Why no radiation failures on HW?

I might have chosen brachy except for the fact that my prostate was, as I recall, 88cc, and I think the top limit for brachy is in the 50 cc range. I only know one guy personally who has had brachytherapy, and his was done I think 9 years ago. He has moved on and rarely seems to even think about PCa anymore.

I'm starting to think that seeds with IMRT may be the way to go if you are a G8-10. Although everything I read seems to indicate outcomes are the same.

I think there are several reasons why you perceive them to be less prevalent…

One reason is that brachytherapy tends to have “late-term effects”…stuff starts going wrong somewhere down the road (I read examples of 2 or 3 or 6 years later, after guys have “moved on” from HW). The “effects profile” is opposite for surgery where essentially all the effects are immediate then reduce over time (usually within about a year), so guys are still hanging out at HW immediately after surgery but fade away as side effects diminish.

Another reason is that when guys start bleeding from their butt, their brachy oncologist refers them to a proctologist for further treatment…it’s no longer an oncologist’s problem to treat. These guys might generally be looking for other support pages

Also, as sexual function begins to diminish as another post-brachytherapy late-term effect, the patient thinks of this as an ED issue, not as a PC issue from several years before. It seems like a natural diminished capability...although perhaps it happened sooner than it might have otherwise happened. Further to that point but a little off your question, I think it’s clear that American society generally celebrates immediate gratification, and oncologists tend to describe the immediate effects of a PC therapies…perhaps understating the late-term effects of all types of radiation therapy. Here’s a quote from the article titled: “Management of Sexual Dysfunction After Prostate Brachytherapy”

The young patient who chooses radiation based solely on his desire to maintain sexual activity may be gaining very little in the long run, and may be choosing an inferior therapy based upon incomplete information. If the patient has a better chance of survival at 10, 15, or 20 years with radical prostatectomy, but chooses seed implantation to reduce the risk of erectile dysfunction, he may still find that there is a significant reduction in erectile function at 3 to 6 years posttherapy. The trade-off may not be worth it to him and his family, and they may ultimately believe the short-term gain was not worth the long-term pain.

Lastly, regarding cancer control itself, patients considered for intersititial brachytherapy are generally those classified as low risk, more specifically, those with stage T1c–T2a (tumor confined to the prostate gland), PSA less than 10 ng/ml, and Gleason score of six or less. (REFERENCE) These guys pretty much do well in cancer control with any of the major treatments.

Hope this helps answer your question...

Amazing, this criteria at the end of the post above, was right in line why it was reccomended to me at the time of my primary treatment decision process, not to do seeding as I had desired. I didn't seem to meet any of the acceptable criteria.

im a gleason 7 with intermediate risk.  you can see my treatment in my profile, and i saw other similar cases at the radiation clinic.  my urologist and his associate, both surgeons, did not like to operate as a primary treatment when there was a good chance that the disease had jumped the capsule.  of course they would operate if you prefered or did not qualify for BT.

ed

 

"Why no radiation failures on HW? "

Well, there is the obvious answer...

I asked at two major centers about seeds, but having a complete coverage of 4+3 and 4+4 biopsies (9 of 12 positive, 3 quadrants of the prostate had two 4+4, one had three), no one would do anything but suggest I was not a good candidate.

Hey, I tried.

Tud,  I would hazard a guess that most of the Brachy and IMRT folks have good outcomes and don't bother to post.  At age 74 I have many friends and acquiantances that had trouble free brachy and IMRT.  They are in disbelief that I chose surgery.  Here is a sample report from Schiffler Cancer Center.  I don't know if this is typical but it surely makes me question my decision.

"What did they find?
Based on a median follow-up for the entire population of 58.6 months they projected that 98.2% of the low-risk men would survive progression-free after 8 years as measured by PSA levels. Among the intermediate-risk group they estimated that 98.4% would survive progression-free after 8 years, and 88.2% of the high-risk group would survive that long without PSA progression.

At last follow-up, only 5 patients (0.8%) had died of metastatic prostate cancer. When they analyzed multiple factors they found that Gleason score, percentage of biopsy samples that were positive for cancer, and ADT predicted PSA progression in high-risk patients. In low- and intermediate-risk patients, none of the evaluated variables predicted PSA progression."

When I made my decision, I down played the incontinence side effects because I thought they were aberrations.  Now I realize that my uneventful surgery was the aberration.  Most of my surgery friends are incontinent, have ED and one had a rectal fistula. 

I'm throwing in the towel.  You and John T win.  I'm a full convert to brachy and IMRT.

