SBRT for favourable intermediate - interested to hear your experience

[45RPM]

hi there, interested to hear from the intermediate favourable men who had SBRT for primary treatment who are within the same clinical range as me. How did it go, what about the side effects, did you also do or consider adjunct treatment, why did you choose SBRT over RP?

I am 59, T2c, G3+3, 3T-MRI no EPE, nothing visible yet in lymph or seminal, correlates to biopsy. 23cc gland. PSA 0.7. No prostate-related hereditary mutations detected from genetic testing. Decipher 0.4, low risk.

factors - perineural invasion, PSA <1.0.

Interested also to hear opinions on the following (sorry for so many questions):

Wonder if i am a suitable candidate for SBRT. Maybe because of PNI and PSA it is better to get RP to know for sure the aggressiveness and extent and PSA expression problem?

Is it best to radiate prostate bed now along with lymphs and seminals given complications?

What are the chances that some cancer is missed vs gold standard of RP? in this case, if i want to get aggressive now and SE be damned, is RP better for my situation?

What did you do for recurrence? Is maybe a better strategy to radiate the prostate bed, etc now instead of waiting given my complicating factors and material chance of up staging?

Thank you gentlemen for any experience and thoughts around this.

As always, 45rpm.

[Tall_Allen]

Most of your questions can be answered by an RO who specializes in SBRT. Here are questions to ask.

prostatecancer.news/2017/12...

I had it for low risk and know many men who've had it for intermediate risk.

•No lasting side effects of treatment 10 years ago, other than dry orgasms. Had the typical urinary frequency/urgency for a couple of weeks. I now pee better than ever.

• No adjuvant treatment. I took daily low dose Cialis for about 6 months to protect erectile function. I don't know if it was necessary, butI have ne ED

•Chose it over RP because I didn't want to risk ED and the stats for SBRT are much better. I also didn't want to risk any incontinence. I didn't need to see a pathology report. Here are questions to ask yourself:

prostatecancer.news/2017/12...

• "Wonder if i am a suitable candidate for SBRT. Maybe because of PNI and PSA it is better to get RP to know for sure the aggressiveness and extent and PSA expression problem?" A biopsy and Decipher can tell you how aggressive it is. I don't follow how RP helps with your low PSA issue. That remains a monitoring issue for you no matter what treatment you use.

•"Is it best to radiate prostate bed now along with lymphs and seminals given complications?" No - you can always get them later if needed. Radiation always treats a margin around the prostate.

• "What are the chances that some cancer is missed vs gold standard of RP? in this case, if i want to get aggressive now and SE be damned, is RP better for my situation?" RP is not the "gold standard" except in the imagination of some urologists. It is not more aggressive. RT treats outside of the prostate, whereas RP treats the capsule only, For your type of PC, results are the same.

• "What did you do for recurrence? Is maybe a better strategy to radiate the prostate bed, etc now instead of waiting given my complicating factors and material chance of up staging?" For recurrence after SBRT, if it is in the prostate, focal brachytherapy can be used. There is very low (2%) local recurrence rate with SBRT. If it is regional (like pelvic LNs), salvage radiation can be used. RT already treats the "prostate bed"- you are confusing it with the salvage radiation of the prostate bed because RP alone doesn't treat there.

[mperloe in reply to Tall_Allen]

Tall_Allen, Thanks for sharing this information response. Can you point to a source that compares and congrats the myriad of types of RT and what differentiates them?

I heard that robotic RP may not be as effective as open surgery. One experienced robotic surgeon reported microscopic disease at the margins. Is there info on the percent of RP patients who go on to require adjuvant RT due to microscopic cells, nodes or PET scan results?

[Tall_Allen in reply to mperloe]

There are quite a few comparisons of hypofractionated RT with conventional freactionation, if that is what you mean. ASTRO did a good job of summarizing them:

prostatecancer.news/2018/10...

There are also randomized comparative trials for SBRT:

prostatecancer.news/2018/04...

prostatecancer.news/2016/09...

prostatecancer.news/2019/02...

prostatecancer.news/2016/12...

