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SEEDS: Why are people rejected for this treatment?

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Posted 7/11/2010 3:29 AM (GMT 0)
When you look at the studies and charts, brachytherapy combined with IMRT SEEMS to have the best 10 year outcomes...Why isn't it "The Gold Standard"...??

Why are people turned down for this treatment?? Is great skill needed to administer it?
Posted 7/11/2010 3:44 AM (GMT 0)
Too high of Gleason scores, suspected non localized are probably the two main ones. We still need a few more years to be able compare its stats with surgery, but you are right, it does appear to be a treatment of the future.

There have been some bad cases of administration, that have given it a bad name, most notably the VA case. We have heard of some not so great results on here as well, probably due to malpractice as well.
Posted 7/11/2010 3:56 AM (GMT 0)
It seems to involve some pretty tricky equipment, an "afterloader" to feed the "seeds" into position after the O.R. staff have left the room.. Lots of tubes and needles. I'll have to study up on the exact methodology..
Posted 7/11/2010 4:12 AM (GMT 0)
And of course for all those with enlarged prostates -- well, you might be too big. 60 cc is the cutoff point for Brachy. Sure you can go on Avodart for a while to bring the size down but if you are antsy about 'doing something now' you might not want to wait a month or two or more.
Posted 7/11/2010 12:24 PM (GMT 0)
Fairwind,

As Jimstar says, a large prostate usually calls for Avodart (or something) to shrink it.  Mine was large (ended up being 70 grams) and my uro said I would need to shrink it before the seeds.  My uro said it would take a couple of months.  After studying the procedures I decided to be Davincied.  Basically, I felt that if the gleason was low, and that if the cancer was confined to the prostate then removing the prostate would remove all of the cancer; whereas, with radiation I would be unsure if some small tumor within the prostate had been missed.

I see you are in Denver.  I am interested if you are going to The Urinary Clinic of Colorado (TUCC).  I have two friends that were treated there and they really liked it (especially the post treatment support).  I was treated by Kaiser, and although I feel the outcome of the surgery has been better than I had hoped (knock on wood ... hmmm) and they have complied with everything I have asked for, I had to be smart enough to ask for it ... thank God for the internet and books.  Also, I've gone to a couple of TUCCs forums and learned alot about ED treatment, rising PSA trreatments, etc.  I am thinking of switching to BC/BS so I can use TUCC.

Best wishes in making your decisions.

Posted 7/11/2010 1:23 PM (GMT 0)
First of all RCS there are no guarantees for either radical surgery or radiation. If treated with seeds the prostate is destroyed but as with surgery that doesn't mean all PCA cells are eliminated on a microscopic cellular level. In fact "cure' rates are identical in both procedures for low risk PCa. Then of course only time will tell if anyone's PCa is local or systemic.

As far as TUCC goes it's a very nice building but it depends which doctor you go to there. If I had decided on seeds and I almost did, I would've gone with Dr Westmacott but the couple of urologists I saw there initially I wasn't impressed with. Instead after seeing Mike Landess' PCa special I went with the advanced researchers at the CU Medical center and would recommend them over all other local treatment in Denver. Fairwind if you wish contact me and I'll give you the info as who to see there. I'm also a living testament to targeted focal treatment over radical destruction or removal of the prostate. Mine was done with cryo but now lasers are being experimented with.
Posted 7/11/2010 1:36 PM (GMT 0)
Realziggy,

I don't think I claimed there was a guarantee for either radical surgery or radiation. 

I agree with you that CU Medical is a wonderful facility ... my wife has worked there, she is now with Rocky Mountain Cancer Center.

