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Meeting with "Seed doctor" Terk

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Posted 6/15/2011 3:04 PM (GMT 0)
My wife and I met with Dr Terk of FROG (FL Radiologist Oncologist Group) Monday. He was referred to me by the radiologist oncologist tat the Mayo. He has done thousands of implants (hundreds each year), teaches and writes. Click here for Bio

He is the last doctor I wanted to see before making my decision on my plan of treatment. He said that I have three basic options.

1) Surgery 90% success rate after 10 years
2) Seeds Alone 93% success rate after 10 years
3) Seeds, wait two months, then 5 weeks (5 times a week) IGRT 96% success rate after 10 years

You may want to dispute the percentages, but all are above 90%, so all good choices and I will not dispute them. His first choice would be seeds and IGRT. A close second choice is seeds alone. Third choice is surgery (as you might expect).

He said the side effects can be burning and frequency when urinating (because the urethra gets a full dose of radiation) for a month or so and while doing the IGRT. Four percent will need a catheter after the procedure. No incontinence. ED in less than half of patients. It's an out patient procedure very similar to a template biopsy. He said that out of all the procedures he has done he has only had one where there was a major problem.

He recommends the seeds and IGRT for me because of the location of the biopsy findings (4 apex and 2 base - out of 6 positive) near the edge of the prostate. He said that he would be comfortable with either choice. If I went for seeds alone, then I would get a higher does of radiation in the seeds. If I went for seeds and IGRT then a lower does n the seeds, they would plant gold markers and then get the IGRT in two months.

I know many here are pro-surgery and we all have unique circumstances. I have liked the idea of seeds from the start. My wife liked the idea of surgery after meeting with Dr. Wehle at the Mayo. After meeting with Dr. Buskirk at the Mayo and Dr. Terk, she is now in favor of the seeds also. My reasoning is this. The cure rate is about the same and there are less side effects and it's a less evasive procedure.

My only decision at this point is seeds alone or seeds and IGRT. The IGRT treatment would be an hour commute to and from the center, so that is quite a commitment time and gas wise. Also I trust Dr. Terk to do a good job on the seed implants, but worry about additional radiation done by a radiation team. It seems that I have read stories here about IGRT gone wrong. I'm tempted to just do the seeds alone, but don't want to have regrets that I did not do everything I could later, should I get a re-occurrence.

Any thoughts?
Posted 6/15/2011 3:20 PM (GMT 0)
>>His first choice would be seeds and IGRT.<<

that's what i had, along with lupron.  i think it's a superior treatment meant to hit the cancer with both barrels, which makes more sense to me than the incremental approach.

ed

 

Posted 6/15/2011 3:35 PM (GMT 0)
The advantages to seeds/IMRT are that you can get a higher dose and a wider margin. Having an APEX tumor getting a wider margin would be a good thing. Also having two different types of radiation will hit any cells that may be resistant to one form.
The numbers he quoted are common for the best Brachy centers. Just as in surgery skill is a major determinate of both cure rates and side effects and I would not expect that all Brachy centers would get these results.
I did not suffer any more side effects from IMRT after seeding.
JohnT
Posted 6/15/2011 3:40 PM (GMT 0)
Dear G6:

Sounds like an excellent visit and excellent advice.  Interesting...my wife made the same transition from surgery to seeds after visiting the rad-doc and further discussion.

You are on the cusp and there is no perfect answer.  I had fewer positive cores than you with low % and not near apex...but with 3 + 4.  Both my uro and rad-doc told me that both options would likely work for me and I ended up deciding on seeds only.  The safest approach for you is probably to do both but it's also likely that seeds only will do the job.  Anytime you add treatments you also add opportunities for more side effects...but also increase the odds of success.

Bottom line is it's a crap shoot but with pretty decent odds either way.  Good luck and let us know what you decide.

Tudpock (Jim)

Posted 6/15/2011 4:10 PM (GMT 0)
Dear Gleason,
Oh to have a crystal ball!
Really do feel for you and your wife – another dilemma and decision making process thrown into the mix.
Jeff wasn’t offered +IGRT so that wasn’t a decision we had to make. Had we been offered the two options, shooting from the heart I suspect we would still have gone for seeds only. If the success rate had been 70% v 90% that would have been a different matter of course but 93% v 96%?
I have no words of wisdom to offer but have been following your journey so wanted to wish you all the best with whichever choice you make.
Susan
X
Posted 6/15/2011 5:34 PM (GMT 0)
Many studies point to equivalent results between radiation and surgery and show that radiation has less drastic side effects, which usually reverse with time.

