M59, Gleason 4+3 (second opinion confirmed by Jonathan Epstein at John Hopkins), PSA7.8 average past 1 year, T2C stage. Haven't been operated or radiated before.
Currently am being offered:
1) 5 fraction Cyberknife (SBRT) therapy that is concentrated to the prostate.
2) 1 time high dose rate Bracytherapy combined with 5 week EBRT radiation therapy.
None of docs believe ADT is necessary as of now.
I can't make the choice.
On one hand, SBRT efficacy is often compared with level of Bracyhtherapy.
It is apparently very similar in results, but I'm worried if Brachy+EBRT won't be way more effective ensuring that pelvic lymph nodes are also captured in the beam?
After all my case has a rather high recurrence rate after Radical Prostatectomy according to nonograms, however if lymph nodes are radiated, doesn't that lower the risk dramatically?
And how can Cyberknife compared in efficacy when it radiates only the prostate?
There are some talks that SBRT high dose radiation is more effective in killing cancer, but it can't kill mets outside prosate, can it now? While EBRT can.
Cyberknife would be ideal solution and its close to home. Brachy+EBRT requires 5 week living in another country.
What do you think, which case would you choose in my situation?
Pros and cons of each?
What do you think of met risks with Cyberknife?
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FiguringOut
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You are incorrect in assuming that BBT hits the pelvic LNs while SBRT doesn't. They both can. Or the both can be done without it. They are separate decisions.
Also, the pelvic LNs can be treated in the same 5 SBRT treatments (25 Gy/5fx), or they can be done using IMRT (say, 45 Gy/25fx) with a 10.5 Gy/2fx SBRT boost to the prostate. UCLA does the former. UCSF does the latter.
Whether or not the pelvic lymph nodes require treatment is determined on the basis of the Roach equation or the Yale equation or institutional nomograms. Based on your numbers, it does not seem to be necessary, nor does adjuvant ADT. That could change if you have a high Decipher score or if you have a PSMA PET scan that shows involved pelvic LNs.
HDR brachytherapy monotherapy may also be an option.
BBT has higher rates of late-term urinary side effects than any monotherapies.
> You are incorrect in assuming that BBT hits the pelvic LNs while SBRT doesn't. They both can. Or the both can be done without it. They are separate decisions.
This is strange. Maybe it can hit LNs in separate targeting.
My Cyberknife doc said "We don't target lymph nodes".
> Also, the pelvic LNs can be treated in the same 5 SBRT treatments (25 Gy/5fx), or they can be done using IMRT (say, 45 Gy/25fx) with a 10.5 Gy/2fx SBRT boost to the prostate. UCLA does the former. UCSF does the latter.
My Cyberknife doc also said there were studies where SBRT mono was compared to SBRT+EBRT and SBRT+EBRT didn't prove to be any more effective, therefore they don't use EBRT boost. Do you have any other information that would counter this? Please share if you do.
> Whether or not the pelvic lymph nodes require treatment is determined on the basis of the Roach equation or the Yale equation or institutional nomograms
Could you please link which nonograms you mean? I used this one mskcc.org/nomograms/prostat... and they showed high lymph node met risk, so of course I got worried about that.
> HDR brachytherapy monotherapy may also be an option.
Brachy doc said this is an option, but to really ensure maximum prevention against mets he recommended additional 5 weeks of EBRT on top of 1 HDR Brachy. Do you think that argument stands ground?
> That could change if you have a high Decipher score or if you have a PSMA PET scan that shows involved pelvic LNs.
Do you think the nano-MRI PSMA/PET scan from radboudumc.nl would be useful additional diagnostic in this case or not really?
Whole pelvic treatment is restricted to those who have significant risk of pelvic lymph node involvement. The two popular risk tools are the Roach equation and the Yale equation. You do not meet the cutoff. (The MSK nomogram is only among men who opted for surgery and is irrelevant to you). In general, whole pelvic radiation is unnecessary unless you are high risk, or have a high Decipher score, or have discovered cancerous pelvic LNs.
Sorry for using abbreviations. BBT=Brachy boost therapy = EBRT with a brachytherapy boost to the prostate.
There is no therapy that is zero risk, and in general, the higher and wider the dose and coverage, the higher the risk of side effects. These are decisions only you can make. You can do a lot of work and spend a lot of money on tests. Outcomes are good without the extra tests, but if you have a nervous personality and money is no object, why not?
Oh I see. It's really strange about pre-radical prostatectomy nonomgram from MSK with lymph involvement. If it calculates possibility of lymph involvement using my data what makes it irrelevant? I'm not arguing, I just don't understand the subject. I thought that it shows risk either way with current Gleason and PSA.
Which method would you choose in my case? It seems you think additional EBRT is not needed here with brachy?
Because the cancerous lymph nodes were often found using pelvic lymph node dissection, or with long-term monitoring. Radiation treats an area outside of prostate that may already include some close-in LNs and they were later discovered by bone scan/CT when they grew large enough. If your Roach score < 15%, you don't need such treatment.
I can't answer for you. I am not you. These are decisions only you can make.
Actually now that I am looking at Roach score. It's on the border. At some point during year my PSA was 9. If I enter 7.8 PSA or 9 PSA with Gleason score 7 it shows 15,16% lymph node involvement. What do you think?
