Tall Allen or anyone else with helpful information, please advise. I am deciding between two large cancer centers for radiation treatment. My background: PSA was 45 in 2/24, now .04. Lupron/Xtandi taken since 2/24. Gleason score = 9 (4 +5). 75 years old.
Cancer Center I - Radiation to prostate - 55 gray (2.75 gray x 5 days x 4 weeks). Radiation to prostate and seminal vesicles. No radiation to pelvic areas or pelvic nodes. No Barrigel provided with the concern being that the gel would push the cancer cells away from where the radiation is targeted.
Cancer Center II - Radiation to prostate - 72 gray (28 fractions x 2.5 gray daily). Radiation to seminal vesicles - 61 gray. Radiation to pelvic area and pelvic nodes - 50.4 gray. Barrigel provided to protect the rectum.
Which approach is better?
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buffman
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The decision on Barrigel should depend upon if the cancer in the prostate seems like it might have grown into touching the rectal wall. If so, avoid Barrigel.
Thank you for your response. I did have a PSMA and the findings were:
Head and neck: There is expected distribution of the radiotracer throughout the head and neck with the anatomical structures appearing grossly unremarkable on co-registered CT.
Thorax: There is expected distribution of the radiotracer throughout the thorax with the anatomical structures appearing grossly unremarkable on co-registered CT.
Abdomen and pelvis: There are discrete foci of tracer activity in the right lower abdomen that appears to localize to right common iliac and right internal iliac lymph nodes. Mildly increased somewhat focal activity is also seen in the posterior apical prostate. There is otherwise expected distribution of the radiotracer throughout the abdomen and pelvis with the anatomical structures appearing grossly unremarkable on co-registered CT.
Questions: Does it appear that whole pelvic radiation therapy (WPRT) is appropriate for me? If WPRT is appropriate for me, must Barrigel be used in order to protect the rectum? Or, since there is activity in the posterior apical prostate which is closely related to the rectum, is Barrigel ruled out as a procedure? If Barrigel is ruled out, does that mean that WPRT is not an option?
Tall Allen, I've followed your responses to others for some time and very much appreciate your response to my issues.
You have cancer in your pelvic lymph nodes, so you will have to have whole pelvic radiation with a boost to the right common iliac and internal iliac lymph nodes. You will also need 3 years of ADT and 2 years of abiraterone.
Barrigel does very little anyway. And the cancer in the apex may rule it out depending on your mpMRI.
Your RO can carefully contour the beam so that the rectal dose is minimal.
If you can travel for treatment, I'd recommend you get treated with a Viewray MRIdian linac that minimizes the margins. I know Dr Kishan at UCLA uses it, as does a few other ROs. I think it is particularly good for whole pelvic radiation because they can restrict the bowel dose.
Can you please provide me with the data that says 3 years ADT? When was diagnosed with Oligometistatic (3 small lymph nodes) I was told that the new data from Stampede said 2 years ADT + 2 years Abi+P. I am approaching my 2 years and my local MO said I'm done. I also reached out to my MO at MD Anderson to see if them treatment schedule had changed and they said I can stop at 2 years.
That is a great article TA. Most interesting. Do you think that 3 years ADT is necessary if Brachy Boost is added into the mix? I'm certainly hoping not.
STAMPEDE gave that to patients who were radiologically identified with enlarged pelvic lymph nodes. It didn't matter what kind of radiation was used on the prostate.
No, the STAMPEDE protocol (3 yrs ADT+2 yrs abiraterone) was among men who had lympn node invasion identified using conventional radiography (e.g., not PSMA PET scans). IMO, it would be reasonable to extend its use to all men who had lymph node invasion on any kind of scan - although I am making an arguable leap there.
I would be asking why are the proposed treatment fields different? (perhaps the difference is a difference in tumor burden reduction vs risk?)
Are the recommendations based on same investigative findings? I would want all available investigation methods to achieve highest certainty possible that all the cancer is within the treatment field.
This is a good, fair question for both your physicians. I know my husband had differing opinions. BTW we traveled to obtain the MRI guided radiation. He has done wonderfully.
I’m no expert but IMO the second option seems better. I would ask if at the end you can add Brachy Boost and then continue with ADT for another 12 months.
