IGRT, EBRT, IMRT..Update..perplexing dr. appt

Updates, questions and flabbergasted at a doctor's visit. Bob saw a radiation oncologist in Little Rock (4 hours away round trip). We both really liked him and he's very knowledgeable any question or study I threw at him he could finish my sentence and knew exactly what I was talking about. This oncologist specializes in prostate cancer. He suggested 40 treatments of IGRT IMRT. We got a second opinion today with a radiation oncologist 2 hours away round trip. This oncologist treats all types of cancer. First the consult nurse taking Bob's medical history took a personal call during his assessment then proceeded to tell us all about it after she got off her cell phone, then finished the questions. (We had already been waiting 45 minutes past appt. time). Then the oncologist came in, went over what he had learned from the faxed over records. He off the bat recommended EBRT with one shot of Lupron during treatment. (Not before treatment starts). As soon as I started firing off my questions, every single time he'd say, I don't know I'll have to look that up, then grab a book and look up the answer. For instance Me "Standard protocol used to be biochemical recurrence is when PSA reaches .2 however, new studies are suggesting treatment is more beneficial at .03 what's your opinion?" Doctor "I've never heard that biochemical recurrence is .2, I have never heard that number, let me look that up." Seriously folks, every question he had to look it up in a book and then if he couldn't find the answer would say he didn't know. Then he holds up Bob's prolaris test and says "I've never in my life seen one of these, I showed it to our genetic physicist and she's never seen this either. We cannot even order to have this test done here and all I can do is look at what the paper says but I don't know anything about it". So we go out and I look at Bob and ask him what he thinks. He didn't like anything about the doctor today but is still entertaining using this facility. I told him take the money out of the equation (the facility today is close enough he could still work, be home every day, and they pay all medical costs not covered by insurance vs. Little Rock that potentially will cost him 7 thousand dollars and he will have to be off work because it's so far away) if that wasn't an issue where would he go. He of course said Little Rock (although he's not happy being away from home 5 days a week). Anyway, that's the background, now here's the question, what's the difference between EBRT VS. IGRT or are they same? IMRT? Weigh in on the best treatment and feel free to weigh in on the doctor visit today. Hope all of you are doing well.~Miki

Prolaris is the wrong genetic test. The one used to decide whether a man is likely to have a metastasis in the next 5 years is called Decipher. The downside of the test is that 5 or even 10 years may be too short a time span for metastases to become visible. Also, it's much better at ruling out, than ruling in.

I would also question the need for ADT when it is likely that all that was left behind is some Gleason 6. Of course, there may be some grade progression in that tissue by now, and it may be transforming, but hopefully not in just a year and a half. It's very much a judgment call.

He may not be knowledgeable about the latest research (few in community practice are), but how are his treatment plans? What's his record with salvage radiation? What kind of IGRT does he use (e.g., fiducials/Calypso with cone beam CT)? What limits does he set on bladder and rectal exposure? How does he track patient outcomes? What kind of patient-reported outcomes is he getting? (see the questions in the sticky)

What I'm saying is that a really meticulous and experienced technician with excellent equipment and good patient aftercare may be more important than him knowing the latest studies. If you want both, try a major tertiary care center/university hospital. The trade off is that daily travel can be a drag.

- Allen

If it already has not been done so, I think it would be reasonable to have Jon Epstein look at both the biopsy slides and the post prostatectomy slides and confirm the Gleason sum. This may help in the decision to add HT or not. But the conflicting pathologies warrants further investigation.

If HT is recommended, it should be done before radiation to stay in step with standard of care.

While your local doctor's visit sounds a little "back country", at the end of day, if he's treated 100 patients with similarity to your husband's pathology, and has a high success rate, I would think that his stats may be far more important than his disease intelligence.

For me, it wouldn't matter if it he was a witch doctor, as long as his success rate gave me the best chance at winning.

Wishing you and your hubby every success in the fight!