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Newly available SBRT

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Posted 10/10/2016 9:56 PM (GMT 0)
My local RT facility has just announced that they will begin offering SBRT for prostate Cancer and I may be a candidate. This is a quite busy center with fairly extensive IMRT/IGRT experience using Calypso and SmartArc equipment ... so far only with standard fractionation, however.

Would I be really foolish to be one of their first hypofractionation patients? I would like to stay in the local area. I could, of course do that and stick with their standard fraction protocol. And there seems to be some argument that, with my TURP history and somewhat poor IPSS score, that would be advisable anyway. My other local option would be RALP. Or, of course, continuing on AS for another 6 months or so before the next PSA assessment.

All of this in the context of my recent MRI guided biopsy which found Gleason 3+4 (the G4 was about 10%) in the three cores taken directly from that PIRADS 5 area located in my previous MpMRI.

All H/W inputs appreciated! Thanks!

Whippoorwill
Posted 10/10/2016 10:37 PM (GMT 0)
I'd be nervous about being patient #1. SBRT isn't just a shortened version of IMRT. There are many differences.

Where are you located?
Posted 10/10/2016 11:11 PM (GMT 0)
Hello TA,

I'm not surprised by your comment, of course, and I do trust that our local team is at least up to speed on knowing that SBRT is not a shortened version of IMRT. Actual experience is another matter.

I live in Eugene, Oregon, and just cannot get myself excited about a trip to L.A., say, or to some even more distant center. And there is that question that SBRT may well not be best for my case anyway.

Whippoorwill
Posted 10/11/2016 12:08 AM (GMT 0)
A man in my support group with prior TURP had it with no problem. I think it's more a contraindication for brachytherapy.

The following study addresses urinary obstructive symptoms following SBRT. 10 patients had prior TURP.

Obstructive voiding symptoms following stereotactic body radiation therapy for prostate cancer

I know you can get it from Robert Meier at Swedish Medical in Seattle. Alexander Gottschalk at UCSF, and Stanford offers it too. Maybe one of those would be convenient for you.
Posted 10/11/2016 2:25 PM (GMT 0)
I see you live in Eugene. My son lives there as well. I don't have any information on practitioners in the area but our recent visit was very enjoyable and we will be going a few times each year. Perhaps on our next visit we can meet.

Best wishes

Jack
Posted 10/11/2016 3:52 PM (GMT 0)
Hi JNF,

Let me get back to you on that possibility, okay? I'm right now a bit distracted by all this prostate stuff. But I do a lot of local area golfing and note that's one of your interests. Perhaps you'll be able to bring clubs when you visit your son?

Cheers
Posted 10/11/2016 4:24 PM (GMT 0)
TA,

Thanks as always for your excellent input! That obstructive voiding symptoms article was helpful and encouraging. I've run across a number of other sources, unfortunately, including at least one also drawn from the Georgetown SBRT program (see, Gurka, et. al., "Hematuria Following Stereotactic ...") which seem to draw less encouraging conclusions. [I spent about an hour this morning failing to teach myself how to incorporate nice hyperlinks ... sorry]

There is also a review article (Ishiyama, et. al., "Is There An Increase in Genitourinary Toxicity in Patients Treated with Transurethral Resection of the Prostate and Radiotherapy?" which concludes: "Our systematic review strongly suggests that TURP is one of the risk factors of GU toxicity after RT. This needs to be taken seriously when prostate cancer patients with TURP are considered for RT either external beam or brachytherapy."

Your suggestions re possibilities in Seattle and the Bay Area are appreciated and will be kept in mind!

For now I continue to hover in indecision. You remarked in you first post above that you'd be nervous about being patient #1 for a new SBRT program. How nervous would you be about being a man with my profile and just waiting watchfully for another 6 months or so and then getting another PSA, DRE, etc.?

Whippoorwill
Posted 10/11/2016 4:41 PM (GMT 0)
Whipporwill,

Sounds good. I do like to golf and saw how beautiful the area is. My son works at Noisette, the bakery downtown where he is a chef. His name is Andrew. Stop in and say Hi and let him know we are acquainted.

Best wishes with your treatment search,

Jack
Posted 10/11/2016 7:00 PM (GMT 0)
Whipporwill,

Maybe I misunderstood you when you wrote, "Would I be really foolish to be one of their first hypofractionation patients? I would like to stay in the local area. I could, of course do that and stick with their standard fraction protocol. And there seems to be some argument that, with my TURP history and somewhat poor IPSS score, that would be advisable anyway."

Certainly a TURP is a risk factor for urinary problems after any kind of radiation. But what you seemed to be implying is that it is worse for SBRT than for conventional fractionation. I have never seen anything to indicate that that is a particular concern. It is a particular concern for brachytherapy, especially seeds, and I doubt you would be able to get a seed RO to treat you.

Every TURP is different, and before any kind of radiotherapy, the RO has to consider how much tissue was removed, how long ago, how high towards the bladder neck, and what kind of scar tissue you experienced. You seem to build scar tissue easily, so I don't know if any kind of radiation is a good idea for you. This is stuff to discuss with a very experienced RO. Surgery may be a better option for you if the bladder neck has been well-preserved.

Many AS programs use the discovery of a GS 4+3 as the threshold for treatment, and it seems safe to do so.
Posted 10/11/2016 9:45 PM (GMT 0)
TA,

I think you are correct that TURP is a risk factor for urinary complications with any RT. Even that first source I cited above, which does definitely focus on SBRT, and even at times seems to imply some added risk in that case, ends by concluding: "SBRT for clinically localized prostate cancer was well tolerated with hematuria rates comparable to conventionally fractionated radiotherapy...."

My RO is the one who has been suggesting that standard fractionation may be more appropriate in my case. It would be easy, of course, to explain that by his greater comfort level in general with doing things that way.

Your other remarks are very appropriate as well, by the way, and it's my understanding that TURP almost guarantees a widening of the bladder neck. This is why retrograde ejaculation is pretty much inevitable following TURP, at least for the type of BPH intervention I received. The many other details of TURP effects (scars, their extent and location, etc.) that also need to be assessed in achieving the best RT outcome may just argue for surgery. As you indeed note!

So then your qualifier: "... if the bladder neck has been well-preserved" seems important again. The RALP physician I've considered using has implied that my TURP history and the widened bladder outlet in particular would pose no outstanding difficulty. Does that not seem correct?

Thanks, again, for all your helpful input!

Whippoorwill
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