Brachytherapy HDR

Hi Michael_T,
Thanks so much for your input Michael. Everyone opinions are helping me so much as I am overwhelmed with this Pca. It’s comforting to see the outpouring supports that I have received from this forum and I appreciate it so much.
Last night I have read some of the posts on HW and someone said that SEs are happening right away with surgery while with RT they’re coming later and it concerned me. As of now HRD Brachy appears to be the one but I believe my husband should give more thoughts about other options before making the final decision. I have searched online for the successful rates beyond 10 years for Brachytherapy but have found nothings. Do you or anyone have this information? Today I asked my husband to considering the possibility of having his appointment rescheduled so we can get a 2nd opinion with Epstein. Of course the active monitoring would be better but it’s not possible with the current pathology report. I do agree with everything you said about getting Epstein’s opinions as it will give us a peace of minds and go forward from there. It would also help his RO to treat him more effectively. His RO has excellent credentials as he went to Yale for his undergrad, A. Einstein for medical school and University of Chicago for residency. They are all the top schools so he is probably an outstanding doctor but he has only about 4 years of experience. Some may say it’s better to get a young doctor as they have more up to date medical learnings and teachings but I just want make sure that we have chosen the right one when it comes to cancer. I noticed that some people here has more than one type of treatments for their PCa like yourself and wondering if you have made that choices or were they recommended by your doctors? My husband’s doctor did not mentioned anything else other the radiation and that why I asked. Thanks again Michael.

On the subject of side effects:

The commentary on this forum is not an accurate reflection of side effect statistics--which are notoriously difficult to get with any accuracy anyway. Why? This is a self selected group. The men who hang around a long time tend to be those who either have a personal commitment to being there for the newbie, and/or are those with severe cases and continual problems.

Yes, it is likely that more men get treated with surgery than with radiation on a big picture basis. I suspect there are two reasons for that: As JNF said, the vast majority of men are diagnosed by a Urologist--who is a surgeon, after all, and that urologist operates on them and they are done. The second reason is that relatively few cases fall in the high risk category, where surgery is not automatically recommended. The vast majority of PCa diagnosis fall in Low and Low-intermediate risk categories--and since most men are diagnosed by surgeons, most have surgery, and have uncomplicated recoveries--and never show up here.

I suspect it is true that in the historical past--more than 10 years ago, before advances both in surgery and in RT, that side effect stats were very different. Both treatment methods have gotten LOTS better over time. So, be very careful when looking at the data that is out there, and look at when the treatments were done, as well as the other variables, such as age of the patient at the time of treatment, severity of the case, other issues the patient might have had, etc.

I'll repeat what we've said to you all along: You're at a world class institution for HDR. HDR is a great treatment protocol. Relax into that knowledge. The treatment recommendations, and the treatment process itself is a team project, not just one doctor by himself. It's important to do due diligence--but it's also important to not overthink it.

For the record, I'm a surgery patient, 7 years out. My cancer falls in the 'cured' category, and I don't have any significant side effects, and never did after the initial recovery period.

ConfW

Like F8 I am nearly 12 years out with no negative treatment side effects and an undetectable PSA….best of both worlds. The link I gave for Demanes shows 15 year results and that was six years, or so, ago that he last published. He actually started publishing 15 year results some 15 years ago. Permanent seeds brachytherapy pioneer, Frank Critz here in Atlanta, has published 15 and 20 year seeds experience. I’ll find the link to the studies for you. I had his initial 20 year study when I interviewed him as part of my treatment search back in 2010. One of my business partners had used Critz in 1995 and never had a recurrence nor negative side effects. Another compendium of some 15,000 peer reviewed studies that compare treatment efficacy and side effects by risk factors can be found at www.prostatecancerfree.org.

Coincidence that my great urologist was Yale and Einstein, and then chief resident here in Atlanta at Grady. I am sure he knows of the RO you are talking to and I will be happy to get his insight for you. As to being young, my uro and RO were both in their late 30’s when I was treated. At that time they had done more than a thousand HDR procedures. The age is not important, but look at the number of procedures. Surgery usually takes at least 750 to be considered as good. With HDT the catheter placement is critical and is done with ultrasound and CT guidance with the urologist usually doing the initial placement, then the RO fine tunes the placement under CT in accordance with the carefully prepared radiation plan unique to each man. The RO has an amazing team developing and delivering the plan including a nuclear physicist, dosimetrist and several radiation technicians. So ask about all the team and you will find at a place like UCSF even the very young have great experience. Your RO actually has more like 8 or 9 years experience when you count the residency.

