Undecided surgery or brachytherapy

CH...I know you're suffering from information overload, but the combination of HT, brachy and IMRT would not be used for a G6--at least here in the U.S. That particular combo is generally targeted toward higher risk diagnoses (I had that combo as a G9). A G6 would typically have either brachy or IMRT as a monotherapy--and no HT would be used.

What seems odd to me is that you have a recommendation or AS and another recommendation for the combo therapy--those are two different sides of the spectrum. Good luck...this part of the journey isn't easy.

I may be wrong, but what we know about this case is that biopsy shows a moderatly high volume of PCa and the mri show a PIRADS 5, also indicating high volume and high possibility of significant PCa or upgrading. Moreover, mri also shows that the lesion is close to the capsule. BT alone only destroys PCa inside the prostate and this is the reason it is not so safe here. Maybe some kind of external radiation would be more adequate as monotherapy if the final choice is radiation.

All forms of radiation treatment extend beyond the capsule, that's why it' a better treatment choice.

I really did not plan to reply. But after three answers telling I am wrong without any source supporting this opinion I just went to the maybe most basic information available, the ACS web:
"Brachytherapy alone is generally used only in men with early-stage prostate cancer that is relatively slow growing (low-grade).
Brachytherapy combined with external radiation is sometimes an option for men who have a higher risk of the cancer growing outside the prostate."
My point is that we are advising somebody with 6/12 positive cores in his biopsy and a mpmri revealing a PIRADS 5 lesion (very high probability of significant PCa). His doctors are recommending combined radiation or surgery and I give him the non-professional and less informed advice to believe them. Despise the biopsy G6, it is not completely clear it is an early-stage low-grase case. I really hope it is, but I was in a similar situation and I know now (after a path report) that I am not low-grade.

Madrid,

I regularly refer men to the website of Dr. Jeffrey Demanes. He started using HDRBT in 1981 and pioneered HDRBT mono-therapy in 1996. He has been a pioneer in HDRBT for PCa and many other cancers. He also chaired the department at the UCLA Medical Center.

His website is www.cetmc.com. In the PCa section he explains the radiation cloud from HDRBT as extending out at least 5 mm from the prostate capsule and explains it can extend further as warranted. He also explains the coverage of the seminal vesicles.

Another top PCa radiation oncologist is Dr. Alvarez Martinez in Detroit. I read several of his papers on the HDRBT protocol as my radiation oncologist followed the Martinez protocol. He cited that he would extend the radiation cloud out as far as 10 mm as appropriate.

When using permanent seeds it his reported that the radiation cloud extends 3-5mm outside the capsule. Among others so reporting is Dr. Frank Critz in Atlanta. He pioneered the use of concurrent permanent seed brachytherapy with external beam radiation in the 1970’s. His clinic, Radiation Clinics of Georgia has treated more than 20,000 men for PCa.

Thus, the greatest radiation cloud coverage is when HDRBT and IMRT/IGRT are used concurrently. My HDRBT included the seminal vesicles and extended outside the prostate capsule by 10mm in most areas. Due to my high risk status I also received IMRT radiation to the pelvic and many abdominal lymph nodes. All this with curative intent. Obviously the advantage of such coverage is that surgery simply can not reach such a large area without inflicting tremendous harm.

Contemporary trends in treatment of PC continue to slowly evolve...you should research this on your own (use these key words). The most significant change is the uptake of AS as first-line therapy...not, however, the best choice for you. (There are various "protocols" for AS, not one universal, one-size-fits-all, in the US, in Australia, in Colombia...everywhere; but your 50% positive and +DRE logically exclude you from most.)

The second most significant trend in the last decade is the shift of radical prostatectomies being almost exclusively robotically-assisted, whereas 10 years ago it was about 50/50 "open" RP.

The third most significant trend in the last decade is the rapid near elimination of brachytherapy as a mono-therapy. 10+ years ago, nearly 10% of PC cases had first-line BT; today it's less than 2%. Many facilities have dropped BT, and schools are not generally teaching it...at least not here in the US.

EBRT+BT usage has remained steady (but low, overall) for high-risk cases (somewhere between 1-1.5% of all treatments), but dropped 25% for intermediate cases in 10-years, and is rare (<0.3%) today for low-risk cases such as yours.

With the increase in AS, all forms of radiation combined have taken most of the hit; the steady growth of RP in the preceding decade also flattened out. Patients undergoing treatment continue to be younger, which aligns better to RP compared to RT, contributing to the overall shifts. Overall, RP remains the most frequent treatment, EBRT second, SBRT is an emerging yet minor contributor, BT is going away.

I know this is really not related to this thread, but the last time I was at Dr. Moran's office (Chicago prostate center) I asked his assistant if anyone is training with the Dr. Her answer was no. I'm pretty sure he is in his early sixties and has performed 20k LDR procedures. He is pretty much the top 5 in his field, place is always busy, in other words, there a lot of people going there. Still Its interesting that when he stops it looks like there will be no one to replace him. On one of his blogs he even talks about Brachytherapy being a dying (art) procedure, not because it doesn't work, but because doctors are going different routes. Well, maybe I should re-phrase that last sentence… I sure hope it works.

