Should SBRT be THE preferred treatmen... - Prostate Cancer N...

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

Tall_Allen
Tall_Allen

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/...

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

How does clinical trial SBRT vary from normal SBRT?

Tall_Allen
Tall_Allen
in reply to cesanon

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.

DadsPCa
DadsPCa
in reply to Tall_Allen

Tall_Allen I agree that Dr. King is the choice for SBRT. After speaking with him and explaining my father situation, we decided he would be the best person to treat my Dad. Actually, my Dad had an issue with his diaylsis acess site infection/rash and delaying his SpaceOAR procedure at UTSW would cause him to be dropped from the trial ( Also they said his tests, CT, MRI-would become outdated and needed to be redone).

The clinical trial at UTSw raised alot of red flags in general. After doing more research we felt the SpaceOAR procedure is unecessary and the high gy level causes so many toxcities, I don't even know how they allow but then again I forget its a clinical trial and they push the limits on gy. Thank you a million times for Dr. Kings referral on one of my previous posts. We hope after everything is okay with my Dads acess site we will be in UCLA by August 2019. I will definately have to ask him about treating his whole pelvic area also as I didn't know that was an option.

Tall_Allen
Tall_Allen
in reply to DadsPCa

Feel free to use my name, Dr King knows me well.

DadsPCa
DadsPCa
in reply to Tall_Allen

Thank you TA! You’re the best and I definitely will 🙏🏻🙏🏻

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...

Tall_Allen
Tall_Allen
in reply to tallguy2

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.

tallguy2
tallguy2
in reply to Tall_Allen

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.

Tall_Allen
Tall_Allen
in reply to tallguy2

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

tallguy2
tallguy2
in reply to Tall_Allen

Roger that, thanks for the clarification.

Why not RP for intermediate risk patients?

Tall_Allen
Tall_Allen
in reply to Lisa7739

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/...

tallguy2
tallguy2
in reply to Tall_Allen

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.

Tall_Allen
Tall_Allen
in reply to tallguy2

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.

cesanon
cesanon
in reply to tallguy2

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.

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

Tall_Allen
Tall_Allen
in reply to Dogdays1

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.

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..

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?

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.

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.

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.

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

Considering SBRT. Prostate 56g worried that will be a factor in severity of side effects. Urinary retention etc. Currently G6 showing more aggressive on Prolaris test therefore considering treatment. SBRT shows promising cure rates. What was your experience?

Tall_Allen
Tall_Allen
in reply to Sunfire

My prostate was around 60g. That's not big for SBRT or HDR brachy - only for LDR brachy. I'm cured. No lasting side effects other than loss of ejaculate.

Sunfire
Sunfire
in reply to Tall_Allen

Great that gives me reassurance. Did you have urinary symptoms prior to treatment? At 56g the bph via mri is plentiful here. Currently on flomax.

Gleason?

6

Sunfire
Sunfire
in reply to Longterm101

6

Tall_Allen, Gleason 9, prostate size 77g. Dr wants to do Brachytherapy Boost + external radiation but first needs to shrink prostate. Have been on Casodex for 2 months resulting in improved flow. Just added Aligard 3 month injection. Will do MRI in October for results on prostate size. If still to large will do 45 external radiation sessions.

Will do one of the two treatments early November.

Would appreciate any feedback.

Sounds good to me. You may want to get an ultrasound for prostate size - it's actually more accurate than MRI. If your prostate doesn't shrink enough for seeds, you can still get high dose rate brachytherapy even with a larger prostate. If you're in Orlando, Dr. Biagioli does HDR brachytherapy.

Thanks T_A. Planning on HDR Brachytherapy Boost in Tampa at Moffitt Cancer Center with Dr Daniel Fernandez. Again prostate size controls type of treatment.

Appreciate your input!

Again, prostate size does not control type of treatment with HDR brachy. You have time to talk to Biagioli to get another POV - why not do it?

HDR-BT is recommended as a dose escalation technique combined with EBRT for patients with intermediate or high risk of failure with life expectancy longer than 5 years. The exclusion criteria are: prostate volume bigger than 60 cm3 (hormonal downsizing to reduce benign

ncbi.nlm.nih.gov

T_A, now I’m somewhat confused btw drs explanation and what you say about prostate size and HDR Brachytherapy

Your link doesn't work, but HDR brachy does not have a size limit:

"3D inverse treatment planning algorithms are used to optimized plans that provide excellent target coverage even in cases where the prostate volume is large. Traditionally, based on low dose rate experience, some brachytherapists have shied away from implanting large volume glands (> 50 cc). However, there are a number of experts describing successful HDR brachytherapy of large prostates without significant increases in toxicity."

This is a quote from the ABS Consensus Guidelines for HDR Brachy:

americanbrachytherapy.org/A...

Also, see:

brachyjournal.com/article/S...