Posted 7/11/2010 3:36 PM (GMT 0)
Fairwind, From what I have learned, very large prostates and PSA scores of 8+ don't seem to be treated with seeds....though there may be exceptions. Your stats should be OK. I started out with surgery as my first choice and changed my mind after doing more research and reading a lot on this site. In my case the seeds were implanted by a team: a radiologist who "mapped" the prostate and calculated the radiation dosage he wanted in each area, and a urologist who used the multi-needle device to implant the seeds. As with surgery, you want docs that have done hundreds of these procedures....which mine had. (note: the reality is that you will have to take their word for how many since you really have no way to check.....same with surgeons who do radical and/or robotic removals).  My procedure was done on an outpatient basis....I was in and home the same day with only minor discomfort. Three days later, I was back to all my normal activities. I am very happy with my choice and admit to being biased about BT combined with IGRT as it relates to quality of life issues....and with comparable outcomes to surgery. Regardless of your choice of treatments, you will find a lot of support on HW. Learn all you can, ask a lot of questions about side effects, make the decision that feels right for you and then don't look back. Regards, Joe  
Posted 7/11/2010 3:57 PM (GMT 0)
Prostates over 60mm are not candidates for seeds, although a large prostate can be shrunk up to 50% with a combination of Casodex and Proscar for a period of a couple of months. Patients with urinary issues may not be candidates for seeds as the radiation will make the issue worse.
Seek a Brachytherapist that has done at least 500 procedures. Like surgery this is a skilled and experienced based procedure and better doctors get better results. The Dattoli Cancer Center, Chicago Prostate Center, Seattle Prostate Center and RCOG all have long term reliable data on both cure rates and side affects.
A combination of seeds and IMRT is very effective for high grade gleason, higher cure rates than surgery alone. The advantage of a combination therapy is that two different types of radiation are used, so if a pc cell is resitant to one form the other will kill it. Also dead spots are reduced and margins can be targeted up to 15mm. The higher dose about 140 to 150 gy is far higher than radiation alone at 81gy with no increase in side affects. A combination of Surgery and salvage radiation will approach these cure rates, but with much higher side affects and complications.
There are many 15 to 20 year studies comparing brachytherapy and combination therapy to surgeryacross all Gleason grades.. The Prostate Cancer Study Group details all theses studies and was composed of well known doctors from all fields, pathology, surgery, oncology and radiation.
JohnT
Posted 7/11/2010 4:51 PM (GMT 0)
Hey, thanks for all the great info..Yes, TUCC is my primary treatment center..My daughter works at CU Medical, Anschutz, so that pathway is open too..My insurance, Medicare Advantage, is an HMO style and my treatment choices are limited to the metro Denver area..I can sign up for a broader coverage, more expensive plan in September during "open enrollment".

My team at TUCC are Sorensen, Jones, Westmacott but I have consulted with a radiation doc and a medical Oncologist doc outside that umbrella.

My main concerns are my Gleason 9 and the fact that my TRUE PSA is somewhat unknown because of 18 months on Finesteride (Proscar). I had a PSA done in May and it was 7.0, so I have doubled it to 14 but that's just a guess..
Posted 7/11/2010 5:17 PM (GMT 0)
Dear Fairwind:

I'll be happy to give you my perspective on your questions:

1.  "Gold Standard".  IMHO, surgery is still considered the "gold standard" mainly as an historical artifact and due to the perputuation of this persepctive by the fact that the most common "treaters" of PCa are urologists/surgeons.  Let's face it, most of us get referred to urologists when PCa is suspected.  And it's only natural that these doctors would suggest the treatment with which they are the most comfortable.  We have a poster on this forum who is a physician (non-urologist) who opted for surgery for his PCa treatment.  I recall that he once stated that he didn't even CONSIDER any other treatment but surgery!  I think that might be indicative of the understandable bias that uro-surgeons have towards steering their patients to surgery. Forget about the monetary aspects...I think it's just natural for surgeons to want to provide their patients with surgery and have a vested interest in perpetuating the idea that surgery is the "gold standard".  Couple this with the fact that surgery has been around a long time and many stuides are available to demonstrate its effectivenes.  (there are also many long term studies that demonstrate the frequent onerous side effects). 

     Prostate cancer is one of the few cancers not routinely referred to oncologists for treatment.  I venture to say that if we ever reach a point that our PCP's refer patients to oncologists who are experts in PCa rather than urologists who may be experts in treating PCa surgically we might find multiple "gold standards".  These would be based on the particular diagnosis, a full battery of testing that urologists do not routinely do today (see JohnT's many posts on this) and a reasonable balancing of quality of life issues.

     For some there will never be enough long term studies that demonstrate the effectives of the various radiation treatments.  For some of us - me included - my research showed the high efficacy of radiation and the considerably less onerous side effects that led me to my decision.

2.  Why are people turned down for this treatment?  Primarily for large prostate size, urinary problems or evidence that the cancer has spread beyond the prostate.  The latter meaning that surgery is also not a reasonable approach.  Unlike some of the inferences of poster on this thread, the experts in combination radiation treatment frequently treat high Gleason cases with success.

3.  Is great skill needed to administer it?  Absolutely.  Just as you would not want to go to a surgeon with just a few robotic surgeries under his belt, you would not want the radiation treatments administered by rookies.  'Hundreds" is the key phrase here.  In my case my radiation oncologist had done over 1000 seed implants and had done over 500 in conjunction with the urologist who participated in the procedure.

If you detect a bias in my answers I unabashedly admit it.  I think surgery's rep as the gold standard is tarnished and brachytherapy or combination therapy offers a better option.  But, that's just me...you obviously have to make your own educated choice and I wish you luck.

Tudpock (Jim)

Posted 7/11/2010 6:22 PM (GMT 0)
JohnT - two questions about your post. First, is it really true that RCOG has reliable long term data on cure rates, or has that center, without any public explanation, ceased providing updated data on its success/cure rates? Second, in the "Prostate Cancer Study Group," what was the breakdown of specialties? Who were the surgeons in that group? Were prominent surgeons adequately represented in that group?
Posted 7/11/2010 8:20 PM (GMT 0)
Tud has given you a very good answer about radiation but, for me it was an issue of side effects. With surgery you have the SEs up front and know what you have to deal with. Radiation SEs seem to peak 3-5 years after treatment.

