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BCR After SBRT for Contained Cancers

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Posted 8/4/2018 6:15 PM (GMT 0)
Hello All:

Are there any studies on the percentage of BCR after SBRT where the cancer was 100% contained within the prostate?

And if so, how did they confirm that the cancer was contained, in the absence of post-surgical pathology?

The reason I ask-- where I am coming out in my decision process is that if SBRT is close to 100% effective in preventing BCR for contained cancers, then it is a far superior treatment to surgery or other forms of EBR in terms of convenience (4-5 treatments, no cutting/rehab) and lack of SE's. But if not close to 100%, then surgery becomes a possibility.

For non-contained or ambiguous cancers for intermediate/unfavorable risk guys like me, the "triple play" combo of HT, BT, and IGMT seems like the way to go, given the excellent numbers on freedom from BCR posted by the Ascende-RT and U. of Michigan studies that Tall Allen has posted.

Thanks for any and all feedback!


Age: 62
PSA, 3/18: 6.1
DRE, 4/18: Stage T2a, right side
Biopsy, 6/18: Left = 2/6 positive, G3+3; Right = 6/6 positive, 3 @ G3+3, 3 @ G3+4; PNI identified in 2 cores
Posted 8/4/2018 7:59 PM (GMT 0)
Without removing the prostate, you cannot determine if the cancer was contained within the prostate. Containment is a very positive surgical outcome, but there are a few surgery patients who will progress to BCR even with containment. So having a pathological stage that implies containment will improve your odds, but does not 100% guarantee that there won't be BCR.

You are making a decision now based on clinical stage, which is your best guess of the severity of your disease based on physical exam, blood tests, biopsy and imaging. Often the pathological stage is different from the clinical stage after surgery, sometimes better, most often worse. I've seen some research which said that about half of G6 and below patients were upgraded to G7 after surgery. You appear to be a G7 and the studies vary. Some studies show that there are an equal number of upgrades and downgrades, while others show more upgrades than downgrades.

Whether you choose surgery, SBRT or other forms of radiation, as an intermediate risk patient, you have an excellent chance of cure. However data from SBRT, especially on longer term survival and SEs' isn't complete yet for the medical authorities to consider it a mainstream treatment, much like proton therapy. Nontheless, SBRT is looking very good given the convenience and has many enthusiastic supporters on this board. There are several trials completing after 2020 which will shed more light. So far the studies have been relatively small, at least from my browsing. TA will know better.

Surgery has the greatest risk of incontinence and ED. EBRT has issues with rectal issues, while brachy has issues with urinary obstruction. Most people manage fine regardless of chosen treatment. Not sure why you think you are unfavorable intermediate risk? You seem to be favorable intermediate risk and should have 95%+ probability of cure, whatever you choose. As for SEs' avoid the treatments with SEs that you are most afraid of so for example, if you fear ED, perhaps surgery would be less preferred. If you already suffer from urinary obstruction, brachy might be less preferred.
Posted 8/4/2018 8:50 PM (GMT 0)
WeightLoss: Thanks for your insights.

I did not know that BCR was possible if the cancer was contained and the prostate removed by surgery. If that's the case, and the likelihood of BCR is roughly the same between surgery and SBRT in the case of contained cancers, then that would eliminate surgery from my consideration. I lead an active life with lots of biking, weight training, and yoga, so am very concerned about the loss of urinary control for a minimum of 2-3 months, plus pressure-generated "accidents" for a year or more afterwards. ED is also a concern.

Point taken about the short history of SBRT, but Tall Allen has highlighted large-scale 7 year studies, and in the case of 1 doctor (Katz), 9 year studies, that show SBRT is as good or better than other forms of EBR for efficacy and lack of SE's for the intermediate risk group. Agreed, 10 or 15 year studies would be ideal.

Technically, I am intermediate unfavorable because more than 50% of my cores tested positive, although one RO I spoke with felt the positive cores should not be given much weight, and that the G3+4 (rather than 4+3) almost certainly meant I should be treated like a favorable intermediate. He thought the triple play might be overkill, but that an MRI would help make a much more informed decision.
Posted 8/4/2018 9:28 PM (GMT 0)
There is actually an ongoing clinical trial that will answer if SBRT is superior to surgery and conventional radiotherapy.