I did IMRT and HDR (temporary seeds) brachytherapy. I also looked at IMRT with permanent seeds. Both do a great job. Surgery has the toughest time with the apex where most positive margins result. With the radiation you are getting the entire gland and the margin from both inside out and outside in. As John T said the combination shakes up the cancer and the combination appears to be synergistic, thus more effective than either treatment alone.

I had to add ADT as I am more advanced than you. My side effects from radiation were the normal, minimal and completely cleeared within two weeks of the last radiation session.
Posted 6/15/2011 6:59 PM (GMT 0)
I a bit nervous about the IGRT, especially after re-reading Compiler's adventure and the radiation going within 1mm of the rectum. Boy, I can see where things can go wrong real fast. On the other hand, I want to feel like I gave this my best shot should the cancer come back (which none of us want). I thought I was done making decisions once I decided on radiation!
Posted 6/15/2011 9:10 PM (GMT 0)
G6,

I am a DaVinci + IGRT guy, so this may rumple the pro-surgery bias assumption a bit

smilewinkgrin  

I actually wanted seeds. I had been involved, back in the mid 1980's, with the company that brought the idea to market. I was then, and still am, quite convinced that the concepts and application are a good match.

I had surgery, but not before a couple of big national named cancer centers told me seeds were not the best choice for me after long discussions. I was actually disappointed.

So, my comments on surgery are biased only in that I did that, and it is the path I know best.

Based on what I know now, seeds + IGRT may well have been as good a choice, but there is no reason for me to dwell on that now.

Have a look at my IGRT thread (see sig). I had side effects earlier than Mel, and still have some a year out, but if the surgery SEs were taken out of the equation, and I had not had colon issues in the past, I wouldn't be that bad off. You will find a lot of folks (many who were going the RT path with me, but as primary treatment) who had no issues to speak of other than the impromptu floods caused by the water torture. Then there is the other side, represented by the likes of me somewhere past the middle, and worse, David.

If they tell you 90% do great, there is another 10% out there. I just happen to live in that corner of the world.

Isn't it wonderful to have a choice, and horrible to have to make a choice? devil

Posted 6/16/2011 12:02 AM (GMT 0)
G6,
You can't compare SRT side affects with IMRT after seeding. The common dosage for SRT, like Compiler and David received is about 75 gy. The dose you will recieve is about 45gy. With SRT the margins are much wider while you will be targeted mostly to the prostate.
Posted 6/16/2011 2:57 AM (GMT 0)
G6,

I had IMRT first and then BT. I see your doc is recommending BT first and then IMRT. I'm curious what his reasoning is for going in that order. My doc said he had less urinary side effects going IMRT first and then BT afterwards. I'm not sure what the differences would be. I haven't had any urinary side effects at all.
Posted 6/16/2011 4:28 AM (GMT 0)
JohnT,

I agree. If 45 gys is typical iMRT for use with Seeding, then I think most men would be able to tolerate that level of gys without anticipating any major side effects from the radiation. When my SRT planning was being calculated, there was a thin line on the max. dosage to be delivered safely. I ended up with 72 gys. They had contemplated as much as 76 gys. Since mine went very, very wrong, I can only imagine the additional damage that would have been done with 76 gys. And yes, with SRT, the targeted area would generally be a larger area than in how RT is administered in conjunction with Seeding. Think you made a good point there. Seems like Mel got 68.x gys, not positive, and I have noticed quite a few guys here have gotten 70.2 under SRT.

David in SC
Posted 6/16/2011 1:28 PM (GMT 0)
My rad onc showed me information that indicated that for IMRT alone 72 gy over 40-45 fractions is the threshold to get the best results and that at 80 gy the damage to non cancerous tissue started getting very bad.

