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Never have 40-44 IMRT treatments as primary therapy unless you're a rich masochist.

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Posted 9/20/2016 2:41 AM (GMT 0)
If there was any doubt before that hypofractionated IMRT (done in fewer treatments) was preferable to the 40-44 treatments that are conventionally given, this should bury that doubt. No different in oncological results. No different in patient-reported urinary, rectal, or sexual outcomes. Costs less. Takes less time. This is based on a series of randomized clinical trials reported over the last couple of years. This latest one was from MD Anderson.

Hypofractionated radiation therapy using IMRT has a clear advantage

I feel like I've written about this so many times that I've become a soap-box crusader on this issue. Now, if we could only figure out how to bring this crusade to ROs who get rich over delivering more treatments.
Posted 9/20/2016 11:17 AM (GMT 0)
Geez, Allen. I hope you can delete a post with such a title. That's outrageous, even if you do believe in that study wupporting your chosen RT method so strongly. 30 treatments vs. 44 is definitely an improvement. That's a study with 173 people, with thousands, tens of thousands, treated with standard fractions. Perhaps it is sufficiently stated to change the standard of care. I'm not sure what level of evidence it takes to do that.

But to call people choosing a more proven method "rich masochists"? Criminy.

I wish this forum had a way to block a thread. Unfortunately, all we can do is block a forum name.
Posted 9/20/2016 2:37 PM (GMT 0)
Well, speaking as one who had IMRT in 45 sessions as primary treatment, as well as being, unfortunately, not rich, and being, fortunately, not masochistic (as far as I know), TA's thread title definitely got my attention.

First, as far as questioning TA's science, the accuracy of what he us saying in his post, there is little point in doing that. He is just too good.

But what I would like to point out is that, while it is not his central theme, TA is touching upon something that is, or can be, a huge issue for all of us who have ever had any kind of treatment for anything. And I think it is something that should be noted.

I've felt it myself and I'll bet most everyone of us here has as well, at some point or another following the treatment we had.

I'm not sure it has a clinical name (I did a quick websearch, to no avail), but it is a psychological phenomenon that is probably universal and goes like this. A patient gets some form of treatment (RP, RT, whatever), hopefully successful, but also quite possibly with side effects. Then, as a year or two rolls by, or possibly longer, he reads of remarkable improvements in the treatment method he chose, perhaps less pain, fewer side effects, better outcomes, etc.

And then he wails to himself, perhaps with some hand-wringing, "Why, oh why, couldn't I have been able to wait just a little bit longer until this oh so much better treatment had come along, so that my situation today would be so much better! Oh why?"

What shall we call this? "Patient's remorse?" Remorse not so much over the form of treatment chosen, but over the timing of it?

But then we must realize that this will always be the case. That advances and improvements in treatments will always be happening (and thank goodness for that), and that whatever the time it was when we had our treatment, the odds were very good that the treatment was going to get better in the future. But too late to help us, as we may note with regret.

So while it may be natural to feel perhaps a bit of "patient's remorse" like this, we need to remember that it was going to happen anyway.
Posted 9/20/2016 3:05 PM (GMT 0)
Waddya mean "he" is too good? He's just showing results of studies....he didn't do them and anyone can read them.
Posted 9/20/2016 3:53 PM (GMT 0)

sheepguy said...
Waddya mean "he" is too good? He's just showing results of studies....he didn't do them and anyone can read them.

Good point.
Posted 9/20/2016 4:32 PM (GMT 0)
In an effort not to shoot the messenger here (which is all Tall Allen really is in this case), I believe the argument can be made that TA's extensive knowledge of these matters, which he has repeatedly demonstrated here, gives him an edge up on understanding what's going on with the items he posts about.

No, he's not "too good" to challenge, nobody is. And yes, "anyone can read" what he talks about and form their own conclusions. But how many of us can really interpret and explain these things to others as well as he can? I sure can't and wouldn't even try to.

Quite frankly, I admire his depth of knowledge and very much respect his opinions.

Also quite frankly I think maybe he did come on a little strong in his wording of this thread's title, and to some degree in his opening post, but I attribute that more to his passion for accuracy and a sincere desire to communicate the facts to us, and certainly not to any malevolence on his part.

I did sense a little impatience in his tone ("… I feel like I've written about this so many times …"), so perhaps that's all it was, just a little frustration.

And that's something all of us here feel once in a while..
Posted 9/20/2016 4:37 PM (GMT 0)
I interpreted " he's just too good" as meaning he's good analytically not good at doing the study. He admits he's no doctor but he appears to take considerable time to understand the science. I once asked TA where he learned all this stuff and he responded something like " I'm just a nerd or geek". I won't try to speak for the tall one but I've sensed that he is incensed by practitioners who over treat and overcharge their patients. He's definitely helped me a few times. I wish I had run into him before choosing RP.
Bob
Posted 9/20/2016 4:42 PM (GMT 0)
Redwing- I do not think it's outrageous at all now that 4 major randomized clinical trials have shown that there is nothing to be lost by doing it in fewer treatments. Going through 40-44 treatments is an ordeal, as you well know, and it is costly. Now that it has been proven that it can be done with less of an ordeal and with less cost, who in his right mind would do otherwise?

