Radiation question

Was the G6 at age 42 treated in any way?

The primary case for surgery over radiation would be based on your age. You are a young man and have an excellent chance of fully recovering from the surgery itself, and given time ahead of the surgery to get your pelvic muscles tightened up will likely suffer very little with incontinence. It appears that the more they look for your cancer, the more they find, which means you probably have "multi-focal" or numerous small areas of cancer throughout your prostate, all of which have the likelihood of growing over the coming decades of your remaining lifetime.

Radiation OTOH leaves much damaged tissue behind. You're never sure of your actual PSA as it bounces around for a while until it stabilizes at your "nadir". Recurrences following any type of radiation DO occur, and there is always the possibility of developing secondary cancers from the radiation. I'm not bashing primary RT here, just saying it's probably not that you would want to live with the questions about after effects for another thirty years or so.

When I was diagnosed and making my treatment decision I found a site called prostatecancerfree.org to have value. There is a section that contains graphs comparing treatment success by risk grade. Initially they are very busy; but, once you ‘uncheck’ some of the boxes it makes comparing much clearer. The data is from an accumulation of medical studies including some that maybe a little old. The more time I spent on that site the greater the value I saw. You can click on each data point to find out more information about each study.

My interpretation of PCF data suggested the cure rate for most guys was slightly better for radiation treatments than surgery was. It’s true that younger guys recover from surgery more quickly than older guys; however, they have longer to live with unwanted side effects as well. I would expect that younger guys would be less likely than older guys regarding side effects as well. For myself I used 50% as the risk factor for urinary and sexual side effects. At age 69 with very good urinary and sexual function…50% was simply too high of a risk to take. My urinary and sexual function six years following SBRT remain the same as before treatment as best I can tell. Sometimes I think my urinary function maybe a little better since I sleep the entire night without getting up to pee.

Radiation can treat not only the prostate but the margins around the prostate. I believe modern guided radiation to be extremely effective and safe. As far as radiated tissue remaining generating new cancer I can only believe that it’s rare. I believe most radiation failure or recurrence is the result of PCa that has already escaped the prostate and not in the radiation field.

There are a lot or radiation options available and it does take some effort to evaluate them. HDBT and SBRT are both very effective and convenient. I hope you give consideration to both and I’m glad you’re asking questions. The best treatment decision is an informed one based on your individual circumstances. Terry

"The primary case for surgery over radiation would be based on your age. You are a young man and have an excellent chance of fully recovering from the surgery itself, and given time ahead of the surgery to get your pelvic muscles tightened up will likely suffer very little with incontinence. It appears that the more they look for your cancer, the more they find, which means you probably have "multi-focal" or numerous small areas of cancer throughout your prostate, all of which have the likelihood of growing over the coming decades of your remaining lifetime."

that's sounds like it's straight out of the prostate snatcher handbook. i believe that is BS. but then again take a look at my signature.

Anecdotally, I can't think of anyone in all my years on this website that had radiation, had a recurrence and then had a subsequent scan or biopsy that showed cancer in his radiated prostate (as opposed to a more distant location). Please correct me, if I'm mis-remembering some examples of this! At any rate, it's certainly not a "big issue" as per the question you've raised in your post.

As to the radiation vs surgery decision, based on your diagnosis you are extremely likely to be cured no matter what treatment you choose. I'd go for the one that you feel a greater comfort level with--I think we all have different factors that we use in evaluating that. (Not that I think it's as simple as I just made it sound--I agonized over my choice.) Good luck to you!

From everything I know, I would say surgery is actually your best option at such a young age. I had my surgery last May at the age of 62, and had zero side effects. I did have ED prior to the surgery, and still have it now, so it was not caused by surgery. Unfortunately my cancer had spread to a lymph node and I ended up needing RT and hormone therapy anyway. I know my ED is treatable, but since I'm on ADT I don't care. I know that sounds weird to men hopped up on testosterone, but it is what it is. Maybe I can get some mojo back after I'm done with my course of generic Zytiga, but for now I am feeling good and cancer free.