/clinicaltrials.gov/ct2/show/NCT01584258

There are several different treatment options for early prostate cancer, all of which result in a high rate of cure, albeit with a moderate risk of side-effects. The principle options for treatment are radiotherapy or surgery, but a new option of stereotactic body radiotherapy (SBRT) has emerged over the last 5-10 years. We do not know which of these three treatment options produces the highest rate of cure with the lowest rate of side effects. This trial aims to answer this question by randomising over two thousand men worldwide to surgery versus prostate SBRT and prostate SBRT versus conventional radiotherapy. We will monitor the cancer control rates, by measuring the PSA, and will collect extensive data on the side effects of each treatment and the effects on quality of life.

Unfortunately, we will not get the answer until 2026 when the study is complete so this trial is not useful for RichBinSD in his decision. But it shows that nobody can say which method of treatment is superior (even though we sometimes can see posts that claims that SBRT is superior).

Post Edited (Gemlin) : 8/4/2018 3:31:20 PM (GMT-6)

Posted 8/4/2018 10:04 PM (GMT 0)
Refresh my memory, did you have your slides sent out for a second opinion? If not, you should.
Posted 8/4/2018 10:39 PM (GMT 0)
"Without removing the prostate, you cannot determine if the cancer was contained within the prostate."

I've seen plenty of guys who were "contained" after surgery experience BCR.
Posted 8/4/2018 11:29 PM (GMT 0)
"There are a few surgery patients who will progress to BCR even with containment"

Curious where this stat comes from. Thx.
Posted 8/4/2018 11:33 PM (GMT 0)
There is a difference between clinical staging and pathological staging. Pre-therapy only clinical staging is used based on DRE (but sometimes doctors will include imaging or biopsies through the capsule unofficially). Nomograms can be used to estimate the likelihood it has escaped the capsule. Over 90% of PC patients have clinical stage T1c or T2a. So the radiation BCRs are based on clinical staging, whereas most of the RP numbers quoted are based on pathological staging.
Posted 8/5/2018 12:32 AM (GMT 0)
Gemlin: agreed, we will probably have to wait for the results of the UK trial to see with a scientific degree of certainty how SBRT fares vs. surgery and other forms of EBR re: survival, BCR, and SEs. What I meant to say was that SBRT would be superior for me and my priorities (no cutting, no rehab, no loss of urinary control, no ED), based on admittedly limited evidence, specifically in the context of contained cancer. What other people have said here is beginning to make me question whether the "contained" scenario is academic, because there is no way to tell in advance with a high degree of certainty that the cancer is contained in the prostate. (The RO thought that an mpMRI could indicate in some cases where it was likely that the cancer has escaped the prostate, because the image shows it bulging against the capsule, and in certain other cases where it was likely that the cancer is contained, and in certain other cases were it is ambiguous, but I did not follow up on that.)***

CAdogsRus: my biopsy slides are en route to JHU for a second opinion. Also trying to schedule an mpMRI at UCSD.


***After doing a little detective work, it appears that the RO slotted me for a Restriction Spectrum Imaging MRI (RSI-MRI), which may be a lot more accurate than even other forms of multi-parametric MRIs, especially in picking up G3 cancers. It is still under trial. https://sperlingprostatecenter.com/new-mri-technique-improves-prostate-imaging/ But this appears to be the basis for the RO's belief that at least in some scenarios, he could say with a high degree of certainty that the cancer either was or was not contained within the prostate.

Post Edited (RichBinSD) : 8/4/2018 7:26:34 PM (GMT-6)

Posted 8/5/2018 12:59 AM (GMT 0)
Simply put there is no way to ever know whether the cancer was contained in the prostate. Your risk factors all provide probable direction but even a surgical pathology can not be conclusive as it only examines the excised tissue. PCa could be undetectable somewhere outside the excised prostate and adjacent tissue even though the margins are clear and it appears to the pathologist that the cancer was contained. Remember, PCa can often be found in the blood and this can travel outside the prostate and not be found in the pathology.

My nomograms gave me 0% probability of being organ confined. Nearly eight years following treatment I remain PSA undetectable. So was I organ confined? Don’t know. Am I cured? don’t yet know. What I do know is that the combination of HDRBT, IMRT and ADT has put my high risk situation into a long and durable remission; hopefully a cure. So I am very pleased with my results. However, I continue with quarterly PSA tests to closely monitor my situation.

