Sister's 76 year old husband diagnosed with prostate cancer. He has permanent Afib takes Xarelto & Metoprolol. She has stage 4 BC bedridden in pain. He takes care of her. Seeing urologist. PSA was 43, 2nd one 41. Had MRI. Biopsy 6 cores Gleason 7 4+3. Painful with bleeding from penis for 6 days. Prescribed bicalutamide 50 mgs in Dec and recently believes pain from it. Had abdominal and pelvic CT scans and Nuclear Medicine full body bone body scan. All scans were clear. Dr. wants him to take Eligard injections, but does not want. Do not know if can continue bicalutamide without damage to liver, etc. Advised after surgery would probably need to wear pads for leaking and recommended radiation instead which would probably be 5 days a week for 8 weeks. Supposed to see radiation oncologist this week
PLEASE Give Feedback: Sister's 76 year... - Prostate Cancer N...
PLEASE Give Feedback
I went with radiation to prostate. No problems, no significant SEs. I went to a major cancer center of excellence for the radiation. Make sure you provider uses fiducials (3 gold implants placed in prostate to assist in accurate targeting) and the latest radiation technology.
Since on Xarelto blood thinner worried about implants and bleeding. Can he skip those? Did you do IMRT? How many?
Talk to RO about bleeding due to implants. I not sure but I don’t think I had any bleeding. They put an instrument up your butt and go directly thru your large intestine wall into the prostate. This is probably what they did when you had your biopsy. I know people who had the radiation that did not get the fiducials. Yes, IMRT, 28 sessions, 5/week Monday thru Friday
He can get radiation completed in just 5 treatments, like I did. Importantly, since he is a primary caregiver, it won't cause fatigue and the shortened schedule keeps him away from sources of Covid-19. He should have his pelvic lymph nodes treated and should have Eligard for at least 6 months (it's not permanent). It's called SBRT or CyberKnife. He has to find a specialist in it. Most radiation oncologists do not offer it.
Thanks TA. How can SBRT which is shorter be less dangerous? Seems like more radiation in less time and more toxicity.
Is it covered by Medicare?
Do you have to have anything put in prostate for SBRT and/or IMRT - fiducial markers?? Do not want...
On Xarelto a blood thinner -- worried about bleeding like biopsy.
SBRT stands for stereotactic body radiation therapy. The "stereotactic" part means that INTRA-fractional tracking of the position of the prostate is used. Whereas IMRT just looks at position once per each treatment (INTER-fractional tracking). Position (on both SBRT and IMRT) is tracked using 3 fiducial markers placed into the prostate. The total dose of radiation given with SBRT is about half the radiation given via IMRT (40 Gy vs 80 Gy), but because of a unique property of prostate cancer cells, it is much more biologically effective. Randomized trials have proven it to be no more toxic than IMRT.
prostatecancer.news/2019/02...
prostatecancer.news/2016/12...
It definitely is covered by Medicare.
There is a new linac called Viewray MRIdian that does not require fiducial placement because it continuously tracks position of the prostate via a built-in MRI. UCLA has one that Amar Kishan is using for SBRT. If fiducial placement is a problem, you may want to go there for treatment. Kishan is fantastic!
Thank you TA for input.
Feeling lost & overwhelmed. Is View Ray less toxic and is it in Dallas. Is it covered by Medicare?? Do not want fiducials. Cannot travel.
Yes it is covered by Medicare. Check with UT Southwestern to see if they are getting one or have one. You may want to schedule a second opinion telemedicine appointment with Dr. Kishan.
TA, sorry for so many??
Looked at first report...With PSA in 40's and Gleason 4+3 7, does he qualify for SBRT and or View Ray?
UCLA has a high risk protocol using SBRT. The standard of care is external beam radiation with a brachytherapy boost to the prostate and 18 months of ADT. But with your urinary problems, it may get complicated.
SBRT is not recommended for treatment of pelvic lymph nodes in primary RT. The appropriate therapy is IMRT which in leading centers can be performed in 20 sessions (3Gy per session).
That is incorrect. UCLA is routinely using it to treat pelvic lymph nodes as well as the prostate. They treat the lymph node area in the same 5 sessions with 5 Gy, and the prostate with 8 Gy.
The UCLA protocol is not yet proven. I have just been treated at the Royal Marsden in London. I requested SBRT, but was informed that it was not suitable for lymph node involvement despite the experiments taking place at UCLA.
Well, it depends on what you are willing to accept as "proof." They have treated several hundred patients safely using that protocol. I am aware that at other institutions, some are treating the pelvic lymph nodes with IMRT with an SBRT boost to the prostate, but that seems to just be a patient inconvenience.
The entire concept of simultaneous primary irradiation (using even IMRT) of the pelvic lymph nodes is not "proven" because it hasn't been established yet by a randomized clinical trial. There is one (RTOG 0924), but results are not expected for several years.
clinicaltrials.gov/ct2/show...
Meanwhile, PSMA PET scans are showing occult metastases in the lymph nodes of many such patients like Concern972, so it seems prudent to treat the entire pelvic lymph node area along with the prostate when the PSA is 41.