This demonstrates why one should never take info from a practitioner outside of his area of specialty. Talk to specialists before deciding.

Your links support your position on treatment for larger prostate and I thank you for bringing to my attention. Will definitely discuss with RO.

Yes - 3X a night - I took Flomax, then Rapaflo. Also took Proscar.

Currently on Flomax 2 a night. No others as of yet. mpMRI Pirads1 and Pirads2. The only thing pushing me towards treatment is the Prolaris testing and family history. SBRT seems to be least invasive with high cure rates. SpaceOar would be placed too. Concern was for urinary due to larger prostate. Glad to hear your doing well and cured. Can't ask for better than that!

Your prostate is only large for seeds, not for SBRT. I'm not a big believer in SpaceOAR. Who is your RO?

Sunfire
Sunfire
in reply to Tall_Allen

Not a believer in SO? Why? I have some internal hemmroids that I'm told will help in protection too.

RO is Perch at LVHN in PA. The center is part of Lehigh Valley Cancer Institute, a national leader in cancer care and a member of the Memorial Sloan Kettering Cancer Alliance. Perch has done rads on thousands of Pca patients with good results. SBRT is fairly new there within last 2 yrs. For SBRT it's the Varian Edge/Calypso. If I understand correctly it's even more precise than Cyberknife equipment. Do you know RO of Perch at LVHN in PA?

Considered surgery simply because of the possibility of reoccurrence and no other options but ADT which we hope to avoid like many but leaning towards SBRT.

Tall_Allen
Tall_Allen
in reply to Sunfire

I think of SpaceOAR as a solution in search of a problem. Their big claim is that it can reduce late term rectal side effects. But that only occurs in about 1% of patients. You can read my analysis here:

pcnrv.blogspot.com/2017/01/...

I also had internal hemorrhoids, and radiation will inflame them. I went to a proctologist before radiation, and he got rid of them all (he injected them with soothing phenol).

I don't think there's much difference in precision between the Varian Edge and CyberKnife. I was treated using the Varian TrueBeam with RapidArc. The big difference is that each of my treatments was 5-10 minutes vs about 45 minutes with CyberKnife. Calypso and fiducials have exactly the same accuracy.

I don't understand what you wrote about recurrence after surgery.

Sunfire
Sunfire
in reply to Tall_Allen

Interesting analysis on SO. Great share and something to consider reevaluating thanks.

I meant if there is a reoccurrance after surgery it allows you the option of rads after. If having SBRT first and you have reoccurrence as I understand you have limited options. ADT, chemo. It makes a difficult decision even more difficult.

Still doing pro/con list but SBRT continues to be more and more in the lead. Mainly after significant study in terms of percentages it is one of the most promising in terms of cure for low/intermediate risk.

Thanks for the tip on hemmoroid treatment prior to SBRT that is good to know! It is a concern even though they are currently no bother. Recent colonoscopy showed a few and years ago were bothersome.

Do you know any RO's in Lehigh Valley PA? Steven Perch through research is apparently the prostate RO expert here affiliated with Sloan Kettering but I had considered going to Penn or Mayo.

Tall_Allen
Tall_Allen
in reply to Sunfire

That is incorrect about limited options after failed RT (although it is a common misperception). See the table in this article:

pcnrv.blogspot.com/2017/09/...

But as you suggest, with a 90+% cure rate, salvage is a minor concern.

I'm sorry I don't know any ROs in the Lehigh Valley. The SBRT ROs I know of are mostly in NYC. Alan Katz in Flushing probably has done more than anyone. Michael Zelefsky at MSK has done some really good studies. I don't think UOP or Mayo even offers it. If you can travel, my RO, Chris King at UCLA was the guy who first did it (in 2003).

Sunfire
Sunfire
in reply to Tall_Allen

Thank you! Your information is valued and appreciated. This particular part of my life journey I'd rather have skipped over!

Sunfire
Sunfire
in reply to Tall_Allen

How soon after SBRT monotherapy is it best to test PSA? Had SBRT in Feb and rad onc and urologist said 6 mo in Aug is soon enough. Had G6 1 core and 2 cores 3+4 less than 5% was 4. Prior MRI's were PIRADS1 & 2.

Tall_Allen
Tall_Allen
in reply to Sunfire

You're in it for a long haul. I did every 3 months for the first year, then every 6 months for the next year, and then just once a year. But there's no set pattern. Whatever makes you comfortable.

Sunfire
Sunfire
in reply to Tall_Allen

Thanks I've heard some do shorter intervals others longer. It seems the norm is every 3 and wondered if there was a certain protocol.

Tall_Allen
Tall_Allen
in reply to Sunfire

It's up to the RO. There is a balance between getting more data points and patient anxiety. Although PSA bounces and longer time to nadir are a good sign, that does not ease the mind of the patient. I speak from my own experience.

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