Log in
Prostate Cancer Network
1,820 members850 posts

Should SBRT be THE preferred treatment for intermediate risk prostate cancer?

Unfortunately, not enough patients meet with a radiation oncologist who specializes in SBRT. While the authors stop short of recommending SBRT as the preferred treatment option for intermediate risk patients, I think every intermediate risk patient should strongly consider it - I chose it for myself. Low risk patients should first consider active surveillance. High risk patients should consider an SBRT clinical trial (if available) or brachy boost therapy otherwise.

pcnrv.blogspot.com/2019/04/...

21 Replies
oldestnewest

I have always wondered about this since I learned about SBRT.

Reply

How does clinical trial SBRT vary from normal SBRT?

Reply

For high risk, the widen the margins a bit. In Dr King's clinical trial ,e offers the option of whole pelvic treatment and up to 9 months of adjuvant ADT.

Reply

I'll add an anecdote. My RO has treated me twice, the first time in 2012 and the second in Dec 2018-Jan 2019. He expressed concern that, without the results of a clinical trial, which the article indicates will not be available until 2025, insurance companies will force SBRT upon patients who might otherwise benefit from EBRT. They would do this presumably because 5 treatments with SBRT will cost considerably less than, say the 46 EBRT treatments I received in 2012. I encourage fellow patients to question the RO accordingly.

For those who wish to read more:

accc-cancer.org/docs/Docume...

Reply

The opposite is true- ROs are compensated by the number of treatments. Therefore, they prefer to give 44 treatments to 5. Insurance companies all cover the full 44 treatments.

Reply

I disagree. My RO provides the treatment that's right for me, without regard to the cost. It would have cost less to have SBRT but the treatment would not have been right for me. In my case I agreed with him for the second round: 26 of EBRT covering a broader area that was originally suggested by my MO.

Reply

I just checked your profile -- none of this applies to you. You had SRT, not primary treatment of localized PC.

1 like
Reply

Roger that, thanks for the clarification.

Reply

Why not RP for intermediate risk patients?

Reply

Certainly RP is an option for intermediate (until we get the results of PACE A). Every man starts with a urologist, who usually recommends surgery. I encourage men to explore other options. Since radiation and surgery have equivalent outcomes out to 10 years, many men prefer radiation because of the lower side effect profile.

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

2 likes
Reply

Tall _Allen,

I agree that, had proton therapy been available for me in 2012 I might have chosen it over the RP, to avoid the side effects of the RP. But, and of course we have the benefit of hindsight here, the RP revealed in my case that the PCa had spread to the bladder neck.

So while the clinical trials reveal similar outcomes, what do we say to men who've had proton therapy yet find out a few years later that they are actually Stage IV? As you point out, it doesn't affect outcomes...

I'm asking without knowing the answer, not my usual style BTW.

Reply

According to your profile, you were high risk (Gleason 9) at the start. Brachy boost is certainly the best standard therapy for high risk men. SBRT should only be done for high risk on a clinical trial. A proton boost was available for high risk in 2012. Radiation of any of these kinds would have treated your bladder neck and you might have had full pelvic treatment at the same time to take care of any cancerous pelvic LNs. But I don't like this questioning of past decisions - it does you no good.

1 like
Reply

If you had gone to a proton place they might have done proper imaging diagnosis first.

Surgeons it seems, all they need is a 70 percent accurate biopsy.

1 like
Reply

I was diagnosed 12 /2016 as a G9’r. Actually got an opinion from you on another forum regarding this. After being told by my urologist to have my prostate removed, I got an opinion from a different surgeon and a radiation specialist, Dr. Zelefsky, at MSK. Treatment plan (not a clinical trial) developed was LDR brachy, SBRT and 18 months ADT (Lupron). ADT was started in March of 2017 and last shot was 7/18. Brachy was done in July of 2017, SBRT in August 2017 (5 treatments). At this point my PSA is <.05 and my testosterone is coming back up. It’s at 57 currently from a low of 6. Next MO appointment is in mid June. So far, so good

Reply

Looks like the excellent response brachy boost therapy often provides.

He is running a clinical trial of that combination for intermediate risk men

clinicaltrials.gov/ct2/show...

I suppose he just treated you using that protocol. I think it's a good treatment, similar to brachy boost except using SBRT instead of IMRT. I'm more excited though to see how pure SBRT works out because the potential for side effects is so low.

Reply

As another G9, my treatment is ADT 24 months and IG/IMRT/ARC, 45 treatments, 81Gy, 25 pelvic and prostate, followed by 20 prostate. 6 weeks post radiation PSA is undetectable. Side effects have been minimal.

That's one of two standards of care for RT with G9. So far it seems to be working. For the past 3 weeks have been making it through the night with no nocturna. That's very nice..

Reply

What about more atypical case such as mine? I spent a lot of time talking with a highly experienced (academia, NCI, private practice) radiation oncologist but eventually chose Robot Assisted RP.

The multiple DRE's, 3T mpMRI, and 12-core TRUS Biopsy ALL identified an ~18cc prostate (DRE was "small, firm, not abnormal"). The MRI was PIRADS-3 with a 0.32cc area of abnormal tissue in the left lobe with no extension beyond the capsule. The Bx confirmed PCa in only the Left lobe.

Post surgery pathology found a 37cc prostate and 7cc G7 (3+4) tumor in BOTH lobes with G6 extraprostatic extension and G6 surgical margin.

Would the proposed SBRT have been effective based on the single lobe, small, isolated tumor found in the MRI and Bx?

Reply

I expect that TA will have an authoritative reply, but would comment that SBRT is a whole gland treatment. Your concern would certainly be applicable to focal treatments.

Reply

Yes, as ASAdvocate says, SBRT is a "radical" treatment (=the whole gland is treated). 80% of prostate cancers turn out to be in both lobes in spite of biopsies and MRIs.

Reply

A consideration I did not anticipate after PC diagnosis is how diificult and exhausting it is to find, get appointments with and consider/contrast the advice of various urologist’s, med oncs, and rad oncs. SBRT sites don’t always have an IMRT option and objective advice is very hard to come by. While an available technology may be ten years old in major cities it may be new or unavailable in even medium size markets where a clinician will simply recommend to you what they know how to do. It took me six months post biopsy to get a second opinion on the biopsy, 2 uro’s, two rad onc’s and one Med onc. Two cities 100 miles apart, any book or blog I could read and four medical groups while working full time. I am sort of young and have a lot of energy and this crap wears you down. If you are in a major metropolitan area, options are better but adding a plane flight and days on the road is out of reach for many. I think I was lucky to find SBRT for my 3+4 small contained lesion confined to the right prostate, but if it was at all practical or affordable, I would have looked at an other-than whole gland option. I can see how guys pick RP based on a urologist they know. I also agree with a previous post that second guessing is of no value. Thanks for everyone who posts and for a venue for my rant.

Reply

I guess I'm spoiled living in a big city (LA) where all options are available.

Reply

You may also like...