Criteria for using HD Brachy vs. LD Brachy

I'd guess it would boil down to the doctor. Believe the side effects are the same, roughly.

BenSam,

I'll say my RO, who does both plus some other forms of radiation therapy, said both LDR and HDR would serve my case well (as would surgery). I filled out a questionaire and he talked to me about any urinary issues I've experienced.

Not that it "bothered" me, but in hindsight I have noticed a little dripping and different feelings about urinating prior to finding out about my PCa. After that discussion, he said "based on what you've said I think HDR would be best for you, if you're choosing between LDR and HDR, because the urinary side effects will be shorter". Maybe it wasn't exactly those words, but there was a mention of that and something about six months vs. a month or two, etc.

He had a side-by-side comparison chart of all treatments on the sheet and went through it with me discussing cure rates, side effects, invasiveness, etc.

I think if you speak to an RO who does it all he/she will offer such a comparison.

BenSam, I looked very closely at both LDR and HDR after I had made my decision to go with BT as my primary treatment. I did a huge amount of research into these two modalities, and ultimately chose LDR based on a number of points:

*LDR-BT is primarily administrated as a monotherapy in early detected, low to intermediate risk prostate cancer, which is what I presented. HDR-BT is usually applied along with external beam radiation to patients with prostate tumors non qualified by strict stage terms and that present the potential of cancerous cells escaping the capsule.

*HDR-BT is relatively new as a monotherapy, and at the moment there are limited data about the results and the complication rates in longer follow-up as compared to LDR-BT with experience and results of over 15 years and more.

JNF mentioned seed shifting, which in the early days of LDR-BT was a potential albeit small risk factor. Currently in LDR-BT there is an advanced technique of seeds implantation called stranded seeds. In this technique, the seeds are embedded in a polymer strand spaced from 5 mm to over 50 mm apart, and placed in typically an 18-gauge needle. The main advantages of this technique is significant improvement in D90 parameter without increasing of toxicity rate and even less number of seeds migration incidences.

Finally, here's a link to a study I found in the March 2013 Journal of Contemporary Brachytherapy that provides a great comparison of the two modalities:

www.ncbi.nlm.nih.gov/pmc/articles/PMC3635047/

From the "Conclusions" of this article: "At present, the available clinical data with these two techniques suggests that they are equally effective, stage for stage, in providing high tumor control rates." While I made my choice of LDR-BT, I would agree with this conclusion as well as with JNF's point about choosing the "best" practitioner.

Continued best.
Yoop

My oncologist that specializes in prostate cancer felt there was little difference in my case between HDR and LDR brachy. I went with HDR mainly because I was doing it in conjunction with IMRT at UCLA and HDR is the protocol there. (In fact, it's where the pioneer of HDR brachy practices from.)

There does seem to be a case made for HDR by some of our more technical-minded posters here, but I would be amiss if I were to say I fully understood enough to make an argument either way. There's a lot of happy campers here that have had either LDR or HDR.

BTW, maybe you've posted this elsewhere, but I don't see your Gleason score in your signature. That's an important piece of info to add as part of your biopsy results.

more decisions more decisions..... getting thumbs up from both camps... I am lower risk/ no prostate size or urinary retention issues. Though I have found a few LDBT specialist docs in the Chicago area I am not yet aware of HDBT docs.

Yep, it's all about THE decision! As is usually the case with this stuff you can go out there and find pro's and con's for each, about each. I continue to believe either will be equally successful but again I weighed more on the long term results with LDR to aid in my decision. Even the for me, I still narrowed it down to both approaches - and if LDR it would be Moran in Chicago and if HDR it would be DeManes at the CET/UCLA. This is one time where I don't fully agree with TA's take on something - "Doctor selection is critical for LDR, not so much for HDR." I would strongly urge anyone (and unfortunately there's a lot of you newbies out here recently....) that once you decide on YOUR choice of modality to go with "the best."

I think its def different from one RO to another. My RO, said that HDR has had really good results, but he feels more comfortable with LDR until HDR shows longer term data, for "younger" guys (i loved that) like me.
This is in pretty direct contrast to what JNF got from his Doc.

HDR has been used as a monotherapy since 1996, and as part of a combo therapy for many years before that. How many years of long-term data is long enough? In my opinion, any follow-up data beyond 10 years has become irrelevant. What I look for is 5-10 yrs of follow-up, with oncological results measured by surrogate endpoints like biochemical recurrence-free survival.

The MSK LDR brachy data for men treated between 1986-1996 was absolutely horrendous by today's standards - anyone looking at such long-term data would run screaming from the room.

www.ncbi.nlm.nih.gov/pubmed/10889379

In all kinds of radiation, there have been tremendous advances since the 1990s in the knowledge of curative and toxic doses, in technology for insuring precise and conformal delivery, and in technical expertise of practitioners.Radiation used to be only for older guys with lower expected survival back then - it's not just for old guys anymore. Older results are irrelevant.

- Allen

I think a rough rule of thumb is that the number of Iodine seeds= prostate volume+45, but that can vary depending on anatomy, freshness of the seeds, etc.

Prostate shrinkage after brachy takes quite a while, and the radioactivity fades over time, so I don't know how apt the "crushed paper cup" model is.

A much bigger challenge is the prostate edema caused by the needle insertions. The swelling occurs when the seeds are at their most potent point at the start, and resolves as they lose potency. This is the opposite of what is desired. A good RO will then place more seeds to avoid cold spots, but because edema varies between individuals, the correction is imprecise.

Another big problem is getting the seeds to stay where we want them. Think of pushing a metal staple into a sphere of jello, and you get some idea of the problem. Pushing it in compresses tissue and moves the prostate. It is done under ultrasound guidance, which has limited precision too. Seeds move around on their own in the jello, even if stranded. They usually check placement a month later to assure that it is close to the pre-placement CT-based plan - sometimes they have to add a few seeds to correct for cold spots.

As I said, a Seed Artist eventually gets good compensating for these effects, but it takes a long time to develop that "feel."

- Allen

You know what I love about this thread???...that we have a critical mass of radiation guys that can debate the comparative great results of the different excellent options! Six years ago it was "Just Julie" and me...

Jim

BenSam,

I'm not sure about the movement of seeds but I can tell you, two weeks out from HDR Brachytherapy, that I have NO desire to ride a bike. They put 16 needles through my perineum and into the prostate. It's not all that sore standing around but I imagine it too would hurt like heck riding a bike.

I see. Thanks Allen - much appreciated.