New to this forum: SBRT or Brachy to minimize chance of ED?

[golfbiker]

I recently entered the realm of unfavorable intermediate risk PCa after nearly 3 years on Active Surveillance. My Medical Oncologist has started me on ADT for 6 months and has recommended external radiation. I'm scheduled to see Dr. Kishan at UCLA on September 14 for a consultation and probable SBRT.

I'm 73 years old, in good physical shape, and still sexually active (at least until the first Lupron shot 3 weeks ago). Reading some of the posts on this forum, I get the feeling that HDR brachytherapy has less chance than SBRT of causing ED, which I would very much like to avoid.. The NCCN Guidelines recommend either EMRT+ADT or EMRT+brachy+ADT, but not just brachy+ADT. Is brachytherapy better than SBRT in terms of ED, and if so, is it less effective alone as treatment than SBRT?

I know that Dr. Kishan is excellent for SBRT, but I also know that there is an excellent RO at UCLA who does HDR brachy. and also another RO at Cedars-sinai who does it.

PSA is 10.84 (first time ever above 10). MRI shows 3 localized lesions that have grown since last year, with two abutting the capsule. Biopsy 2 years ago showed low volume 3+4=7 (although last year all that was found was low volume Gleason 6). OncotypeDX on the older biopsy was 46 (unfavorable). No extraprostatic lesions were seen, and bone scan is clear.

[Adf2529]

With both SBRT and brachy at UCLA your chances are very good to maintain erectile function. I had SBRT at UCLA about a year ago for low/intermediate risk prostate ca (GL 3+4, PSA 7, indistinct tumor). Sex function is fine. I still have urinary irritation but hopeful it will abate in time.

[doc1947g in reply to Adf2529]

How many Rx and did you get ADT

[Adf2529 in reply to doc1947g]

I had five treatments over a 10 day period. I did not get ADT. I was on AS for two years. As soon as my ca reclassified to 3+4 I started researching treatments with the intention of making a decision, within a year. It was a toss up between brachy and SBRT. I chose whole gland therapy. My interest in brachy was for localized, but I wasn’t a great candidate because of the indistinct tumor area. Good luck in your journey!

[Darren1962]

I had brachytherapy and then 6 weeks of Radiation. All is good with ED. However I’m 58 and all results can be different. I’m just glad I did not have my prostate removed.

I still have a good ejaculate about 50% less than it was. My best advice for you is take your time and go on you tube and do the research. You have real patients on there and do not listen to the doctors. My doctor wanted to remove my Prostate because he is a surgeon. I’m glad I didn’t. I lead a very normal and healthy sex life.

[GoMonday]

I was diagnosed with High Risk prostate cancer. Biopsy scores were T2a, GS 4+4=8, 4/12 cores positive for GS 8 disease, 4/12 cores positive for GS7. The rest of the cores were benign. PSA 8. My urologist wanted to remove but I opted for a second opinion and chose brachytherapy. I took my first 6 month shot of Lupron had 70 seeds implanted and 25 daily radiation treatments. I had another 6 month Lupron shot and was scheduled for a third. Original Lupron treatment was for 18 months. My PSA was less than .01 so I did not take the last 6 month shot. For me the Lupron was the worst part of the treatment. I changed my diet from less or no red meat, reduced all milk to almond milk and wild caught fish. My T scores went from 10 to 300 over a year period. Still taking time to get back to my old sex life.

Similar to one of the replies. They also wanted to remove my prostate. Be strong.

[golfbiker]

Thank you all for your responses. I appreciate the help.

I pulled some figures from several blogs by Tall_Allen from a few years ago. He quoted 10 year results for HDRBT with potency preservation of 69-89%, which translates to 11-31% incidence of ED; SBRT had 43% ED. On the other hand, long-term serious urinary and rectal side effects with HDBRT were 10% and 5% respectively, whereas for SBRT they were 2% and 1%, which, if I'm interpreting the figures correctly, gives me pause. Additionally, I'm still not sure if HDR alone is suitable for my risk level.