For myself, I figured that I could deal with things in the present rather than in an uncertain future.
Posted 7/11/2010 9:58 PM (GMT 0)
Medved,
I recognize three surgeons, Crawford from U of colorado, Shinohara from UCSF and Wong. I don't know the specialities of the international guys. Bostwick is a patholigist and Scholz an oncologist. There are definately more radiologists and brachytherapists than surgeons in the group.
Re the RCOG: I have seen a couple of posts on other sites regarding this and other issues with RCOG,
but don't know enough about it to intelligently comment on it.
JT
Posted 7/11/2010 11:43 PM (GMT 0)
Geezer,
Over the last 2 years I've probably read over 100,000 posts from various PC sites and about a few hundred of them have delt with long term radiation side affects. about 40,000 have delt with surgical side affects. Do you see any pattern developing here? I'm not saying that there are no long term affects from radiation, but I would make my decisions based on data, not on the small probability that something may happen years in the future. Of all the posts I have read I never read one about a secondary cancer caused by radiation yet it is also a commonly used arguement against radiation.
When taken as a whole all the posts indicate some common patterns that go against conventional thinking; perhaps it's my 30 years of experience analysing data patterns that some things just seem very clear to me. A few things that certaintly stand out are that reoccurrances after surgery are much higher than most patients expect and the side affects and complications are much higher than expected. Radiation and especially seeds work much better across all risk catagories than most patient think, and side affects, both immediate and long term are much less than expected.
My golfing buddy and I were treated about a year ago; he had surgery and expected to be golfing again in 3 to 4 weeks. I was golfing the next day and he has still not picked up a club. How many radiation patients do you know of that have ever worn pads one day out or 5 years out?

JT
Posted 7/11/2010 11:44 PM (GMT 0)
Geezer,
Over the last 2 years I've probably read over 100,000 posts from various PC sites and about a few hundred of them have delt with long term radiation side affects. about 40,000 have delt with surgical side affects. Do you see any pattern developing here? I'm not saying that there are no long term affects from radiation, but I would make my decisions based on data, not on the small probability that something may happen years in the future. Of all the posts I have read I never read one about a secondary cancer caused by radiation yet it is also a commonly used arguement against radiation.
When taken as a whole all the posts indicate some common patterns that go against conventional thinking; perhaps it's my 30 years of experience analysing data patterns that some things just seem very clear to me. A few things that certaintly stand out are that reoccurrances after surgery are much higher than most patients expect and the side affects and complications are much higher than expected. Radiation and especially seeds work much better across all risk catagories than most patient think, and side affects, both immediate and long term are much less than expected.
My golfing buddy and I were treated about a year ago; he had surgery and expected to be golfing again in 3 to 4 weeks. I was golfing the next day and he has still not picked up a club. How many radiation patients do you know of that have ever worn pads one day out or 5 years out?

JT
Posted 7/12/2010 11:39 AM (GMT 0)
Regal, every treatment has side effects ... there's no way around that. I think Tud's point is that there is simply more data available for surgical treatment than for other forms of treatment. This long-term data is what is keeping surgery in the #1 spot for PCa treatment. I suspect that over the next few years, with more men opting for radiation as a primary treatment, we'll start to see better data for this line of treatment.
Posted 7/12/2010 7:43 PM (GMT 0)
Tudpock18 hit the nail on the head with his observation, “IMHO, surgery is still considered the "gold standard" mainly as an historical artifact and due to the perpetuation of this perspective by the fact that the most common "theaters" of PCa are urologists/surgeons. Let's face it; most of us get referred to urologists when PCa is suspected. And it's only natural that these doctors would suggest the treatment with which they are the most comfortable.”

This was certainly my case, where preliminary PSA screening by my primary physician led to a referral to a urologist, who first did a DRE and then a prostate biopsy that confirmed PCa. I feel fortunate in that my urologist was not a surgeon, and while he did recommend surgery he also explained other options. He also stated that if money were not an issue he would recommend having the surgery done at a large cancer center. I personally feel that there is very much a conflict of interest if the urologist who makes the diagnosis and first recommendation for treatment also does surgery, or is part of a practice that does surgery. But my opinion is not likely to have much impact on these guys.

After doing my own research, which included consultation at several of the major centers in the east, I decided that brachytherapy + IMRT + HT for a couple of years was the right choice for me, in spite of a high Gleason score. And in fact I had very few complications from the radiation, which amounted to a total of 145 gy. HT is another matter but given my Gleasons number it would probably have been recommended with RT also.

In any event there are options other than RT that studies show to be just as effective and one should do the research and weigh the options, regardless of what the urologist recommends.

Sancarlos
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