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Posted 5/11/2022 3:06 PM (GMT 0)
I am in process of determining my treatment options. Age 69 in good health. With a Gleason score of 8, supposedly contained in the prostate, psa of 5.6, and with normal size prostate with one lesion. With a focal biopsy, I had 14 core samples, 2 cores was targeted where the lesion was on the MRI. the 2 cores came back with gleason score of 8, the other 12 cores came back negative for carcinoma. One book I am reading is "The Key to Prostate Cancer" by Mark Scholz. He breaks down what treatments are suggested depending on stage. In his book I am in the "Azure" treatment grouping. He mention a standard treatment is the triad of seed implantation, testosterone inactivating pharmaceuticals (TIP) and IMRT. I see a radiation dr next week, and a medical oncologist in few weeks.
Any thoughts? Not sure what the sequence would be? I assume the seeds first?
Posted 5/11/2022 3:23 PM (GMT 0)
Hello Cancerfight...sorry you're the latest member of our club. Hope we can be of help to you.

The combination of brachytherapy, IMRT and ADT is fairly common for high-risk guys, meaning G8 or higher. It was the treatment that I had as a G9. (FYI, I'm a patient at Scholz's practice and you should know his book uses some non-standard terms like the color ratings and TIP that won't make sense to other docs when you meet them. Regarding the testosterone treatment, the standard name is Androgen Deprivation Therapy or ADT.)

Regarding the order of treatment, it varies among different facilities. I had my brachytherapy prior to my IMRT, but I've also heard of it being done the other way. More important to note is that there are TWO kinds of brachy: low-dosage radiation (LDR), which uses seeds. And high-dosage radiation (HDR) in which the radiation is inserted directly into the prostate and then withdrawn. (Seeds as you can imagine are permanent.) In my case, I had HDR brachy.

In talking to a radiation oncologist, you should know that not all practice the same types of radiation--you might actually have to talk to more than one RO. Ideally, you can get an idea on what the RO's practice is set up to do first. The medical oncologist may or may not have an opinion on radiation--an oncologist like Scholz does nothing but prostate cancer so he's very familiar with the potential treatments, but most MOs treat all types of cancer and aren't experts on first line treatments. (I had a very disappointing appointment with an MO early in my cancer journey.)

Hope we can help as you go through your options.
Posted 5/11/2022 4:16 PM (GMT 0)
Welcome Cancerfight,

Michael lays out the radiation treatments very well. Like you and him, I was high risk (see my signature) 12 years ago and used combination therapy comprising of HDR brachytherapy, External Beam Radiation (IMRT), and ADT (Lupron and Eligard). My sequence was about 15 IMRT fractions, then two HDR procedures a week apart, then the remaining 10 IMRT fractions. My first shot of Eligard was one month before my radiation started and I stayed on ADT for 36 months. Today, the HDR would be done in one procedure and I probably would do 18-24 months of ADT as HDR technique has been refined and a few newer studies have shown reduced periods of ADT for many men.

Regarding permanent seeds brachytherapy a large practice here in Atlanta pioneered the combination of seeds with external beam radiation back in the 1970’s. They follow a similar pattern of about half the EBRT fractions, then implant the seeds followed by the balance of the EBRT fractions. They say this combination provides the best balance of radiation cancer killing power with limited radiation toxicity. I interviewed them as part of my treatment assessment, but chose the HDR brachytherapy due to the more advanced technology and not leaving the active radiation in the body for 6-9 months. This treatment combination has served me well as I have been PSA undetectable since treatment and have no negative treatment induced side effects.

Please pose any and all questions and if you want more specifics regarding my decision process and treatment experience you will find my email in my profile.
Posted 5/11/2022 4:26 PM (GMT 0)
Hello Cancerfight and welcome. So sorry you need to be here but we will help in any way we can. Both Jack and Michael have given you excellent responses so the only thing I will add is a suggestion to get your biopsy slide re-read by an expert. Dr. Epstein at JHU is a go-to doc on this. With a low PSA and only two cores positive it would behoove you to make sure it's G8 and not G7 before proceeding with a treatment. Dr. Epstein can give you some assurance on the grading.

