I'm new here, High Decipher Score still good for SBRT

[JDL_Coffee]

Hi, appreciate all the info here. This is my initial post, I'm 64, biopsy in Feb. 2021 shows 5 of 12 cores with PC, 3 with Gleason 6 and 2 with Gleason 7 (3+4). PSA is 5.7, up from 4.6 last year. My Urologist said it looks confined in prostate based on MRI and he considers it intermediate risk. Decipher score of 0.74, high risk.

RO wants to do ST hormone and IMRT. I asked about SBRT and both my Urologist and RO (same Company, IMRT only) said the high risk does not make me a good candidate. Talked to another RO (who offers SBRT, of which he has done a total of 50) and he said I would be a good fit for SBRT (did not mention hormones). Meeting with UCSF next week for consultation, but from what I have researched, SBRT looks to be a good option overall, just not sure since my Decipher score puts me at high risk and seems like SBRT is mostly with low to intermediate risk.

I would appreciate any thoughts and comments about treatment and if performing 50 procedures would make the RO considered experienced enough. Thanks.

[Tall_Allen]

You are still "favorable intermediate risk" Your high Decipher score is an indicator that you can't just watch it with active surveillance. It predicts what will happen if you don't treat (i.e., high likelihood of future metastases.) At your PSA and risk level, ADT is not required. Gottschalk is the UCSF expert at SBRT. Outcomes are excellent for intermediate risk:

prostatecancer.news/2018/10...

[JDL_Coffee in reply to Tall_Allen]

This is very helpful! Thank you Tall_Allen, I learn a lot reading your replies.

[Canuck2020 in reply to Tall_Allen]

I agree with Tall _Allen. I had HDR as monotherapy just recently with similar Gleason Scores but only 2 of 10 cores.

When I asked my RO about SBRT she replied," In general it is only used for men who are not suitable for brachytherapy because they are too unwell to have an anesthetic or their prostate is too big. Proponents of SBRT like to think it is as effective as HDR but we don’t yet have evidence for that and we do know that it doesn’t drive the PSA as low afterwards (a good indicator of cure) and we know that you cannot recreate an HDR-type dose distribution with SBRT".

Not sure if this applies but I'll throw it out there. I understand there have yet to be clinical trials for the two monotherapies.

[Tall_Allen in reply to Canuck2020]

I agree that an RCT is required. I think Canada has one in the works. This is exactly what I went thru when I was trying to decide between them. I think they are both excellent and had a hard time deciding. I met with the biggest RO for each therapy.

HDR-BT drives the nadir down quicker, but they both reach the same nadir eventually. There is some evidence that longer time to nadir may be prognostic for better results.

SBRT proponents argue that the acute side effects are milder. The SBRT hypofractionation is actually based on the success of HDR-BT. However, she is right that the dosimetry is different. With HDR-BT you get hot spots where the catheters are and cold spots between catheters. This is called "heterogeneous planning." With SBRT, the dosimetry tends to be more even throughout - this is called "homogeneous planning." Some SBRT ROs tried to simulate heterogeneous planning. The effectiveness was the same, but the toxicity was a little higher.

The success of either is highly dependent upon the experience and care the RO takes.

[CarverD]

Great information from Tall_Allen. I have a similar case as yours: 3 lesions [a 6, a 7 (3+4), and one unknown GS], favorable intermediate risk, PSA 6.4, age 63, with OncotypeDX results showing my cancer to be on the aggressive side, requiring treatment rather than surveillance. The 5 doctors I consulted with all agreed mono therapy was sufficient to treat my disease and none even mentioned the idea of needing ADT. Have you considered HDR-BT? After much research, contemplation, and prayer, this is the treatment I chose and so far I am very pleased with the outcome. All the best to you on this journey.

[JDL_Coffee in reply to CarverD]

Thank you CarverD for your comments. It's reassuring to hear about the ADT from you and Tall_Allen. I did look at HDR-BT, but I got scared off by a friend who did Proton and when the PC came back, he did HDR-BT and he said it was very painful and had an epidural for three days. I believe the cure rate is slightly better than SBRT, but it looks fairly intrusive. Could you let me know how your procedure was in regards to discomfort, time, and side effects afterwards? Thanks again!

[CarverD in reply to JDL_Coffee]

I'll send you a PM as I have written that up for a few others. My experience sounds radically different than your friends. I know several other guys who had HDR-BT and we are all fans of the procedure.