Salvage focal HD brachytherapy

[billy1950]

Had radiation in 2004-2005 and now have localized recurrence.

Interested if anyone has done salvage focal HD brachytherapy after previously been treated with EBRT.

Thanks…

[AlanMeyer Moderator]

Apparently this has been tried. See for example: pubmed.ncbi.nlm.nih.gov/288... It looks like it had some success. See also the information posted below the abstract. There are other articles about this, a published review, and 14 citations of the article.

Is this something that a radiation oncologist has proposed to you?

Alan

[billy1950 in reply to AlanMeyer]

Yes, MSK is recommending this treatment…I am interested in hearing experiences of others…I am concerned about GU toxicities…The below article outlines both GU and GI toxicities..it’s a study out of the Netherlands…Determining the safety of ultrafocal salvage high-dose-rate brachytherapy for radiorecurrent prostate cancer: A toxicity assessment of 150 patients.

I think the title has to be put in a browser in order to read it…

[AlanMeyer Moderator in reply to billy1950]

Here's a direct link to your article that, I hope, will work: sciencedirect.com/science/a...

It looks like MSK has been using this technique for many years. The article I cited, published in 2017, was authored by seven MSK physician/scientists, including a statistician and a "medical physicist". Obviously, MSK has extensive experience with HDR salvage therapy.

I do have experience with HDR brachtherapy, augmented with Lupron and with external beam therapy - though it was for primary treatment, not for salvage. I think the most direct adverse effect that I experienced was swelling of the tissue around the urethra, which clamped it shut and made it hard to urinate. At the beginning I needed two tamsulosin (Flomax) every day and still needed to pee about once per hour, a minor annoyance during the day, a bigger annoyance at night. That declined over a period of about five months, after which I was off the tamsulosin and was able to go several hours between bathroom visits. I also experienced a gradual loss of potency which I think may have been more due to the external beam radiation than to the HDR.

Here's what I suggest:

1. Try to figure out what your goals are. What odds are you looking for in treatment success and what would side effects would you tolerate to achieve those odds. I know that figuring that out is impossible, but you may be able to get some ideas about your balance of outcomes to help you make a decision.

2. Get an appointment with the radiation oncologist and go through the issues with him.

2.1. Where are the tumor sites that he or she will target? How close are they to the most sensitive places in terms of causing adverse effects?

2.2. How does the siting of the tumors affect your odds of adverse effects? Will your odds of side effects be more, less, or about the same as the averages from MSK's previous treatments?

2.3. Have there been any improvements in imaging or treatment techniques since they did their last studies?

2.4. What are your odds of a cure. What are the outcomes in previous experience and do your particular odds look better, worse, or about the same?

2.5. What are the worst outcomes MSK has seen? What happened to the patients who experienced them? What are the best? How likely are each of these extreme cases?

3. What are your best alternatives to this treatment? And why does the oncologist recommend the HDR instead of those alternatives?

I don't think you'll be able to make a mathematically precise conclusion about all of your odds, but maybe you'll be able to make a more informed gut level decision about what to do. You might be unlucky and get bad side effects and no benefit, but at least you'll know that you made the most logical decision you could make with the best information you could get

I wish you the best.

Alan

[billy1950 in reply to AlanMeyer]

Alan,Thanks for your response…

It’s your comment in 3 that i am most concerned with in having possibly some bad side effects. I may have to live with them for awhile. GU grade 2 and 3 seem to be somewhat common with both LDR as well as HD BT. However, MSK will do focal salvage HD brachytherapy which claims to have lower toxicity…Using Catheters indefinitely is a scary proposition…Possibly having a permanent one would be possible. Don’t know…

However, i don’t know if any salvage treatment after radiation is going to promise anything better…All of them, Cryoablation, HIFU, SBRT all seem to have some possible bad side effects. It is also surprising in a way that there have been no responses to this post except for yours. Has no one experienced salvage brachytherapy???

[AlanMeyer Moderator in reply to billy1950]

Hello Billy,

Sorry I didn't respond earlier, I was off the group for a few days (and may be again for some time.)