JRK you are an excellent candidate for radiotherapy. In my opinion, both SBRT-external beam and High Dose Rate brachytherapy should be seriously considered. SBRT can be done in 5 or 6 non invasive 20 minute procedures. HDR-BT can be done in one outpatient procedure taking about 4 hours in total. Neither result in any cutting damage from surgery, no overnight catheters and probably only one day lost from work. Both are equal to or superior to surgery for cancer control and markedly less significant negative treatment induced side effects.

Of the two (and surgery) HDR-BT is the most conformal to the cancer and affects other tissues the least as the radiation does not pass through the body. It is entirely focused on the prostate, seminal vesicles and about a 10mm margin around the capsule. Very effective for cancer control, low side effects and can be done in one procedure so it is the also most convenient and least stressful for the patient. It also avoid the risks inherent in surgery and a hospital stay. Further it has essentially no real recovery time or restrictions on activities.

As to radiation dose, it is not really determined by the risk level measured by Gleason. Rather it has been established by hundreds of trials and studies over the past several decades that have established a “sweet spot” or “Goldilocks effect” of finding the optimum dose that provides effective cancer killing without being overly toxic. Too little and the cancer survives, too much and the patient is too negatively affected. For the benchmark measure using the traditional fraction EBRT is 76-81 Gy delivered over 45 fractions. A recent study showed 78.1 Gy as the median of thousands of traditional fraction EBR treatments studied. So this difference is a matter of only 2-3fractions or about .2 Gy per fraction. Thus, a very narrow range. No oncologist says we use 76 Gy for G6 and 81 Gy for G9. Total dose depends on the time of radiation exposure. For HDR-BT the usual single fraction currently is about 19 Gy delivered in 15-20 minutes. On the other end of the range is about 135 Gy common in low dose permanent seed brachytherapy that is continuously delivered over a period of about 9 months. A recent British study used a single fraction of 25 Gy EBRT. SBRT uses a range of about 35-40 Gy in 5 or 6 fractions. When EBRT is combined with HDR-BT usually about 45 Gy is delivered by EBRT and 18-25 from the HDR-BT.

The important measure is the biological effective dose to kill the cancer without harming the patient. The biological effective dose is a function of the radiation dose and the time it takes to deliver it as illustrated. Unlike most cancers, PCa is more affected by higher dose of less time. Thus the effectiveness of SBRT and HDR-BT.

As to age, it is ridiculous to say that 50 is too young due to secondary cancer concerns. There is simply no real evidence using today’s modern methods, especially HDR-BT, to make such a charge. After all, look at the tremendous use of radiotherapy for childhood cancers. A recent Swedish study of some 400 men found a possible radiation induced secondary cancer incidence of about 0.3% at 15 years and that was based on the older styles of EBRT. The risk of dying from surgical risks and complications is close to 1%. Modern radiotherapy for PCa is of no real risk and those that speculate and warn of it are simply wrong or misinformed. And of course the surgeon that warns you are too young for radiotherapy will be the first to suggest salvage radiation therapy when the surgery fails to control the cancer, as it does in about 35% of cases. For men the most common cancers include bowel and bladder…that a man has PCa and then subsequent bladder cancer is not due to the treatment of the PCa. My brother-in-law had PCa and successfully used SBRT. about five years later bladder cancer was found. His golfing buddy said it was from the radiation. When asked, his medical oncologist laughed and said the bladder cancer most likely developed before the PCa and was in no way related to the radiation. Remember, correlation does not infer causation.

JRK, if you haven’t done so, please consult with a HDR-BT specialist and an SBRT specialist for assessment and your consideration. I would postpone any other treatment until you have done so. You get only one shot at this and will live with the consequences for hopefully another 50 years. Tread lightly and decide very wisely. Your life is not currently on the line and another month or two before treatment will not be of consequence regarding controlling the cancer, but could have profound consequences for the quality of your second half of life on earth.

JNF said...
...
As to radiation dose, it is not really determined by the risk level measured by Gleason. Rather it has been established by hundreds of trials and studies over the past several decades that have established a “sweet spot” or “Goldilocks effect” of finding the optimum dose that provides effective cancer killing without being overly toxic.
...

