Second opinion from radiation oncologist

Well, bros, got my second opinion today from a military radiation oncologist out of Bethesda. He agreed with the first RO that SRT should be enough for now, he didn't recommend ADT with it. His reasoning was based on two things: (1) if I add ADT we wouldn't know if the SRT worked until the ADT was out of the system and (2) there are no studies that show ADT providing a benefit in the SRT case, only in the case before surgery where radiation is the primary treatment.

Since he said there are no studies I asked him if, from a theoretical sense, does it make sense that ADT would weaken the PC cells to make them more susceptible to radiation. He said maybe, but he could also argue the opposite, that radiation works best when cells are dividing, so ADT may make them dormant and less susceptible to radiation. I have to give him credit for that, not something I had thought about.

I asked him about the various machines, and he definitely recommends IGRT because of the daily CT scans to determine the exact location of structures. about tomotherapy, he said he recommends it for head and neck cancers but he doesn't think it's all that necessary for prostate cancer.

At this point, I'm inclined to go with him for several reasons. They have the same equipment as my regional civilian hospital (Varian iX and Trilogy), I can see him on a weekly basis to see how it's going (same as the other doctor), it's 20 minutes each way closer (30 vs 45 minutes away), and it's close to a 36 hole golf course, so I could go play golf before my treatments.

I wonder, though, about my current urologist who referred me to the RO that he works with. If I go with a different RO, I wonder if I can still work with my urologist or if he will wave me off? I also forgot to ask him what his treatment plan would be. The first guy said he recommended 68 Gy with a little more to the right side than the left.

Have I missed anything?

Mel, I asked him about this New Zealand study and he said he was pretty sure it was about primary radiation and not SRT.
http://doctor.ndtv.com/storypage/ndtv/id/5093/type/news/Hormone_therapy_boosts_prostate_cancer_survival.html

I still don't understand why ADT would work with primary radiation but not SRT. Cancer cells are cancer cells right? But I can also see why you'd want to have them try to divide while getting zapped.

Not sure I'm in a doctor ego issue, just want to clear the field. Got a phone message tonight from my uro, said he'd call again Friday. My second opinion RO said it didn't matter to him if I went with him or the other guy, would not affect his pay at all. He's military do that makes sense.

For my husband's case, our RO wanted both HT (ADT)+ ART while our urologist thought only ART should be fine for the time being. At the end, the RO agreed with our urologist.

I think if you explained to your doctors about the proximity of the golf course to the treatment center they'd all agree and understand...

proscapt, thanks a lot for that referrence. I've read through it, and really can't add to what you stated. As you say, it's retrospective rather than controlled for what that's worth. When I saw Figure 2 from that article, I recall having it shown to me a couple of years ago when I first considered SRT, and it was shown to me by another doctor in the same practice as the doc I got the second opinion from, so he knows about it. I guess it all comes down to odds. My doc did say that at my age (67) I'm more likely to die from a heart attack than from PC even with my PSA, and I'm sure age is a factor. Also with age comes the quality of life issues associated with ADT. A younger guy with 40 years to live might make a stronger case to hit the PC with all they've got, than someone with only 15 or 20 years left at best.

I haven't decided for sure, but I'm really leaning away from ADT now, even though I have 30 pills of casodex sitting on my counter right now. My urologist said he'd call me tomorrow, so I guess I'll have another discussion with him before making a final decision.

JNF, I note from your numbers that you received primary radiation, not surgery, is that right? If so, that's consistent with what my docs say, that there is data showing ADT is effective when the primary treatment is radiation. For PC that comes back after surgery is where they say there are no controlled studies, though as proscapt pointed out there are some retrospective studies.

As far as there being cells outside the radiated area, yes I can see that, but if they're there, HT won't kill them, it will just make them grow slower. I don't know, seems to me that HT is a delaying action, pay me now or pay me later. So if I have SRT and it cures me, I'm done. If I have SRT and the PSA comes back, it's because there were cells outside the radiated area, and whether or not I had ADT the PSA would eventually have come back when I stopped ADT. At least, that's how I'm seeing it now.

What burns me about this disease is that after so many years, so much research, so many patients, we still know so little about even the most fundamental treatments. Sometimes when I'm thinking pessimistically I think once we know we have PC there are cells all over the body anyway, so it's just a matter of how aggressive they are. If they are not aggressive, any treatment will show improvement or a cure. And if they're aggressive, it doesn't matter what we do, they will grow.

David

You said "I would go with this doctor, surprised they wouldn't want to give you 70-72 gys."

So I emailed the doctor this morning with that question (how many docs can you email?) and he called me back at the end of the day (ditto). He told me there is a Radiation Therapy Oncology Group (RTOG) with an Atlas database that gives guidelines for how much radiation to give. He said those guidelines call for between 66 and 70 Gy and he would give that in a 1.8 fraction (?) if my scans showed that would be OK for my bladder and rectum. He'd give that over 39 sessions. Unlike the first RO, he would not favor one side over the other because he said there's no way to tell where the cells are.

Glad to see you know the Bethesda hospital. Not sure if you're aware, but the old Walter Reed is no longer there, it finally succumbed to age. It got consolidated with a new Navy-run hospital at Bethesda that's really state of the art. Good news for our returning war heroes. Along with that, they built a new state of the art hospital at Fort Belvoir in northern Virginia and that's where I'm thinking of going.

Hey, as a Nam vet, salutes to you, buddy. I was in the military then, and volunteered for Nam (believe it or not) but the Air Force sent me elsewhere. Go figure, maybe they thought anyone volunteering for Nam was too nuts to actually be sent there :)

Hang in there!