I have had meals with RO's on cruises and other trips, and they told me that BT was declining not due to any performance deficiencies, but because it was less profitable for the providers. Insurance companies will pay a lot more for 40 treatments than for one or two sessions. I asked about SBRT, and they said that was now being paid reasonably well, but only after much argument.

I had consultations at Sloan Kettering when I was researching procedures 4 1/2 yrs and I was interested in HDR-BT, but it was apparent that at the time it was done there only rarely as a mono therapy. But now see they have a new HDR program. So maybe there will be some renewed interest in places.

ASAdvocate said...
I recently attended a local PCa support group that featured a panel discussion with a surgeon, radiation oncologist, and medical oncologist.

One of the most interesting take-aways was the radiologist stating that his large hospital had just installed new HDR-BT devices. He said that they were very unlike previous versions. Much easier on both the patients and doctors. He was highly impressed with the graphics that allowed very precise real time monitoring.

This was from a guy who had extensive experience with IMRT, SBRT, and protons.

So, I guess that we may be seeing a new dawning of HDR-BT.

Interesting JNF. I will never forget my primary care doctor trying to talk me out of a PSA, saying it would just add unneeded stress. Grrr.

JNF said...


He has also reported several times over the past couple of years that there are proportionately more men further advanced at diagnosis. Many of these are choosing combination brachytherapy and IMRT instead of surgery with the high probability of either adjuvant or salvage radiation. This is in line with his initial treatment advice for me nearly nine years ago. He thinks fewer men are being routinely screened compared to 5-10 years ago. When I was diagnosed and for many years prior many groups sponsored free screening events several times a year. That appears to have completely stopped.

The screening recommendations of 4 years ago, that have since been revised do seem to have had two seemingly opposite--but both predictable effects: On the one hand, there are fewer men getting screened, so there are fewer low risk diagnoses that end up with early or unneeded treatment. On the other hand, with fewer men being screened earlier, there are more men showing up with higher level initial diagnoses, that might well have been caught earlier if they had screened earlier. And, both of those outcomes were entirely predictable with the change in screening recommendations.

Blackjack, my urologist's practice does not own any radiation clinics. In the Atlanta area the largest seed practice (RCOG) is owned by Northside Hospital. Northside also owns the clinic where I had my HDR and IMRT treatment. They also perform SBRT. The other HDR clinics are Emory Hospital and Cancer Treatment Centers of America. So none of these are owned by urology practices. Your point about urologist owned radiation centers may be valid in other markets but your innuendo regarding Atlanta is incorrect and inappropriate.

Regarding my Urologist's practice, he has long said he would only operate when there was an extremely high probability surgery would be curative and not require salvage radiation. That precludes those diagnosed as high risk. He practices in such a way as to avoid the greater risk of more significant negative treatment side effects when one is exposed to both surgery and radiation. He also would not operate on low risk men as he was a very early proponent and adopter of AS treatment protocol and since his residency has determined that surgery for low risk is unnecessary over-treatment. . As such, he was not doing very many prostatectomies and stopped performing them several years ago. I like to share his professional approach as it appears to be rather unique. He is a urologist first, not a surgeon practicing in the area of urology. He looks to ways to avoid surgery and is a strong proponent of non-surgical treatments for PCa. If a PCa patient truly wants surgery, he refers them to one of his associates that is a full time PCa surgeon performing many each week. He specializes in prostate work (and continence issues in both men and women) with much of it being enlargement and BPH and he does surgical procedures where appropriate, just not for PCa.

Atlanta has a long history of large PCa radiation practices that makes it different than most other large cities and obviously doesn't follow the national trends cited by Blackjack. Since I was treated there are more radiation clinics for PCa not fewer. And has added a Proton Center. My urology group is the largest in Georgia and I have reported how their PCa practice has been changing which doesn't appear to be following the trends that Blackjack cites.

AS, I am not aware of mono-therapy BT (seeds or HDR) ever used in high risk cases. The RCOG here in Atlanta and other seeds doctors like Moran and the late Peter Grim use seeds with IMRT, except in low risk situations. Their use of seeds mono-therapy would have been limited to lower risk. You can see from the Demanes website that mono-therapy HDRBT is clearly not for high risk. My clinic explained to me at my dx that it would be combination HDRBT and IMRT due to my high risk dx. In the past few years they have been offering more mono-therapy HDRBT and basically follow the protocol established by Demanes and limit the practice to low and favorable intermediate risk, never high risk. Martinez in Detroit limits HDRBT mono-therapy to risk profile similar to Demanes. Emory Medical Center here in Atlanta offers both HDRBT and seeds and explain that the risk profile will determine when mono-therapy can be used.

I don't see any complication in comparing treatment therapy results and there have been numerous studies that we have all read. As long as there are multiple methods to approach PCa we will be reliant on such comparisons and they would not be moot in my opinion. While I find it good that there are several different PCa treatment methods that often can be pursued, it also complicates the decision making for many men. But we need these comparative studies to both guide the specialists with their protocols and their recommendations as well as for the patient in comparing different treatment methods.