Is this an acceptable radiation treatment?

[maley2711]

Thinking about a recent RO consult at Kaiser. Was offered 28 sessions hypofractionation ( with 18 mo ADT for high risk). Would be VMAT-type radiation, with sessions just 2-3 minutes each...that seems good. I asked about fiducial markers, and was told that none are used , just tattoos for body alignment I've subsequently read that lasers are used as part of that process?

I wasn't looking forward to placement of fiducials ( required propofol sleep sedation for successful TRUS biopsy). Nevertheless, fiducial seems to be the norm and allow smaller margins , thus possibly lower risk of later adverse consequences caused by larger margins. BTW, was told they use Cone Beam CT for this protocol.

I've Googled this subject, and most of what I've found is similar to this.........

Target margins in radiotherapy of prostate cancer

ir.lib.uwo.ca/cgi/viewconte...

" Thus, while there is variability in the literature with regard to strategy and recommended PTV margins, the literature would support the use of online IG using either implanted fiducial markers or soft tissue matching with in-room CT or ultrasound. With such IG, PTV margins in the range of 6–8 mm (3–5 mm posteriorly) were the most commonly reported............ Overall, if skin tattoos only are used, the literature would suggest that generous margins (at least 10 mm)

are required.................................Toxicity in patients with prostate cancer treated to 78 Gy, based on daily IG of fiducial markers and 5- to 7-mm PTV margins, was less than in those treated to 76 Gy with 3D conformal radiation therapy and 1- to 2-cm PTV margins............ . In general, the literature would support PTV margins of 10 mm or more when using set-up based on alignment to skin marks or bony anatomy; PTV margins of 5–8 mm when using daily crosssectional imaging based on soft-tissue registration or when using implanted fiducial markers; and PTV margins of 3-mm when using highly sophisticated techniques such as rapid delivery coupled with real-time tracking, adaptive replanning or protocols that incorporate corrections for rotations as well as translations. "

So, am I on the right track, or misunderstanding the benefit of achieving smalller margins obtainable only with implants? This would seem t be very important, especially with respect to rectal damage, and other soft tissue? Appreciate any and all insights.......... I know very little re all the various nuances of prostate radiation as achieved with different types of equipment, protocols, etc. Also, in response to my question, Kaiser did not offer SpaceOar to me, though perhaps for other patients with different anatomical challenges?

Finally, I have found some info re radiation evidently offered by Kaiser in Central California ( I'm 700 miles North in Oregon). A video by one of their ROs mentions a new machine with built- in low energy imaging scanner..... and this is called image -guided RT, and gold markers may be used.

Assuming my understanding of what is offered here in Portland is correct, ie VMAT with only tattoos and without fiducial implants........ would I be facing much greater SE probabilities with that compared to the IG system apparently offered by Kaiser in California. Worth the inconvenience and cost of a 6 week stay down there?

The video.......

mydoctor.kpnvly.org/cancer-...

Finally, just to mention that Kaiser here does offer SBRT (done with VMAT), but doesn't all SBRT, because of higher session doses, require use of fiducial implants? They will not do SBRT for high risk men...waiting for more evidence of non-inferiority I believe.

Thanks for any help on this topic !!! Important decisions pending !!

Dale

[Aodh]

I’m not competent to answer your questions, I can tell you that I was diagnosed as very high risk CT3bNxMx with a PSA of 87 and a Gleason of 3+4 but with tertiary grade 5 and given 39 sessions of imrt to the prostate and all pelvic lymph nodes with neoadjuvant ADT Zoladex every 12 weeks for 3 years. That’s the soc in Ireland.

I had 3 alignment tattoos placed during my planning CT session and my body was aligned by the team at the beginning of each radiation session using the lasers. Additionally a CT scan was taken every day in the first week while I was on the radiation table prior to receiving the dose. Any minor movements that were required after viewing of the daily scan, were performed remotely i.e. the table was remotely moved in any direction necessary to ensure proper alignment of my innards prior to receiving the radiation. I was on the table less than 5 mins each day.