81GyGuy - I agree completely! We are all looking for self-approval and the knowledge that we did the right thing is a big part of that. When something conflicts with our self-approbation mechanism, it causes cognitive dissonance and an active search to resolve the conflict -- the data must be wrong, they are lying or misleading us, it's a conspiracy, etc. (called "belief bias"). On the other side, we look for any data that will confirm our firmly held beliefs (called "confirmation bias"). This stuff was very important to my previous work in marketing. Everyone naturally has these biases, but we can overcome them if we become conscious of them.

Anyone who tracks the very rapid development of radiation technology will not be much surprised by this. We just saw (in the ProtecT trial) that they were using in 1999 a technology and dose now considered inferior. IGRT and IMRT did not really come together until the 21st century. CyberKnife began for prostate in 2003. Then we got VMAT technology, which improves with each iteration. I'm sure the technology I was treated with will be outmoded in a few years time. Changes in medical knowledge and technology move very quickly.

Honestly, if I knew in 2010, when I was treated, what I know now, I would have gone on active surveillance for as long as I could. Back then, the long-term results of AS were just starting to come in, and mpMRI monitoring techniques were not widely available. So I made the best decision I could, given what I knew back then. I am thrilled when something new comes along and replaces what I used to think was best. It does not reflect badly on me at all. I make the conscious choice to not dwell in the past and to not live with regret.
Posted 9/20/2016 4:51 PM (GMT 0)
I was typing the above while the other comments arrived.

Yes, you are right that I believe that I and other patients must come on strong with our ROs if this is to ever change. There is a lot of financial incentive to do more treatments rather than fewer. I am hopeful that at next week's ASTRO meeting, they will endorse hypofractionation and pull endorsement from conventional fractionation. It most likely will not happen. But I do think that if enough patients insist to know why the treatment plan remains so long and costly, that what is now standard will change - to the benefit of patients.
Posted 9/20/2016 4:54 PM (GMT 0)
The Vero Brainlab machine for SBRT was supposed to be a big deal and looked promising. There are only a few in the USA . Upstate medical center in Syracuse at their brand spanking new 50 million dollar cancer center can't figure out how to use it for anything apparently let alone PC. Even our dinky little Cayuga Medical Center does hypofractionated prostate therapy. They don't do a lot,though, but do have an affiliation with Roswell Park..so I may look into it if it comes to that. Sure would be convenient...but maybe not so convenient down the road.
Posted 9/20/2016 5:31 PM (GMT 0)
This post definitely got my attention.

Do I even begin, for fear that I might get lambasted for voicing my opinion from those that have been here longer or that have much more "knowledge" than I?

I think I will...here goes..

I don't think it's the information that you shared, but the way you presented it and the title you gave it.

Being new here and just choosing that exact treatment( 40gy IMRT for G9 Dx) how do you think it made me feel? Or are you just about the facts and nothing else here. (just the facts ma"am ,just the facts)

Funny that I just posted on the 3 myths post yesterday about this very thing.
https://www.healingwell.com/community/default.aspx?f=35&m=3704625.

It was suggested that maybe I get away from this forum for quite awhile because it may not be good for me right now in my emotional state. That might be true. Maybe in my "HT emotional state" it would be better. I'm actually considering it. And that's too bad because I still see myself as a new guy here and I need the support, but I will voice my opinion. That's just the kind of guy I am. (emotional)

Don't shoot the messenger? Why not! Shouldn't we be more careful about how we carry that message especially when you consider that there might just be a new guy here that is looking for support?

It's like this in my "emotional" mind. Oh... you picked 40 gy IMRT for G9 as your treatment? What are you a "rich masochist or what!?"

You can defend your "knowledge" and the "facts" or the "truth".. but in my "HUMBLE" opinion... you can't defend the way you presented this....

Now go ahead....tell me I'm too emotional or I shouldn't take this personal or what ever you are going to come back at me with....

Allen..you help thousands of guys with your wealth of knowledge including me. Just know (and I'm sure you do) that there are many here that respect you and look toward you for answers. That includes me!

Just own it and please...try to be more thoughtful in how you say things...or not... I'm just a lowly new guy..

Humbly... The Artistic One - Mark
Posted 9/20/2016 5:54 PM (GMT 0)
Wow...it's obvious some of you guys are very sensitive about how this was phrased. My take on this is a bit different (not that Allen needs any help). I understood this as a STRONG comment that future men who choose radiation should think twice before accepting the old standard of IMRT. I didn't at all take it as criticism of those who have already been treated.