There are quite a few comparative studies of brachy boost therapy in unfavorable risk patients.

The NCCN risk stratification system is based on recurrence rates after RP using Gleason score, cancer volume, PSA, and stage as risk factors. They have not yet incorporated genomics and PET scans into their system, although they endorse them. The MSK nomogram is probably the largest database using those risk factors to predict recurrence:

mskcc.org/nomograms/prostat...

[mperloe in reply to Tall_Allen]

Thank for offering the doubt of good information. I've got my reading cut out for me.

[maley2711 in reply to Tall_Allen]

Allen - Just taking another look at this post and replies. Somewhere else, I read a man's explanation for choosing 40 day standard IMRT. His RO argued that the enemy of optimal radiation results is ANY movement. The argument was that with standard IMRT, damage from movement can be minimized compared to any hypofractionation. Did your RO mention this....or perhaps some ROs are just more aware of reduced compensation for fewer days of treatment? Do comparative studies show zero SE benefit of standard IMRT compared to any type of hypofractionation.......I know I can do the research, but.......you probably have already done it in making your decision previously.

[Tall_Allen in reply to maley2711]

His RO is either ignorant of SBRT or is misleading him to make more money.

Prostate/organ movement during SBRT is certainly a concern, which is why, from the time it was first used for PC in 2003, the linacs have tracked intra-fractional motion (prostate position throughout each treatment), while IMRT only tracks inter-fractional motion (prostate position between treatments). (A full bladder and no bowel distension are important to prevent motion either way). The linac automatically stops and realigns if the fiducials do not perfectly line up with the position in the plan.

But that is all theoretical, and there is actual clinical data comparing SBRT to conventionally fractionated IMRT on toxicity. There is no difference.

prostatecancer.news/2019/02...

In fact, SBRT seems to outperform moderate hypofractionation. This article explains why:

prostatecancer.news/2016/12...

[maley2711 in reply to Tall_Allen]

Thanks Allen.....I'm not informed re the actual differenc in the equipment for the different types of radiation...guess i should be . So one reason that some outfits wouldn't offer SBRT is the extra equipment investment?

Like you said, I do look at the comparative studies....so as you can see, wondered about that Doc's claim. Evidently that Doc claimed that both methods will be subject to second to second adjustments...and that even a split second mistake of higher dose will cause more damage than split second error with lower dose. Your are saying that I either misinterpreted what I read about the other Doc's claims.....or the Doc is actually ignorant re SBRT?

I did think I've seen a couple of studies showing a very slight SE advantage for conventional....but maybe poor memory? Ah, but actually slightly better long-term "cure" numbers for SBRT?

[Tall_Allen in reply to maley2711]

CyberKnife (robotic step-and-shoot) and VMAT (arc) have both been used for SBRT. I was treated on VMAT. CyberKnife could theoretically be used for IMRT but would take too long per treatment. VMAT could be used for either, but uses intra-fractional tracking when used for SBRT. As you read in one of those links, there are other differences in how the same machine would be used. Precise contouring and smaller margins are used with SBRT.

ROs have a financial incentive to hang onto the 40-44 treatment regimen - they are reimbursed by the number of treatments, so they make a LOT more from IMRT vs SBRT.

I am very aware of the randomized comparative studies, and my links include all there is.

[maley2711 in reply to Tall_Allen]

Thanks Allen for the info comparing VMAT and cyberknife.....so I think several radiology centers here may have VMAT..not sure about Cyberknife...perhaps an unneeded duplicative expense? are you convinced that either is the superior? yes, thanks for those links!!!!! I probably have then scattered here and there in my bookmarks!

Those links would probably be great as the basis for an informational post so-titled?

[Tall_Allen in reply to maley2711]

No, neither is clearly superior. They have advantagees and disadvantages but they are minor as far as the patient is concerned. There is another kind MRIdian made by Viewray (non-fiducial-based) that is in a randomized clinical trial at UCLA, but I doubt that either is a clear winner.