My PSA was reduced to 0.51 prior to initiating radiation. Post radiation PSA was <=0.08 and has remained at <=0.08 since. I completed radiation April last year and will finish ADT next spring. I hope this helps. I too thought that I’d need fiducials but my RO said they were unnecessary now because of the equipment and imaging throughout the course of radiation.

Hugh

[maley2711 in reply to Aodh]

Hugh -

What was your experience with Zoladex re side effects and QOL?

[Aodh in reply to maley2711]

Hi, Sorry for the delay in responding, I had a colonoscopy yesterday! My reaction to Zoladex included an increase in headaches (I have both classic and common migraine which predates prostate cancer by decades) plus general aches and pains. I used 2 solpadeine (500mg paracetamol 8mg codeine phosphate) daily at night and that got me back to near normal.

I experienced mild hot flushes after a while and used ceiling fans to deal with them, which works within a minute or two.

Yes I have fatigue, which sometimes makes me feel terrible for a short while. I walk daily as exercise; exercise was never my thing and still isn’t! I’m aware there is more available to me in this regard but I have placed a certain value on being a couch potato and I’ll stick with my values 🤣🤣

Sexually I’m lucky to be single as I’ve lost all interest and ability, I’ve more interest in watching paint dry and I’ll get round to that some day!!

Cognitive decline has been the hardest side effect to bear for me, though it isn’t all that noticeable to others. I knew that it was likely as I age, but it hurts my self esteem and sense of self. I feel reduced as a person and that sucks. I’m very independent though not afraid to rely on others when appropriate, it just makes me fearful for my future. I’m not aware of any way of addressing this other than to suck it up and be grateful for what I have, which I am.

Cancer treatment isn’t cost free for anyone and I didn’t expect my journey to be as easy as it has been so far; I expected a much rougher ride.

The only side effect that I’ve experienced from my cancer (as distinct from treatment) has been the grief of the loss of the future life that I assumed that I would have; arrogant certainly, human definitely and that grief puts me in very good company on this site where I have found very helpful and caring people.

Hugh

[maley2711 in reply to Aodh]

Thanks so much Hugh ! I read your history and you've had a rough time......heart attack and PCa. Thank goodness you seem to be having good luck (except SEs) with your treatments.

Sounds like you blame ADT for increased cognitive decline......wouldn't know it from your writing!! Had a big problem with weight gain? Other SEs with Zoladex?

I think you are just past age 60? I wouldn't give up on living to 80 . Makes me feel somewhat guilty to bemoan that I have this crap in my "early" 70s......when I read about the guys who have had to face this at much earlier ages.......so sad!!

Ireland...would love to visit! Has Covid slowed down the pub business?

Thanks again Hugh !

dale

[Aodh in reply to maley2711]

Hi Dale, yes I did gain weight, a lot of it; though the walking is slowly reducing it again. Both my RO and Dietitian told me to gain weight in the first year of treatment, better to be alive and fat than dead skinny!

The RO admitted that while on ADT weight is very difficult to shift, but not impossible. The cognitive decline also facilitated me in forgetting to say that I also developed type 2 diabetes! I’m reversing this through diet i.e. eating helpful foods rather than just not eating as much and walking.

My A1C is now regularly just into the pre-diabetes range rather than deep into the diabetic range.

Covid shut down (well the government did and was supported by the majority of people) the entire country in March last year, the pubs were closed until near the end of July this year and then faced severe restrictions (mostly drinking outside) until the last week or so.

There’s still no drinking at the bar, all patrons (in groups of 6, I think) must be seated and must wear face masks when moving around etc. But it has been worth the hassle, we lost almost 5,500 lives throughout the country, it could have been so much more deadly.

We now have 90% of everyone over the age of 12 in the country fully vaccinated and although the pressure on hospitals is still tough, the country is almost fully open again, the economy recovering and life settling in to the new normal.

I’m still cocooning as there’s still virus circulating but I have to admit the country really pulled together, the local supermarket delivered my groceries throughout for free and as I live in a retirement village if I needed anything the local Gardai (police) fetched it for me.

If you ever get a chance to visit Ireland, do so, we always welcome our American (actually all visitors!) cousins. Just have deep pockets, prices ain’t cheap no more!! Steer clear of the cities, rural communities are friendlier and the pace of life is refreshingly slow!

