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Posted 1/5/2012 3:06 AM (GMT 0)
Hi,

We are new to this since Sept. 2011 when diagnosed with low risk PC. I have read some posts on here and a lot of them pertain to surgery so let me know if I should post radiation treatment questions elsewhere. Here it goes.

57 yo
just diagnosed 09/11 (3+3) = 6 gleason
last psa 07/11 = 5.9
tumor stage = T1c
no regional lymph node metastasis
no distant metastisis
12 biopsy samples were taken in all 4 places of prostate
4 = 10 - 20% tissue 3+3 = 6
2 = high grade prostatic intraepithelial neoplasia
1 = focal high grade prostatic intraepithelial neoplasia
1 = atypical small acinar proliferation suspicious for adenocarcinoma
4 = benign

Today my husband and i had the last of consultations on all possible treatments that are available to him.

surgery - decided no
IMRT ext beam - decided no
CK - insurance won't cover and hesitant because another ext beam method

LDR - sounded really good to husband after we saw a very good Dr. that has done over 4,000 of these procedures. This Dr. said he did not think HDR (catheters) had as effective outcome as LDR, which was fine with my husband as he did not like the sound of the catheter situation. This Dr. would use Palladium 103 as opposed to Iodine 125. He gave us a graph showing how seeding was very good at control and had low side effects. (this Dr. works at a center that does both LDR and HDR). I can email the powerpoint slide if anyone would like to see it. I now can't make heads or tails of it.

Then today we saw another Dr. (at a very well known cancer center) who said that although LDR and HDR have about the same control %, HDR had less problematic side effects (this center also does both LDR and HDR)

He said side effects with LDR = @5% rectal problems; about 90% for one year; @ 20% long-term

He said side effects with HDR = less than 1% rectal problems; 80% short-term; @1-5% long-term

He also said if my husband did choose to do the LDR seeds that he would do Iodine 125 instead of Palladium 103 something to do with seeds moving a little and then . . . can't remember what he said.

Iodine 125 = 60 days 1/2 radiation in seeds is diminished
Palladium 103 = 17 days 1/2 radiation in seeds is diminished
(let me know if I have this wrong)

We did actually meet a gentleman on vacation last month that had the seeds procedure, although did not get technical about Iodine or Palladium. His treatment was done in England and it has been about 3-5 years and he said it was a piece of cake and no problematic symptoms worth noting. . . .

I have tried to do a search on the net regarding LDR vs. HDR but really just a lot of old information comes up.

Does anyone have any experience with either of these procedures or more facts or any more information about which Dr. is being more accurate

Any thoughts would help us. Thank you.
Posted 1/5/2012 3:08 AM (GMT 0)
Hello and welcome to HW,

From your reading your husbands stats, sounds like "seeds" would be a good fit for him. Good luck ahead in your decision process. Please keep us posted.

David in SC
Posted 1/5/2012 10:39 PM (GMT 0)
i know it sounds good but does anyone have any facts about which one has less long-term side effects

or thoughts about iodine vs. palladium for the seeding?
Posted 1/6/2012 12:26 AM (GMT 0)
Here is a pretty good study, as good as any...

www.prostatecancertreatmentcenter.com/ProstateCancer/ProstateCancerResultsStudyGroup.aspx
Posted 1/6/2012 12:58 AM (GMT 0)
Hi Tangerine:

First of all, welcome to HW.  Sorry you have to be here but you will find lots of good info here and lots of good people as well.  Most of the posters are surgery patients but there are several of us brachy folks here including both LDR and HDR folks AND LDR-Palladium and LDR-Iodine folks.

There is less long term data on HDR but the science is sound and it appears that the long term curative outcomes are likely to be similar.  Perhaps one of the HDR guys will chime in on this.  I believe the long term side effects are also likely to be similar, i.e. some chance of ED but significantly less than surgery.

