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Advanced Prostate Cancer
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Brachytherapy: Most Effective Therapy?

Esteemed friends,

Looks like hubby has decided to go the Brachy route. What is the success rate for HD Brachytherapy? My husband has a Gleason score of 7 (3+4) T2b. Cancer is contained in the capsule. He was diagnosed back in Dec 2017. His PSA has been a steady 6.4. Hubby is 57 so we are looking for long-term surviving outcomes. In addition is there any other things he can do pre and post Brachytherapy procedure to optimize success. Also, I'd appreciate if anyone could explain to me the difference between HDR and the seeds. I'm terribly confused. I found a video online for HDR but there are no seeds involved. Rather, they have catheter needles. see link here:

So what is the difference between seed implant brachy and is seed implant brachy considered low dose? Also, regardless of seeds or needles, what happens to the prostate after it's "nuked" does it stay in the body as a dead organ?

I'd appreciate any clarification.

Thanks!

As a reminder, his stats are as follows (copy and pasted from a previous post):

were 21 biopsy cores taken and the results as written in the report were:

R-base (3+4), Involving 1 of 2 Cores & 5% of Tissue Submitted Gleason's Score 7

R-mid (3+3), Involving 1 of 3 Core & <5% of Tissue Submitted Gleason's Score 6

R-apex (3+3), Involving 1 of 4 Cores & <5% of Tissue Submitted Gleason's Score 6

L-base (3+3), Involving 1 of 3 Cores &<5% of Tissue Submitted Gleason's Score 6

L-mid (3+4), Involving 3 of 4 Cores & 15% of Tissue Submitted Gleason's Score 7

L-apex (3+4), Involving 4 of 5 Cores & 40% of Tissue Submitted Gleason's Score 7

They found cancer cores in each sample taken, although mostly low amounts the L-apex was almost 50%.

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First - who told you he was stage T2b? (this is often something patients get wrong)

In the following study the 5-year biochemical recurrence-free survival was 100% for stage T2b (which is a rare staging)

ncbi.nlm.nih.gov/pubmed/220...

High dose rate brachytherapy (HDR-BT) involves the TEMPORARY insertion of radioactive pellets that are then withdrawn. Nothing is left inside. Depending on the RO's protocol, the insertions may be repeated 2-6 times. Low dose rate brachytherapy (LDR-BT) involves the PERMANENT insertion of radioactive "seeds" that give up their X-rays over several months.

After any kind of primary radiation therapy, the prostate is retained. The radiation destroys the cancer and many of the healthy cells are left behind. It may take several years for the PSA to drop to its lowest level (nadir).

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My husband had same treatment 13yrs ago. All went very well and cancer was gone until earlier this year. Cancer returned and it was determined that some cancer cells were able to get out thru the path the needle made/left from when seed therapy was performed. He is currently at a stage 1 and Gleason of 6. Now on chemo, Zytiga and hormone suppressant.

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How can he be on chemo, Zytiga and hormone suppressant with Stage 1 and GS6? You can't get those without metastases, which is stage IV, and metastases have never been found in men who are currently GS6.

It is true that any invasive procedure can potentially spread cancer, but the incidence seems to be very small:

pcnrv.blogspot.com/2016/08/...

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He did have an apricot sized tumor in groin and has lesions on pelvic bones. Staging n Gleason is as stated. Tumor is now gone, chemo is working on bone lesions. Oncologist stated his type of occurence (thru needle path from seed proceedure) is extremely rare, only 4th case he has seen in over 40yrs of practice. We are also being watched by Dr that did seed proceedure and he is in complete agreement of course of treatment.

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How tragic that something so rare happened to him. The staging changes after remote tumors are discovered - he is re-staged as stage IV after bone mets are discovered. The Gleason score no longer matters at that point.

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Would you mind sharing who the doctor is?

Thanks

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Dr. Nicholas Vogelzang is our current treating oncologist. He is not the one that did seed implants

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Who did the implants please?

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I am a bit hesitant to state name as I don't want to cast a shadow upon this doctor. Please know that we STILL have a VERY high opinion of this doctor and feel that he is the best at what he does and he is STILL involved w/our case.

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Dr. Gordon Grado did my husband's and I was just wondering.....

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Vogelzang (Las Vegas) is cool, I think. I have heard him speak at PCRI.

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Dr. Vogelzang is pretty cool! He is a leading researcher worldwide. We are very confident in his treatment plan. He is a cancer survivor himself, he not only talks the talk, he has walked the walk...

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How did they "find out" that a cell, or a few cells, were able to get out through the hole that the needle made? Was there a long thin straight tumor possibly? Sorry if I am insensitive to a story that i find unlikely to be knowable.

The background rate of cells going out a hole compared to the background rate of cells going out in general makes it unlikely that the cells went out a hole, and since it is also unknowable, just plain unlikely.