When he combines IMRT with BT he uses about 45 gy over 30 fractions for the IMRT as John T also reported. They gy of the BT depends on the type. Permanent low dose provides more gy over a longer period of time but with much lower radiation intensity for 60-90 days of the half life radiation. HDR bt provides less gy but in a very short intense period of time. In my case I received about 30 minutes total radiation divided into two fractions of about 22.5 gy per fraction. In total I received approximately 90 gy with half of that coming in two 15 minute HDR fractions and the other half in thirty IMRT fractions.

Thus the issue is not the absolute number of gy, but how the radiation is delivered, the intensity per fraction, and the number of fractions over a given time frame.
Posted 6/16/2011 2:05 PM (GMT 0)
I wasn't really expecting to have the IGRT thrown into the mix and I'm not up to speed on "gy"s fractions or any of the terminology or what effect it may have on me. I wish I'd known, as I would have been able to ask more or better questions. Seems like I need to learn more (and here I thought I knew it all! :). I don't know how many gy's or what is planned for me.

I have a lot of faith and respect for Dr. Terk and having him implant the seeds, but I'm not so sure about the IGRT and that process and the negative vs. positive effects it may have. Maybe I should just do the seeds, but I want to know I did the best I could. Hmmmm...

I thought they would do the seeds and then the IGRT, in that order, because they plant the gold markers when they do the seeds.
Posted 6/16/2011 2:14 PM (GMT 0)
Seeds first or last??? another contraversy in the world of PC treatments. It depends on where your radiologist was trained. Advantages and disadvantages are quoted; but as far as I can tell there is no difference and absolutely no evidence to support which is better.
Posted 6/16/2011 7:23 PM (GMT 0)
>>I thought they would do the seeds and then the IGRT, in that order,<<

that's how mine was done.  the combination treatment is a better way to go if you can handle it.

ed

Posted 6/17/2011 12:34 AM (GMT 0)
A group here in Atlanta pioneered the use of IMRT during the seed radiation. They implant the seeds and then 21 days later start the IMRT or IGRT. They claim a synergistic effect of radiating the prostate while the seeds are at their peak. They call it Prostrcision and have performed over 13,000 procedures. Thus we have seeds then IMRT, IMRT and then seeds, and seeds and IMRT concurrently.
Posted 6/17/2011 12:48 AM (GMT 0)
 >>They implant the seeds and then 21 days later start the IMRT or IGRT.<<

i had IGRT about six weeks after seeds. my SEs from BT were improving but i remember thinking that i needed more time to recover.

ed

 

Posted 6/17/2011 2:42 AM (GMT 0)
I also had IMRT after seeds, though in my case the IMRT began a bit more than two months after the seeds.

BTW, I had the seeds done in Jacksonville by another of the FROG doctors (Jamie Cesaretti), who at the time was (may still be) in the same office with Terk. And I met Terk briefly during one of my post-op visits to Jacksonville. Perhaps I was having a bad day but I found him obnoxious and rude. I had IMRT here near my home in Greenville , SC at a center about 10 minutes from my home.

I was told that the immediate side effects from the seeds would be much greater than from IMRT. In retrospect, the side effects from IMRT were greater in terms of fatigue, and lasted longer. But none of it was a piece of cake.

Radiation affects cancer faster than it does healthy cells, so while you will notice a great drop in PSA in 4-9 months after the end of radiation the long term damage to healthy cells may not be apparent until a couple of years, or longer, after the end of radiation. about 14 months after the last radiation treatment I developed some urinary urgency and slight burning during urination. I began to take Flomax again at the advice of my oncologist and the symptoms have abated, but not gone away entirely.

Let's face it, there are no issue free treatments with PCa, especially if it is high risk.

Sancarlos
Posted 8/10/2011 4:37 AM (GMT 0)
Hi,

I just want to say I hope all goes well. My dad had 2 friends that had the same procedure done and they are fine. I went to the doctor and they found a nodule via DRE test. Last time I saw the doctor 2 years ago the PSA was .6 now it is .8 on 8-9-2011. I don't know to much about the condition and have a appt. to see a specialist. I know the psa is low but you never know. For now on no matter what the outcome I will go to the doctor ever year. As I said I know nothing and wanted your thoughts.

Thank You,

Andrew 

Posted 8/10/2011 12:04 PM (GMT 0)
Drew,

Your PSA is very low, but if the doctor found something with the DRE then you are doing the right thing seeing a urologist. Please keep us posted.
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