Hugh

[maley2711 in reply to Aodh]

and thanks to you Hugh!! if I can somehow get past this and return to some kind of "normal" life, my wife could retire and she'd love to see your country, and visit her 2 Filipina sisters and kids in Germany!! I'm guessin we need to budget at least $200 US daily for any visit to europe? Or is that too low? Just clean not luxury accomodations!!

[Aodh in reply to maley2711]

Hi Dale, you’d need at least that and it wouldn’t include car hire, that’s very expensive here (might be cheaper to buy before you fly). July and August are usually the most expensive months, also avoid Easter and Xmas, price wise.

I’d expect Germany to be cheaper, though I haven’t been there in at least 15 years!

Don’t forget that we drive on the wrong side of the road, just like the Brits!

Hugh

[CAMPSOUPS in reply to Aodh]

You have a knack for communicating so well what so many of us feel.the grief of the loss of the future life that I assumed that I would have

My wife and I finally started to see a future that despite lifelong financial disaster was looking good. Then the diagnosis took that away. Took away the way in which we dreamed of the future. Of course it was never guaranteed....but.

Tall Allen mentioned another emotion that was strong and I had not identified in my self with a word but felt it very heavily "regret".

[Aodh in reply to CAMPSOUPS]

My ability to communicate comes from very very dark places in my soul (assuming that I have one!) that I needed to look into and acknowledge in order to heal my self, which was very heavily damaged.

Luckily for me, I was introduced to a 12 step program of recovery when I was 20 years old. I had been in need of it for some time. It required me (among many things) to be honest with my self. Up until then I didn’t even know I had one (a self, that is). For another 20 years I applied the 12 steps as best as I could each day, one day at a time.

My broken self attempted to live life well, but I wasn’t particularly successful (at anything other than trying!). I was very good at attracting (and being attractive to) the wrong type of person (nothing to do with sex).

I had another breakdown at 40 (the 3rd one!) and managed to get my self to a very good therapist, who I saw for 5 years. In that very painful time, I stared into a terrifying blackness and talked out the shards of my broken self and with my therapist’s guidance integrated my personality together for the first time. That process (still ongoing as I learn more about my self each day) enabled me to communicate without fear and without needing embellishments; and that was just with my self!!

I’m glad that I can now also communicate with others and sometimes be helpful to others, just by being me. That’s very joyous for me.

Experiencing emotions used to be impossible for me, thankfully I’ve moved forward considerably.

Appreciating that I’m a spiritual being having human experiences has allowed me to become me, warts and all. It hasn’t led to financial success or any other material benefits but I can take what comes my way and move forward.

In 2018 I was made redundant (for the 2nd time in my life, I was fired once as well), I had no job, no home, no prospects and found out that I had very high risk locally advanced prostate cancer. Was I stressed? Of course!!!

I’m human.

Last week I had my last shot of Zoladex (of 3 years treatment) and together with the 39 sessions of EBRT, I continue to have an undetectable PSA.

I have my own home (for life), enough food in my belly and the prospect of at least a few good years ahead of me.

Regrets, yes I feel those too, at least I know how to avoid making new ones and am much better at living my life than I ever was and I’ve given my self permission to make a few more mistakes along the way.

Being a grumpy old man is my next endeavour; I’m sure I’ll be good at it!!!

Hugh 🤣🤣🤣

[CAMPSOUPS in reply to Aodh]

Well thank you. Your presence is special. Of course is all our brothers here.I appreciate what you say. I can relate.

I had a similar but apparently not as devastating of a self experience at the age of 30. I didn't continue to keep or dive into the self awareness and outlook on life I learned at that time as much as I could have instead diving deep into work/life but none the less I was better for the experience and would have soon been hospitalized, in prison, or dead had I not had help.

Grumpy old man? I am already that ha!

[treedown]

My experience was the same as Aodh though I had 44 treatments. My tattoos were just stickers with a pen mark. Only one washed off and needed to be replaced during the 9 weeks.I had RT pelvic and aortic LN's up to aortic bifurcation. I had a low imaged CT prior to each treatment. No Spaceoar my RO was against it but I did not ask if he meant for me or in general.. My insurance is Kaiser but treated at a local non Kaiser facility. Finished treatment in April 2020. As of this date no side effects but I know we are all different and whereas some people are made nauseous by RT I was not.

