SBRT for low/intermediate risk prostate cancer has excellent 5-year outcomes

[Tall_Allen]

I updated this to reflect some extra detail that is now available. The clinical trial covered 309 patients at 21 institutions. The 5 year progression-free survival was:

• low risk- 97%

• favorable intermediate risk- 100%

• unfavorable intermediate risk - 93%

These excellent results were achieved without adding hormone therapy and are similar to results achieved for conventional IMRT with hormone therapy.

There were very low rates of late-term serious side effects (0% rectal, 1% urinary).

There are ongoing clinical trials for SBRT use with high risk prostate cancer.

pcnrv.blogspot.com/2016/09/...

[cesanon]

Is the trial population just non metastatsic patients?

[Tall_Allen in reply to cesanon]

Yes- only patients with localized PC.

[cesanon]

Allen

While it generally doesn't make sense to use sbrt for metastatsic cancer, but if you have a metastatsis in a strategic location such as a vertebrae, then it may make sense.

[Tall_Allen in reply to cesanon]

I agree that using SBRT for metastasis-directed therapy may make sense in certain situations, but that is a completely different situation and a topic not addressed by this study. I know this is off-topic for an advanced cancer board, but I didn't know where else to post it. Perhaps Darryl will someday start a separate board for localized and pre-diagnosis PC.

[George71 in reply to Tall_Allen]

What are your thoughts about SBRT to pelvic bed and surrounding lymph nodes with NO ADT for node positive (4 of 10 post operative pathology report in April 2016).

I Just had PSMA scan -CT scan and bone scan August 2018 -- all were negative.

PSA immediately after surgery was 0.03 PSA currently 0.6

Only taking Avadart and OTC supplements for last 8 months -- nothing else.

[Tall_Allen in reply to George71]

SBRT is a way to get the biologically effective radiation dose higher without increasing toxicity. I know that Dr King's ongoing clinical trial where he treats the prostate (8 Gy x 5 treatments) and all the pelvic lymph nodes with SBRT (5 Gy x 5 treatments) doesn't seem to incur any undue toxicity, at least so far in the first year. After a few more years of data are in, I think it will become a standard of care.

There is some controversy about this. Dr Dottoli, for example, takes the opposite tack. He uses very low doses of about 1.5 Gy over an extended time period to treat the pelvic lymph nodes.

[ezhoe]

Hi TA.. came from HW to check it out over here.. is it ok to site this study to my RO who is trying to get me to go ebrt/ht only.. Ed

[ezhoe in reply to ezhoe]

I meant "cite"

[Tall_Allen in reply to ezhoe]

Of course- just copy and paste the full URL

[dorke]

Thanks Allen,

Any preliminary info regading SBRT to high risk patients?

Can SBRT be given together with WPRT in N1 patients? any advantages of SBRT over IMRT in terms of survivability/QOL ?

Been reading scary stories about fiducial markers implantation which make me doubtful regarding SBRT

[Tall_Allen in reply to dorke]

Here are the reports so far for high risk patients:

pcnrv.blogspot.com/2017/03/...

SBRT CAN be given as a WPRT to men with detected cancerous lymph nodes (N1) - either as salvage radiation (see George71's comment above) or as primary therapy. But I haven't seen any large scale studies of it. I did review the observational studies of salvage IMRT for N1:

pcnrv.blogspot.com/2017/12/...

And for primary EBRT for N1:

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

The latest study of SBRT vs EBRT showed no difference in outcomes among intermediate/high risk men:

pcnrv.blogspot.com/2018/04/...

Fiducials are used for both IMRT and SBRT. They (usually 3) can be inserted either rectally or transperineally (which lowers infection risk). It is a minimal procedure, much like a mini-biopsy. What is your concern?

[dorke in reply to Tall_Allen]

My biopsy wasnt a walk in the park.

The pain was intense ,rectal bleeding and difficulties to urinate for ten days after the biopsy.

In addition the adverse reaction list of fiducial markers implantation is no fun neither.

Those are my concerns.

But life has a funny way to ease our concerns : it gives us a greater concern to deal with.

Up until this morning it was the gold seeds, and then I got a phone call from a genetics consultant secretary to set up a meeting tomorrow.He wants to see me after been checked for BRCA 1/2. I guess I'm not going to hear good news tomorrow

[Tall_Allen in reply to dorke]

If you ask for a pelvic plexus block, that will obviate any pain. It's only 3 fiducials. You can also request transperineal placement.

Let me know what the BRCA1/2 test says.

[dorke in reply to Tall_Allen]

Got a BRCA2 mutation.

He explained the implications for me ,my daughter, my siblings.

I have about 8% chance to develop breast cancer ...If it wasnt enough getting boobs, I may have breast cancer. At least I dont have an ovary.