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CARIS mapping was done, and doctor's extensive background and experience treatment and research studies. Location and shape (tentacles) of tumor. YES it is very rare, as stated, this only the 4th time he has seen this in over 40 years of practice.

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Interesting. Any citations? The "he" in "he has seen this" is Vogelzang?

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Yes, Dr. Vogelzang is the current treating oncologist that has said it's only the 4th time he has seen this happen.

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If you want to learn more about invasive procedures spreading cancer, read:

pcnrv.blogspot.com/2016/08/...

Fortunately, it's rare, but it does occur, even as a result of biopsies.

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Allen, do you think more highly of one or the other, HDR v/ LDR?

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I think they are equally good for most men. Because HDR treats outside of the prostate, it has the advantage as a monotherapy with intermediate risk; with seeds, external beam is required to supplement. I also think HDR has a lower side effect profile, but that may be due to the RO. HDR can be done with any prostate size, whereas LDR requires that the prostate be under 45 cc.

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At age 57 and an emphasis on long-term surviving outcomes, 5-year stats aren't much help. Speaking strictly for myself, 10 and 20-year outcomes are much more interesting, and quality of life plays a significant role in my decisions.

The fairly recent PROTECT trial compared active monitoring, radical prostatectomy, and external-beam radiotherapy. They didn't have an arm for brachytherapy but it is a type of radiation therapy.

After following 1643 men for 10 years, the authors concluded:

"At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments. "

There was also no significant difference for all cause mortality. The only statistically significant difference is that men who underwent surgery or radiation had lower incidence of disease progression and metastases. The difference was about 3 metastases per 1000 man-years, and about 14 additional cases of disease progression per 1000 man-years.

Those are pretty small differences; it is testament to the care and statistical power of the study that they can detect them.

nejm.org/doi/full/10.1056/N...

The surgeons will claim close to 100% cure rates for the 553 men they cut; the radiologists will likewise believe they cured all but 4 of the 545 men they treated. But by that logic the 537 men alive after 10 years of active monitoring were "cured" as well.

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I have a friend who had the seed implants, they were affective for about 10 years, then he started having problems again.

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Did they go out the hole?

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After review of seed placement films, records. Also location and shape (tentacles/roots) of tumor.

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You don't meant that the tumor had a tentacle back into the prostate through the seed hole, do you? Or do you.

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Yes

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That I don't know. Sorry

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That I don't know. It's a delicate subject to discuss with a friend.

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no no. I was being a jerk.

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Often, they didn't used to give high enough doses to be curative.

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I think HDR has the best results. In addition the procedure seems relatively easy to do well, since the tube placement is checked before the radiation treatment is begun, so there is no reason for the plan to differ from the actual.

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Anthony and I spoke on the phone. Dude is golden. You know I'm going full tilt with this and getting it out. I'm pretty scared of all these types of therapies that "might" work. I'm going to "root cause" (Term we use at work for outages. I'm a Windows server guru). I'm hoping they get it all and that will be it. I know I might have to get radiated if they don't get it all. That will make me mad. Giving up my prostate "for nothing" when the cancer is still there, but I'm not going to put the cart before the horse. I'm going to keep a positive attitude and hope and pray they get it all out.

God bless, and it was wonderful speaking with you sir!!!

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In 2003, with a Gleason 7 (4+3), I went that route adding 25 sessions of IMRT afterward. It is the same route which I would go again.

Unfortunately a year later I had two mets. The reason was because of what my Medical Oncologist explained - micrometastatis; i.e., minute cells had already escaped into the vascular system. It mattered not which primary treatment I undertook - seeds and external Radiation or surgery, it was too late.

After the time both primary treatments yielded on average about the same cure percentage (92%). Your husband might discuss the relevancy of adjunctive chemotherapy to help cover his bases. Had this been available in 2004, I certainly would have enrolled. Should your husband have micrometastatis, chemotherapy can kill the little buggers floating around his vascular and lymphatic systems before they find a place to land and multiple...... it's a crap shoot; either he has them or he doesn't. If he does it's called reoccurrence; if he doesn't, it is called cured. Good luck and keep fighting this bastard.

Gourd Dancer

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We're all going to "own" cancer (beat it). Cancer doesn't "own" us. I will keep swinging until I go down, but I don't plan on it (going down). We're all fighters, that's why we're here, because we care. God bless all of us, and give us strength to beat this monster they call cancer.

Dave

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I'm with you brother, grab the bull by the tail shake him a little, ride him a little than put his bad behind out to pasture. I'm counting down with you and in the process of scheduling my big day too. We got this!!!

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Perioperative search for circulating tumors cells in patients undergoing prostate brachytherapy for clinically nonmetastatic prostate cancer.

ncbi.nlm.nih.gov/pmc/articl...

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