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New member BANDA: My dad is at the point where he needs/wants to make the decision

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Posted 1/20/2015 4:05 PM (GMT 0)
Banda posted this in another thread - thought I'd start one for them:

My dad is at the point where he needs/wants to make the decision for the next step. Surgery and Seeds are not an option, so which one of the well know radiation therapies would you recommend - proton, IGRT, IMRT or .....? We have not discussed this with a radiation oncologist yet, probably in the next few weeks.

Age 69 y.
Intermediate grade t1c - located in the prostate - not spread outside
6/11/14 biopsy - Gleason score 3+3=6 - 5%; 3+4=7 - 20%; 3+3=6 - 1%; 3+3=6 - 10%; 3+4=7 - 30%; 3+4=7 - 40%; and 3+4=7 - 20%
PSA:
3/15/13-7.71, 4/1/13-7.22, 3/11/14-8.89, 3/18/14-10.52
After diagnosed, started hormonal therapy (Lupron 3 months). First PSA Nov.'14 was 4.3

Thanks in advance!
Posted 1/20/2015 4:06 PM (GMT 0)
Welcome Banda - sorry you had to find your way here but you'll finds lots of help, advice, experience and support.

My first question would be why "Surgery and Seeds are not an option?"
Posted 1/20/2015 4:15 PM (GMT 0)
Welcome Banda! I'm not a radiation guy so will only extend my best wishes. Lots of knowledgeable members here who will do their best to help you guys along. Best of luck!

Cheers, Doug
Posted 1/20/2015 4:23 PM (GMT 0)
Hello Banda,

Welcome to the forum. Sorry you have worries about your dad but glad you found us.

I, too, would like more information about why surgery and seeds are off the table. There is a rule of thumb that after 65 years of age men tend to do better with radiation than with surgery because older patients recover more slowly from the surgery but it is only a rule of thumb. A very fit 70 year old may be a good candidate for surgery while a diabetic 50 year old may not be. And seeds (brachytherapy) are usually possible for most men.
Posted 1/20/2015 4:26 PM (GMT 0)
I'l lmake it unanimous. Welcome. Why not seeds or surgery?
Posted 1/20/2015 4:40 PM (GMT 0)
Hi again Banda.

I am a little confused as with the others why your father is unable to have seeds or surgery. If he has other health issues then I would understand about surgery. But with a GS of 7 and organ confined I would think he is a strong candidate for seeds. I myself am a GS7 and organ confined and I am having seeds at the end of this month.
Posted 1/20/2015 8:30 PM (GMT 0)
There are two you didn't mention - probably the best two of the remaining alternatives - SBRT and HDR brachytherapy. They are both excellent for his intermediate risk PC. SBRT (often known as CyberKnife) entails just 5 short treatments. Here's a good link about it, showing 7 year results. HDR brachy monotherapy usually entails an overnight hospital stay. Both have established records of excellent cure rates with low side effects.

Proton is no better than IMRT, but costs a lot more. IMRT is no better (and possibly worse) than SBRT but costs a lot more, and takes a lot more time.

I don't know of any benefit to hormone therapy for his favorable intermediate risk disease. It seems a shame to put him through that unnecessarily.

There may be lots of reasons for no on seeds - large prostates, prior TURP, urinary issues, bowel inflammation, etc.
Posted 1/20/2015 8:43 PM (GMT 0)
Banda, as we discussed via email I have locked the duplicate thread. I will copy and past the responses from that thread on this one. Here are comments from Dewayne:

Why aren't seeds an option? (I'm not hinting it might be I just don't know).