In the past, salvage radiotherapy for prior radiotherapy was considered inadvisable. When I was treated in 2003-4, the mantra was that, if you got surgery, you could get salvage radiation. If you got radiation there were no safe salvage procedures, neither surgical nor radiological. My understanding was that radiation did enough damage to the prostate and surrounding tissue that further radiation was likely to do as much or more damage as good. The state of the art has advanced since then but I bet there are still many doctors and patients who shy away from salvage radiation after primary radiation. That may be why you're not getting any responses. It's something to ask the MSK specialists about.

I think your concerns are on target. All of the treatments have potentially serious side effects. Ask about how many patients at MSK have had to engage in long term catheterization.

If it were me, and I thought the odds of a cure were good (75%? 50%? 25% - I really don't know what constitutes "good") and the risk of long term catheterization was low (1%? 5? 10% - don't know that either), and I weren't too old (<60? <70? <80 - same issue) and if I had confidence in the radiation oncologist, I think I'd go for the hoped for cure and take my chances. Long term prostate cancer is no fun either though it seems to be getting a little less dangerous every year.

I always ask my doctors, What would you do in my situation? But the question is not easy for them to answer either and, like us, they hate the idea of telling someone to try something and then finding out that the treatment failed.

The only thing I can say for sure is that you are considering all the right questions and, whatever decision you make and however it turns out, you'll have no reason to beat yourself up afterwards for making that decision. The opposite decision might have turned out just as bad or worse, and either alternative might have been good or bad.

I think if it turned out for me that I got stuck with long term catheterization I'd twist my head around, determine that life is more important than catheter annoyances and, from now on, I'd force my attitude to make them into annoyances and not horrors.

I know that this is not much help, but I want you at least to know that there are people out there rooting for you.

Alan

[billy1950 in reply to AlanMeyer]

Hi Alan,

I had a long conversation yesterday with the care team at MSK. Dr. Zelefsky talked some about the possibility of rectal damage.

Wondering if you know of anyone who had some rectal damage and needed a colostomy…I know they use the gel (SpaceOar) to protect the rectum. I am also asking them to do focal brachytherapy since it can be targeted to the tumor. There is only cancer on one side of the prostate…

Would appreciate any feedback…

Thanks,

Billy

[AlanMeyer Moderator in reply to billy1950]

I've heard of colostomies but don't know anyone who has had one. However, if you're trying to find out what they are like you can search HealthUnlocked and find a lot of postings, though I don't think any are for prostate cancer. Searching Google for (colostomy experience) or (colostomy prostate cancer), will get lots of hits. Some may be relevant for you.

Did Dr. Zelefsky offer his opinion on what you should do, or on what he would do if it were him? He'll know a hell of a lot more than I do.

On the issue of focal vs. whole gland, I think it's commonly believed by specialists in prostate cancer treatment that whole gland treatment is more likely to work. There are just too many cases where the amount of cancer in some areas is too small to show up in biopsies or scans, but still enough to grow and become a problem some day. However, like everything else in prostate cancer, the best you can do is play the odds and hope for the best. Maybe focal will work. Maybe it won't. Maybe whole gland will do more harm than good. Maybe it won't. I think we must do our best to get all the odds ratios and expert advice, then go with what our guts as well as our brains tell us to do.

Best of luck.

Alan

[billy1950 in reply to AlanMeyer]

Hi Alan,

Dr. Zelefsky’s team is recommending the treatment plan. He gave me the impression that the decision was made by both him and some of their physicists. That is, the BT with HT…

I am also looking into salvage Tulsa Pro…Have you known anyone having salvage Pro after radiation.

Thanks,

Bill

[AlanMeyer Moderator in reply to billy1950]

I don't know anyone who has had the Tulsa Pro procedure. I have known men who had HIFU a decade or more ago. At that time, if I remember correctly, clinical trials indicated that HIFU was not as effective as radiation and wasn't superior in regard to side effects. However all experimental treatments tend to be less effective than the standard ones but, if they are good enough to continue working on them, they do get better.