[Tire2222 in reply to Tall_Allen]

So is there any reason to have an RP these days? For any stage of cancer? For any age of the man being treated? Are there no long term side effects of SBRT? Seems the surgery needs to go away immediately.

[Tall_Allen in reply to Tire2222]

I think the biggest advantages of prostatectomy are:

(1) You get a pathology report telling you exactly what was in there

(2) If it worked as hoped, PSA falls immediately to undetectable and stays there

Both can provide a lot of confidence if results are as hoped for.

For me personally, I didn't care about the details of what was in my prostate and I was patient enough to wait for PSA to reach nadir without getting anxious (thanks to practicing mindfulness). Risk of ED and incontinence with surgery was a non-starter for me. Other men may not care as much.

Here are the comparative long-term side effects of surgery, EBRT and "active monitoring":

prostatecancer.news/2020/02...

The 10-year physician and patient-reported outcomes of SBRT are here:

prostatecancer.news/2017/09...

[Tire2222 in reply to Tall_Allen]

Thank you very much

[45RPM in reply to Tall_Allen]

Thanks T_A as always, super helpful and much appreciated. My thinking on radiating LN and SV as adjunct to primary gland treatment is to zap potential microcancer since there seems a material chance it is there now (i understand from pathology of RP patients), and since PSA may not indicate for me it may be safer bet at this point for long term outcome?

Also do you know of any other ways i can monitor to be sure cancer is not recurring if PSA doesn't express as normal? Anything that is on the horizon?

[Tall_Allen in reply to 45RPM]

They are always looking for new biomarkers of progression, and in LN-only spread, it is especially challenging. But with GS 3+4, with only 2% pattern 4, I think the risk is a lot lower than if there were any pattern 5 or predoninant pattern 4 (you got a second opinion from Epstein, right?). I think pelvic LN treatment sounds like overtreatment. What does your RO think?

[45RPM in reply to Tall_Allen]

Talking to my RO next week, will ask. yes had two additional opinions on the biopsy and they both were 3+3 but they upgraded volume. what nags me into thinking i should go harder at this is the volume of cancer (40->50%), the PNI, and that the 12-core biopsy is likely to under estimate what i really have, although the MRI seemed to corroborate fairly well (at least i think it did and that's what Drs told me).

[Tall_Allen in reply to 45RPM]

The mpMRI is pretty good at finding what significant cancer there is, so that should give you some peace of mind. You wrote that your Gleason score was GS 3+4 (grade group 2). Is that an error? Epstein is the gold standard for reading biopsies, I wouldn't bother with anyyone else. Volume of GS6 is not a major risk factor for recurrence. PNI on biopsy is a minor risk factor.

[45RPM in reply to Tall_Allen]

Thats good to know, i put the details of my MRI in my bio now

The 3+4 was the first read at my local Dr as i have detailed in my bio.

[Tall_Allen in reply to 45RPM]

That's why I only suggest Epstein. What he says is definitive.

[45RPM in reply to Tall_Allen]

Hey TA a few follow up questions for you - so on the Decipher report it showed 0.41 (high end of) low risk score, 20% chance of high grade.

Does mpMRI results in my bio (PR -3 for the lesion area, else PR-1/2) tell me anything (like reduce maybe) this 20% chance of high grade? Or we can't draw anything.

On another note - you mention you only had acute side effects for a few weeks? That sounds not so bad (or is it really horrible two weeks)... is there any info on how this varies across men - can it go on for months in some?

Thank you - i think i am finally converging now after gathering info, and you've really helped me, can't thank you enough.

[Tall_Allen in reply to 45RPM]

mpMRI only tells where and what to biopsy - nothing more. Good result from Decipher - tilting you toward treatment as opposed to AS.

Side effects are worse in men who have pre-existing urinary symptoms. My acute symptoms were typical - very few men have symptoms that are serious (grade 3) or long lasting. I just took naproxen and Rapaflo for a couple of weeks. I did have a return of urinary symptoms a year later (which happens in about 10%) that I treated with Rapaflo until it resolved.