Best of luck with your treatments.

[Tall_Allen]

The tatoos (positioned by lasers) provide rough alignment. They are used to adjust the bench under you. It positions your body but not the organs within your body.

With any kind of hypofractionation, fiducials are essential. Your organs (especially bowels and bladder) move quite a bit between sessions. With moderate hypofractionation, positioning with a CBCT or stereo X-rays at the beginning of each session is necessary to avoid toxicity.

[maley2711 in reply to Tall_Allen]

He mentioned using CBTC,but not the implants . Been doing this since 1990, but screwing up? So, with 28 sessions and CBCT, need implants, but not with 39 sessions. Guys above had 39 sessions and no fiducials. He also does SBRT...just not yet for high risk for some reason. He MUST use implants for SBRT, correct?Think I can find an official SOC treatment guide for hypofractionation somewhere using Google? Whole pelvic would not obviate the need for fiducials, correct? Thanks Allen. always challenges.

Peacehealth hospital, which has some type of affiliation with Kaiser, nearby Wa mentions use of CBCT and IGRT>without fiducials, would not be IGRT, correct?

[Tall_Allen in reply to maley2711]

CBCT is always used with fiducials. What else would the X-rays bounce off of? Since the early 2000s almost everyone changed to IGRT/IMRT using fiducials because of the lower toxicity. It is especially important with hypofractionation. With extreme hypofractionation (SBRT), it is even necessary to check positioning during each treatment.

Whole pelvic is especially challenging because the upper bowels (which cannot hold fiducials) move independently from the prostate. I know UCSF uses "adaptive planning" to correct for that.

I know that some use a rectal balloon to limit prostate motion.

There are new MRI based linacs that use soft tissue image images (called gating) instead of fiducials.

[maley2711 in reply to Tall_Allen]

Thanks again TA. Maybe Google provided something relevant to my concerns? use of VMAT and CBTC, combined with soft tissue guidance, not fiducials?

pubmed.ncbi.nlm.nih.gov/277...

Just 16 subjects, but useful? Kaiser here uses "soft tissue" ?

[Tall_Allen in reply to maley2711]

Kaiser is going to have your RO be there for every set up for every treatment and manually align to some soft tissue landmark. I doubt it. Which landark will they use?

[maley2711 in reply to Tall_Allen]

Interesting debate between 2 medical physicists re tissue based vs implant fiducials......

aapm.onlinelibrary.wiley.co...

The issue of importance of total session time is mentioned. I think you'll agree that real-world results/studies more important than theoretical advantages? I'll look for more real-world comparisons?

I don't know if it means anything or not, but Dr. Nautiyal was on U Chicago Med School faculty prior to moving here and joining Kaiser. I will do it, but of course take no pleasure in challenging Docs.

[Tall_Allen in reply to maley2711]

I think you are trying to make a round peg fit into a square hole.

[maley2711 in reply to Tall_Allen]

Just trying to be more informed before confronting a highly experienced Doc?

[Tall_Allen in reply to maley2711]

Don't confront - discuss. Get second opinions.

[maley2711 in reply to Tall_Allen]

TA - as you may have read in other replies, apparently many men are having radiation without fiducials for standard non-hypofractionation treatment> would that be too risky from your perspective?

No doubt the use of fiducials from a theoretical perspective would be highly preferred for any type of radiation...nor argument at all! I wasn't able to find any study that actually tracked adverse consequences and PCa control with/without fiducials over a long time period. Probably just didn't search long enuf.

Evidence of long-term damage from whole pelvic...another thing to worry about? risk/reward?

[Tall_Allen in reply to maley2711]

I don't read other replies, but it is very risky to hypofractionate without fiducials. Why do you suppose they were used in the first place, around the early 2000s when IGRT was first used? Idk why you seem intent on taking a giant step backward.