I look at this a bit like Allen's commentary on SBRT vs. LDR Brachy. Recent research has shown equal cure with SBRT but reduced side effects when compared to LDR Brachy. As an LDR guy I could choose to be offended by this; I'm not. Rather I take this as clear evidence that men should now look at SBRT as a viable option. I didn't have this opportunity when I was treated but I'm really glad for other men who have it today.

Anyway, just my take.

Jim
Posted 9/20/2016 6:09 PM (GMT 0)
Sorry for being too sensitive. You don't seem to understand the point I'm making. It's not the info but the way it is presented.

I don't see how you can't see this. I'll just shut up now cause I'm obviously to sensitive. .my bad...later I'm out...

Best of luck to everyone. ..

Mark
Posted 9/20/2016 6:29 PM (GMT 0)
Mark, I certainly didn't mean to offend you and I apologize if I did. I understood your point well it's just that I disagree with it. I found no issue with the way this was presented - it's a clear warning for newly diagnosed men to ask a serious question. I did not see intent to criticize those who had already made the choice.

Perhaps I'm too insensitive to your point but honestly I prefer bluntness as long as it is not disrespectful...

Jim
Posted 9/20/2016 7:49 PM (GMT 0)
Love the title!
And yes, it does have shock value. In this case it's warranted because the finding that fewer, but more intense, IMRT sessions are OK, is a major 'advance' in the prostate cancer radiology field that will benefit many.

As an aside, some of us seem to spend a lot of time on this forum. But others, such as me, do not read all threads. To get my attention, the title of a thread does play a role. And this particular finding warrants widespread publicity. Let's spread the word!
Posted 9/20/2016 8:09 PM (GMT 0)
Ok...so you don't think I should be upset or offended. That's ok. But you do realize that you have been on here since 2008. Your point about treatments SBRT vs LDR is valid and I fully understand. I have only been here a few months. I'm one of the new guys you talk about.
Did this info just come out within the last two weeks about this shorter treatment option ? I "just" started IMRT 2 wks ago. If it is that new and it only became available in last 2 wks I'll buy your defense. Had I known 2 1/2 weeks ago about this you can be assured I would have asked my RO about it.

Maybe it's just another one of those things that I missed up to this point. It has been difficult to get all the info that I got about how HT+IMRT+BRACHY is better than RP for high risk guys and trying to muddle through that argument. When I finally excepted that I couldn't do either one... and was confident that the next best treatment for me was 40gy IMRT+HT......I read that a person would have to be a rich masochist to choose that treatment.

I apologize for my rantings, and I do understand that I am overly sensitive at this point. I'm not used to this new normal yet. And when I got here I only wanted to do my due diligence and to find the best treatment for G9 PC because I was scared to death....Still am.

I'm obviously a tiny, teeny, weenzy, bit.. "ANGRY" at this point. I don't want to be here... and after the fear part has subsided, I am now in the anger stage. I have to be more aware of that...I'm sorry

I am grateful to have you all here to help me through this.....

Wow...what a ride!!... and I have just begun.

I still think it could have had a better title for the post.....


Blessing to all..... The Artistic One - Mark
Posted 9/20/2016 8:52 PM (GMT 0)
Mark-

It was certainly not my intent to offend you. It is my intent to alert guys to the fact that practice-changing research has emerged.

Mark said...
Did this info just come out within the last two weeks about this shorter treatment option ? I "just" started IMRT 2 wks ago. If it is that new and it only became available in last 2 wks I'll buy your defense.

Actually, if you look at the date on the study I cited, it is September 15, 2016 -- it's been less than one week since publication in the American Journal of Clinical Oncology. All of the studies about hypofractionation have been published within the last couple of years. If you think you want to discuss this with your radiation oncologist, it is absolutely appropriate to forward the the journal article to her, perhaps with the studies from Fox Chase, the CHHiP study, RTOG 0415, and HYPRO (links in article below), and tell her you would like to hear her opinions about it.

/pcnrv.blogspot.com/2016/08/hypofractionated-radiation-therapy-for.html

I have never criticized anyone in HW or my support groups for choices they have already made. Patients only make choices that are the right choices for them at the time they made them - how should I presume to know what's right for them? I have a hard enough time figuring out what's right for me. And I have always been supportive of patients afterwards, suggesting remedies for side effects and salvage therapies, etc. I never said "I told you so" to anyone here, and never would. At the same time, I cannot be responsible for what you infer from any of my posts. If you take it as a personal criticism, you are free to do that, but then ask yourself whether that attitude serves you well.
Posted 9/20/2016 8:53 PM (GMT 0)
Dear Artist mark

I feel for you bro having a high risk dx like me. I agree that TA could have come across a little less aggressively. He should have taken his feelings out on RO's not patients. But I've been brutish before too.