[45RPM in reply to Tall_Allen]

If a biopsy sample is Gleason 3, could Decipher show high risk of metastisizing? Thought the whole idea is that is we already know GS3 is known already to be low risk of metastisizing.

[Tall_Allen in reply to 45RPM]

Decipher looks for genomic traits that are associated with risk of future metastasis. It is can sometimes be independent of other risk factors (GS, PSA and stage). That's why it's used by men who are unsure if they should stick with active surveillance. Remember that biopsies can only sample what's there, and may miss some higher grade cancer. GS 6 progresses slowly if it ever progresses at all.

prostatecancer.news/2017/11...

[45RPM in reply to Tall_Allen]

when did you start cilias TA, relative to RT start?

[Tall_Allen in reply to 45RPM]

The first day of RT

[cybertreated2019]

I choose SBRT for favorable intermediate PC confined to the gland. More detail in my profile. Treatment completed in Feb 2019. I read everything I could in the six months between diagnosis and treatment. I can’t site the studies TA can but it was clear to me that SBRT had more than ten years of solid data showing comparable results to RP with far fewer side effects. I am 63 and still believe it is the best choice. Two urologists told me I was making a terrible mistake declining surgery. The Rad Onc was the only honest provider about benefits and risks of SBRT and other options including active surveillance. My only regrets are not getting a genetic test of the biopsy tissue nor seeking advice of an integrative MD before treatment to better prepare my body. Run from anyone pushing for a quick decision or unsupportive of a second opinion.

[45RPM in reply to cybertreated2019]

Thank you so much ct2019, this is very helpful perspective. What do you mean, 'better prepare my body'....? What would you have done ?

[cybertreated2019 in reply to 45RPM]

Since treatment I have read about what I can eat and take to ward off recurrence. No sugar, mostly plant based diet and supplements like resveratral, curcumin and green tea that are supposed to boost your immune system. Lots of others. Many take a dim view of supplements but I don’t. I recently read a book called “ life over cancer” by an integrated medicine md in Chicago and wish I would consulted with him or someone like him after I was diagnosed and before treatment. No Md I had offered any advice on diet or meds. Lots of info out there and good forums but the lifestyle ones are just as important as the medical ones and you are mostly on your own about what you can and will do.. I also took Cialys for a month before and a couple months after. No reason not to. I used the lowest dose and it worked well. Sort of hated to see it go away. I also started taking Metformin as a prophylactic. Pretty good studies on it and cancer. Happy to share more but don’t want to overload you.

[45RPM in reply to cybertreated2019]

would definitely like to hear more, will message you on this if you don't mind

[cybertreated2019 in reply to 45RPM]

Happy to reply

[45RPM in reply to cybertreated2019]

Cyber how were your side effects after the treatment?

[ODave]

I’m meeting with UCSF in the next week to set up treatment. RP has been suggested by a few surgeons and my urologist but I’ve been doing lots of research these last months and surgery just doesn’t sound like it will get it. I’ll post what the RO says this week and which route I go. Also I’m 3+4 high percentages one side of prostate and it’s up against the capsule. Radiation seems logical to hit the margins.

[cybertreated2019]

I had some bowel issues of increased frequency and urgency which is not typical. I had the SpaceOar but there was apparently a gap in its placement. Has not completely resolved. I do not have accidents just Need to poop more often than before treatment. It Burned when I peed for a couple weeks. No blood. First ejaculate after treatment was intense and painful but mostly resolved in a few weeks. I still have some ejaculate but it is reduced and is supposed to be dry within a couple years. That will be weird. I dropped Cialys after a couple months because it was leaving a bad metallic taste all the time. Otherwise I would have gone a couple more months. Sexual side effect was largely limited to the buzz kill that PC is.

SBRT was not a free pass but the Radonc was honest about what to expect. He was wrong on the protection the Space Oar was to provide. My PSA peaked around 6 befor treatment and was down to 2.0 at one year. It will take two years or so for it to reach a Nader and will monitor from there.

[j-o-h-n]

Tall_Allen is a fucking whiz..................

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 07/03/2020 6:00 PM DST