[maley2711 in reply to Tall_Allen]

I AM following up on this..both with Kaiser, and if still dissatisfied, with someone outside. When a Kaiser member uses their site for a listing of Kaiser MDs, the search results include both Kaiser-employed Docs at the Kaiser clinics AND non-Kaiser community-affiliated Docs...some from OHSU. I'll be following up to see if Kaiser actually covers consults/2nd opinions with those outside Docs.

Not sure about step backward...yes , it is, in sense just now realized that this is an issue I should have worried about immediately after that initial RO consult at Kaiser.

Of course, initially I accepted his expertise and was relieved I wouldn't need to endure another invasive procedure like biopsy, where i found I needed propofol sleep sedation in order to overcome the pain from the TRUS probe.

I very much appreciate your comments on this and hope I'll be able to find some study/ammunition on the improved results for side effects when using fiducials for this PCa radiation. I started but have not yet completed my read of the NCCN discussion of PCa radiation.....should expect to see something there about fiducials!!

Or maybe from . some American radiological professional group. Or EAU radiation guidelines? All in my bookmarks. Or maybe Medicare website? Must be something somewhere...if this became standard almost 20 years ago.

[maley2711 in reply to Tall_Allen]

The latest NCCN guidelines basically referred to this set of guidelines.....

Hypofractionated Radiation Therapy for Localized Prostate Cancer: An ASTRO, ASCO, and AUA Evidence-Based Guideline

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

" While utilization of IGRT is recommended, there are many different modalities to evaluate prostate position (ultrasound [US], fiducial markers, cone beam computed tomography [CBCT]) and to track the position (4-dimensional and cine magnetic resonance imaging and radiofrequency transponder systems). Each system has its own advantages and disadvantages by comparing increased radiation dose, additional invasive procedures required, cost, accuracy, and time on the treatment table.91-94 There are a number of studies comparing these technologies with respect to both outcomes and accuracy, yet the definitive benefit of one modality over another has not been identified.93-97 Until randomized evidence regarding the benefit of these technologies is available, it is up to each institution to determine the appropriate modality for utilization of IGRT. "

Is the prostate tracked and beam adjusted continuously during the session? I believe OHSU highlights their use of Calypso......transponders are implanted?

Somewhere there must be some substantial study showing the SE benefit of fiducials!

[Tall_Allen in reply to maley2711]

Sorry, I have no idea what you are asking. IGRT effectively became the standard of care in the beginning of the century. because of reduced toxicity I'm not sure why you want to take a giant step backward.

[maley2711 in reply to Tall_Allen]

I don't of course. Agree 100% that fiducials appear to be SOC....simply trying to find the study/studies that made that the case, to provide the RO in case I haven't misunderstood him! I am happy that apparently they use the short session VMAT technology.. I've definitely made progress finding convincing authority for fiducials......like handout from NHS describing use for Brit radiation patients. Unfortunately , unlike most guys........I would need sleep sedation, based on my previous experience with too-painful TRUS probe for biopsy. Ended up with retention after that biopsy!!

NOT smooth sailing so far!! With your helpful comments and my additional research into this topic, at least I think I could now have a halfway informed discussion with the RO. Hopefully, my preliminary talk with one of the RO advice nurses will provide a satisfactory resolution of my concerns? When the RO mentioned the use of tattoos and not fiducials, I didn't have the background to question him at that point...at least I did ask the question re would fiducials be used..he hadn't mentioned. I then assumed my know ledge was incomplete and that he wouldn't be suggesting something inferior!! Live and learn !! Frustrating for sure!!

[maley2711 in reply to Tall_Allen]

reduce toxicity? avoid???

[Hidden]

Are you getting whole pelvic treatment? If so, what would the fiducials provide? I would imagine fiducials would be utilized for those who are only getting the prostate treated and no surrounding tissues.

[maley2711 in reply to Hidden]

See TA's reply?

[MateoBeach]

You could get a consultation with Arthur Hung MD, Radiation Medicine at OHSU. Top notch. Reviewed all my scans from prior SRT and PSMA PET. Confirmed the plan from my local RT in Bend was what he would do. And that the equipment and targeting technology using daily cone beam CT was excellent. Very reassuring. If you need fiducials for prostate gland, he will clarify it. Radiation Medicine is at the Marquam Hill Campus, Kohler Pavilion at OHSU.

