IMRT + HDR brachytherapy?

I had my first visit with a RO, and I was favorably impressed by his primary concern, which was to layout all the options I have, explain each and make sure I understood the risks of each.

Given my diagnosis and my #1 goal of a cure, he said my options were surgery, SBRT and a combo of IMRT + HDR brachytherapy - all provide similar or even identical potential for a cure. In my case, the 17.3 PSA, Gleason 7 plus 8 of 10 cores cancerous meant that IMRT by itself would likely not be sufficient, hence the combo. He went over proton therapy, but said that accuracy control is not as well developed there as it is for other forms of RT, and that the center near me (Loma Linda) is the oldest with the least advanced system.

Given that my #1a goal is minimizing the chances of SE's, he said the data on SBRT SE's 20 years down the road is very thin, and so he didn't feel comfortable recommending that. Of the two other choices, he said the combo of IMRT and HDR offers the lowest risk of SE's.

All of that jives with what I've read here and elsewhere.

Does anyone see any red flags in that advice? One other thing to note, is that he said that advances in external beam therapy convinced him to stop doing brachytherapy himself, so if I choose that route, he would refer me to another specialist he trusts for that.

I am still going to consult with two surgical oncologists and another RO, but I am now leaning towards IMRT + HDR combo therapy. Finding those specialists is going to take time that I'm worried about using, but I'm more worried about making a decision I won't be comfortable with.

Thanks!

Mark

P.S. - I got the results from a second biopsy reading from John Hopkins, and it matched my original reading.

Thanks Michael.

To be fair to this RO, I think I misquoted him on the SBRT data. He said that the relative lack of data on long term SE's for that treatment made him uncomfortable recommending it for a 60 year old - he didn't want to be responsible for a patient having bad SE's 15-20 years later.

Mark

wait. your doctor is worried about SEs that may or may not occur 15-20 years out? haha. that's funny. your disease is high risk! lets talk about beating it and having a shot at living that long!

ed

I used HDR and IMRT more than six years ago for high risk. I have done fine with complete cancer control The only side effect from the radiation is reduced ejaculate.

This is a much better treatment method than surgery. Provides better cancer control and greatly reduced side effects for most men. Where are you located?

IdeaSave

Go to www.cetmc.com. This is Dr. Jeffrey Demanes website. He is the father of HDR having used it since 1981 for many cancers, not just PCa. He is also head of the department at the UCLA Medical Center. Within the website you will find long term treatment results as well as mono-therapy qualification and long term results (15 years as I remember). In all it is an excellent website.

I agree with Ed.

All good information as always - thanks all!

One thing I left out of what my first RO said, thinking it was unimportant, was that with Gleason 7, I "have the option" of HT to get a "10% improvement on the cure rate". Since then I have spoken with my first SO, and he was surprised that the RO didn't recommend HT as required or strongly urged. In his experience, somebody with my test results usually turns out to have Gleason 8 when the surgically removed prostate is analyzed, and has probably escaped the capsule. Basically, he recommends treating this as Gleason 8/advanced rather than Gleason 7 intermediate.

That seems wise to me, and therefore casts that RO in a lesser light than I held him in previously.

At this point, the only thing that seems clear is that the probability of a cure is essentially the same no matter which treatment I choose. That means that the probability of long term SE's and putting myself in a good position for a followup treatment should the primary fail will be the deciding factors.

For radiation, I like that it is less invasive, is more convenient and quickly accomplished (SBRT at least) and allegedly has a lower probability of SE's - though how true that is I don't truly know. On the negative side, I don't at all like the side effects of HT, though of course I will accept them if I really do need HT. I also don't like the alleged difficulty or even impossibility of a surgical followup should the radiation fail.

For surgery, I like the added certainty that comes from being able to analyze the prostate after removal, and hence the better knowledge of what followup treatment, if any, is needed. I also like that all options are open if the surgery fails. I'm more comfortable with surgery than I was before, but only because of this particular SO, who appears to be brilliant, is very experienced (1100+ procedures, 4-5 weekly) and so far is the only doctor who recommended treating this like Gleason 8.

I'm talking to another RO soon, so let's see what he says. I'll likely also consult with the UCLA RO's mentioned here, though my wife is already sick with worry that this is taking too long (and I'm not happy about it either).

My docs practiced on the aggressive side citing the probability of an upgrade. My uro said that it is almost always a bit worse than the biopsy indicates. And he did away with the nuances of 3+4 or 4+3 and treats based on the highest G, which for me was a 4. Granted, my PSA clearly pushed me into the high risk category making aggressive treatment a no-brainer.

As you see F8 and I had great similarities in dx and age. We pursued the same course and we are both experiencing great cancer control and minimal side effects from the treatment. So the combo of HT, HDRBT, and IMRT proves to be an excellent combination.

More helpful advice, thanks guys! Michael, your point about escaping the capsule making surgery non-curative is a particularly good one.

Regarding HT, the SE's sound horrible, so I hope it isn't necessary.

I've been alternately anti-surgery, anti-radiation and pro both in the last couple weeks, which is the whole problem in a nutshell. I don't want to have a case of paralysis by analysis, nor make a hasty decision.

I'm kind of surprised everybody here is still sane after going through just that much of this process. ;-)

You are on the correct track for research. Personally, I am biased in favor of the radiation treatments. They are as or more effective than surgery for cancer control and come with markedly less side effects for most patients. Plus, I just don't like scars and the cutting of my flesh!! Prostate surgery may be routine, but it is one of the most intricate surgeries to perform and comes with a lot of damage inherent to the operation due to the anatomical aspects. Please do not take it lightly.

Have you, or your doctors, run the nomograms estimating the probability of capsular escape? A good step to do. If it is significant, say above 30%, it would definitely rule out surgery in my opinion as it would strongly indicate that you will need to add radiation to the surgery. This is the combination you absolutely want to avoid due to the increased damage and side effects.

Rules out surgery in my opinion. You will no doubt need radiation. Thus it make sense to start with radiation as your primary treatment.

Sorry...80% chance of "escape" or 80% chance of "contained"? Like JNF (and I followed in his footsteps treatment-wise) I'm biased toward radiation since it worked so well for me. And if it's an 80% chance of "escape" then radiation is clearly warranted. But I wasn't sure in your case--80% chance of contained is a different animal.

Again, the interesting thing with your diagnosis is a high PSA, but not a particularly high Gleason score. I will admit that this is way beyond my knowledge, but I'm giving you the questions I'd be asking if I were in your shoes...

My numbers are near yours also. Although, I'm one of the lucky ones who gets to belong to the GS9 crew. As others have said here, if the chances that there has been extracapsular extension, chances are you'll need RT anyway. My thought process, and the thoughts of others on here, is why go through two procedures, surgery and then RT, if RT can treat the problem. The plan which is being laid out for me is HT, Brachytherapy, followed by RT, which seems the best way to treat, at least my level.
Have you submitted your biopsy slides for a second opinion? It may help you define GS7 vs GS8. On the imaging side, I've had a CT scan and body scan done. But as others have said, those tests may not pick up,everything. I then had an MRI specific to the prostate and prostate bed. It did show a lesion that was cause for concern that the other tests didn't show. Hence a bone biopsy, which thank god, came back negative.
Keeping your sanity is paramount. Believe me, we all know how unsettling this all is. Do your research. Make an informed decision on what is best for you. There's plenty of guidance, help and experience on this board. I'm basically a new guy here, but I've found out that when you walk into a doctors office and know a good amount of what he's telling you and you know what your possible options may be, it makes this easier.
Best of luck