Jim
Posted 5/11/2022 6:07 PM (GMT 0)
"Any thoughts? Not sure what the sequence would be? I assume the seeds first?"

the sequence is the doctor's prerogative. mine was ADT, seeds and IGRT. i had nine months of lupron and i am in my 12th year of remission. never once incontinent and mild ED treated effectively with cialis

you are high risk and your treatment plan, imo, gives you the best shot at a cure. good luck to you!
Posted 5/11/2022 6:52 PM (GMT 0)
One more point regarding the sequence: ADT is always first and is usually begun 1-2 months prior to the beginning of radiation. In almost all guys ADT puts the brakes on your cancer and it also helps the radiation work more effectively. To the extent that you end up talking to a few docs as part of your treatment decision, it could make sense to go on ADT while you're still investigating your options. It would be a good question for the first RO you're seeing since that sounds like it's happening pretty soon. Some guys feel like they're in a time crunch to get started (I sure was) and starting ADT could remove any urgency in that regard.
Posted 5/11/2022 7:00 PM (GMT 0)

Michael_T said...
One more point regarding the sequence: ADT is always first and is usually begun 1-2 months prior to the beginning of radiation. In almost all guys ADT puts the brakes on your cancer and it also helps the radiation work more effectively. To the extent that you end up talking to a few docs as part of your treatment decision, it could make sense to go on ADT while you're still investigating your options. It would be a good question for the first RO you're seeing since that sounds like it's happening pretty soon. Some guys feel like they're in a time crunch to get started (I sure was) and starting ADT could remove any urgency in that regard.

yeah, with your numbers and the course you are on there is no reason not to get your first shot yesterday
Posted 5/11/2022 7:20 PM (GMT 0)
Going through Duke Cancer Center. Getting appointments is so difficult. Not much luck getting timely appointments. Seems late June for appointment with the Seeds specialist. That is frustrating with a "time bomb" ticking.
Posted 5/11/2022 11:44 PM (GMT 0)
I know the ticking time bomb feeling. While I was trying to set up all my appointments, every time I sneezed I felt paranoid as if I somehow was going to blow the cells out of my prostate. If you'd like a benchmark in my own case, I was diagnosed in September and started treatment (ADT part) in November and all was fine. (In retrospect, I probably had cancer for several years prior--I just didn't know it.)

But if you're (understandably) nervous, I don't see any downside to starting ADT now--although you obviously still need a doctor for that. Can you get in with *anyone* at Duke that you could talk to about that prior to meeting with the seeds specialist? Even if you didn't specifically have brachy, ADT would be a part of any radiation treatment for a G8 and it's always started prior to the radiation.

BTW, I had a difficult time getting into Scholz's office at first, but I would call back every few days and ask about cancellations. That got me in about a month earlier.
Posted 5/12/2022 1:53 AM (GMT 0)
Welcome Cancerfight, great screen name for what we all have here. We have a lot in common, both 69 and both GL-8. The vets here are very good at directing a new poster in the right path. I couldn’t have the seeds, but would have, if not for the previous TURP. My best to you.

On a side note, I see a lot of recommendations for getting started on ADT post haste. I just finished reading all of ASAs link on new recommendations for prostate contained PC. I will not go back and read again, as it caused several hot flashes with the effort. LOL. However, I do believe I read where starting ADT before, during or after RA showed no difference in outcomes. I do know that ROs use it to shrink prostates before RA. But, if I read it right, there was no significance with a normal sized prostate. Please correct me if I am wrong. My best to all.
Posted 5/12/2022 10:30 PM (GMT 0)
For excellent information regarding HDR-BT see the website www.cetmc.com. This is from the practice of Dr Jeffrey Demanes the father of HDR-BT. He started using it for many cancers in 1981. He retired a few years ago as the head of radiation at UCLA Medical Center. The website and studies haven’t been updated for a few years but it provides you with excellent information to aid your treatment research.
Posted 5/12/2022 11:56 PM (GMT 0)
Welcome to the club we'd all rather not be members.
I have little to offer beyond my best wishes for you. The day I joined here, my fear's were cut in half and my knowledge jumped 10 fold.
I'm post SBRT and seem to be doing well.
I was hoping for a fast end to it all but now realize it will take time to be cured.
Good luck what ever path you take.

Glen
Posted 5/13/2022 3:23 PM (GMT 0)
Hi

I had HDR then the IMRT. My doc does the HDR first and inserts the Gold Fiducials during the HDR when they do the catheter insertion. They act as land marks when doing the IMRT planning and IMRT treatment.

I would get second opinion on your biopsy slides, Hopkins. Also try to visit some docs who do the HDR, IMHO the HDR is better than the LDR.

Good luck.
Posted 5/13/2022 7:53 PM (GMT 0)

Turboz said...


Also try to visit some docs who do the HDR, IMHO the HDR is better than the LDR.


