In a previous post my daughter AppleTree43 posted a query about radiotherapy. I have prostate cancer with local and some distant nodes in the back. Tall Allen told her all are within dimensions used for NRG Oncology.
Mo at Kaiser and second opinion from UCSF are hopeful radiotherapy of prostate, local and distant nodes could lead to enough of a "remission" that I could take hormone therapy vacations in a couple of years.
I am scheduled to start VMAT 28 times =70Gy with Varian Trubeam Rapidarc.
My question: Is this the latest, best equipment and procedure?
Thanks to everyone
PJ
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pj1121
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It is very good technology - lots of linacs can do a good job. It's like asking whether a Samsung phone or an iPhone is better. The experience of the RO is much more important.
I asked that question of the RO, who would only conservatively advise “prostate radiation is science the rest is extrapolation and hope”. His reply was I have never done this for prostate cancer but I’ve done the same many times for cervical cancer. He also advised against spaceoar gel and did not believe it was necessary to implant markers in the prostate. He said he expects no serious side effects.
I think you might be better off with an experienced RO. Alexander Gottschalk at UCSF would be a good choice. I think fiducials make a difference. Northern Ca. Kaiser also has been treating prostates with VMAT for several years.
I would _run_ to a new RO stat who has experience with prostate cancer. In my case the onco dept at the regional hospital I am using (Exeter NH) is part of a major hospital in Boston (Mass General Brigham) and the RO and MO split their time and have access to dedicated PCa experts downtown. I got lucky as my initial high PSA test was by a primary care doctor in the multi-site medical group that includes Exeter Hospital, and referred me to a urologist there, who in turn referred me to the onco clinic after DRE and biopsy and starting me on Firmagon.
PCa is quite a different hydra compared to most other cancers, certainly cervical. And your current RO's expectation that there will be no surprises could easily be dead wrong. At a minimum you need a prostate MRI to identify any spread outside the gland.
I asked my onco team for aggressive treatment, and it is working now about 1 year from RT and ongoing ADT + Abiraterone. Good oncology doctors have a quality chat with you about treatment options and the tradeoffs of SE's -- you will need to approve the plan at an early point when time pressure and uncertainty are highest.
Metastatic PCa is never called curable andall treatments are palliative. Aggressive early treatments and a lot of luck _may_ lead to a 5+ year time of no progression, IE a cure. The last thing you need is an RO who is a PCa newb, hoping consequences and surprises are unlikely.
Yes, ask for an RO with experience in prostate radiation....in fact, a LOT of experience. No time for someone at his/her first rodeo!!! Your goal is to maximize the odds in YOUR favor of course.
I believe you'll find in the US that the vast majority of treatment is actually administered by a radiation-technologist, not the radiation-oncologist.
So from a point of skill doing a treatment you're perhaps asking about the wrong person. More important is the planning for the treatment - the formula and map that the rad-tech uses to guide the machine. And the skill of the person executing that plan.
In the case of someone who is doing their first planning for prostate treatment - it wouldn't seem unreasonable or insulting to ask that it be reviewed by an oncologist with a lot of prostate experience.
It's just a feeling on my part - but I think the rad-onc will be doing his damndest to come up with an effective treatment plan, he doesn't want to be tossed off the bull at his first rodeo. I'd also guess that the plan may be automatically reviewed by a board of rad-oncs if this is his first one. If so - you're perhaps getting a better plan than one done by someone who after 10-15 treatments figures they've got it down and whose plans are no longer being reviewed.
What's done in other countries - dunno. What's done in commercial radiation clinics (quite popular in the US) I also don't know.
As far as always looking for someone who's done #### treatments - brings the question to me - what about the people who were his ####-1, or -2, or -200 treatments - are they somehow not worth anything? As far as picking an experienced tech or MD - remember - they became experienced doing treatments on other humans.
Sorry people, I guess I was not clear , I did not mean to imply that this was my RO's first go round. I was very specific when I asked if he had done this before ie; prostate, local lymph nodes and retroperitoneal Lymph nodes . He has been doing prostate RT for almost 30 years. But he has never added in the retroperitoneals in someone with oligometastic cancer, although he was done the same area for people with cervical cancer. So, he could not give me specific outcome for this specific treatment which is considered to be novel.
And as "novel" treatment you're unlikely to find anyone who has done more than a handful... If you trust him, do it. If you question is - ask for a 2nd opinion.
The skill of the person executing that plan is a computer program, not the rad-tech. They position you, load the program, and let the HAL 9000 do the work.
Your point? Forget about experience? Yes, or no? I agree ......from my understanding, it is a team effort, but pay grade tells me the RO is the most important on the team.....so , you want a team with significant experience doing prostate RT!
Neither. My point is - selecting your treatment solely based on the experience of the Radiation Oncologist is a very limited filter. And that's what you proposed. You said nothing about the "team" (Rad-Onc, Rad-Techs and the actual facility and equipment.)
I assume this radiation would be done by Kaiser......did the RO mention the use/placement of "fiducials" to help reduce potential side effects...or just the use of daily conebeam to help with image guidance ?
I had Varian VMAT but not SpaceOAR because the tumor was growing outside the capsule. And I had fiducials. It is stunning that a good RO would not want fiducials! Fiducials tie the pre-RT MRI "simulation" along with a custom leg form, to the actual RT machine. They decrease beam damage outside the mathematical target shape/volume. Your RO sounds like they are shooting from the hip (all puns intended.)
Good luck and keep a full bladder (which gets harder as the treatments accrue.)
