Looking for radiation oncologist for IMRT

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Hi.

I was hoping that some folks here (i.e., replicant) could shed some light.

Last week I went down to Mt. Sinai in NYC to see a radiation oncologist there, A Dr. Richard Stock. My current status is:

- prostatectomy, May 28, 2008
- pathology:
- Gleason 8
- extra-capular extension
- negative seminal vesicles
- pre-op PSA: 9

A second opinion from Jonathan Epstein at JHU confirmed the pathology:

--------------------------------------------------------------------------
Adenocarcinoma of the prostate, Gleason grade 4+4=8.

Focal Extraprostatic Extension.

Tumor is present at the inked margin in an area of focal capsular incision.

Seminal vesicles negative for tumor.

pT3aNXMX.
--------------------------------------------------------------------------

So about the only refinement is the use of the words "focal" and "incision."

Anyway, Stock was of the (strong) opinion that I should start radiation immediately, not waiting the 3 or six months for things to heal up. Of the incontinence, which currently isn't too bad, he said that whenever I felt I was ready to start treatment, I should.

He also was pushing concurrent hormone therapy to start at the same time, saying that while there were no clinical studies to show a benefit to using hormone therapy during adjuvant therapy, it is well known to improve the outcomes with straight up radiation treatment. So it's an extrapolation but a compelling one.

In developing his plan he spoke of a paper that was given last month at a Urology conference in FL in which the major US study (the Southwest Oncology one) on adjuvant radiation therapy was updated to show a survival benefit. Any pointers to that would be appreciated.

So I'm pretty much committed to doing adjuvant radiation but am not entirely sure if I should do it locally (Albany, NY) or down at Mt. Sinai. We know people down in the New York area who would be glad to put me up and I could do a lot of work remotely, but it would still be a big hassle, what with being 7 solid weeks. Stock implied that the set up phase of IMRT was a might tricky and that's what you want done right. He didn't know anybody in our neck of the woods.

So my questions for you IMRT people is: Did you end up with somebody who does a lot of prostate radiation? Is it reasonable to expect that you'll be able to find such a person in a mid-size city? Does it really matter all that much? I mean, if a radiation oncologist works day in and day out with IMRT equipment won't they be pretty good at setting things up?

Thanks.

Jim

Replicant · Moderator Joined: 01 Nov 2006 Posts: 244

I bet this is the article your doctor was referring to. It actually was about salvage radiation, however..

http://www.medpagetoday.com/MeetingCoverage/ASCOGU/dh/8357

The above is a summary of the article.

I live in a mid-sized city, but it's part of an enormous metropolitan area. I had IMRT done at a hospital very close to me, where I had surgery. I can see the hospital towers from my house.

My radiation oncologist handles many types of cancer, but that includes many prostate cases since prostate cancer is so common. I was very satisfied with him. I was referred to him by my urologist.

more to come...
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Replicant,

Thanks for your reply.

That link didn't seem to match up quite right with what the radiation oncologist said. A web search turned up this:

http://www.medicalnewstoday.com/articles/108221.php

Which I'm pretty sure is the one he was talking about. I had seen both articles before, as it turns out. This one compares adjuvant with watchful waiting and, not surprisingly, sees an advantage to the former. The article you site only looks at salvage but implies that if you move fast enough on a rising PSA you might do as well as with adjuvant.

Since I have a Gleason 8 as well as ECE I'm inclined to act aggressively rather than to wait. According to the Sloan-Kettering nomograms, I'm in a group that has about 46% chance of being disease free in ten years. My inclination at present is to assume that I'm not disease free. If that's the case, I see no sense in waiting to hit what's left with radiation and perhaps hormone therapy. It will decrease the quality of life for me in the near term but any cancer I have left will only be growing in the time that I'm not doing anything to fight it. And I'm a bit tired of hearing about how very slow growing prostate cancer is. Slow or fast there exists a point of no return in terms of the disease's progression.

I look forward to any additional thoughts you may have.

Jim

Replicant · Moderator Joined: 01 Nov 2006 Posts: 244

Hi Jim. I certainly understand your desire to act aggressively.

You asked about whether you should stay close to home or look farther out for a radiation oncologist. I'm not sure I can answer that. I think I would make sure I was getting someone who did a lot of prostate zapping, but not necessarily one who did ONLY prostate work. I was very happy with my guy, and he does heads, breasts, prostates, whatever. But since prostate cancer is so common, he sees a lot of prostate work just by default.

I would agree in part with the doctor about the planning being the most important part. The planning is very complex, and I think the standard is for the radiation oncologist to work with a medical physicist, using some high powered, 3D computer imaging, to chart out dosages. After that, the radiation is mostly a matter of having technicians line you up and carry out the instructions of the doctor. Of course, those techs (radiation therapists) need to be professional and obsessed about details. A good hospital will have all the pieces to the puzzle.

My inclination would be to commute to a distant site for treatment or temporarily relocate--in order to see a first rate doctor in a first rate institution. I happened to stay very close to home, but I had a high comfort level with the doctor after my first visit, reading his resume, etc.

As for adjuvant vs. salvage--sounds like you've pretty much made up your mind and I don't think there's anything wrong with such an informed decision. Nothing is certain, and you're acting aggressively to err on the side of caution...sounds fine. Keep in mind that radiation does have potential side effects. For what it's worth, I had bowel irritation. I still have it to a small degree. The radiation didn't exacerbate problems with ED or incontinence from surgery in my case, but it's a possibility to keep in mind. I think you've done your homework, so if I were you, I'd take that fork in the road and don't look back.

Very right about the "slow growing" part. That doesn't apply when considering radiation for a rising PSA after surgery. The sooner the better is true for salvage, and I imagine for adjuvant, too.

Thanks for clarifying the bit about the article.

Best,
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1, 11/08 <0.1
http://pcabefore50.blogspot.com

jimschlemmer · Regular Joined: 28 Apr 2008 Posts: 22 Location: troy, ny

Thanks, replicant.

My surgeon said basically the same thing as you about doing the IMRT locally. That there wasn't anybody in Albany, NY that did radiation on *only* prostates but there were a couple of guys who are very good and very experienced with the state of the art equipment. Also, a call to our radiation oncologist friend (on the west coast) confirmed this view. He said that it's really not something any competent rad. oncologist can't do and that he's sure there's somebody in Albany, NY who can do it well.

So that much is settled. The current thing that's got my anxiety back up is that the Mt. Sinai radiation oncologist took blood while I was there. He said by this point (33 days) my PSA should be undetectable. But I found out yesterday that it was detectable: 0.12. While this sounds unbelievably low compared to my pre-op PSA of about 9, it has me quite worried. My surgeon said he didn't know what to make of it since he only sees post-prostatectomy PSA's after 3 months. The west coast rad. onc. said that while there's a reasonable expectation that my PSA would be undetectable after a month he really didn't know if the 0.12 was significant.

The calculation, using a PSA half life of 3 days and a time period of 33 days is 9/(2^11) = 0.004. If I use a half life of 5 days I get 9/(2^6.6) = 0.092. But I don't know much about the testing accuracy. My impression was that it was pretty accurate down to 0.01 which is regarded as undetectable.

So I had another sample drawn today at 41 days.

-Jim

	Cancer Forums Forum Index -> Prostate Cancer Forum	All times are GMT - 5 Hours
Page 1 of 1

A website for discussions about any type of cancer, including lung cancer, breast cancer, mesothelioma, prostate cancer, laryngeal cancer, leukemia, lymphoma, multiple myeloma and others