Salvage after primary radiation: Personal experiences? (This time w/o the survey)

To me the issue for guys with less aggressive cancer is that they are told one path gives them two bites at the apple and the other path only gives them one bite. While I think it's very valid for someone with less aggressive cancer to choose surgery, anecdotally here it seems that some choose surgery specifically because they want that extra bite.

I was ready to have IMRT ,not RP, when I was told that I would need ADT first. That changed my mind back to RP. I was gl9 but thought it was organ confined. I was wrong. So I ended up having ADT and SRT after all. So far so good.
Happy New Year!
Bob

Looks like there are many in Chicago.

/www.americanbrachytherapy.org/aboutabs/absmembers.cfm

Look under 'Member List' in bottom left.

My opinion, based purely on anecdotal references such as one finds at this site, is that the difficulty with salvage surgery post RT for PCa dates from the early years of psa testing. In the late 1980's and 90's psa was first and foremost a nearly perfect way to show early signs of recurrence. Surgeons, at that time, would then try to salvage these men who had received radiation from 30 years ago (or so). This RT was nothing like what has been administered in the 21st century. The literature from that time displayed worrying side effects and long term outcomes were poor.
Contemporary RT is so much more precise, as well as more effective, as was mentioned in a post or two above. Surgery, of course, has improved markedly in these last 20+ years. Thus a man with tightly targeted 3D IMRT RT may now be followed with surgery, in some cases, with reasonable cause for optimism. This is mostly due to the advances in technology, technique, education, and psa identification. This overall trend takes years to accumulate the significant results necessary to change the minds of doctors, who were trained on the results from years ago, not to mention the patients.

BenSam,

I can't vouch for this center, but this page has thee coolest pics of HDR I've seen. I guess this is how it looked in my case in Atlanta as well.

I just googled "HDR Brachytherapy Chicago"


www.chicagocancer.org/our-expertise/treatments-and-technology/high-dose-rate-brachytherapy-for-prostate-cancer/

Tarhoosier,

I went a-Googling for recent writeups that mention salvage RP after primary radiation. After a few minutes of not-particularly-thorough search I came up with these two:

Salvage treatments following prostate radiation therapy: role of the urologist

Radical prostatectomy subject to strict technical conditions is one of the most efficient local treatments, however it comes at the cost of significant urinary morbidity; minimally invasive therapies (focused ultrasound and cryotherapy) have also their place in specific indications.

and

Salvage of locally recurrent prostate cancer after definitive radiotherapy.

The 5-year biochemical progression-free survival rate is approximately 50% after salvage prostatectomy. However, the morbidity rate of the procedure is significantly higher compared with that observed in previously untreated patients.

Both indicate that salvage RP is done occasaionally and it has mildly-OK results in terms of disease control, but its side-effect profile remains pretty dismal.

Hmmm, maybe HW draws disproportionately from the 70%. But this does seem like a high number given that this is for local not systemic recurrence. I'm certainly not knowledgable to dispute it (nor do I read French), so I do hope others weigh in on this.

JNF said...
You hit the nail on the head, Michael.

I absolutely agree.

PeterDisAbelard. said...
BenSam,

I would expect you to do fine with brachytherapy as a mono-therapy, either LDR or HDR.

What would be the reason to not go the Prostercision route, which far as I know is always BT (LDR?) + EBR? Lower side effects, when taking a chance on higher SEs seems un-needed at this low of a risk?

all the drs Ive talked to at upmc cancer centers at pgh,pa and my own dr, ,they told me before my treatment, that if you get seeded, with the rad pellets, and then your cancer comes back, you can"t get your prostate out, you have to go on hom threatment, the drs use the sayingof the gold standerd of treatment , which is about the best, unless you have a very mild case of p c, then you can get seeded, but the best treatment is the rad prostectmy, and most drs do not give hom treatment before,,

kenny123 said...
all the drs Ive talked to at upmc cancer centers at pgh,pa and my own dr, ,they told me before my treatment, that if you get seeded, with the rad pellets, and then your cancer comes back, you can"t get your prostate out, you have to go on hom threatment, the drs use the sayingof the gold standerd of treatment , which is about the best, unless you have a very mild case of p c, then you can get seeded, but the best treatment is the rad prostectmy, and most drs do not give hom treatment before,,

Data I've seen suggests cancer is more likely to return after surgery than after brachytherapy. Surgeons can't 'see' small cancer cells during surgery and often try hard to 'spare' nerves, thus end up leaving some cancer behind. I say "often", but don't mean it's common. It is a major risk though, if cancer has slightly escaped.

