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Thread: Undecided

  1. #71
    Quote Originally Posted by ASAdvocate View Post
    Nonquiote, with SBRT, gold fiducials are inserted during a pre-planning session. The device triangulates the positions of the fiducials to precisely track the location of the prostate despite body movements.

    DJin, I keep reading all the comments about SBRT being new and not quite proven.

    Hmm, SBRT was FDA approved and patients have been treated for prostate cancer since 1994. In contrast, the DaVinci robotic surgery device was not FDA approved until 2000. I never hear anyone questioning its relative newness.

    I have heard a Senior RO state that he could deliver SBRT in one session, but that insurance would not pay enough for it. I believe that salvage HDR-BT can be delivered in a 19 Gy dose. That’s a lot of radiation in one session , but, as you wrote, RO’s are confident of their knowledge.
    Yup, I get the use of fiducials for targeting, but that doesn't keep me from sneezing. It was more the use of photons vs protons that made me turn away to be honest.
    Dx at age 56
    Maternal uncle with PCa
    Gleason Score of 6 (3+3) all cores
    Biopsy 6 of 12 cores positive 5%, 5%, 15%, 20%, 20%, 40%
    24 Needle Fusion Biopsy 8/6/19 - Awaiting hard copy of results, all positive cores are G6
    Oncytype DX score 29
    Perineural invasion: present in 2 cores
    PSA 2.4 Free PSA .4, PCA3 Positive 53H
    Prostate volume 32 mL
    Awaiting scheduling for PBT at UF PBTI

  2. #72
    Quote Originally Posted by DjinTonic View Post
    I believe there is a fundamental difference between non-radiation and radiation treatments. The latter take longer to achieve their initial effect and have short- and long-term toxicities. Both are imperfect with regard to continence and potency, as we know. Both need to have long-term ontological results evaluated, and I don't think we are there yet for SBRT in terms of sufficient number of years with sufficient numbers of cases all with sufficiently similar SBRT regimes, but each person can read the same studies and draw his own conclusions for whatever level of confidence/number of future years he wants. The SBRT studies with long-term in their title are mainly toxicity, not ontological, ones, I believe. I see caveats about the need for longer-term ontological outcomes at the end of SBRT studies.

    I do have to worry about my ontological outcomes, but not toxological ones. I don't mean to preach, nor does my opinion count more than anyone else's. This is just a reservation I have about new(er) treatments in general, but especially ionizing radiation simply because of its nature and the way it works.


    Djin
    OK, DJin, you have baffled me with this “ontological” paradigm. I did a PhD in diplomacy with an undergraduate minor in Philosophy, and actually studied Descartes ontological arguments to prove the existence of a Diety....but, I have no clue as to how you are using that term to describe contemporary medical studies. A quick Google search resulted in total obfuscation, with most citations to Descartes.

    What, exactly, are you trying to specify with your use of “ontological” studies?
    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.

  3. #73
    ASAdvocate, it's the $#%&%$ autocorrect on my tablet. I typed oncological not ontological. Very sorry for the confusion! These are outcomes for cancer control (e.g. persistence, recurrence) rather than non-cancer outcomes like immediate treatment recovery, potency, continence, acute and long-term toxicities except for new primary cancers, etc.

    I won't fully correct my post, or no one will understand yours.

    Djin
    Last edited by DjinTonic; 07-15-2019 at 11:15 AM.

  4. #74
    Here is what I meant by caveats about long-term oncological results:

    Stereotactic Body Radiotherapy for Primary Prostate Cancer [2018, Review, Full Text]

    These promising early results, coupled with the enormous potential cost savings and implications for resource availability, suggest that stereotactic body radiotherapy will take center stage in the treatment of prostate cancer in the years to come.
    Stereotactic Body Radiation Therapy for Prostate Cancer: An Institutional Experience Using MRI-guided Treatment Planning [2018, Full Text]

    SBRT of the prostate is an effective method for treating prostate cancer. We saw excellent PSA control and minimal acute or long-term toxicities after a median of three years of follow-up.
    Stereotactic radiotherapy for prostate cancer: A review and future directions [2017, Full Text]