So I guess I'm still on the fence but leaning toward SBRT. Must do more research and have a discussion with Dr. Kishan when I see him.

[doc1947g]

Update on June 28 2021.

I am 73 y.o. and I am G4+3 Grade group 3.My RO did not recommend the brachy but put me on ADT for 6 months and VMAT hypofractionnated 3Gy X 20 Rx.

After 8 weeks of ADT and 3 weeks post-RO Rx, my PSA went from 20.4 ng/L to 0.18 and my testosterone went from 519 ng/dL to 6. I got my 2nd Lupron Depot 22.5mg/im last Monday/ I am lucky that I have almost no secondary effects.

One of my friend went for bilateral orchiectomy so he did not have to gest more injection but my RO refused telling me that I will just need 6 months (24 weeks) of ADT.

If I need more then we will see.

After 28 weeks of ADT and 38 weeks post VMAT-RT my PSA went down to <0.01 8 μg/L and up to 0.04 μg/L in 3 months . Testosterone down to < 0.2nmol/L - < 5.768ng/dL and up to 6.6nmol/L - 190.2014ng/dL

[golfbiker]

Update: I decided on SBRT at UCLA. Dr. Kishan offered the MIRAGE clinical trial, which aims to compare SBRT with standard in-treatment CT imaging versus SBRT using a machine that does in-treatment MRI, which gives more precise realtime imaging, and in which they set the treatment margin at 2mm instead of 4. I was randomized to the MRI arm of the trial, which is what I hoped for.

This treatment does not require insertion of gold fiducials. I also decided against SpaceOAR because of the increased precision of the imaging, and also because I have some lesions up against the capsule, and I don't want to take the small chance that mini-extensions of the cancer could be protected from radiation. Besides, significant long-term rectal problems occur only about 1% of the time with standard SBRT without SpaceOAR.

Also, planning Cialis during and after SBRT, and upgrading my aerobic exercise regimen.

Thanks to all of you for your support.

[goldenfoot in reply to golfbiker]

Any updates on your procedure? I am scheduled for the same on Jan. 8. I am assuming they will want me to make a decision on the SpaceOAR. I can't do MRI's so will have to just go by a C scan. Perinural Infusion, but not sure if that would make a difference with spaceOAR, Thanks.

[golfbiker in reply to goldenfoot]

I had the five treatments between October 1 and October 14. Each took about 30 minutes, because the MRI guidance was used. I believe the treatments are shorter when using CT guidance. For me, the hardest part was drinking the right amount of fluid before the treatment, in order to have a moderately full bladder, but not be too uncomfortable.

A day after the second treatment, I started to have some fairly severe urinary frequency, urgency, and burning. When I told them about it at the third visit, Dr. Kishan came in and spoke to me and prescribed Motrin for the burning and urgency, and Flomax for the frequency. The symptoms resolved the same day, and have not returned. I have so far had no longterm urinary symptoms, and no rectal symptoms at all.

I'm not sure what I would have decided about SpaceOar if I had been treated with CT guidance and fiducials. As I said before, rectal adverse effects are uncommon, assuming that you are in good hands, which I think I was. You must balance that against possible complications from SpaceOar, which are also uncommon, under the same circumstances.

From your description, I assume that you will be treated by Dr. Kishan at UCLA. Ask him about the considerations for your situation. He's very good about answering questions, in person and online.

[goldenfoot in reply to golfbiker]

Thanks a lot Golfbiker. I am not a gofer but I am a biker. I am going to be treated by Dr. Chang, I couldn't get into the trial that you were in. It is hard to get much info. ahead of time , which is strange. Maybe it is forthcoming soon. I will probably also struggle with the bladder issues as I already have urgency. It is nice to have someone to talk to that has gone through the same procedure. I assume the radiation isn't done by the doctor , but by technicians? I am coming from Idaho, so will have to stay at an expensive place for two weeks apparently. Thanks again.

[golfbiker in reply to goldenfoot]

Best of luck to you. UCLA is a top-rated institution for prostate radiation