As to Palladium vs. Iodine, it appears to be largely determined by the "artist" who performs the brachy.  As you noted, the 1/2 life of Palladium is shorter which typlcally results in more severe short term urinary effects, but ones that last for a shorter period of time.  In either case, the urinary effects are usually well controlled by Flomax and typically subside within three months.  Re movement of the seeds, that is usually an artifact of whether the seeds are "stranded" (tied together) rather than which isotope is used.  I have not noted any data that indicated better or worse ED that favors either isotope.

My particular doc ("artist") used Iodine but I would not have changed if the choice had been Palladium; pick the doc and not the isotope would be my recommendation.

If you want to read a long-winded brachytherapy story feel free to copy and paste my jouney indicated in my signature.

Good luck and congratulations on picking a fine choice in brachytherapy.

Tudpock (Jim)

Posted 1/6/2012 4:40 AM (GMT 0)
Hello Tangerine.

This is a good group and you can ask about anything. Many of us are very early in the journey, just like you and your husband. Others have been here much longer and are very wise.

Your husband's Gleason score and PSA level would probably mean most options are open to you. This is good, but it is a little confusing. There are so many options and little consensus in what's best among experts. I have fairly similar options to yours, though my wife and I decided against LDR brachy with my higher Gleason score. It's been very hard to sort through all the options and come to a conclusion. I just posted, in another thread, my decision to go to HDR brachytherapy. The report mentioned by Fairwind was one of the things that helped me decide. It's possible that this type of report could include some bias, but there seem to be enough different people involved that it should be less biased than some other reports.

I start my first HDR session next week. There is a lot of pretty good data about the procedures available online, but it doesn't have enough history to get really comfortable about. I just decided that I wanted to avoid surgery if possible, and HDR brachy seems likely to deliver more radiation to the right tissues and less to other tissues.

To do HDR you'll probably have to be close to a major metropolitan area as the equipment is expensive and needs enough population to warrant a medical facility purchasing it. I'm going to have to travel 5 hours each way, but to me it's worth it to do what I choose with my own body.

Each man's journey is individual and you two will need to make choices that work for YOU.

Something I found helpful was to join a local PCa survivor's group. There are several different organizations, the one I've gotten involved with is UsToo (ustoo.org). I've been able talk directly with others that have gone through this. I've even talked with people that have done HDR brachytherapy, as well as others that have done most every other type of treatment.

Another site I found useful was yananow.org. It had some good info and tons of stories from real people that have tried different treatment. I did find some of the posts of other experiences scary, but overall I'm optimistic about my chances. I plan to be around at least another 20 years, and my cancer is a little further advanced than your husband's.

Best wishes to you both as you make your decisions.
Posted 1/7/2012 2:35 AM (GMT 0)
syzygy51

So you are going with HDR e.g., inserting the radiation with catheters?

You mention that you are going to choose HDR, but then mention that report in Farichild's post as a deciding factor. We were also given that study by Grimm et al. by the Dr. that is recommending LDR. By reading this study I actually don't see any reference to HDR or LDR separately it just mentions "brachytherapy but doesn't state which method in the study graphs.

LDR meaning seeding and HDR meaning inserting the radiation via catheters.

So it is hard for him to decide between the two brachytherapy methods by using this study. Because they are lumping the two together.

Does anyone interpret this study differently or am i missing something.

And we agree we need to talk to ppl that have actually done either HDR or LDR. We are in the Tampa Bay area.
Posted 1/7/2012 4:46 AM (GMT 0)
Sorry I wasn't more clear, Tangerine. I decided on HDR because I wanted Brachytherapy, not surgery or EBRT, but I heard repeatedly that LDR brachy isn't suitable for a Gleason 7. If I were a Gleason 6, I might have chosen LDR brachy or HDR, or I might very well have gone to watchful waiting and monitored progress before deciding on a treatment. I also think surgery is a good option for a Gleason 6, because the cancer is probably contained and might be fully eradicated with prostate removal. I just didn't want to go through surgery.