    We conclude that initial studies examining the use of SBRT in the treatment of prostate cancer have demonstrated impressive rates of biochemical recurrence-free survival and PSA response, while maintaining a relatively favorable acute toxicity profile, though long-term follow-up is needed.
    Stereotactic Body Radiotherapy for Low-Risk Prostate Cancer: A Ten-Year Analysis
    [2017, Full Text]

    Stereotactic body radiotherapy to a dose of 35 Gy-36.25 Gy is an effective treatment for early low-risk prostate cancer, with acceptably low toxicity. There appears to be no benefit to increasing the dose beyond 35 Gy. Ten-year biochemical disease free survival appears to be higher than with standard intensity modulated radiotherapy (IMRT).
    A Pooled Analysis of Biochemical Failure in Intermediate-risk Prostate Cancer Following Definitive Stereotactic Body Radiotherapy (SBRT) or High-Dose-Rate Brachytherapy (HDR-B) Monotherapy [2018]

    With a median follow-up period of 4 years, SBRT and HDR-B monotherapy provide excellent BRFS in intermediate-risk PC. Longer-term follow-up is necessary to determine the ultimate efficacy of these hypofractionated approaches, but they appear promising relative to standard fractionation outcomes.

    Yes, there are some more recent studies with longer follow-up periods; however, they too are mainly toxicity and BCR studies. And results are often for a specific SBRT regime/use and/or specific risk group(s). That's all I'm saying. Unfortunately for several treatments/regimes (RT and non-RT) we have seen that better interim control (BCR) does not always translate to improved overall PCa-specific survival.

    And the above-linked study:

    Stereotactic body radiation therapy with optional focal lesion ablative microboost in prostate cancer: Topical review and multicenter consensus [2019, Review]

    A number of recently published trials, including late outcome and toxicity data, contributed to the growing evidence for implementation of SBRT for PCa in daily clinical practice. However, there exists substantial variability in delivering SBRT for PCa.
    [All emphasis mine]

    There is also a recent book:

    Stereotactic Radiosurgery for Prostate Cancer [2019] (see TOC).

    One chapter is:

    Overview of Tumor Control Outcomes with Prostate SBRT for Low and Intermediate Risk Prostate Cancer and Comparison to Other Treatment Interventions

    Abstract

    Treatment of prostate cancer has evolved significantly over the last decade. Active surveillance has been established as the primary treatment for low risk disease. National and international guidelines state that for a patient with low risk localized prostate cancer, brachytherapy (BT), external beam radiotherapy (EBRT) and radical prostatectomy (RP) are appropriate monotherapy options and the outcomes data do not provide a clear-cut evidence for the superiority of any one treatment. Available evidence suggests that there is no difference in clinical progression, incidence of metastases or overall survival between RP or EBRT for low risk patients. Similarly, the paradigm for intermediate risk prostate cancer has shifted with introduction of low-tier and high tier intermediate risk categories. While the low-tier intermediate risk patients are treated with one of many available treatment modalities and difference in clinical outcomes has been shown for those receiving prostatectomy or radiotherapy; high-tier intermediate risk patients, on the other hand have better outcome with combination of EBRT and BT. There is emerging, albeit early evidence that hypofractionated radiotherapy regimens may be appropriate choice in select low-risk and low-tier intermediate risk patients as monotherapy, as well as for select high-tier intermediate risk patients in combination with brachytherapy. In this chapter, we summarize key clinical series and trials to highlight differences in the outcomes among various treatment modalities utilized for treatment of localized prostate cancer and compare those to extreme hypofractionated regimens also known as stereotactic body radiotherapy (SBRT).
    Djin
    Last edited by DjinTonic; 07-15-2019 at 12:03 PM.

  5. #75
    DJin, thanks for the explanation. That is really funny😂 Sometimes, auto-correct can cause more problems than it solves.

    Also, thanks for all those specific SBRT study citations. Your contributions to this forum are priceless.
    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. #76
    Quote Originally Posted by ASAdvocate View Post
    DJin, thanks for the explanation. That is really funny�� Sometimes, auto-correct can cause more problems than it solves.

