Brachytherapy for Gleason 7?

I had 15 of 60 samples GL6...one GL7. I had permananent-seed brachy as a stand alone treatment. Couldn't be happier so far.

In my opinion, a doctor that says no brachytherapy for G7 needs some help. I have done well and had several options from excellent brachytherapy centers both HDR and permanent seeds. In fact all of them, plus my med onc, said that for more advanced G scores BT is better than surgery because it covers a wider area that can get capsular escape that would show to be positive margins in surgery.

For HDR information check  www.cetmc.com the website for Dr Jeffrey Demanes, the HDR pioneer; he now heads up the UCLA brachytherapy. For seeds information check www.prostrcision.com the website for Dr Frank Critz, the pioneer of seeds and adjuvant IMRT (here in Atlanta).

I looked at both and decided on HDR. I am a G7 with high PSA. So far so good. Let me know if you need any specifics about my treatment and results.

Sygyzy,

I chose Bt and IGRT with a G6 and have been very happy with my results. Based on what I have read here over the past two years I would have probably done the exact same thing if I had been a G7. Regards,

JoeFl

One thing that I learned is that most advice given on Brachy from most doctors who are not Brachytherapists is most likely wrong. I like a few others on this forum were told that Brachy was not suitable in our cases. This information was wrong just as the information that anything over G6 is not suitiable for Brachy. The evidence is very clear in the fact that Brachy alone is effective across all Gleason Grades.
The following are results from 12 instutitions on their surgical cure rates compared to 24 institutions using seeds:

Low risk: surgery 85%; Brachy 95%
Intermediate risk: surgery 70%, brachy 85%
High risk: surgery 40%; Brachy 75%

This does not indicate that Brachy is ineffective for intermediate or high risk cases as many doctors would have us believe.
If a patient wants advice on seeds he should go to an experienced Brachytherapist and be very careful of the advice given by a non Brachy doctor.
JohnT

John T said...
One thing that I learned is that most advice given on Brachy from most doctors who are not Brachytherapists is most likely wrong. I like a few others on this forum were told that Brachy was not suitable in our cases. This information was wrong just as the information that anything over G6 is not suitiable for Brachy. The evidence is very clear in the fact that Brachy alone is effective across all Gleason Grades.
The following are results from 12 instutitions on their surgical cure rates compared to 24 institutions using seeds:

Low risk: surgery 85%; Brachy 95%
Intermediate risk: surgery 70%, brachy 85%
High risk: surgery 40%; Brachy 75%

This does not indicate that Brachy is ineffective for intermediate or high risk cases as many doctors would have us believe.
If a patient wants advice on seeds he should go to an experienced Brachytherapist and be very careful of the advice given by a non Brachy doctor.
JohnT

Great post John......and in all fairness, sometimes the information can be misleading. The following was taken from my own procedure that I have been posting:

). Who Is Eligible For Seed Implant? Over the past decade
brachytherapy has become an increasingly popular treatment for the early
stages of prostate cancer. But it's generally used only for small,
favourable risk cancers (low grade, low stage, low PSA) that have a high
likelihood of being confined to the prostate or immediate surrounding
area. For these patients, a permanent seed implant will be the only
treatment needed. Evidence-based guidelines recommend that this form of
treatment be applied as the only treatment to those men with: T1c/T2a
tumour, which either isn’t palpable (felt) on rectal exam, or is
palpable as a small nodule Gleason score less than or equal to 6 PSA
less than 10 ng/mL

Outside these criteria, there is a greater risk that prostate cancer
cells have spread into tissue surrounding the prostate outside the
implant margin. Because radioactive seed implants have a short range,
some tumour cells located outside the prostate may not

receive a sufficient dose to be eradicated. These men with more
aggressive cancers may be suitable for a combination of external beam
and implant (seeds or HDR).

Syzygy51,

As you may have learned by now, BT is performed by a team of two...the rad who maps where the seeds go and calculates the dose and a URO who actually does the seed insertions to the proper locations. See if you can find a uro who does both BT and surgery...and see what he/she says.

I was lucky in that one of the UROs that I first visited was experienced with both. I felt that I got a very balanced view from him since he was not trying to sell one option over another.

Regards,

JoeFl

syzygy51,
I suggest you closely look at the post from RandomPseudoNym "RPN",

The comments that JohnT makes are true. But they are also based on bias and miss the point RPN makes. The fact is that Radiation Oncologists also overstate their success rates, and also overstate the "failure rates" of surgical success. Ultimately the determination of success or failure is different for each patient and certainly should not be measured by PSA relapses alone if at all. Prostate Cancer Specific Mortality (PCSM) is the only measurement that matters.

In my five years I have observed surgeons over stating success rates but these issues are not unique to surgeons. In fact I firmly believe that most urological surgeons should not be doing the procedure as they lack the skill level to do so with minimal side effects. But additionally, many RO's use combination therapies and don't state that in their "studies" and they directly compare results to other mono therapies that can easily add additional therapies to achieve the same if not better "success" or PSA control rates. I say that based on the fact that I can find 20 years median studies of surgical results, and I have never met a single patient in my five years on the scene who had seed implants 20 year ago.

The specific comments that caught my eye from "RPN", and I whole heartedly agree with, is that we will almost always make it the first ten years with this disease. There are rare exceptions and you are not showing the disease characteristics that would place you in the likely exception area. But as RPN states, the ten year median studies that are readily available do not tell the whole story of PCSM. They barely tell you any of it.