You like many other guys just happen to be on the bubble of changes in treatment methodology. All I can say is that I hope you're getting RT to the lymph nodes as well as to the prostate because with gleason 9 it's highly likely you'll need it, so do it now. If you think 44 sessions are bad how about 98 sessions of 143.2 gray?!

Good luck.

Bob
Posted 9/20/2016 9:06 PM (GMT 0)
I actually only clicked on this post because of the title so I think TA's wording worked. However, Artist Mark has a good point that 1) he just started ADT and can cry over spilled milk easily, and 2) he just chose that treatment plan and it bothered him. AM is still in the shock phase so I give him a pass on his post and sympathize. I hope that others read this as a discussion point with others who talk about treatment options, I know I will. Good discussions... -JR
Posted 9/20/2016 9:19 PM (GMT 0)
I have to agree with "everyone" wishsy washy huh?....The " Sheepguy " make me laugh !...laughs are good in the middle of all the breaking news !....Thank you all ...my time is coming up soon ....I asked my RO about the Hypofractionating.....and he sluffed it off and gave me some reason it was`nt right for ME.....pisses me off ...I think I got the run around on that ( will bring it up again in a few weeks ,with print outs) ....stuck with the 45 sessions ...or 25 with HDR ..if I`m able.......yeah..the title was attracting...understand how you feel Mark,,hang in there my artist friend.....David- the potter, jeweler,hairstylist,etc etc
Posted 9/20/2016 9:21 PM (GMT 0)
Allen.. please accept my apologies. I am an artist. We are a unique creature. I can see the overwhelming amount of time and effort you put in to the cause for PC. I often take things personal and tend to spew at any given moment,especially now. Thank you for sharing the info and knowledge you have.

Bob, thank you for your response. It seems I need to quit compaining about my situation an realize that there are guys that have endured much more than I and there needs to be respect given and less whining. And yes,my RO is doing the lymph nodes.


Mark

Post Edited (Artist Mark) : 9/20/2016 4:06:48 PM (GMT-6)

Posted 9/20/2016 9:51 PM (GMT 0)
Allen,
What's the skill level difference of an RO that does SBRt and one who does normal IMRT?
What is the learning curve for an RO to convert to SBRT?
Is the equipment exactly the same or does it require additional investment?
Posted 9/20/2016 10:18 PM (GMT 0)
John T-

The price of a linac for IMRT is roughly $3M I think. Maybe a million more if configured for SBRT. The cost is higher because of the intra-fractional tracking with SBRT. CyberKnife has all of that built-in and is only used for SBRT, as far as I know. Other linacs, like Truebeam with RapidArc can be used for both, but require add-ons for SBRT. Some, like Tomotherapy, cannot be used for SBRT even with add-ons, I am told.

As intensity increases, as with hypofractionation or SBRT, more care has to be taken with planning. Margins are tighter, and dose constraints must be more strictly adhered to. When you only get 5 chances at it, you'd better be right. When you have 40 chances, a little miss here and there doesn't matter as much.

I haven't seen any analysis of the relative learning curves. The basic skill set is similar, I would imagine. I know that when you buy one of these linacs you get training from the manufacturer as part of your purchase. The learning curve is not as steep as for surgery or LDR brachytherapy. I was told when I looked into it for myself, that something around 50 would be good (on top of 100 or more for IMRT). I think Dr King had only been using RapidArc for it for a couple of years when I had it done. For 7 years before that he'd used CyberKnife technology. Dr Katz told me he has used linacs made by Accuray, Varian and Elekta.
Posted 9/20/2016 10:35 PM (GMT 0)
Mark-
I certainly do not fault you for having those feelings, especially at a time when you have gone through so much effort, overcoming obstacles, to get to the point of treatment. One guy in my support group who is on Lupron said, "I have accepted the fact that a menopausal woman has moved in." I don't know if you are feeling emotionally labile, but that is certainly one symptom.

You are so right that we artists have to be in touch with our emotions - it's essential for our art. My psychotherapist always said to me "Thoughts are just thoughts, feelings are just feelings. They come, they go, like clouds in the sky. They never define who you are." You actually strike me as very good about this. You seem to recognize the emotion, express it, and then let it go rather than attaching yourself to it permanently.
Posted 9/20/2016 11:24 PM (GMT 0)
Jerry I thought I sensed some tongue in cheek. Appearance toy not
So it looks like we are all so driven to improvement by technology.....faster...better...cheaper. Except for PCa treatment? Give me a break. TA posts some great information that uses improved technology to get faster...better....cheaper and you all go off on him. Well so will I. I am biased to HDR brachytherapy....having learned from Intel founder Andy Grove. I think HDR mono therapy is much better than either SBRT or hypo fractionated IMRT.

So there.
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