Simply put, HDR-BT is a method that provides great cancer control with usually the least significant negative treatment side effects. As for me, zero treatment side effects after nearly 12 years. I have never worn a pad for urinary leaks, no bowel issues and fully capable sexually without ever having taken a pill. Sounds lucky, but most HDR men will similarity report. At our meeting last week we had about 20 men with only 4 that were radiation for initial treatment, one seeds, one SBRT, one IMRT and me with HDR; none reported treatment side effects problems. Most all of the surgery men reported continued issues, from mild to significant, with incontinence/urgency and/or ED and have to consciously manage their situation. A few have had to use surgical interventions like the sling to help their management. We had a doctor speaker that specializes in treating the side effects and there wasn’t much for me to take away as he was mainly addressing the surgery men. And he reported in his practice he sees very few men that used radiation as the initial treatment.

Not all surgery men have negative effects, but comparable studies most always show that radiation therapy is inherently less damaging regarding side effects than surgery. And look at the big shift over the last decade when public attention was drawn on the surgical overtreatment of low risk men and the articles chronicling the negative side effects of surgery. Radiation therapy was rarely mentioned in the reports and articles. Some radiation men experience more significant side effects, but they are usually the ones that use external beam radiation and the culprit is the effect on the bowel. You simply can not use external beam radiation (IMRT/IGRT/SBRT/Proton and CyberKnife) without about 10-15% of the dose being absorbed by the bowel. Since there is much less radiation outside the prostate with HDR, the side effects are usually very minimal.

ConfW said...
I noticed that some people here has more than one type of treatments for their PCa like yourself and wondering if you have made that choices or were they recommended by your doctors? My husband’s doctor did not mentioned anything else other the radiation and that why I asked. Thanks again Michael.

Multiple treatments are the result of higher risk PCa conditions and/or failure of primary treatment. Everyone would like a "one and done" treatment scheme but that is not always possible or recommended in some cases. A surgical or radiation only primary treatment is best for those with simple cases where most never look back (or spend a lot of time on forums).

As the PCa risk increases, ADT is typically added to primary radiation as a concurrent therapy. In the case of high risk cases, ADT + focal radiation (HDR or SBRT) and broader radiation (IMRT) are used as the "belt and suspenders" approach which you see in some signatures here.

Surgery is somewhat different in that some decisions are usually made after the prostate is removed and examined and all risk factors get a second look vs. limited biopsy conclusions. This is both good and bad and the subject of much discussion. If the risk level is high, adjuvant radiation (IMRT) is done after surgery regardless of PSA. If risk level is not as high, salvage radiation is done when the PSA becomes detectable or starts rising at a predictable rate. ADT can be added as well during these secondary treatments.

Please note that there is a sensory overload condition that sets in after studying PCa for weeks and months. There are studies and opinions that will support about any conclusion that one wants to draw from them. The subject of bias is another factor that is hard to remove from one's thinking as well.

Based on everything your have described so far about your husband's situation and barring any significant changes by Dr. Epstein's review, he would be well suited by the proposed HDR Brachy treatment at UCSF in my opinion especially if that is what he prefers.

"If the risk level is high, adjuvant radiation (IMRT) is done after surgery regardless of PSA.'

in a perfect world, yes. but in my many years here that is not always the case

Mumbo said...
F8 - Agreed but I think that is mainly because the doctors don't urge it upon the patient. Both my URO and RO said after my 3 mo PSA <0.10 "Hmmm, ART would be indicated based on the pathology but then again you may not need it and might be treating something that is not there until your PSA shows something. It is your decision and I/we can support either decision" Both doctors also indicated that ART tends to stop progress on continence and ED so if those are concerns, waiting for resolution might be a good idea. Thus more study and decisions were left to me. (As a side note, Dr. Epstein pushed me over the edge when I asked what would he would do and got a straight answer.)

I have found almost all doctors nowadays are very "wishy-washy" regarding recommendation and decisions and will be very clear that you have to make the decision. The over treatment and malpractice issues have neutered many doctors from speaking their minds.

ConfW - Sorry to get off track but it may be of interest.

surgeons are subject to denial. there is no other explanation i can think of as i watch the PSA climb after failed surgery while the doctor orders more tests and wastes more time

i think telling a high risk guy "we got it all" right after surgery is irresponsible but i think many doctors believe it

@JNF, I am reviewing my husband’s phone conference notes and one of the treatments mentioned was CyberKnife. My husband feels that HDR Brachytherapy is better than CyberKnife and I saw a post on HW posted earlier this year that someone had issues after his CyberKnife procedures. Since you are a long time member and have more knowledge of treatments, what do you think about CyberKnife vs. HDR?
about HDR Brachy treatments, my husband’s OR doesn’t recommend using SpaceOAR as he feels it will cause more complications. What do you think about that?

@Sr Sailor, Thanks and I have read the above link. I understand about SpaceOAR, but from what I read @Urologyhealth.org, nothing mentioned about its side effects, only its benefits. This is confusing. Just saw an article about SpaceOAR side effects. https://pubmed.ncbi.nlm.nih.gov/31452385/
My husband’s doctor is also performing SBRT, according to his profile. One thing that confuses me was from an old HW post, someone said it is recommended to get doctors that perform one or the other, but not both. What is your opinion on this statement?