Your description of the fiducials might be true if everyone had the exact same PCa. We don't and that "stunning" isn't stunning at all. In some cases it might provide an advantage, especially if your radiation technologist isn't very skilled or experienced. They don't necessary decrease beam damage - it depends on the treatment plan, the location of the tumors and the skill of the tech running the machine.
My keeping a full bladder wasn't any harder from the first to the last of 48 treatments - I just timed a liter of water on the drive to the hospital (about 20 minutes), then 10 minutes to get on the table - and I was ready to pee. Worked like a charm - enough so that one of the techs commented how I had a perfect bladder fill every time I was on the table. Using a laxative the night before took care of the rectum.
That's just my experience - obviously YMMV, but since every cancer is different in some respect you shouldn't be stunned by differences in treatments given. What gives you the leg up (pun sorta intended) is a plan that's really just for you and designed around your needs. Fiducials? Gel? Or not? Maybe, maybe, maybe. If it's not - ask for an explanation. I did and the answers satisfied me.
Don_1213 Did you get a small tattoo dot on each hip? Those were done when my simulation MRI was done and my legs were confined by a custom molded brace, to be used on the VMAT machine, where the techs aligned my dots to green lasers. Then a pre-VMAT CT was done to locate the fiducials and a last couple of mm table adjustments were done before RT. Of course my RT was exactly to a planned volumetric shape = prostate, seminal vesicles and margins. Without spaceOAR, it was critical my rectum was spared as much as possible. Maybe with spaceOAR it is not as critical to be aligned within 1-2 mm, but I doubt it since a good RO will also try and not overly fry your urethra.
Indeed I did - and two more - mid-chest between the nipples and down below my belly button. There were 4 laser beams that aligned me using the tattoos.
Those are my only tattoos, but I can now say I have some so the millenials don't think I'm quite as square..
They also had done a lower body cast (aka brace) that was fastened to the table. Making the cast was "interesting" - they used fiberglass cloth with rapid setting epoxy draped over a plastic cover for the table, and a very thin plastic cover between me and the epoxy. I laid on it - they shaped it to my body. It really helped in keeping perfectly still. They offered it to me when I was done with the treatments - I didn't take it. I can't imagine what I would have done with it.
I also had the traditional 48 treatments. I've heard it claimed that this is done solely to keep the machine busy and making money (more treatments = more $$$). Probably partly true, but when I asked my RO about it - he said the reason he wanted 48 sessions was that decreases the risk to organs at risk. More patterns can be used since more sessions are done, and if one isn't done precisely, less damage is done. I've seen some discussions on SBRT where it sounds as if everyone should be treated that way, somehow in some respect I believe that may also contain a money argument - but the people saving money (which equals making money) are the insurance companies and Medicare, instead of the radiation department meeting some annual revenue goal.
FWIW - while it's true that "HAL" (the computers on the machine) performs the actual radiation dose, pattern, and treatment, following the plan developed by the Rad-Onc, without accurate positioning of the beam on the target, there will obviously be some issues with exposing OAR's and missing exposing parts of the tumors. That's where the radiation techs come into play. There were 3 techs who worked the console throughout my treatment. As I mentioned - one was a good personal friend. He spent the time with me showing how things were aligned (without fiducials) and what was done on the machine manually to make sure the treatment went as planned. Everything done on the machine is recorded, and can be reviewed later to make sure treatments were done correctly (and probably kept forever in case any legal case came up, they'd have the evidence if they did it correctly.)
Also at Kaiser Northwest, an experienced RO said he uses fiducial only for SBRT, not for 28 session RT. I have been unable to find a SOC for these different RT protocols...and no definitive random studies for conebeam only versus conebeam with fiducials, for either SBRT or hypofractionation 20-28 sessions.
As I ended up with a catheter for a week after biopsy, fiducials seemed to be a concern for someone who had such an experience as result of biopsy.......already a VERY enlarged prostate, and then additional swelling after trauma of biopsy or fiducial placements?
2nd comment You are going if not already are on Firmagon. This initiates T shutdown and resultant accelerated bone mineral density (BMD) loss and muscle loss (sarcopenia.)
Get a DEXA scan if you can. Start exercising your arse off. Lots of material on BMD and sarco management elsewhere here on healthunlocked.com
I'll have to agree 100% with T_A - the skill of the operator of the accelerator (who probably won't be the doctor) is of primary importance, followed by the skill of the treatment planner - who likely will be the doctor - and "RO".
In my case - somewhat usual - my operator was a good friend, an old motorcycle buddy who I've done many thousands of miles with on 2 wheels (well - 4 counting his bike..) He also is quite experienced and highly thought of by the doctors at the institution. We had dinner with he and his wife on Labor Day..
Despite automation - human eyeballs at the moment seem to be best for orienting where on the prostate the treatment will be targeted for "today's session".
FWIW - my rad-onc (a quite experienced one, and head of the radiation department at a center of excellence) also thought there was no need for fiducials (he feels they make the techs lazy and they tend to rely on them rather than the image of the actual prostate), and he felt the gel was unneeded if the treatment was administered accurately and according to plan.
He also was hesitant to use fiducials since he felt that with my Gleason (a 10) he didn't want to physically disturb anything perhaps knocking PCa cells loose in the body.
My PCa was contained in the prostate - other situations may require a different decision. I don't think anyone can say that the gel is always needed or that fiducials are always the best idea. In this case - I'd suggest having the treatment plan reviewed by another radiation oncologist - and if he concurs - the treating RO will probably take extra care with the treatment since it's one of his firsts.
Get a second opinion. Or third. Dr. Mohan is in the Kaiser SF. Very accessible and will spend as much time with you as you need. Pay for a consult with Dr. Kishan at UCLA. Look up some of his video presentations on YouTube. Best of luck!
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