He draw blood from me to double check and if again positive I'll have a detailed summary.

As for the PCa ,It adds some ammo (PARP inhibitors) to the already in use.Will have to talk with the MO about it

As for myself I dont care much. My biggest issue is the "legacy" I'm leaving my daughter.

The issue of genetics testing is an interesting one.

on one hand not knowing you carry a mutation can save you from worrying and living with anxiety, on the other hand ,knowing you carry it can save you.

Would I know I have this mutation, I guess I would check for PCa much earlier and not wait for it to be stage 4.

[Tall_Allen in reply to dorke]

For others, there is now an inexpensive test ($250) called Color Genomics that checks for BRCA mutations and a host others. There are also lists of clinical trials using PARP inhibitors and Platins:

pcnrv.blogspot.com/2018/02/...

[Cmdrdata]

I am one the first group of patients (#4 or 5) that joined the clinical trial at UT Southwestern, Dallas, TX headed by Dr Timmerman in early 2007. For me it did not work because at the time, unbeknown to me then, my PC has already metastasized elsewhere but not detectable by any standard scans. PSA never nadir-ed below 5. I do think that for those with G3+3 or less this procedure (5 high dose radiation in one week) is equivalent to IMRT (40+ standard radiation). PSA was near 15, G4+3, T1C prior to trial start. I was dropped from the study result. My take is that SBRT is an alternate to IMRT with similar outcome, IF the cancer is not already elsewhere. If it has already metastasized, then it is just a matter of time before the cancer returns.

[Tall_Allen in reply to Cmdrdata]

I'm sorry it wasn't curative, but it MAY have slowed your cancer down - it's hard to say. With PET scans getting better, perhaps it will someday become routine to screen unfavorable risk patients.

[Hidden]

I googled the acronym:

mdanderson.org/treatment-op...

[Tall_Allen in reply to Hidden]

Sadly, they don't offer it yet.

[ARIES29]

Tall_Allen, do you think i could be a candidate for this SBRT treatment. I will be going for the lutetium 177 treatment here soon but i will give you the latest MO report. It reads...PSA now at 17 & he has PSA positive recurrent desease in the prostatic bed as well as in the lymph nodes in the pelvis and retroperitoneum up the renal helum and also the left supraclavicular fossa.He has no evidence of psma osseous or other solid organ disease.

I might add i have not been on any ADT treatment for 6 weeks now & the psa rising therefore.

[Tall_Allen in reply to ARIES29]

SBRT isn't the right treatment, as far as we know, for salvage radiation for a recurrence after prostatectomy. You might be better off with salvage whole pelvic IMRT. Talk to a radiation oncologist.

[ARIES29]

Ok thanks TA,hopefully the lutetium 177 while clear it for the time beign.

[j-o-h-n]

Thank you... you're always ahead of the curve...

Good Luck and Good Health.

j-o-h-n Wednesday 09/12/2018 4:50 PM EDT

[Kevinski65]

Dear Tall Allen, , I don't know if you can help me. Ive written to you before. At 59 I was diagnosed with PC a. PSA was 31, Gleason 9 doubling every 5 months. I'm a twin and he was diagnosed the same week. His was operable, Gleason 7. I was told I was M1 distant metastasis. I had 3 bone mets, one on L1 one on scapula, one on t3. I was put on Lupron and 2 weeks on Casodex for flare. I did Lupron for 2.5 years then psa went up from .1 twice. I took every conceivable supplement I could afford. The I signed on at NIH for Xtandi or Xtandi and Prostvac (a fowl pox vaccine). I got in the Xtandi alone arm of the trial. I've been 3 years now on Xtandi and Lupron at NIH (no supplements since trial). Since Xtandi and Lupron I've had a PSA of .02 undetectable. All 3 bone mets not visible. A few lymph nodes oversized now normal. I've read about John Hopkins is messing with high doses of testosterone. The article talked about a cure this way. Do you know anything about it? If you were getting good results from Lupron and Xtandi would you sit back and enjoy the ride. I'm 65 now.

[Tall_Allen in reply to Kevinski65]

No one at JH is talking about a cure for metastatic PC with testosterone. For some men, it's a way to prolong hormone sensitivity. You can read about it here:

pcnrv.blogspot.com/2016/09/...

I think you are getting a great response to Xtandi.

[allwobbly]

Thanks for your inforative reply.

Alan

[wa64hoos]

just finished first year of SBRT. PSA started before treatment with 3.5, - 5 cores, none more then 30% , diagnosed with low intermediate. 1st follow up 3mo 1.9, second follow up 3mo

was .9, but third follow up 1.28 and 3months later 1.54(now). The Urologist says he is not

concerned. Should I be? Perhaps the SBRT did not work

[Tall_Allen]

Learn to love your bounces:

pcnrv.blogspot.com/2018/03/...

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