred' approach - you are just assuming that based on a few things you have read.

1) there is no sterilization that takes place.
2) whether the BT dose comes first or second, the dose to organs at risk is the same.

. This is a natural outcome of your anxiety. You should let your doctor follow the protocol he has the most experience with. Don't micromanage him.

Post Edited By Moderator (Tudpock18) : 7/23/2018 11:02:10 AM (GMT-6)

Please play nice guys. This thread could quickly veer off into no mans land

In the spirit of what Prato asked I have also edited out Rule #3 violations and close calls.

Jim

Tudpock18 said...
In the spirit of what Prato asked I have also edited out Rule #3 violations and close calls.

Jim

Jim,

I have no issue whatsoever with your need or right to edit things on occasion, nor do I take issue with any of the specific edits that you've already conducted here, but it would be awfully nice if the fact that those edits had occurred could be somehow indicated in the empty spaces left by those edits, for ALL parties or posts that were edited. Just a sincere, well-intended suggestion.

Thanks.

JNF said...
. . . I had two thirds of my IMRT then my HDRBT then finished two weeks of IMRT.

The leading seed clinic RCOG overlaps the IMRT over the seeds claiming a complimentary affect by externally radiating after the seeds are implanted.

JNF,

Thank you for your comments.

Although it may not be well-established in terms of published literature, if there is in-fact a difference, I wouldn't expect that it would apply to HDR (only LDR), as discussed above.

However, your RCOG comment is certainly of interest to me. Could you please explain who or what RCOG is for the uninformed?

Thank you.

Balladeer-

You have to distinguish between general guidelines and what one practitioner believes. Dattoli does not speak for all practitioners. In fact, the ASCO guidelines don't even mention the order:

/acsearch.acr.org/docs/69399/Narrative/
ascopubs.org/doi/full/10.1200/JCO.2016.72.0466

The American Brachytherapy Society sets forth the standard of care. They state: "Timing: Either before or after brachytherapy is acceptable. "
/www.americanbrachytherapy.org/guidelines/prostate_low-doseratetaskgroup.pdf

The ABS HDR Task Group specifies that external beam radiation may be delivered "before, after, or sandwiched"-
/www.americanbrachytherapy.org/guidelines/HDRTaskGroup.pdf

The ACR appropriateness criteria states:
"HDR prostate implants have been used as a boost in conjunction with EBRT. Typically, this involves 4-5 weeks(40-50 Gy) of EBRT treatment with one or more implants, which are sandwiched between, before or after EBRT."
/acsearch.acr.org/docs/3082863/Narrative/

I'm sure every practitioner has his reasons, and there is no reason to favor Dattoli over any other practitioner, especially when he does not give sources for his opinions. If anyone wants his opinions to be taken seriously, he has to publish data demonstrating it. If you have more faith in Dattoli's protocol, you should consider using him.

Edits applied and thread reopened. As Prato suggested, please play nice.

Thanks,

Jim

The point that was made repeatedly is that the sequence doesn't matter as far as we know from published sources. And, as has also been pointed out repeatedly, the experience of a particular practitioner matters much more. As always, try to find a RO with extensive experience in the 'triple' therapy that you think is best for you.

As an aside, I received SBRT first and IMRT second (while enjoying ADT). The SBRT parameters historically were derived from HD-Brachy.


Finally, I place greater value on judgments from organizations such as ASCO and ABS and peer-reviewed publications than a booklet from Dr Dattoli, even though he may be a great prostate oncologist.

O.K., so, I want to start-off by thanking the moderators (particularly Tudpock and Pratoman) for graciously unlocking this thread late yesterday. I didn't ask them to do so, but unlike many here, I think they concluded that the topic itself is a perfectly legitimate one, and worthy of open discussion. However, that said, what we appear to have here is a classic case of "Mexican Standoff", and as such, I don't believe that continued discussion of the matter is likely to be anymore fruitful than sweeping a dirt road.

On the one hand, we have a community of people (lay folks mostly), who believe that there is no significance to the order in which the two radiation treatments are administered, and that in practice, there is no demonstrated difference or preference in the order. Those folks believe that they have "repeatedly" provided firm, indisputable evidence of their assertions, and they've gone as far as to bash or essentially slander others who dare to disagree with them, including well-respected, well-recognized, accomplished practitioners who are actually out there, performing these procedures on a daily basis.

On the other side, we have me, and perhaps a few others including Dr. Dattoli, who 1) aren't available to defend themselves or present their arguments here, and 2) who believe that there is in-fact a significance to the order in which the two procedures should be administered, and 3) who firmly believe that there is a clear and demonstrated preference in actual practice nationwide. Add to that, the clear and simple fact that despite "repeated" claims of having been aptly demonstrated, and despite ALL of the postings and ALL of the drama associated with this thread, and despite the fact that it was the original goal in initiating this thread to begin with . . . not a single soul has yet to come forward here who has received LDR-BT 'before' IMRT. Not a one!

So, if the order doesn't matter any, if in-fact there is no difference whatsoever between the two approaches, if there is no demonstrated preference in actual practice nationwide and this whole exercise is an uninformed, pointless witch hunt, then where are these legions of people who had their seed implants (LDR-BT) 'first'. Its honestly pretty basic. If you're here, please stand-up!

My money is on Allen. Thanks for being here and sharing your knowledge and expertise, you were a great help to me when I started this journey. I declare you the hero of this board.