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SBRT verses IMRT for high risk

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Posted 9/14/2016 7:49 PM (GMT 0)
Hi all,
I had posted earlier about my decision to use SBRT instead of IMRT but now having second thoughts. My radiologist, Dr. King at UCLA, will not comment if SBRT is any more effective than IMRT and my urologist in Marina del Rey thinks it is less effective. My local urologist has no opinion. Plus my insurance has denied coverage because of no proven effectiveness on high risk patients. I am going to appeal to insurance company but I am not very hopeful. Is it possible that the dreaded insurance company may be right? I have some options to do the SBRT that will be more expensive but possible but now I wonder now if it is more effective.
I am bummed out! I had my decision made and now am second guessing it.

On another note I have started Lupron a month ago and am scheduled for RT in about a month. So I am moving forward. So far the HT hasn't been too bad, sleeping at night has been troublesome though.

Rosewood
Posted 9/14/2016 8:28 PM (GMT 0)
SBRT monotherapy for high risk is new. Although there are good theoretical reasons why it may be as effective as a brachy boost, it remains to be proven definitively. That will take many years. Dr King is doing it as a clinical trial. A brachy boost has been proven to have better oncological outcomes than IMRT. Brachy boost is the "tried-and-true" for high risk, but that may have a higher risk of side effects than IMRT alone.

The largest trial of SBRT for high risk was from Alan Katz in Flushing, NY. He used mostly 35 Gy (King uses 40 Gy) on 97 patients, only half received adjuvant ADT, and about half received pelvic IMRT (not SBRT) at a dose of 45 Gy. King believes his protocol is an improvement, but results are years away.

Stereotactic body radiotherapy with or without external beam radiation as treatment for organ confined high-risk prostate carcinoma: a six year study

There is certainly a convenience factor in having it all done in 5 treatments. But if you don't want to go with something that is not yet proven, and your insurance won't cover it, you can consult with Dr. Kamrava about getting the HDR brachy boost therapy. And you can always go for a long course of IMRT treatments - you may be lucky, and it may turn out just as well for you.

Sometimes insurance companies may approve it when it is a clinical trial on investigational therapies - you might want to appeal.

Your urologist is not a radiation oncologist and probably doesn't know much about it. The specialists know whatever there is to know about their own therapies.
Posted 9/14/2016 9:48 PM (GMT 0)
Good to hear from your Rosewood...sorry that your treatment isn't settled yet, but glad you're not finding HT to be too difficult! As I recall, you couldn't do the combo therapy with HDR brachy due to your TURP. That said, I'm not sure if you had a chance to consult with Dr Kamrava at UCLA about that to 100% confirm since there is good data on how effective that combo is for high risk patients.

I'm certainly not smart enough to compare the effectiveness of SBRT and IMRT as mono-therapies, although SBRT certainly would be a lot easier with the shorter number of treatments. Off the top of my head I can't think of any high risk guys here that have done SBRT as a mono-therapy but as Allan says it's application for that is new. There are several high risk guys here that have done IMRT as a mono-therapy.

It would be too bad if the insurance company ended up making your decision for you. Even if you're on the fence between the two treatments, it would be good if you were the one making the call...
Posted 9/16/2016 2:46 PM (GMT 0)
Hi Rosewood:

For what it is worth, I have had SBRT on two occasions 5 years ago to my prostate and 3 bone mets in the pelvic region. Recent C-11 PET/CT scans with Acetate done in AZ show no activity in these treated areas, and I have had no SEs.

Houseboy
Posted 9/16/2016 4:03 PM (GMT 0)
houseboy, did your recent C-11 Pet/Ct show where your PSA is coming from?
Posted 9/17/2016 1:28 AM (GMT 0)
Rosewood:
As an alternative, have you considered combining SBRT plus IMRT? As you can see (I hope) from my signature, this method is being used by the Georgetown U group (Dr Collins et al) for intermediate and high-risk patients (like me, with multiple Gleason 9 foci). Three sessions of SBRT followed by 25 IMRT treatments.
Data have recently been published:
Mercado et al. Front. Oncol. 6:114 (2016). Access to this paper is 'free'.
To me, the most important result is shown in Fig 1. The 3-year biochemical control rate was 100% for the intermediate-risk group and 90% for the high-risk group.
Side effects (the main topic of the paper) were acceptable.
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