New member JohnNW recently diagnosed looking for options.

John, in the end, there is no right answer, no ideal treatment for everyone. In your case, any of the standard protocols are likely to be curative. The questions that you'll need to answer are very individual and very personal.

I chose surgery with similar numbers to yours, and have had a great outcome. My reasons were:

1. I knew from the start I wanted a standard, well understood and well used treatment. My dad used an experimental treatment for his PC...without the best results.

2. Radiation creeped me out. Especially brachy...the idea of having radiation sources inside me for life gave me the willies. I also was aware that there is a lifetime limit to radiation, and I didn't want to start there. I'd already had one cancer deal (melanoma) and wanted to be able to maybe use it if a third deal came along.

3. Which left me with surgery. I had two different specialists basically tell me that I could do AS, but I would likely be in the group that would only last a year or two on it. I knew I was in a good situation both healthwise and life-wise to do it now instead of later, so that led me to where I was.

You'll have to weigh all the facts yourself and make a good decision. And you will, make the one that is right for you.

Well it may not be his standard of care, but it is according to NCCN and ASTRO.

Using both HDR brachy AND SBRT is redundant. SBRT is designed to mimic HDR brachy - I can't think of any reason to use both on favorable intermediate risk. SBRT alone treats the entire prostate plus any specified margin around the prostate and conforms to whatever shape it has. HDR can also treat a limited area outside the prostate. The reason not to do both, if it's avoidable, is because side effects get worse when you combine them.

I suggest you talk to a few others before deciding.

- Allen

Tall Allen said...


I suggest you talk to a few others before deciding.

- Allen

I agree. Plus, did you ever get a second reading on your biopsy slides? That may affect your decision making.

Jim

Hey John...

FWIW. ..I also felt as if surgery was akin to killing a gnat with an atom bomb. But when I asked several surgeons and as many RO's that very question...They all sang a resounding chorus of "No".

The delimna I felt I was faced with my disease was that focal therapy was the way to go. One major problem with that for me was that a leap of faith that large in my own judgement was just to large a one to make. (in other words....i was caught in a "do as I say and not as I do" with myself!!). There was a conflict between my better judgement and my personality style.

In the end...my personality style won out. "Get the thing out and get on with your life" was my decision.

"Go with the numbers and stop over thinking it" I told myself..."and everything should will turn out just fine".

Maybe I just couldn't handle the responsibility of having to live with my own instinctual choice should I had been wrong and the cancer came back. If that happened. ..i could see myself blaming myself for not going with proven therapies.

As to my decision for surgery. ..i felt the need to treat. So AS wasn't an option. I wanted this stuff gone out of my life for the rest of my life. Surgery seemed the easiest "way out" for me.

I say all that to say this....

Sticking with one's guttural instincts can be a tough row to hoe.

Good luck with whatever course you choose to take. I'm confident you will not regret your decision. ..no matter your choice.

(Btw...i chose brachytherapy in the pole. Lol)

I don't regret my decision. Disappointed maybe. But...One goes with what one goes with and you live to fight another day.

Things get better once one decides...and gets to this side of the deed.

Good luck. Everyone here has been where you are.

Edit: I resoundingly agree with what's been said about going with experience in whatever choice you ultimately make. To wit... That comment...""It's the standard of care..." is redflag to my way of thinking. Fwiw..

Gentlemen

I was able to get an appointment for a second opinion at Fox-Chase with Dr. Eric Horwitz who does HDR brachy monotherapy .
Thanks for the recommendation - Tall Allen.

John

Greetings

Had my meeting at Jefferson in Philadelphia and discussed radiation treatment. The want to do the HDR Brachy followed up with 5 external radiation sessions.

I am going for a 2nd opinion. I am seeing Dr. Horwitz at the Fox Chase Cancer Center also in Philly. He was recommended by someone on this site (thanks)

Was told he is sometimes in favor of a monotherapy which will reduce the radiation amount. Based on his recommendation I will have a plan

Dr Dicker says it's a matter of being thorough. That's all I was able to get out of him.
Looking forward to hearing what Dr Horwitz has to say.

Tall Allen said...
You have some great places in Philly ...
• At Fox-Chase you have Eric Horwitz who does HDR brachy monotherapy for your type of PC. They used to be excellent for LDR brachy as well - I don't know if they still are.
• The Philadelphia CyberKnife Center has published some impressive results:
journal.frontiersin.org/article/10.3389/fonc.2014.00312/full
• UoP used to offer protons but no longer does for prostate because results were no better than IMRT.
• I don't think IGRT/IMRT, at least in the way it's been traditionally done (40-44 treatments), is justifiable given the impressive results of hypofractionated regimes and of SBRT (5 treatments).

Because you only have one core of GS 3+4, you may be a candidate too for focal ablation, an experimental treatment with very low SEs.

John, welcome, sorry you have to be here.

I'm from the Philadelphia metro area as well. I actually live in Delaware about an hour south of Philly, but work in center city weekdays. Feel free to email me or PM me here if you would like to meet someone in our boat face to face.

