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Thread: How to pick a radiation option - any suggestions?

  1. #1
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    How to pick a radiation option - any suggestions?

    I've completed meeting with my urologist and just met with an oncologist to discuss treatment next steps. I've ruled out surgery and cryo and that pretty much leaves radiation.

    The options are EBRT, HDR Brachy and SBRT.

    The good news is that all of these options have a high success rate and about the same risk of long term side effects which is low.

    Oncologist (and Urologist) say I'm a good candidate for any of them (as does the Scholz book) and there's not one that stands as "best" based on my profile. (favorable intermediate)

    I will be seeking a second opinion from a cancer center but does the choice of radiation option really boil down to convenience? (ie 40 visits vs a few visits)

    For those that had to choose an option, are there any other decision factors I'm missing? I'm kind of leaning towards EBRT with a spacer.
    '15-'18: Gradual PSA velocity ramp from .9 to 2.1
    12/18: DRE normal but PCP referred me to URO
    1/19: URO said recheck PSA in 6 mo, DRE normal
    7/19: PSA up to 2.7
    7/19: URO scheduled BX at age 68
    BX Report: 9/12 cores benign, 28cm Prostate
    1 core, left medial mid, 3+4, 3mm, 25% tumor, 10% Grade 4
    1 core, right medial apex, 3+4, 1mm, 14% tumor, 45% Grade 4
    1 core, left lateral apex, 3+4, 7mm, 70% tumor, 10% Grade 4
    Diagnosis: Intermediate PCa (T1, Gleason 7/WHO grade 2, low PSA)
    8/19: Next Steps TBD

  2. #2
    Hi davefr. Topic (H) of the Subforum here (near the top of the main page) has a number of studies of these RT options -- perhaps something might catch you eye in the outcomes, short- or long-term side effects, or discussion sections of those studies that helps you decide. Keep in mind that the newer treatment or treatment regime, the fewer the years of truly long-term follow up stats.

    You might discuss with your RO whether any of the RT modalities can be hypofractionated (fewer sessions with a higher dose per session or "fraction"). Another topic of discussion might be the size of the radiation field with regard to pelvic lymph-nodes coverage. One of your cores was estimated at 45% Grade 4. If the biopsy needle had gone into that lesion at a different angle or direction (or read by a different pathologist), that percentage might have been >50%, which would have given you a biopsy G score of 7 (4+3) rather than (3+4), which is why I mention node coverage.

    I don't know if it might pertain to your treatment, but be aware of reported complications with the SpaceOAR® Hydrogel System.

    I'm sure you'll arrive at a RT plan that suits your needs!

    Djin
    Last edited by DjinTonic; 09-04-2019 at 07:08 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    7-05-13 TURP (90→30 g) path neg. then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  3. #3
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    LDR Mono Therapy

    Quote Originally Posted by daverfr View Post
    I've completed meeting with my urologist and just met with an oncologist to discuss treatment next steps. I've ruled out surgery and cryo and that pretty much leaves radiation.

    The options are EBRT, HDR Brachy and SBRT.

    The good news is that all of these options have a high success rate and about the same risk of long term side effects which is low.

    Oncologist (and Urologist) say I'm a good candidate for any of them (as does the Scholz book) and there's not one that stands as "best" based on my profile. (favorable intermediate)

    I will be seeking a second opinion from a cancer center but does the choice of radiation option really boil down to convenience? (ie 40 visits vs a few visits)

    For those that had to choose an option, are there any other decision factors I'm missing? I'm kind of leaning towards EBRT with a spacer.
    Dave good luck with your journey.. I had a similar biopsy report to you with 3 cores positive with 3+4 with small percentages >25%.. I was on AS for two years - first biopsy found 3 cores with 3+3 but when I found out on next biopsy(year later) I had some 3+4 so I decided it was time to act.. My URO was ready to cut on me the first day but I didn't like odds for potential side affects at my age 58.. I chose LDR mono Brachytherapy and I had it one year ago.. I had minimal side effects with exception of some urgency for the first 6 months.. My PSA dropped from 4.8 to 1.5 at 6 months and just had my yearly PSA at 1.2.. As long as PSA is showing trend down than doctor seems ok with progress.. My Dad also had LDR Brachy with boost 25 years prior to me but my doctors determined I didn't need the boost. My oncologist also said I was a candidate for EBRT but my thinking was the LDR was more precise.. So far I am happy with the results as long as this is done and over with. Good luck on your journey, I think the hardest part of the whole was deciding which option was best for me.. The URO guys thought the Oncologist were crazy and vice versa.. Listen to all the options and pick what is best for you.. Good luck

  4. #4
    Hi davefr! Good job researching your options and getting 2nd opinions. Having multiple curative treatment options is a good problem to have!

    While I have no experience with any form of RT, I can pass on that a friend (early 70's) underwent HDR BT in the last year. He has not had a single issue or complaint. He went to a major academic program that is an NCI Designated Cancer Center. It required 2 procedures spaced 1 week apart. He checked in in the AM and was home for dinner both treatment days. He did mention that the process requires a high degree of coordination between the Departments of Urology and Nuclear Medicine.