Guidelines for radiotherapy of prostate cancer (2020 edition) (Full Text)

If you look at Appendices 4 and 5, you'll see that the recommended doses for primary treatment vary according to one's risk group, which encompasses the biopsy Gleason score (<7, 7, and 8-10 corresponding to 76, 76-80, and 80-80+ Gy, respectively). I posted a link in this thread to the MSK study about suboptimum SBRT doses being administered. It takes quite a few years to work out the ideal doses and regimes (e.g. fractionation schemes) for a new modality.

Djin

JNF said...
Thanks for the distinction, Djin, but I see it without much of a distinction in practice. The effective range in the report agrees with what I reported, 76-81.
..

And most importantly back to our Op, JRK. With him being an intermediate G7 he is certain to get between 76 and 80 if he goes with traditional fraction EBRT. However, he is very likely to choose a more convenient treatment like HDR-BT or SBRT making the discussion of 76-80 rather academic and superfluous. Hopefully our rather detailed discussion will not confuse him. Wishing him the best.

I, too, wish our OP the very best and naturally do not want to confuse him. However, I do not think the dosage is academic. If I were weighing SBRT, the MSK study that looked at the 32.5 Gy to >40 Gy range would concern me enough to discuss it with my docs:

"Highlights

• SBRT dose levels of 40 Gy associated with improved post-treatment biopsy outcomes.

• Two-year positive post-treatment biopsies pre-dated PSA failure in majority of patients.

• PSA level at time of 2-year biopsy was <1 in majority of those with positive biopsies.

• Positive biopsy pts had higher 5-year BCR compared to negative pts (57% vs 7%; p < 0.001).

Conclusion

Based on two-year post-SBRT biopsies, excellent tumor control was achieved when dose levels of 40 Gy or higher were used. Standard SBRT dose levels of 35–37.5 Gy were associated with a higher likelihood of a positive post-treatment biopsy. Two-year positive post-treatment biopsies pre-dated the development of PSA failure in the majority of patients."

Djin

Post Edited (DjinTonic) : 9/14/2022 2:47:22 PM (GMT-7)

Mumbo said...
Then there is hypofractionated IMRT which is halfway between with 20-30 sessions at higher dosage which is a much more common choice right now from what I have observed. The basic decisions are tough enough for most men and all the shades of grey just make it harder. At some point, trusting a selected doctor is required.

From what I understand, the total dose of a RT modality remains the same across different fractionation schedules and is related to best practices. These, in turn, are based (or should be based) on research. I agree with you, Mumbo, about finding a doctor you trust, and that has always been my touchstone. But it has never prevented me from asking questions and inquiring about things I've read in the literature. It was trust in whatever uro I had at the time that led me to say yes to yet another biopsy whenever my PSA went up a little more than expected. Although this resulted in a long string of negative biopsies over the years, it also was the reason my high-grade cancer was found when there wasn't very much of it volume-wise.

Djin

Post Edited (DjinTonic) : 9/14/2022 3:22:28 PM (GMT-7)

I expect that a small fraction of surgeries release cancer cells into the body following surgery, which results in BCR. It just makes too much sense.

It's an interesting line of research. A general, recent paper on the topic.

Surgery induces increased shedding of cancer cells into the circulation, suppresses anti-tumor immunity allowing circulating cells to survive, upregulates adhesion molecules in target organs, recruits immune cells capable of entrapping tumor cells and induces changes in the target tissue and in the cancer cells themselves to enhance migration and invasion to establish at the target site. Surgical trauma induces local and systemic inflammatory responses that can also contribute to the accelerated growth of residual and micrometastatic disease.

It appears the inflammatory response is a key component. This 2018 paper backs up the argument, and further argues that taking anti-inflammatories (like Advil) after surgery for pain can help reduce that effect. . At least, it worked in mice for breast cancer.

Another good article.

I just had my aviation medical exam, where I discussed my cancer with the flight surgeon, who had had PCa back in 2014. He chose radiation for a big part based on an argument echoed in the paper. He also went to Florida for radiation, because he says that's where all the old prostates are.

He now has lung cancer that metastasized to the brain. Still working at almost 80 too. Amazing dude.