I will reiterate TA's recommendation to get multiple opinions from multiple centers. I've been to the NIH-NCI in Bethesda (Dr Pinto) - looked at focal ablation therapies, Johns Hopkins in Baltimore (Dr. Partin) - looked at RALP, my local urologist in Delaware (Dr. Lobis) - also for RALP, Fox Chase Cancer Center in Fox Chase (Dr. Horwitz) - for HDR BT monotherapy or IMRT/IGRT, Penn Medicine (Dr. Vapiwala) - for PBRT.

If you haven't already, make sure to get copies of all medical records, scans, path results, etc. I took them with me whereever I went and also keep electronic softcopies that I could deliver to other consults easily.

As others have said, there is no one right answer, and that's the hard part. You will have to come to a decision on your own as to what you feel is the best answer for you, specific to your diagnosis, along with your doctors.

JohnNW said...
Gentlemen

I was able to get an appointment for a second opinion at Fox-Chase with Dr. Eric Horwitz who does HDR brachy monotherapy .
Thanks for the recommendation - Tall Allen.

John

John, glad to hear. I Have HDR BT monotherapy scheduled at FCCC on Feb 17 and Feb 24, per my sig, with Dr. Horwitz. Spoken with him at length on more than one occasion, personally I really like his bedside manner and his approach. YMMV.

I also agree, you should have your slides reviewed by Dr. Epstein at JH Brady Urological Center. He is known to be among the best in the business.

Tall Allen said...
CJ,

I haven't seen it -- have you? I suspect it's a clinical trial. MSKCC is doing a similar trial of LDR brachy with SBRT that also leaves me scratching my head.

Found the clinical trial here:

/clinicaltrials.gov/ct2/show/NCT01655836

Tall Allen said...
There is no "may" about it - it does respond better to hypofractionation. Otherwise HDR brachy monotherapy which has been used since the 1990s, and SBRT, which has been used since 2003, would never have been curative.

Agreed, I just don't like to talk in such definitive terms myself since I'm not a doctor and I'm fairly new here to boot.

Tall Allen said...
No. These are apples and oranges. To make them comparable, ROs compute a value called "biologically effective dose (BED)" for cancer control as well as healthy tissue based on a factor called the alpha-beta ratio. Because of the very low alpha/beta ratio, somewhere around 1.5 for prostate cancer, there is a multiplier effect of hypofractionation - an SBRT schedule of 5 x 7.25 Gy (=36.25 Gy) is biologically equivalent in cancer killing power to a dose of about 97 Gy if it had been given in typical IMRT dose rates of 1.8 Gy. This is far beyond what can be safely given with IMRT.

At the same time, acute toxicity is based on a much higher alpha/beta ratio of about 10 for healthy tissues. This means that that SBRT schedule of 5 fx x 7.25 Gy has a third less acute toxicity than a typical IMRT treatment schedule of 44 fx x 1.8 Gy. Both the cure rates are higher, and the acute toxicity is lower with SBRT (or HDR brachy).

I think we were saying the same thing in lamen's terms - though you said it much more specifically and accurately then I did.

I was referring only to hyperfractionated RT initially - so your example proves my point - a hyperfractionated RT that would deliver 97Gy would deliver far higher SE's when compared to hypofractionated RT. I've read the studies on dosage levels between 70-82Gy for hyperfractionated RT that do have better cure rates and BC, but also worse SEs.

What I was not as aware of was the lower alpha/beta ratio for hypofractionated RT, resulting in lower acute toxicity. That's great info and thanks for passing this along with numeric examples.

I do understand that the short term SE's for hypofractionated RT tend to be more acute - because of the higher fractional dosage, but the long term SEs are not as bad. Again, your numeric examples prove this out in more detail.

Tall Allen said...
All radiation therapies treat the entire prostate, so there is no need to localize where the tumors are. It is multifocal 80% of the time, so cancer foci are assumed to be everywhere. Some ROs have experimented with something called a Simultaneous Integrated Boost (SIB) to identified lesions within the prostate, with uncertain benefits and possibly higher toxicity. The argument against SIB is that since we know the cancer is spread throughout, perhaps microscopically, then the whole prostate should be given a curative dose consistent with low toxicity.

Got it, it was my understanding that if a tumor can actually be seen on MPMRI or CT, that the dosimetry and maps are sometimes altered to deliver, when possible, higher radiation dosage to the tumor area. I know in my case that my MPMRI results and my fusion biopsy results are being used in this manner for my HDR BT treatment - or at least that is what I was told. I'll have to follow up to be sure. In any case, thanks for sharing your knowledge - it helps us all to learn more about Pca, which is a good thing at least for me.

Got a second opinion from Dr. Horwitz at the Fox Chase Cancer Center and it went really well. He disagrees with Dr Dicker at Jefferson on the use of HDR Brachy followed with SBRT. He gave me a choice between 2 treatments of the HDR or 5 treatments using SBRT.
Any opinions?