I had HDR brachytherapy a month ago. The procedure seems rather moderate and my first PSA was 1.7 - a drop from 4.6. They expect a steady drop over the next couple of years and a cure for me. I'm feeling good, and except for moderate fatigue for a week and some urgency urinating I don't have any issues.
Age: 48
Family History: Father - prostate, colon, intestinal, bladder, brain, and melonoma cancer. He's 81 and still alive.
PSA: 2013 - 2.5, Aug. 2014 - 4.5, Oct. - 4.0
Diagnosed 10/15/2014
3+3=6 (<5% of core), 3+4=7 (10% of one core), 3+4=7 ("Discontinuously" involving two cores, 40% and 50%) Left base, mid and apex.
Hobbies: Pickup basketball 3x/week, crossfit 2x/week.
HDR Brachy 12-2-14
Posted 1/20/2015 8:44 PM (GMT 0)
And here are comments from Buddy Blank:

Yes, agree with the others re: Seeds not being an option. Why not?
PSAs: 4.76 5/12 - 4.23 8/12 - 3.98 10/12 - 4.9 2/13 - 2.9 6/13 - 2.7 11/13 - 1.31 3/14 - 1.07 7/14 - 0.69 10/14
Biopsy right prostate: Benign tissue
Biopsy left prostate: Prostatic adencarcinoma, Gleason score 7 (4+3), Tumor involves 2 of 10 cores & 5% of total tissue sampled, Positive for perineural invasion
TRUS measured prostate volume 19.36 cc
Stage T1c
66 Pd-103 seeds implanted 3/13
Posted 1/20/2015 8:45 PM (GMT 0)
Finally, here are the comments from Skeeter:

Seeds might not be an option if you have a history of urinary retention, urination difficulties (reduced flow, trouble starting), enlarged prostate, etc. One of the reasons I opted for proton therapy was that I had a history of urinary flow problems (difficulty starting, weak stream, frequency) and none of my physicians thought BT to be a viable option. Thus I chose proton, have had a good result so far and no regrets. BT is a great way to go for some people, but it isn't necessarily the best choice for everyone.
Age at time of diagnosis: 61, psa 4.6, 30 days cipro, psa 4.3, biopsy 4/28/11, 2 of 12 cores positive, Gleason 6
T1c
Central Ky
Approved (insurance) for Proton Therapy at IU @ Bloomington 7/14/2011
8/17/2011 Proton Therapy Treatment begins
10/19/2011 Proton Therapy Treatment Completed!
11/1/12 psa 0.4
4/11/13 psa 0.2
5/23/14 psa 0.05
Posted 1/24/2015 4:49 AM (GMT 0)
First I want to say thank you to all of you. Honestly I was not expecting to get a response that quickly (same day). Looks like I found the right web forum.

Let me start all over again. I’m not familiar with the prostate cancer (no family history or friends with prostate cancer) and the treatment options, so bear with me while I’m learning.

He was diagnosed with prostate cancer sometime in July ’14 (biopsy). The first suggestion from the doctor (urologists) was surgery, but since he had two small hard attacks in the past and pulmonary embolism (takes blood thinners) 2 years ago, we wanted to get second opinion (family doctor, urologist, my ant is a doctor...).
He does not have any urinary issues. In addition, although he is overweight he wants to stay in shape and goes to the gym at least 3 times a week (water aerobics, bike).

During our initial consultation the hormonal therapy came up as option until we make the final decision – Lupron every 3 months (so far two doses). Based on how he feels, hardly has any side effects from the treatment. PSA after first injection 4.3, after second 2.07. We know is not the right option but better something than nothing.

So, based on his health history and age we are planning radiation therapy.
To correct myself from the first post, the brachytherapy was not completely out of the game, but since he is taking anticoagulant it was not discussed with the urologist (few months ago). I know he stop taking the anticoagulant 1 – 2 days prior the biopsy, so he might do the same thing for the brachytherapy. He has an appointment with the urologist on Monday (1/26) to discuss about the latest results and next step.

Who makes the decision/suggestion what type of radiation therapy he will get - radiation oncologist or the urologist?

Here is the summary:
Intermediate grade t1c – organ confined – CT and Bone scan negative.
Hormonal therapy (Lupron 3 months)
Biopsy 6/11/14 -7 out of 12 cores positive - Gleason score 3+3=6 - 5%; 3+4=7 - 20%; 3+3=6 - 1%; 3+3=6 - 10%; 3+4=7 - 30%; 3+4=7 - 40%; and 3+4=7 - 20% - No perineural invasion and No extension into extraprostatic fat.
Prostate volume 37.8 cc
PSA:
3/15/13-7.71; 4/1/13-7.22; 3/11/14-8.89; 3/18/14-10.52; after hormonal Nov.’14 - 4.2; Jan.’14 – 2.07

P.S. “Tudpock18” thank you for combining both threads
Posted 1/24/2015 7:12 AM (GMT 0)

Banda said...
based on how he feels, hardly has any side effects from the [Lupron] treatment.