SBRT is not applicable to locally advanced cancer with LN involvement in the context of Gleason 8-10. There is absolutely no evidence that SBRT would be successful in that cohort and the likelihood is that it would prove to be insufficient. Fyi, my RO is Nick Van As, who is an acknowledged leader in the development of SBRT at RMH London. The issue is not whether the UCLA protocol is safe but whether it is superior to IMRT in terms of OS. Currently, the SOC in the scenario outlined here is prevalent.
You are not looking at the correct diagnosis. The OP has no known LN involvement on a bone scan/CT. He is just high risk, not locally advanced. I think the UK is behind on this. NCCN, which is one of the major organizations that establishes SOC in the US recognizes SBRT for high risk. (NCCN Physicians Guidelines: Principles of Radiation Therapy Table 1 PROS-E 3 of 5).
As you know, a PSMA PET is a much superior means of establishing whether there is any spread beyond the prostate. Your comment regarding SOC and the UK is surprising given that Van As is Chair of the UK SBRT Consortium and is also the chief investigator for the international clinical trial PACE. As I said earlier and as you conceded there is no firm evidence (yet) to support the use of SBRT in high risk scenarios.
My RO, Chris King, was the one who invented SBRT for prostate cancer in 2003. So, Royal Marsden was late to the party. I am aware of the PACE trials at Royal Marsden, which so far show no toxicity disadvantage to SBRT. Other randomized clinical trials in Scandinavia have established that there is no oncological difference. NCCN is one of the organizations that establishes SOC in the US. I trust the UK will one day catch up. It is especially important during the pandemic.
BTW- a blue ribbon RO panel, which included ROs from the UK, had this to say about treatment during the pandemic:
"If treatment is deemed necessary and safe, the shortest fractionation schedule that has evidence of safety and efficacy should be adopted. For localized prostate cancer, 5- to 7-fraction stereotactic body radiation therapy (SBRT)/ultrahypofractionation should be used, which is in accordance with the 2020 National Comprehensive Cancer Network guidelines as an acceptable regimen for intermediate- and high-risk prostate cancer."
advancesradonc.org/article/...
The authors included Ananya Choudhury at the University of Manchester, Ann Henry at the University of Leeds, Isabel Syndikus at The Clatterbridge Cancer Centre, Alison Tree at the Institute of Cancer Research, Sutton. So at least some in the UK are catching up. You may want to share that article with Dr. Van As.
Your first comment is risible given the number of times you've mentioned RMH as a centre of excellence. Your latter comments conflate the use of SBRT and hypo fractionation in different circumstances. I appreciate that you are a cheerleader for SBRT (not surprising given your treatment protocol!) but you really should be cautious about promoting its effectiveness (as opposed to safety) for use in locally advanced/high risk cancers, until the results are unequivocal.
If one is in the UK, RMH is certainly a center of excellence. And Johann de Bono is certainly one of the best oncologists in the world. If I were in the UK, that is certainly where I would go for treatment. I never said otherwise.
You misread the quote. Read it again. It says, "ultrahypofractionated" and it specifically says "high risk." I'm pretty sure that RMH accepts the NCCN definition of high risk.
On SBRT effectiveness, the Scandinavian RCT of its effectiveness that I alluded to says this: "Ultra-hypofractionated radiotherapy is non-inferior to conventionally fractionated radiotherapy for intermediate-to-high risk prostate cancer regarding failure-free survival."
thelancet.com/journals/lanc...
Can the data be more clear?
The Swedish study you refer to excluded patients with LN involvement. For those with LN involvement, SBRT is not suitable.
I have no idea why you are bringing up LN involvement. The OP does not have LN involvement. As I said to you before, he is "high risk," which means the cancer is localized. You are talking about a different diagnosis than the one under discussion.
73 y.o. with Lymphoma LNH and many Acute Chronic Diseases.
I am in the Ufavorable Intermediate Risk with a G(4+3=7) Grade 3.
My PSA went from 6.76µg/L to 22.4µg/L in 6 weeks.
Prostate went from 24.7cc to 45.86cc.
I had 6 cores out of 12 positive on the right side at 85% G4, then on a Special pre-RT Scan they found multiple tumors on both sides.
I got and injection of Eligard 45mg/24weeks on April 4th 2020 that was screw-up.
So I have been on Lupron Depot 22.5mg/12weeks X 2 from May 2020 to Nov 2020 and on
VMAT-RT 3Gy X 20Fx on 139.57cc in June 2020 and my
PSA = 0.01µg/L and my
Testosterone = 0.3nmol/L or 0.086526µg/L or 86.526ng/L or 8.6526 ng/dL
On Dec 15th 2020.
Next tests on March 1st 2021.
The OP has not (to my knowledge) had a PSMA Choline or Ga-68 scan which may well reveal LN or other metastases not visible in the CT. As you pointed out above: "Meanwhile, PSMA PET scans are showing occult metastases in the lymph nodes of many such patients like Concern972, so it seems prudent to treat the entire pelvic lymph node area along with the prostate when the PSA is 41". If, in the outcome, there are occult mets, then IMRT is the appropriate SOC, not SBRT.
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