I did what Tall_Allen said: "You have cancer in your pelvic lymph nodes, so you will have to have whole pelvic radiation with a boost to the right common iliac and internal iliac lymph nodes. You will also need 3 years of ADT and 2 years of abiraterone. Barrigel does very little anyway..."
I had IMRT for prostate without gel. Two years later, after a PSMA scan, I had IMRT for pelvis with boost to a node, and started Orgovyx ADT and abiraterone. None of this has caused me any discomfort.
Given your PET scan report and G score I believe the second approach would be more appropriate. I agree with Tall Allen that a boost to the know iliac nodal disease would be appropriate. I would be surprised if that was not already a part of the planning protocol.
The RO and the rad techs will ask you to empty your rectum as much as possible and to have a relatively full bladder prior to each treatment to minimize the dose to both rectum and bladder.
There is controversy within the Radiation Therapy community if the benefits of the rectal gel outweigh the potential side effects or complications. This is something you should discuss with your RO.
The second option is delivering 72 gray to your prostate which is pretty much maximum dose with curative intent. Lesser, but substantial, dosage to the seminal vesicles and pelvis sounds reasonable to me. The reason for delivering a smaller dose (usually 1.8-2 gray) per session over about 30-40 sessions is because the cancer cells can't repair the damage inflicted by the radiation as well as the normal tissue. So, the normal tissue "rebounds" but the cancer keeps getting degraded. When the cancer cells attempt to divide (grow) they die if the DNA is sufficiently damaged.
I have read much about proton vs photon, IMRT vs cyberknife vs IGRT vs SBRT, etc etc. At this time there is no definitive evidence that proton therapy is superior to traditional photon treatment for prostate cancer. The studies are mixed as to the side effects. If you go to a major medical center/COE, they will treat you with what they believe to be the best radiation treatment for your cancer.
Your RO will almost certainly want to put you on one of the drugs to lower your testosterone (ADT). Depending on the RO this could be as little as a year or up to 3 years. There is no magic number and opinions differ in the RT community. ADT can have significant side effects for some men. After treatment with ADT, return to normal levels is dependent on age, length of ADT treatment and pre treatment testosterone levels. Data would suggest that men in their mid 70s treated for 2 or more years may have difficulty in regaining normal testosterone levels. This is also something you may wish to discuss with your physicians.
You may want to consider SBRT, which Dr. Kishan at UCLA is a big proponent of. This involves only 5 sessions total of high-dose rate X-ray irradiation, done every 2 days, for a total of 10 days. This is a big benefit if you need to travel to a remote center.
This is what I did, and I haven't had any side effects so far.
Be sure to ask your RO about this option. I agree with Tall_Allen that your pelvic lymph nodes need to get irradiated, plus you need to get an PSMA-PET scan. Very important.
By the way, I did the SpacerOAR gel. I was in "unfavorable intermediate risk" category.
is there a better?! I can’t speak to the specifics but radiation has gotten SO much better over the years. My husband did 35 rounds and had such minimal side effects we were amazed. (Basically none…fatigue did catch up to him at the end) Go for the treatment that will give you the best quality of life outcome…that’s our goal in all of this. Best of luck!
I can not speak to the more technical aspects as some of the guys above have already done. I am 79 so this might help since we are on the older side when diagnosed.
I had the prostate and pelvic area radiated at the same time. It took me about 6 months post radiation before all of the side effects were gone. I feel great and back to my normal active self.
I did not have that many options as are being recommended above nor did I have a second opinion. I was limited to my regional medical center so what machine they had was the best I could get.
My only other choice was the length of the treatment - 25 or 45 sessions. The same goes for the one RO available. She was just out of residency. I did have the gel placed by the urologist as requested by the RO.
I am almost 13 months post radiation and off the ADT. Happy to report that all is well. My year checkup showed my PSA was holding steady at .05. So far so good but that could change in a heart beat.
Good luck on whatever you decide. We all know how stressful this decision making process is at this stage.
Try to do something like resistance and aerobic exercise, diet change to reduce weight gain, etc and to relieve the mental stress and side effects of radiation and ADT.
There is very little mention of side effects from this array of treatments. There is a tendency in genera in this group and the most outspoken individuals to ignore them here. Me on the other hand pray for the most comfortable qol. I am 60 y/o. This is a decision you and only you must make at 75 y/o Good Luck.
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