I know Fox Chase Cancer Center in Philly only does HDR now.

https://www.foxchase.org/clinical-care/conditions/prostate-cancer/treatment/radiation-therapy/brachytherapy

Since 2015, the radiation oncologists at Fox Chase have been performing only the HDR prostate implants because patients continue to achieve excellent clinical results and are experiencing fewer side effects compared to the permanent seed implant.
Posted 5/14/2022 12:26 AM (GMT 0)
Back in late 2017 I was in a similar situation as you are now. I'm healthy with a BMI of 21.

After a targetted biopsy one core was positive with GS8 and the other 12 cores negative.

I chose brachy boost but without the ADT. In Vancouver at BCCA according to their guidelines, ADT was optional with my low PSA and only one core being positive.

My external beam radiation was first followed by the seeds on February 1st 2018.

It was a rocky road with a significant spike in my PSA in December 2019 which was 2.3 above the nadir of 0.9 seventeen months earlier. That triggered a PSMA PET/CT scan in August 2020 which turned out to be negative.

My last PSA was 0.6.

However I recently completed 2 treatments for radiation proctitis. I'm also on cialis due to ED.

I now feel like I'm back to normal.
Posted 5/14/2022 11:12 AM (GMT 0)
MacroMan, it appears you experienced the very common radiation PSA spike. about 65% of men do so and it is thought to be a mass dying of cancer cells. The spike is correlated with a better long term remission, so it is most always a good sign. Glad you are doing well with your effective treatment method.
Posted 5/14/2022 2:05 PM (GMT 0)
To MacroMan and others, thank you for your thoughts and sharing. I am seeing a Radiation Oncologist monday to get started. Question to those that had seeds and IMRT treatments - Was the same Radiation Oncologist used for both treatments? The Radiologist I am seeing does not do seeds treatments. If you used different doctors, how did you coordinate the treatments?
Posted 5/14/2022 2:32 PM (GMT 0)
It's a good question about the coordination. In my case I had my treatment at UCLA (HDR brachy instead of seeds) and the doctors were completely different teams. But they did coordinate: my fiducials for IMRT were implanted during my brachy procedure and the radiation plan for the IMRT was designed with the brachy in mind. But I actually wished I had asked more questions about this--it simply didn't occur to me at the time and I most of my questions during my follow-up visits.

In general, a doctor that performs any kind of brachytherapy specializes in that and you wouldn't expect to see him/her practicing external radiation.
Posted 5/14/2022 2:38 PM (GMT 0)
Yes the same RO handled both the IMRT and seeds.

In fact, the RO wasn't going to be available to implant the seeds two weeks after the external beam radiation ended, so he had me double up on the IMRT. The 23 treatments were finished in 21 days. On those 2 days with two treatments there was a gap of six hours allowing for some healing to take place.
Posted 5/14/2022 2:47 PM (GMT 0)
JNF I had two significant bounces with the one just before my scan.

My RO wasn't familiar with double bounces and though that I was 'not' in the clear. A day after my PSMA PET/CT scan he called to say nothing was found. I think he really thought something would show up.
Posted 5/14/2022 4:10 PM (GMT 0)

Cancerfight said...
To MacroMan and others, thank you for your thoughts and sharing. I am seeing a Radiation Oncologist monday to get started. Question to those that had seeds and IMRT treatments - Was the same Radiation Oncologist used for both treatments? The Radiologist I am seeing does not do seeds treatments. If you used different doctors, how did you coordinate the treatments?

i was treated at a prostate cancer center that my uro was affiliated with. there were three doctors at the center. one doctor consulted with me at the initial consultation, and a couple of other times (perfect guy for that job). another doctor (highly accomplished) implanted the seeds and the newest doctor met with me regularly, while i was being treated and after for several PSA tests until i was handed back to my uro

my uro's office did the lupron shots and did the follow-up tests, DREs etc until i was around five year out and then my follow up tests have been with my GP

my treatment overall was seamless. my uro scared the hell of me initially and he was never overly optimistic. while the prostate center front man said i had a 90% chance of a cure he gave me a 60% chance

i still remember the day after a couple years out of treatment my uro scanned my latest numbers, cracked a hint of a smile and muttered "i think we got it"
Posted 5/16/2022 2:07 PM (GMT 0)
My RO is part of a Group of 5 RO's, they treat all kinds of cancer including prostate. They have 4 locations with Linacs.

The RO who treated me, handled the HDR, note he had done over 1500 LD procedures but switched to HDR about 10 yrs ago, said it was much better. Had done about 300 HDR as stand alone or with IMRT boost. He did the catheter placement and the planning for the HDR.

He handled the IMRT, but reality is the Physicist does the planning and he and another RO reveiw the plan, I assume he prescibed the dosiemtry and volumes. I have copies of the plans with the DV info. As he says it is software which computes all the stuff.

Good luck.
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