Unfortunately, it's a cumulative thing, increasing over time. There are also potential cardiovascular side effects, so I'm glad he's being watched closely by a cardiologist. Also, there's a danger that his testosterone will not recover afterwards. Also, with radiation on top of androgen deprivation there's a possibility of longer lasting impotency. There has never been any evidence that androgen deprivation is of benefit with radiation for Gleason 3+4.

Banda said...
Who makes the decision/suggestion what type of radiation therapy he will get - radiation oncologist or the urologist?

He does, in consultation with his doctors. Unlike many cancers, where there is only one choice - take it or leave it - with his kind of PC, he has several choices all with about equal and excellent (90+%) chances of a lasting cure.

Here's the rub - in this era of specialization, one kind of specialist can't be expected to know all that much about the other specialties. It falls to the patient to go out and meet with each specialist, taking with some healthy skepticism what each has to say about the other specialties. If they are not boosters for their own specialty, they wouldn't be doing it.

So unfortunately, you can't just meet with a generic radiation oncologist and expect him to know all the details of the other radiation treatments. You have to meet with one who does SBRT, one who does HDR brachy, one who does LDR brachy (seeds) (if that's still a possibility).

If you care to share what city you're in, perhaps we can recommend some good specialists nearby.
Posted 1/24/2015 9:49 PM (GMT 0)
Tall Allen thank you for the advice.

He lives in West Detroit Metro Area.

To all, any good specialist in that area that you can recommend.

Thanks!
Posted 1/24/2015 10:53 PM (GMT 0)
Alvaro Martinez is in Detroit at 21st Century Oncology in Pontiac, MI. He, along with Jeff Demanes, originated the use of HDR brachytherapy as a monotherapy in the 1990s. Here's a link with contact details.

Oakwood Center for Cancer Care in Dearborn offers SBRT/CyberKnife but I don't know the ROs there.

He's also close to William Beaumont Hospital, the Barbara Ann Karmanos Cancer Center at Wayne State, and Henry Ford Hospital - all excellent cancer care centers.

That should get him started.
Posted 3/17/2015 3:33 AM (GMT 0)
Hi everyone, I hope you are all doing well.

As I mentioned in my last post, we decided to do a radiation therapy and my dad started the preparation. Initially based on the first results (MRI, CT, PSA) doctor suggested 43 days IMRT, but after doing the second MRI we found out that the tumor extended beyond the prostate in to the seminal vesicle (no bone, bladder or lymph node involvement). It is a very small area but still.... Now we are back at the begging since the doctor mentioned that we should consider two more options:
- Seeds plus 25 beam (less heavy on seeds with more beam)
- 10 beam with heavier seeds

Which one will you prefer: external only or combined?
Suggestion, comments...

Thanks in advance
Posted 3/17/2015 5:48 AM (GMT 0)
Of the two, I recommend he hear other options.

HDR brachy and SBRT have an advantage over Seeds (LDR brachy) in that they alone can treat the seminal vesicles whereas seeds alone cannot.

SBRT is as effective if not more so as IMRT at stopping the cancer,but it only takes 5 treatments and is half the cost. If he can't get that for insurance reasons, he should consider HDR brachy - Martinez is among the best.

Did he talk to Alvaro Martinez and the Oakwood Center?
Posted 3/17/2015 1:45 PM (GMT 0)
I would just add that U of M has an excellent cancer center as well. They will be able to discuss all of the modalities.

You are getting great advice, but try not to overthink it. Most treatments are equal in their outcomes. The medical teams will not recommend a treatment that would be bad for his medical issues without discussing it with you. What you are looking for is the treatment with the least disruption to his life. IGRT or brachytherapy really are the least offensive to the body.

Good luck to you and your dad. He is lucky to have you assisting him through the maze of medicine.

Goodlife
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