Personally, I hate the fact that there are so many treatments, each pushed by a different group of practitioners in competition with each other. The equipment and training for each different technique - robotic surgery, HDR brachytherapy, HIFU, proton beam, etc., - is expensive and the doctors and investors that lay out the money for it must then recoup their costs by convincing men to buy the treatment. I think that, in more than a few cases, men are persuaded to try some new treatment even when there is no reason to believe it is safer or more effective for them than other treatments.

Again, personally, I'm attracted to MSK because they are a leading institution with a very high reputation for knowledge and competence. But I don't know the doctors there and don't know the docs offering Tulsa Pro. You may have personal impressions of both groups that can help you make a decision.

Good luck.

Alan

[billy1950]

Hi Allen,

There are more questions about Salvage HD brachytherapy? I have been reading about guys having radiation proctitis as well as radiation cystitis. Both sound difficult to treat. The closest place that has hyperbaric oxygen is about 50 miles from me. Do you have any thoughts on these two conditions?

Thanks, Bill

[Jordache in reply to billy1950]

Hey sorry to hear that you are dealing with this however I also was a Gleason 8 got Brachytherapy and external beam therapy along with a DT. I too am a patient of Dr. Zelesfki and so far so good after a year my numbers are still declining and I’ve had no complications pretty much with the exception of a erection problems. All I can say is with Zelesfki you’re in great hands.

[billy1950 in reply to Jordache]

Thanks for responding!

I originally had EBRT with no side effects when i was 54…Now 71… I have confidence in Dr. Zelefsky. However, i know that radiation proctitis and cystitis are real possibilities. I don’t know if they would be more so after salvage…Doesn’t sound like yours was salvage treatment…

[Jordache in reply to billy1950]

Yes mine Wasn’t salvage radiation however with technology they’ve come along way with the accuracy. Maybe that’s a question you should ask Dr. Zelesfki as in what percentage of patients have experienced that type of trouble. With today’s technology versus years ago.

[billy1950]

Jor,I talked with Dr. Zelefsky and he assures me that percentages are low with toxicities. Will check again with MSK about these specific ones.

Good to hear that things are going well with you!

Are you having any side effects to the ADT? I have had one shot of firmagon next one at end of October…

Bill

[Jordache in reply to billy1950]

The side effects I’m having from the ADT generally are hot flashes from time to time all during the day and during the night the only last a couple of minutes one minute you’re cold one minute you’re sweating the other side effect I have is a sexual side effect with loss of erections and desire but you know I don’t mind the side effects for the next 18 months if I only have to deal with this once I will follow Zaleski‘s protocol all the way through another side effect that I have also is brain fog which you know you find that you often cannot remember names you know or dates but I think once my testosterone is replaced after the treatment that should clear up also but it’s definitely things that are tolerable

[billy1950]

Sounds bearable! Nothing yet after 1 shot, Next one at end of October… will see!

[LoveyDovey in reply to billy1950]

Hi Billy1950,

I had the HDR Brachytherapy in March 2019 and 25 sessions of LDR at MSK. My oncologist is Dr. Daniel Gorovets and he is excellent. So far my PSA has been at around 1.2 since then. It's the best decision I have made regarding HDR Brachytherapy. So, life is great for me. Good luck to you in what course of treatment you take.

DanS

[billy1950]

DanS, Thanks!

My procedure is salvage. I had EBRT in 2004-2005 and i experienced only fatigue around 5th week. Now at 71, this is a recurrence. My salvage treatment will be HD brachytherapy. Did you have any radiation proctitis or radition cystitis? I understand that they sometimes happen after any kind of radiation. I had neither with EBRT.

I hear that Dr. Zelefsky at MSK is “tops”…

Is your PSA the nadir? or has it gone up?

Bill

[billy1950]

Hi DanS,

I decided to wait at least 6 months and be on ADT before deciding to go with the salvage brachytherapy…It was a toss up to either have it now or to wait to see what happens after being on hormone therapy for 6 months.

Bill