    As with all options, the experience and skillsets of the specialist MDs are paramount.

    Good luck reaching and finalizing your treatment decision!

    MF
    Last edited by Michael F; 09-04-2019 at 09:41 PM.
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 84 Months Post Op: Mean = 0.021 (20x uPSAs: Range 0.017 - 0.026) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  5. #5
    SBRT was designed to deliver the same radiation effects as HDR-BT, but by using external beam equipment. Both have excellent non-recurrence results, but SBRT is more widely available.

    Have you researched Proton Beam Therapy? It also has very high non-recurrence rates. Postings that I had read from PBT guys often speak of no side effects. Worth your checking out.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  6. #6
    Newbie New User
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    I had HD brachy therapy May of this year. So far no problems.

  7. #7
    Top User
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    1,687
    You have a serious amount of cancer, a small prostate, and low PSA. This is not common. There is most likely more than what the biopsy revealed based on the profile of the cancer it did hit. As already mentioned, you may really be a 4+3. The question I have for your RO is what is recommended for a seriously higher risk than your current biopsy.

    The choice of radiation does not boil down to convenience. You have a serious cancer. Your choice should be based on what has the best chance of irradicating your disease. Considering your age, low PSA, small prostate, and the volume of G4 it did hit this has probably been developing for some time.

    I suggest more investigation before you make your choice; i.e. a 3T MRI; genomic testing of the biopsy samples; second opinion on the Gleason grading. This is not your garden variety "I will die of something else" PCa.
    Last edited by Another; 09-05-2019 at 09:50 AM.

  8. #8
    Moderator Top User HighlanderCFH's Avatar
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    Quote Originally Posted by daverfr View Post
    I've completed meeting with my urologist and just met with an oncologist to discuss treatment next steps. I've ruled out surgery and cryo and that pretty much leaves radiation.

    The options are EBRT, HDR Brachy and SBRT.

    The good news is that all of these options have a high success rate and about the same risk of long term side effects which is low.

    Oncologist (and Urologist) say I'm a good candidate for any of them (as does the Scholz book) and there's not one that stands as "best" based on my profile. (favorable intermediate)

    I will be seeking a second opinion from a cancer center but does the choice of radiation option really boil down to convenience? (ie 40 visits vs a few visits)

    For those that had to choose an option, are there any other decision factors I'm missing? I'm kind of leaning towards EBRT with a spacer.

    Hi Dave,

    If you have pretty much ruled out everything except radiation, I would ask the RO about the pros and cons of each radiation option.

    Radiation is just as curative as surgery, so you should do well. From what I have read, the latest radiation equipment for external beam radiation is far superior to older equipment in that it is not supposed to trigger any secondary cancers in the years down the road.

    Also, from what I understand, brachy seems to be the safest & equally effective form of radiation treatment. So I would do some hard investigating on all your options, within the radiation menu of treatment types, and then go with what makes you feel most comfortable and confident.

    Good luck to you,
    Chuck
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Seven annual post-op exams 2012 through 2018: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

  9. #9
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    Quote Originally Posted by Another View Post
    The choice of radiation does not boil down to convenience. You have a serious cancer. Your choice should be based on what has the best chance of irradicating your disease. Considering your age, low PSA, small prostate, and the volume of G4 it did hit this has probably been developing for some time.
    I know it should not be a choice based on convenience, but so far every Dr. has indicated the cure rate among the main radiation options is about the same along with the side effects.

    Thus it's hard to choose. I guess a good question to ask would be what if I was really a 4+3 vs 3+4 and would that dictate an option that stands out as a better choice.

    I have three more Dr. visits scheduled including a second opinion on my biopsy slides. I'm hoping for one single best treatment option to emerge. So far it's been elusive.
    '15-'18: Gradual PSA velocity ramp from .9 to 2.1
    12/18: DRE normal but PCP referred me to URO
    1/19: URO said recheck PSA in 6 mo, DRE normal
    7/19: PSA up to 2.7
    7/19: URO scheduled BX at age 68
    BX Report: 9/12 cores benign, 28cm Prostate
    1 core, left medial mid, 3+4, 3mm, 25% tumor, 10% Grade 4
    1 core, right medial apex, 3+4, 1mm, 14% tumor, 45% Grade 4
    1 core, left lateral apex, 3+4, 7mm, 70% tumor, 10% Grade 4
    Diagnosis: Intermediate PCa (T1, Gleason 7/WHO grade 2, low PSA)
    8/19: Next Steps TBD

  10. #10
    https://consultqd.clevelandclinic.or...ostate-cancer/

    Interesting statement. And yet, use of IMRT is growing, partly due to physicians’ self-referral of patients. The Georgetown study, funded by the American Society for Radiation Oncology, found that urologists who acquired ownership of IMRT services increased their use of IMRT substantially more than those who did not own such services. Self-referral is generally illegal, but is permitted in this case as an “in-office ancillary service,” Dr. Ciezki says.
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)
    9/10/2019. <.02. (198 days)

    ADT - 6/3/19
    ART - 8/5/19

 

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