[maley2711 in reply to MateoBeach]

Thank you Mateo. Did you have 39 session, fewer sessions with hypofractionation, or SBRT? with/without fiducial implant?

Thank you very much for that name!!

[Don_1213]

I'll just comment that I had IM/IGRT/RapidArc (+Boost) to a dose of 83Gy in 45 sessions.

No fiducials, no space oar. I did have the tattoos - and laser alignment on the table. My rad-onc explained that with my case they would be doing the prostate bed and then a boost exposure for the prostate itself. He said he wanted a 10mm margin around the treatment in case of any EPE.

He said that with the cone-beam X-ray that was done immediately prior to each treatment the fiducials were unnecessary, and the X-rays were excellent for aiming the beam and keeping the techs running the machine from getting lazy. I asked a few times to see the imaging - I could easily see the organs and prostate in the display. He also didn't want space-oar, felt it was unnecessary if proper imaging and planning is done, and as he said "he didn't want to stir things up down there.."

This was done on the newest Varian True-Beam machine (2 years ago). For a description of what's possible with the True-Beam machines - this one is excellent: norleenagullettmd.com/treat... - the TrueBeam machine has an accuracy of 1mm. You can't get much more accurate than that since you're dealing with tissue.

That was just my case and possibly has no relation to your case. I suggest addressing your questions to the radiation oncologist. I had similar questions, and the rad-onc answered them to my satisfaction with somewhat more details than I gave above.

Looking at the paper above led me to: pubmed.ncbi.nlm.nih.gov/310... - which is worth a quick view. The conclusion if I read it correctly is - there is no advantage to using fiducials vs soft-tissue based setup for hypofractionated IMRT. It's a 2019 paper.

[maley2711 in reply to Don_1213]

Thanks Don ! Perhaps, as TA suggested, fiducial less necessary because of lower daily dose, 45 session treatment? Just speculating, but I believe Truebeam is real-time MRI and possibly reduces the need for fiducials because of the real-time MRI? I am surprised they didn't offer hypofractionation of 20-28 sessions, or SBRT? And thanks for raising the subject of treating for unseen ECE with wider margin. Did Doc mention the negative of that..... greater benign tissue damage to other organs, eg rectum, etc?

We are still a long way from the ideal PCa treatment!! And then some of us are contemplating the damage from combined ADT !! Hope you avoided that!!

[maley2711 in reply to Don_1213]

Don -

Looks like my speculation was wrong.....can't find anything about True Beam and MRI-linac...just the Unity and Viewray machines.

I think the 1 mm refers to the actual accuracy of the machine in aiming the radiation.....but I believe the biggest problem is actually finding the real target dead-on in real time..thus the use of fiducials which machines can track without the need for RO presence during the session? Lots of complications !!

[Scout4answers]

I want to thank you all for a very informative discussion. I am in the process of engaging a RO for my rad therapy and the information has been very helpful.

TrueBeam looks like it is the state of the art in 2021, 1mm margins!

[climb4blue]

Hi Dale,

I had painful difficulties with fiducial placement, however, I couldn’t imagine getting SBRT without them since the outcome all we want is curative radiation to the entire prostate with minimal margins to reduce toxicity.

I hope you get fiducials as part of your prostate radiation treatment wherever you choose to go.

[maley2711 in reply to climb4blue]

Thanks ! Kaiser RO was negative on fiducials for 28 day hypofractionation with CBCT and VMAT . Yes, he did say fiducials would be used with 5 day SBRT....but they are no tyet using SBRT for my type (Gleason 4+5) of high risk case.

I'm celebrating today....... after bone, CT, and MRI scans last summer found no metastasis, the latest Pylarify PSMA PET scan last week was also negative.......just avid/detected in same area as seen on last summer's 3T MRI. Cheers!!

I'm OK with radiation....but terribly fearful of ruining my current good life with18-28 months of ADT for high risk PCa. Maybe I'll ask about being a guinea pig by using estradiol patches instead of traditional ADT drugs???? Or take a greater risk and RT without ADT?