Carlos 

The brachy plus IMRT doesn’t have much history yet; combined treatment was largely experimental before the 2000’s…it has ramped up in the later part of the decade.  Few early reports exist.  In the early 1990’s, brachytherapy alone was considered investigational, but no longer so.  Even at the 2007 ASCO Prostate Cancer Symposium, researchers were writing that “The role of supplemental EBRT in brachytherapy is controversial.”  A number of the early studies showed no statistical difference in the prostate cancer specific mortality of seeds vs. seeds+IMRT; recently, some studies have shown differences (probably as they are continuing to tweak the radiation doses). 

The reports out there generally end with a statement like this example from 2009:  “Longer followup will help to determine the role of HDR brachytherapy and IMRT in the treatment of early stage prostate cancer.”  For the  somewhat limited set of patients eligible for seeds + IMRT the BCR results look positive...I suspect that this will probably continue to hold true over time, or continue to improve, with respect to the original question on cancer control.

My urologist and two others said that I was a bit high risk for surgery. G7 and T2b with a high PSA. They all said they would expect positive margins that would then require RT. They were all straight with me that PC surgery is tough...one of the most difficult, complex, and inherently fraught with complications with nerves and vessels. Nothing as simple as my wife's breast cancer surgery or even most brain surgeries!. It was posited that I would likely be facing rt anyway so why not start there without the problems of surgery. I feel I spoke with three very honest urologists. I asked each whether Walsh would operate on me and they laughed saying I would screw up his statistics.

I chose HDR brachytherapy over permanent brachytherapy as it is far more focussed, more accurate, and with fewer side effects. My research included the pre-eminent permanent brachytherapy center (in Atlanta...you can do the research) and I was convinced that permanent seeds was the way to go in the last century, but HRD is the way to go now. As was mentioned before, they were able to radiate the gland, a 5-10mm margin, the seminal vessicles, amd the lymph nodes. Can't do that with surgery and still be able to function.

I figure my primary treatment can't fail in the same way surgery can. If down the road I have increasing PSA it means that the cancer was already in the distant nodes or bones and that neither radiation nor surgery would have been sole cure. By definition, surgery fails if there are positive margins or something is left behind to spare nerves, vessels, or non-prostate tissues.

My brother's brother-in-law had RP seven years ago. He was T2, G9, and PSA of less then 2. He only consulted an urologist and wasn't even given the choice or RT. Since then he has done SRT and one round of HT (but didn't know about ADT3) and is looking at his second round of HT as his PSA has continually increased. Obviously, in retrospect, his surgery was not appropriate and his mild incontinence (two pads a day isn't bad after 7 years!!!) and ed should not have been inflicted upon him.

My take is that if you are T1, G6, and PSA<6, than surgery or RT will do you well and you are likely to make the 10 year mark at <0.20......cured. But so would HDR or LDR without the RP side effects. But when I look at the signatures....I don't find many in that range. Thus I think most of us are higher risk than we would like to admit and the intermediate and higher risk just are not good candidates for surgery. I think in the future we will see more urologists partnering with rad-oncs to use RT and get better with HT rather than jumping at surgery and then trying to explain why it failed and we need RT...and HT.... and Chemo....and....

My urologist and I and my wife all agreed that, being realistic, I am looking at long term management, not cure. Much like someone with diabetes or rheumatoid arthritis. I am 60, in great shape and hopefully will make it to 75 or so and living life accordingly. My dad just died at 93, but I don't expect that span so I want to pursue treatment that is life prolonging but doesn't include knives.

John, you bring up some good points, as usual.

So weird for me, as when I had neck & throat radiation, in the year 2000, it was old school EBRT. The side effects and long term damage potential were well spelled out for me, and there really wasn't any surprises. It was a tough way to get 70 gys in such a small area at the time. Took a long time to recover from it too, but again, the negative side was well known.

This time, in 2009, I am told over and over, that the IMRT I had was well focused, very safe, virtually no side effects, etc, etc, and yet it went terribly wrong at 72 gys. And, old story now, but left me with perm. bladder damage and bladder neck damage.

At least with the old radiation, I knew what to expect, there weren't any surprises. With the new radiation, the whole negative side took me by complete surprise ,because I beleived what the radiation oncologist and radiation clinic told me. Boy, was I ever wrong.

David

Tud,

Thanks for asking the question. After visiting HW for over a year, I wondered the same thing myself. I agree with the point someone made that the BT and/or IGRT guys tend to have lower Gleasons (less risk of reoccurance) and very little need to seek advice on side effects. I can't recall a seed/IGRT poster who has had any serious issues. Most probably just move on....if something happens 5 or 6 years down the road they must not be coming back to report.

The reason I stick around is to be sure we encourage the newbies who qualify to carefully explore their options. You are not the only one with a bias for this treatment. That said, I would never question anyone who chooses surgery after doing their due diligence.

Joe