The charts in the report we're discussing did have a lot of data points involved LDR trachy, but for intermediate and advanced cancers there were also some regarding HDR. None of them went out over 7 years and most were 5 years or under. Overall, the charts made me think highly of brachy, and I chose the version that should work better for my PCa.

I sometimes over think things, so take this all with a grain of salt. I think my decision was based on the idea that HDR gives more radiation to the prostate area and less to other places than EBRT, while still getting some radiation just outside the prostate capsule, which I think I need with my Gleason score. Your husband might not need those extras and LDR might be a good choice.

I'm not sure what approach I'd take with a Gleason 6, but all of them are probably viable. Sorry that it's going to be hard to clarify and decide, and please remember that all of us (especially me) are making decisions that feel right to each of us but your decision is solely your own. Take all the inputs, do the study, and decide what you 2 think. Though the thoughts of others can be useful, his is too important a decision to do based on what other people are doing.
Posted 1/7/2012 6:03 AM (GMT 0)
Iodine, Palladium, LDR or HDR all are pretty similar as to both cure rates and long term side effects. Short term side effect vary with the type of treatment. The key is the experience and skill of the Doctor you use. Find the most skilled and experienced doctor and go with the the type of Brachy he does the most of. "It's the Indian and not the arrow" that gets the results. Too much emphasis is placed on the arrow instead of the one shooting it.
JT
Posted 1/7/2012 1:58 PM (GMT 0)
John's point is the key. Practitioner expertise and experience means everything. I chose HDR over LDR for several reasons, but in either case I was really choosing my doctors. I consulted with two HDR groups and one LDR group. In each case they all had performed thousands of procedures, are well renowned, and referred me to patients to speak with. If the HDR doctors were insuffeciently experienced, I would have chosen the LDR with the doctor with sufficient experience. I required a doctor with more than 1,000 procedures as my experience threshold.

The real difference between the two are that HDR does not leave the radiation in the body, and CT scan radiation placement and variable dwell time provides for better conformation to the desired radiation field.....better accuracy, in other words. The radiation is introduced into and removed from the body via the catheters. In LDR the seeds are introduced into the body in much the same way, but the seeds are not removed.   Don't get hung up on the HDR catheters as you will have a very similar "pin cushion" effect to introduce the radiation in either case.  

Both work well and are now showing superior effectiveness than surgery with less side effects.
Posted 1/7/2012 2:31 PM (GMT 0)
Tangerine,

Additional information regarding the procedures can be seen at the websites of the pioneers in each procedure. Dr Jeffrey Demanes is the HDR pioneer and the website is www.cetmc.com. He has 30 years of LDR and HDR experience and has used HDR exclusively since 1991. He has pubished results up to 15 years. He now heads the Brachytherapy at UCLA. He also introduced the use of HDR for many other cancers as well. For the LDR I consulted with Dr. Frank Critz in Atlanta. He pioneered LDR with adjuvant EBRT (he uses IMRT). The website is www.prostrcision.com. Recently a large Atlanta hospital purchased his practice for big bucks and is advertising prostate cancer treatment all over the city. My wife used his center for breast cancer radiation treatment by one of the doctors that specializes with upper body radiation.

Whether you have HDR or LDR the delivery is very similar and uses catheters/hollow needles. With HDR the catheter has a sharp closed end that is guided into place by a long needle. After positioning is confirmed under CT scan, the needle is withdrawn and the radioactive wire is inserted to deliver the radiation. Then the catheter is withdrawn and nothing is left in the body. With the LDR a hollow needle (catheter with a sharp open end) is guided into place and the seeds are then inserted through the needle. When the seeds are in place the needle is withdrawn and the pellets/seeds remain in place.

A disadvantage of the permanent seeds is that they can migrate during the radiation period and the body naturally changes (the prostate and surrounding organs move around and expand and contract as they function and you move around) and thus the dose area changes. The quoted higher side effects of LDR are indicitave of this. Since the radiation is very short term (15-20 minutes) no change in the dose area and the placement of the dose is more controlled. Your LDR information using the shorter life pellets attempts to minimize this.
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