Rich, with your emphasis on radiation have you been assessed for HDRBT? If you are looking for an effective radiation method with a much longer experience than SBRT, then HDRBT should be assessed. In my opinion the best information is at www.cetmc.com. This is the website of Dr. Jeffrey Demanes, the HDRBT pioneer. He has used it for PCa and many other cancers since 1981.
Posted 8/5/2018 1:32 AM (GMT 0)
JNF: yes, as I wrote up top, if it can't be proved with a high degree of likelihood that the cancer is contained in the prostate, then I would probably do the "triple play," including a brachytherapy component. Whether that is high dose rate or low dose rate brachytherapy has yet to be decided. The RO advised waiting for the results of the MRI before deciding whether the triple play is appropriate.
Posted 8/5/2018 1:41 AM (GMT 0)
I'm a fan of RSI - I hope they will publish updated findings:

/pcnrv.blogspot.com/2016/08/will-restriction-spectrum-imaging-rsi.html
Posted 8/5/2018 1:51 AM (GMT 0)

RichBinSD said...
WeightLoss: Thanks for your insights.

I did not know that BCR was possible if the cancer was contained and the prostate removed by surgery. If that's the case, and the likelihood of BCR is roughly the same between surgery and SBRT in the case of contained cancers, then that would eliminate surgery from my consideration. I lead an active life with lots of biking, weight training, and yoga, so am very concerned about the loss of urinary control for a minimum of 2-3 months, plus pressure-generated "accidents" for a year or more afterwards. ED is also a concern.

The likelihood of BCR between SBRT and Surgery looks the same at this point, but there is simply not enough data on SBRT to definitively say that. You would not be rolling the dice with SBRT, but you would be taking a calculated risk.

If ED is a major concern, then you might want to avoid surgery as about half the patients with normal function report poor function at 24 months (vs about 25% with RT or AS). There is also a higher probability of incontinence with surgery, but with most patients, it is not bothersome to them at the 24th month mark vs other treatments.

Many ex-surgery patients like halbert (I mention him because we have met) and myself don't have any worse SEs than before our surgery. You should also recognize that other treatments have other potential SEs and be prepared to accept them as a risk should they occur. There is simply no guarantee in anything you pursue from this point. What I am quite certain about is that whatever treatment you choose, you will have a > 90% probability of cure, while being able to continue your biking, weight training and yoga.
Posted 8/5/2018 2:00 AM (GMT 0)
RichBinSD: Look at all options, as you seem to be doing, but seriously consider SBRT if QoL issues are a BIG concern for you. I and many others will attest to the very low to none status of the SE's after SBRT.

IMHO: Surgery with numbers like you have would be a crime and you would be the victim.

Roger

May all beings be well always free from animosity and oppression.
Posted 8/5/2018 2:04 AM (GMT 0)
For favorable intermediate risk, SBRT has reported 97% freedom from 5 -yr BCR

/pcnrv.blogspot.com/2016/09/5-year-sbrt-trial-high-cancer-control.html

You can check the MSK nomogram for post-RP BCR rates:

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

Standard disclaimer: Only a randomized clinical trial comparing SBRT and surgery can legitimately compare them.
Posted 8/6/2018 11:48 PM (GMT 0)
Thanks for all the great information, everyone.

It really helped clarify my thinking.


Rich
Posted 8/7/2018 1:17 AM (GMT 0)
No wad do sbrt no way hadn’t been around Long enough
Posted 8/7/2018 4:12 AM (GMT 0)
Stan,
SBRT as primary treatment for prostate cancer has been used since 2003.
Posted 8/7/2018 11:03 AM (GMT 0)

Stan1961 said...
No wad do sbrt no way hadn’t been around Long enough

Stan, I gather that's your opinion. Do you have any reasoning for the statement? The first robot assisted prostate removal was in 2000, i.e. only 3 years earlier than SBRT has been used for prostate cancer treatment. Should men avoid RALP because it hasn't been around long enough either? As pointed out earlier, there are studies showing excellent results of SBRT and many men who frequent this site have been treated successfully via this procedure.

Jim
Posted 8/7/2018 4:22 PM (GMT 0)
"No wad do sbrt no way hadn’t been around Long enough"



hats off to you guys who can decipher vicodinese tongue
Posted 8/7/2018 5:17 PM (GMT 0)
SBRT is simply a refinement of external beam radiation therapy that has been around for about a hundred years or so. All it does differently from traditional external beam IMRT/IGRT is that is delivers the radiation in five or six fractions rather than the 40 or so for the traditional method. Constantly improving technology makes these significant refinements possible.

Stan, how long should a procedure be in use before you would suggest using it? Obviously 15 years of use and experience seems too little experience for your liking.
Posted 8/7/2018 5:19 PM (GMT 0)
Ed, your humor is nearly as talented as your photography! Thanks for the language lesson.
Posted 8/7/2018 7:56 PM (GMT 0)
I actually understood what he was saying. Which scares the heck out of me. I must be channelling my inner Logoslidat
Posted 8/7/2018 11:55 PM (GMT 0)
At first I thought it WAS logo. . .
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