For example, the 15 year median success rates using PCSM as the end points, show that surgical patients that had a the surgery, lymph node dissection, and were followed up with various salvage and/or adjuvant therapies had 75% of the patients still alive at 18.4 years median. That would lead one to believe that the 40% "success" stated by the studies that JohnT is quoting is bogus.

RPN points out that we can find 20 years median studies but they are likely for surgery, and that there are pretty much none for brachytherapy. At least not yet.

That stated, I am not endorsing one versus the other. It's just that those who lean towards a therapy will clearly see the good news they want to see in studies and attempt to use them for comparative purposes. That is a very subjective thought process and seldom objective.

Each patient has to make the decision that's best for them. I know of very few patients that had brachytherapy that are not happy with the results, but they exist. I know of very few patients that had HIFU and are unhappy with the results, and I know of very few patients that had surgery that are unhappy with the results but their are more of the latter because even still today surgery patients outnumber all of the others combined although I expect that to change. Looking ahead is a very valuable decision. As we see treatment for advanced disease improving, it may come down to it does not matter so much what local therapy one chooses, but rather what combination is best for a given patient.

Tony

In the spirit of fairness and accurancy may I point out that while Tony accuses JohnT of pro-radiation bias, Tony has consistently shown a pro-surgery/anti-radiation bias despite his protestations. Just so we have the facts...

Tudpick (Jim)

Tudpock18 said...
In the spirit of fairness and accurancy may I point out that while Tony accuses JohnT of pro-radiation bias, Tony has consistently shown a pro-surgery/anti-radiation bias despite his protestations. Just so we have the facts...

Tudpick (Jim)

The problem in my opinion is bias in the system. A great majority of men who get PCa find out via a biopsy performed by a urologist. Urologists are biased toward surgery since this is what they are trained to do. And from what we read here many of them are not up to date in terms of their education about other types of treatment. The end result is that out of ignorance, or professional self-interest, they give inaccurate information to their patients. But the worst part is to see that misinformation repeated here by people who should know better. We continually hear people affirm that brachytherapy is no good for high risk PCa, and/or that an enlarged prostate makes brachytherapy impossible, when in fact neither is true.

BTW, regardless of possible bias I am very appreciative of people like Tony and JohnT who research these issues and report on HW. It is important to keep our minds open, not to justify the treatment we had in the past, but to be better informed about what may be needed in the future.

San Carlos

RandomPseudoNym said...
In the only direct example I have handy (my own) the urologist (who was not my eventual surgeon) went through all available options (including leaving the country and my insurance coverage to have HIFU) and would not make any suggestion at all - perhaps in response to complaints about urologists pushing treatments. Active surveillance/watchful waiting was included.

This experience was very different. My urologist insisted that open RP was the only option for me, and ridiculed my questions about various forms of radiation. After some research on my own, and subsequent discussions with him, I realized that he had not learned much if anything since he graduated from medical school in the 1970s. My wife, who was devastated by the diagnosis, initially wanted to follow the advice of the urologist, but after consultation with experts at several national centers, relented and allowed that brachytherapy offered as good a chance for cure as RP, and with far fewer side effects.


San Carlos

Interesting pictures here. My uro (an open surgeon converted to DaVinci) sent me away to talk to MD Anderson for seeds, Loma Linda and MD Anderson for Proton, a couple of national centers for IGRT, another surgeon for open. He made sure I had talked to all of them before we proceeded with any decision.

I really wanted to do seeds, but was told I was out of the acceptible specs, and they offered a poor % success rate for those in my group.

 

I went surgery, without any bias.

 

OK, honestly I have a bias against HIFU - they sent me info on getting a second mortgage to pay the bills (my insurance does not cover it).

syzygy51,
All doctors have some sort of bias that will shine through in their recommendations. Even doctors who do not believe that there is adequate data to support a particular treatment regimen have bias to evidence based information. I believe that for the most part, doctors bias is based on their genuine belief that the way they are practicing is in the best interest of each and every one of their patients when in fact we as patients we know that it might not be the best way for us as individuals. Their are guys here who made their own decisions against the advice of their doctors.

I do not mean to discredit JohnT except in his interpretation of data. The data he pulls to extrapolate comparisons as he did above was not the way the data was intended to be used, and it did not use the best metric to make the comparisons. Is it a bias towards a surgical preference or more my bias that data not be misrepresented or misinterpreted? I'd like to think I've grown beyond that in time but either way it's a bias that is real within me.

Look at JohnT's and my cases. You'd be avoiding the facts in saying either one of us made a bad decision. After five years, my multiple high risk characteristics and advanced prostate cancer is in remission. It wasn't known if surgery alone could have delivered that good fortune. I used additional therapies and arrived at where I am today. John is similar. He had the same Gleason, and while he didn't have as much cancer specific data available as I did, he was likely high risk and he added the post brachytherapy EBRT and HT to get the same results at three plus years post treatment. He also may have arrived at that result without the EBRT and HT. But that is good for him, and good for me. There's too little data available to say that we lived this experience enough to say for sure when in fact we both know that the aggressive nature of our own cases requires diligence monitoring for the rest of our lives.

The purpose of my post was not to discourage you in going the seeds rout. It was only to let you know that for every point about local therapies there is a counterpoint. If I was 60 years old instead of 44 when I was diagnosed would I have done anything differently? Probably not. But I'm like that doctor that wants evidence that I can make 80 years old and it's just not available. The longest term data for brachytherapy is far less than a median of 20 years. But if I was 60 and my family has an early history of death by coronary failure, I may have skipped surgery. This is an individual decision. Put everything together you can learn in a short while and make a decision, but never look back on it.

Good luck in your decision making. Be well and know that you will likely do very well for a very long time.

Tony