You could get surgery and radiate the pelvis later if the PSA value should begin to rise. This is what most patients do if they choose surgery.
If you select radiation you cannot be sure that the affected lymph nodes will be radiated. This does not depend on the radiation type but on the area selected for radiation. Affected lymph nodes can always be outside this area.
"Brachy doc said this is an option, but to really ensure maximum prevention against mets..." Usually there are micromets already and radiating the prostate with brachytherapy and EBRT does not prevent mets.
The SBRT doc will only radiate mets if these can be detected with a PSMA PET/CT or other imaging. As long as he does not know which lymph nodes are affected, he will usually only radiate the prostate.
Really leaning towards radiation. If I have to do radiation after surgery anyway, why not start with radiation from the get-go? Surgery seem to have bigger side effects and I would have to travel further for a high quality DaVinci tech and expert surgeon. Will be more costlier as well. And side effects seem worse from surgery. Please let me know if I'm missing something.
In the meantime I had extended my post, please take a look at it. Bottom line, radiating the prostate, no matter how, will not treat affected lymph nodes. You would have to extend the radiated area to the pelvis and this can cause side effects. And you cannot be sure that all your micromets are in the radiated area.
The side effects of surgery depend on the experience of the surgeon. If the side effects of surgery would be worse than radiation all patients who get surgery would make a mistake. Maybe you will need no radiation after surgery. Or it can take years until this is required.
With a Gleason score of 4+3 you are high-risk, at the lower end though, but high-risk. In this case the radiation oncologist should recommend two to three years of ADT following radiation. The ROs usually avoid to mention that in the first meeting because many patients will then decide against radiation.
However, the recurrence rates you get using the nomograms are based on three years of ADT following radiation using EBRT, because the guidelines recommend that. Without ADT your recurrence rate after radiation will be much higher.
The radiation doc said there is no need for hormone therapy now and he is head of department in a large University Hospital. Do you think he is saying incorrect info or lying?
I'm confused now. Both Brachy doc and Cyberknife doc say I don't need hormone therapy, yet the forum says I do. Whom to believe? Get anther third opinion?
The combination of Brachy+EBRT is used in high-risk patients. You can expect that these results are based on adjuvant ADT, i.e. ADT following radiation.
Your RO is right that you do not need ADT now, before radiation. But he will recommend ADT when the radiation is finished or you started with it. The Cyberknife doc does not recommend ADT because he uses high dose radiation to the prostate only, higher than EBRT. Studies show that you may not need ADT then. Other doctors recommend a short course of ADT after Cyberknife.
"Whom to believe" - believe the guidelines. Doctors should follow these. Here is the European guideline on adding ADT to radiation:
Citation: "The main message is that for intermediate-risk disease a short duration of around 6 months is optimal while a longer one, around 3 years, is needed for high-risk patients." - If you group yourself into the intermediate-risk group it will be 6 months for you. However, three years used to be the standard.
Well, in this case Cyberknife seems WAY more convenient. Only 5 visits to a nearby town versus driving to another country to live there for 5 weeks for radiation+brachy and THEN adding ADT?
So what am I missing? Is Cyberknife really superior treatment? The statistics in website I linked have different sections for "EBRT Seeds ADT" and "EBRT Seeds", so you compare the results. Both seem really good options.
It also seems that uroweb site doesn't talk about SBRT+ADT. Or did I miss it?
I would choose SBRT. As you said it is more convenient and the combination of brachytherapy and EBRT (including pelvic lymph nodes) is more likely to cause side effects than SBRT to prostate only. As Allen wrote above: "... in general, the higher and wider the dose and coverage, the higher the risk of side effects".
You seem to try to base your decision on the recurrence rate. However, your Roach score shows 15% probability of recurrence caused by affected lymph nodes. So there is 85% probability that there will be no recurrence! I would look at possible side effects, these can cause trouble every day for the rest of your life.
It can tell you what medications would be effective for you. I don't think it can determine which of those treatments would be best. You need to contact them directly, and speak with your Oncologist.
Well now, in 2003, with similar diagnosis, I had to decide. Researched every night to find out these percentages of success. Both removal and brachytherapy with 25 sessions of IMRT had the same percentages - 92%. I opted for the later. I would make the same decision today. My PSA never really came down. I was solid in the 8%. Within a year, I was metastatic. My resea4ch Medical Oncologist told me not to second guess my treatment choice as I already had micro-metastasis occurring at initial diagnosis.
Point is find the best at which procedure you choose..... in my case the Radiation Oncologist who did the brachytherapy already had over 2500 under his belt. The other RO, was a professor at a major medical school and helped to develop the IMRT machine....... with that good luck in choosing, and I pray that the little unseen bastards have not escaped the prostate.
prostatecancerfree.org/comp... It seems that right now statistics comparing recurrence in surgery and brachy+EBRT makes Brachy+EBRT superior. Did they put you on hormones also?
No Lupron until the day I received a diagnosis of metastatic disease. Treatment then..... I was most fortunate to enter into a six month clinic of chemo and hormones.
I have no idea, but check your stats and who they come from. Then ask each RO, their personal statistics and a comparison with national norms. Words like superior mean nothing to me. I wanted to know the hard percentages...... superior is a word most used on opinions. Good luck. Like I wrote, it’s your decision.
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