    Also, thanks for all those specific SBRT study citations. Your contributions to this forum are priceless.
    Thank you for the very kind words! Returning to ontology, in the non-theological sense of the word it is used in science.

    a set of concepts and categories in a subject area or domain that shows their properties and the relations between them.
    A quick search turned up, e.g., Computerizing clinical pathways: ontology-based modeling and execution [2009]

    Clinical Pathways (CP) stipulate an evidence-based patient care workflow for a specific disease within a localized setting. We present an ontology-based approach for computerizing CP so that they can be executed at the point-of-care. We present our CP modeling approach that features the integration of multiple localized CP to realize a unified disease-specific CP. The execution of the ontological CP model is achieved by our property abstraction method that assigns functional behaviors to existing semantic properties to facilitate their execution. Using our methods we have developed a prostate cancer management system.
    but, please, let's not go there
    Last edited by DjinTonic; 07-15-2019 at 01:03 PM.

  7. #77
    Top User
    Join Date
    Aug 2016
    Posts
    1,687
    Ontology is the basis of the technology I use in choice and being.

  8. #78
    To the above SBRT I added this one to the Subforum, Topic (H) this morning:

    Sexual Function in Patients Treated With Stereotactic Radiotherapy For Prostate Cancer: A Systematic Review of the Current Evidence[2019]

    Abstract

    INTRODUCTION:
    Sexual function can be impaired by all prostate cancer treatment modalities, but studies specifically addressing the impact of stereotactic body radiotherapy (SBRT) on sexual function are scarce.

    AIM:
    To systematically evaluate sexual outcomes in patients treated by SBRT for prostate cancer and determine clinical factors associated with erectile dysfunction (ED).

    METHODS:
    A systematic review of the available literature was performed on PubMed/Medline, Scopus, and Cochrane Library databases in June 2017 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Only articles providing data on baseline and post-treatment sexual function after SBRT (≥5 Gy/fraction) were included in this analysis (n = 12).

    MAIN OUTCOME MEASURE:
    Sexual function deteriorates after SBRT of the prostate.

    RESULTS:
    Deterioration of sexual health was found, with Expanded Prostate Cancer Index Composite-26 sexual domain scores showing a median decrease of 9.2 at 12 months and a median decrease of the Sexual Health Inventory for Men subdomain score by 2.7 at 12 months (from baseline median value of 56.3 and 16, respectively). At 60 months, ED was reported by 26-55% of previously sexually functioning patients in 5 of the 12 studies.

    CLINICAL IMPLICATIONS:
    ED affects ≤55% of previously sexually functioning patients at 5 years, as reported for other non-surgical treatment modalities.

    STRENGTHS & LIMITATIONS:
    This study enforced strict inclusion criteria of selected studies and exclusion of patients receiving concurrent androgen deprivation therapy. However, inconsistencies in the choice of assessment tool and definition of ED hamper a robust meta-analysis of pooled data.

    CONCLUSION:
    Sexual function decline after SBRT for prostate cancer appears to be similar to other modalities and should be specifically addressed in future studies.
    [Emphasis mine]

  9. #79
    “ At 60 months, ED was reported by 26-55% of previously sexually functioning patients in 5 of the 12 studies.”

    Seriously, what can we learn from this abstract? Nothing certain. What was the data from the other 7 studies? If these were the highest, what were the lowest? 26 to 55 percent, wow! How could anyone place a bet on a treatment with those outcome possibilities? What explains such divergent results?

    I saw some study elsewhere today stating that RP patients had a 79 percent likelihood of long term ED. Even I (not a fan of surgery) dismissed that as not credible.

    Where are the editors and peer reviewers in some of these sources?
    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.

  10. #80
    The abstracts are what they are. Anyone seriously interested in a topic, especially if you are researching treatment options, has to get hold of the Full Text (when it exists) and read it carefully. If it's a review paper, it should state the search and selection criteria. Then you can go through the references of interest and judge whether their comments about it are accurate. Most of the time we scan abstracts or read a Conclusion or Results section here and there.

    Even a basically crappy Abstract or even study can be precious for one's own research for its References.

 

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