Post Edited (ConfW) : 5/3/2022 5:57:19 PM (GMT-6)

ConfW, let me take a stab at a number of your comments and questions going back many responses. I hope these make sense and trying to do it in order of some of your comments and questions.

I don’t understand what you meant when you said “my husband isn’t taking anything” in regards to the catheter placement to deliver the radiation. These are not urinary catheters. Please refer to the link I suggested that will show you how the HDR radiation catheters are placed. See www.cetmc.com. These are the very thin long straw like catheters that the radiation pellet is introduced into and removed providing the radiation treatment.

Regarding Dr. Scholz, everyone makes money including him. The key is to cut through any marketing clutter and undo influence and choose the doc that provides the treatment best for you husband. I hope all my docs make a lot of money. If they didn’t it would indicate they weren’t worth seeing. I also like it when I work hard and do the right thing for my clients and am well compensated.

If surgery fails we can save it by radiation. But if radiation fails….then what? All radiation covers an area larger than the surgeon can cut. Radiation rarely fails locally. When it fails it means the cancer was already outside the radiation area, and surgery would have also failed. If recurrence is truly local, it is not best to use surgery as salvage, but often focal radiation, like HDR can be used as well as non-radiation focal methods like HIFU, cyro, and nano-knife can be used. In an intermediate man like your husband, the use of these are thankfully rare as the radiation has a high rate of efficacy. See the studies I referred you to that compare treatment methods.

HDR versus stereotactic (SBRT/Cyberknife). SBRT and Cyberknife are external beam radiation. A radiation beam is produced and sent through the body in order to radiate the prostate and cancer. The entry and exit of these beams radiate healthy tissue and do some damage. Hence the side effects from the treatment. This is low due to the placement of the beam which rotates around the body to minimize radiation on one spot. HDR brachytherapy is interstitial, meaning from within. The pellet is introduced into each of 15-18 catheters placed in the prostate and seminal vesicles. Thus the radiation does not pass through the body to find the prostate, rather it emanates from within the prostate and does not affect healthy tissue outside the prostate. This makes the radiation more conformal to the prostate and cancer and spares much of the healthy tissue that external beam must go through. This reduces the negative side effects particularly to the bowel. My risk factor was too high for SBRT. Because of my high risk I used a combination of HDR and IMRT external beam. This is a well proven combination for high risk. Also, I needed my pelvic and abdominal lymph nodes radiated as they were suspect for cancer spread. Only external beam can do that.

Space Oar, when used, is usually with SBRT/Cyberknife. Remember this external beam radiation must pass through the body, especially the bowel. Space Oar is a gel that is infused to create a space between the bowel and prostate to create a distance for the radiation beam away from the bowel. Many studies and the useage indicates it is a bit of a coin toss as to use it. If it was so great it would always be used. From my understanding, it is not usually used with HDR as there is no need. Myself and about 10 different people I know using HDR in the past couple of years did not use Space Oar. The current best known at HDR, Dr. Alvarez Martinez in Detroit, does not use it.

Today most any radiation oncologist performs both traditional fractionated and hypofractionated radiation(SBRT). It is the same machine and radiation, just a difference in how much radiation dose and how many fractions. Not all RO’s perform brachytherapy, either permanent seeds or HDR. These are radiation sub specialties that require additional training and equipment. Most all that perform brachytherapy also perform external beam. Often they combine the two for higher risk, like myself, where the combination has proven to be more effective than either separately. For lower risk, there is no need for the combination treatment.

I hope this is helpful, let me know of any questions or clarification you may need.

I'd like to add: this whole straw man argument about surgery being better because there are things you can do if it fails, where Radiation has no additional options is so, so wrong.

We've talked about it a LOT in here. There are at least 2 assumptions in the argument: One is, that we assume that the primary treatment will fail. For low to intermediate risk patients, does anyone know what the cancer control failure rate IS? I bet it's in the fractions of 1 percent. In other words, it's a non-issue. The second is that we assume that primary RT (in any flavor) is all that is possible. Also not true. Primary failure--whether it is surgical or RT, usually means that the patient has already metastasized out of the prostate into surrounding tissue or beyond. When that happens, it wouldn't have really mattered what the primary treatment was--the horse was already out of the barn, as it were. As JNF said, primary RT is actually better in that respect, because it treats a larger area than just the gland by it's nature.

In comparing treatments such as HDR-BT and SBRT, it is useful to note that SBRT was specifically designed to deliver the same radiation dosage effect as HDR-BT, but by external beam, rather than momentary implants.

So, there is similar efficacy between the two treatments.

This PCa is really depressing especially when I browse through the forum from cancer.org. It appears that more people selected surgery than radiations from that forum. Someone said one’s life will never be the same after PCa and I am so sad 😢. I would like to ask everyone who’s in remissions about their eating habits and nutritions. Do you all cut back or eliminate all meats, alcohol? I am always pushing for fruits and vegetables in my family even when they don’t like them and yet it’s still not enough to prevent this cancer.