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Update on HDR Monotherapy Treatment

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Prostate Cancer
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Posted 8/9/2018 9:48 PM (GMT 0)
In July, I made my final decision to have HDR Monotherapy to treat my Gleason 7 (3+4) cancer found in one core of my 12 core biopsy back in February. In preparation for the treatment, we agreed to schedule an mpMRI to make sure we had all the information needed to finalize the HDR procedure. The MRI results show no evidence of seminal vesicle invasion, no evidence of EPE and the neurovascular bundles and capsule intact. I believe this was all positives signs that the cancer is most likely still localized to the prostate. However, the MRI did identify one lesion (1.1 x 1.0 x .8 cm) scored PI-RAD 4 in an area on the opposite side of the prostate from where the original positive core was found. (I did find it interesting that nothing showed up on the MRI in the area of the original positive core.) My radiation oncologist said we can't move forward with HDR treatments until we determine if the PI-RAD 4 lesion is cancer and if so, what is the Gleason score. I am now scheduled for a fusion biopsy on August 22nd to check the pathology of the lesion. I assume if the fusion biopsy shows the new lesion to be not cancer or cancer of Gleason 7 (3+4) or less, we will move forward with HDR Monotherapy. If the new lesion is a higher grade cancer, we may need to combine the HDR with external radiation and/or Hormone Therapy. This setback has been a little frustrating because mentally I was ready to get my treatments finished and move on. Now I am back to playing the waiting game and hoping for the best on this next biopsy. Would be curious on any feedback board members have on my circumstances and path forward.
thanks MJ
Posted 8/9/2018 10:06 PM (GMT 0)
It sounds to me like your doc is being cautious--I almost wonder if he's being overly cautious since as you said, I think the only thing that might change your treatment plan would be if it were a G8 or greater. And it may not even be cancerous at all.

When I had my HDR brachy (combo treatment, not mono therapy) I had assumed they would use larger amounts of radiation where my G9 was located. But the doc told me they don't do that--it's blanket coverage throughout the entire prostate. Assuming your RO follows the same plan, the location of another tumor wouldn't make a difference in the HDR plan, but I guess it could make a difference in deciding if you need combo treatment and/or ADT.

Good luck...I can see how this is very frustrating for you.
Posted 8/10/2018 12:27 AM (GMT 0)
Michael T - did you have the triple play instead of monotherapy because of the G9? - MJ
Posted 8/10/2018 1:52 AM (GMT 0)
Yes, the G9 drove my treatment choice. I don't know if you've seen Jeffrey Demanes's (UCLA doc who was a pioneer of HDR brachy) website about HDR brachy, which has a discussion about mono therapy vs combo. He certainly seems to think mono therapy is adequate for intermediate risk PCa. www.cetmc.com/prostate.html

I have no clue is what the the chances are that your PI-IRAD 4 is high risk. Maybe TA or someone else has some stats on that, but I'd assume the chances are pretty low. But sure seems like your uro thinks it's important to know for sure. I can certainly see why you're anxious to get moving on this.
Posted 8/10/2018 2:23 AM (GMT 0)
That's annoying to have to get another biopsy. I've not heard a case like this before, but it kind of makes some sense.

Hopefully they don't find anything bad and you can move on.

Still, if it is bad - you want to know know and get the right treatment.

Andrew
Posted 8/10/2018 9:25 AM (GMT 0)
I get how waiting sucks. But you want the best first treatment. I am sure they want to know the exact extent of your disease so if hdr is a go they can plan the catheter insertion properly. I suspect you will have to wait so time after biopsy before treatment to let the prostate calm down from being poked. Hang int here. Denis
Posted 8/10/2018 1:41 PM (GMT 0)
Thanks Denis, Andrew and Michael T for your support and feedback. - regards Mike
Posted 8/28/2018 10:24 PM (GMT 0)
Just received the results of my fusion biopsy. Not only was the PIRAD 4 lesion on the left side of my prostate Gleason 7 (4+3) but the six other cores from the left side of my prostate showed varying degrees of Gleason 6 and 7 cancer. All cores from the left side of my prostate were benign on my last biopsy from February of 2018. The right side had 1 of 6 cores with Gleason 7 (4+3) only change from February was change from Gleason 7 (3+4). I was surprised to see such a big change in biopsy results in just six months. Has anyone had a similar experience? Also looking for some feedback on whether this will eliminate my plan to have HDR as a monotherapy? I have follow-up with RO next week. Do you think he will recommend HT and/or external radiation along with HDR based on the new biopsy results? regards MJ
Posted 8/28/2018 11:54 PM (GMT 0)
MJ...there's a certain degree of luck in a biopsy, so it could have been just where the needle poked or perhaps you do have more cancer than you previously did. My suspicion is that you still qualify for HDR mono therapy and you would not need ADT, but that would depend on how your RO looks at these things. I do know that Demanes at UCLA uses mono therapy for intermediate risk cases and you're still intermediate.

Not sure if you want to get a second opinion again from Epstein. It does look like you've gone from a G7 (3+4) to a G7 (4+3). That actually changes your risk classification a bit, as opposed to the new G6 and G7 samples.
Posted 8/30/2018 3:02 PM (GMT 0)
Michael T - thanks again for your thoughtful feedback. I spent the last 5 months doing my due diligence based on a certain set of data and getting comfortable with my plan forward. Now the data has changed significantly and I may have to modify my plans in a short period of time. I am scrambling to find information based on the new data and I hope my visit to the RO next week will help. regards MJ
Posted 8/30/2018 3:42 PM (GMT 0)
Jeffrey Demanes MD (HDRBT pioneer) website (www.cetmc.com) excludes 4+3 for mono-therapy unless it is a very small amount of the cancer discovered in the biopsy. He also references it needs to be less than 50% of the sample. It appears you might still meet his requirement. I suggest you read it yourself and consider sending him your dx information for an assessment.
Posted 8/30/2018 4:04 PM (GMT 0)
JNF - thanks for the information, I just sent you a personal email with a few questions. thanks MJ
Posted 8/31/2018 4:22 AM (GMT 0)
so six cores positive on one side and one on the other, G7 and what was your PSA? i'd say your risk is similar to mine except I was 3+4. but really we both know I could have been 4+3 or 4+4 or 5+4.

i'd say combo therapy would be wise now. its really odd that all six on one side are positive and last time all were negative. just goes to show that without extracting the prostate there is no way of knowing for sure.

so it comes down to how lucky you feel. we assumed worst case when I was treated. good luck!
Posted 8/31/2018 4:23 AM (GMT 0)
"Not sure if you want to get a second opinion again from Epstein. It does look like you've gone from a G7 (3+4) to a G7 (4+3). That actually changes your risk classification a bit, as opposed to the new G6 and G7 samples."

also he's now got positive cores on both sides, which also increases risk.
Posted 8/31/2018 6:18 PM (GMT 0)
The good news is your team can treat it accordingly and You do want the best first treatment-so true!
My first biopsy was very low T1c, G7(3+4) & PSA:3.9 but after my surgery: pT3b, G7(4+3) SVI+ with 1% of 5. (Stage III)

You got this...
Keep on pounding!
James
Posted 9/1/2018 5:12 PM (GMT 0)
F8 and James - thanks for the feedback and encouragement. I plan to do some more research on HT over the next few days and try to finalize a treatmen plan with my RO on Friday. - regards MJ
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