A couple local doctors in my town (45 minutes from Atlanta) had never heard of HDR brachytherapy and knew less than I about LDR; so I wouldn't personally be too impressed with their opinions on the latest technologies/treatments on prostate cancer.

PeterDisAbelard. said...
BillyBob,

BenSam said...
Would this group suggest with my stats that I am an excellent candidate for LDR or HDR brachy mono? Even with 5 / 12 cores showing cancer (all on right lobe) with one PNI. I am not inclined to go the surgery route.

He asked if he is a good candidate and he is. I was just answering his question. Actually, he's a pretty good candidate for almost everything (AS would be a stretch). I don't know much about Prostercision, whatever that is, but I'm sure he would be a good candidate for that, too.

Oh right, I know you were, and you answered his question. But it was just leading me to yet another question, a follow up question. Prostercision is/are these guys over in Atlanta, some folks I had consulted with(guess they are not as well known nationally as I had thought): www.prostrcision.com/

Like you, I was also figuring he would be a good candidate for just about anything. But seems to me the Prostrcision guys - who I have heard have big debates/heated arguments at national conferences with some of the really well known Seattle RT guys, about whose results are best- that the only approach these guys take is BT + IMRT ( or I think I have also seen it called EBR that they give) beam radiation. I think they do every one that way, and at least I know several guys who have used them, and that is what they all had.

In fact, because I consulted these guys and I know several guys who have used them, I have only recently become aware that some folks go BT only. These guys- naturally enough- claim an very high cure rate and a very low SE rate, at least for the low risk guys they use in their examples(which has made me question if they have a selection bias). So I was just wondering what would be the advantage or reason for NOT getting this additional IMRT beam radiation as a follow up to the seeds? Since I'm sure they consider it an important part of their high success rates.

I'm guessing- if you or any one knows- lower SE rates for the BT alone? And for someone in BenSam's low risk category, despite their claims of such low SE rates, maybe in some opinions any increased risk of SEs can hardly be justified for such a low risk?

It was just me sort of thinking out loud. I figure that even though these guys only recommend their combo treatment(far as I know), if others recommend BT only there must be a reason, and maybe a good reason.
Bill
EDIT: some more about Prostrcision just so you will know what I am talking about. And I have partially answered my own question, as I see that they say that they give a lower dose with their BT:

"Question 72:
How much radiation do you give with the seeds?

Answer:
On average, 9,000 cGy are administered. Additionally, we place extra seeds, which means increased radiation, in the cancerous areas within the prostate. The middle of the cancer may receive as much as 20,000 to 25,000 cGy of radiation from the seeds. Thus, we tailor the irradiation to each man’s cancer, which goes back to the importance of the Second Opinion Pathology Report. See Questions 23–28.

Question 73:
How much radiation do you give with the accelerator treatment after the seed implant?

Answer:
We administer from 4,500 to 5,250 cGy. Thus, the total amount of radiation we give to the prostate is at least 15,000 to 15,750 cGy. More importantly, by performing an I-125 implant first, which has a 60-day half-life, and starting accelerator irradiation 21 days after the implant, both methods of irradiation can be given simultaneously. This produces a dose intensification or synergistic effect (instead of 1+1=2, think 1+1=5). The effect of radiation with dose intensification or seed activation (synergy) is more intense than simply adding the amount of radiation from each method.

Question 74:
Doesn’t giving two forms of radiation mean twice as much radiation?

Answer:
No. With ProstRcision, we reduce the seed implant dose to 9,000 cGy, as compared to the dose of 16,000 cGy typically given when men are treated only with seeds. Likewise, we reduce the accelerator radiation dose to 4,500 cGy, as compared to the 7,500 to 8,600 cGy men are given when treated only with accelerator irradiation. By reducing the dose of both seed and accelerator radiation, you can combine both treatment methods and compensate for the disadvantages of either, producing dose intensification or dose synergy (seed activation)...................."

Post Edited (BillyBob@388) : 1/3/2015 4:40:33 PM (GMT-7)

There is nothing different in ProstRcision from combo Brachy/IMRT given in many places. The doses are about the same, I had 8500 gy of seeds and 4500gy of Tomo. The only reason for combo treatments is for more aggressive cases where there may be some extra capsular extension where the external beam covers more of the bed or when the tumor load is more extensive. Naming it something different is just a marketing ploy.