Brachy boost vs. monotherapy

[NYC_talker]

Hi all,

Been reading for a few weeks, and let me start by saying: Thanks!

My situation: Active, athletic 60-year-old. Had biopsy 9/21 after PSA went up to 5.74 (8/21) from 5.3 (2/21). GS 3+4

4 of 12 cores positive, all on left side, peripheral zone.

2 are GS 6 (90% and 8%) and 2 are GS 3+4=7 (30% and 67%)

Bone scan clear, and so is CT scan.

I knew a fair amount about treatment because of my occupation. I knew surgery wasn't for me.

My urologist was very even-handed, talked about equal outcomes from RT and RP for people like me, and side effects; if anything, I could see he leaned away from surgery (at least, for me), which is the opposite of what I hear in the group here.

I wanted to pursue AS if possible, mostly because I wanted time to think this through, but knew treatment was probably inevitable. My urologist said that AS "isn't inappropriate" for me and was a "fair" decision. But I could tell he thought he'd probably be recommending treatment after my next PSA test in 3 months.

I went to MSKCC, met with an RO.

MSK analyzed bone scan and CT scan, which conformed with the original lab analysis.

Pathology at MSK is still analyzing biopsy slides; should have their analysis this week.

My RO said, based on the original biopsy analysis (but pending MSK's, which could change his advice), he advises against AS and recommends HDR brachy followed a month later by 5 sessions of SBRT. (Not a rush, he said, and could wait a couple of months, at least until after the holidays). This was a similar treatment combo that a couple of men I know had followed and I've seen it is a treatment combo among some here.

My urologist, having now consulted with my RO, completely supports the RO's plan.

I then had an MRI at MSK: PIRADS 4, high; 1 lesion, 1 cm; Prostate size: 4.6 x 3.1 x 4.0 cm; Prostate volume 29.7; No ECE. No seminal vesicle invasion.

I will meet with my RO next week, after the MSK analysis of the slides is complete and after he's reviewed the MRI, which appears to conform with the biopsy and other tests.

I have noticed that, among those I've connected with as well as men in this forum, there are a fair number in the 3+4 world getting brachy boost. But there are also a fair number doing monotherapy, mostly SBRT. I know the devil is in the details, re: what separates us in the 3+4 world.

Like everyone, I want to make the right decision for myself. The best curative option is important to me, but so is QOL. Mostly, I want to get treatment past me and get back out into my active life, hoping for few long-term issues and not having recurrence. I know -- everyone's dream here. Any opinions welcome. Thanks.

[climb4blue]

NCCN guidelines, a centers of excellence consortium, prescribes monotherapy for favorable intermediate risk patients.

What I notice is that you have been given bone scans which doesn't make sense given your risk category. BBT + SBRT doesn't make sense either for favorable intermediate risk patients.

I suspect something may be unobvious in your pathology report that puts you in a higher risk category.

[Tall_Allen]

You have, what is called "favorable intermediate risk PCa." HDR brachy+SBRT is brachy BOOST therapy which seems like overkill for your diagnosis. It often causes fairly high amounts of late term serious urinary side effects.

HDR brachy monotherapy OR SBRT monotherapy is really all you need.

prostatecancer.news/2018/10...

[NYC_talker in reply to Tall_Allen]

Thank you Tall_Allen. I'm going to get some clarification on this when I speak with him and appreciate your response. From what I've seen in your comments you'd recommend SBRT as the monotherapy if one had a choice between the two, regarding late term side effects, correct?

[Tall_Allen in reply to NYC_talker]

I am largely indifferent between SBRT and HDR brachy as monotherapies. In fact, those are exactly the choices I came down to in the end. I had the choice of perhaps the two greatest pioneers in each. SBRT is radiobiologically nearly identical to HDR brachy - it was designed to be the external beam version of it. The side effects are identical too. In the end, I decided on SBRT because it was easier to lay down on a bench for 10 minutes five times than to have 2 days of anesthesia in the hospital. Also, the co-pays were less. But I would have been happy with either. At MSK, there are some great specialists in either.

[NYC_talker in reply to Tall_Allen]

Hi Tall,

It turns out that, after seeing the MRI (which my RO had not seen before the first visit), and the MSK pathology report of the slides, my RO is indeed advising monotherapy -- brachy or SBRT. But rather than HDR, he's recommending LDR if I choose brachy. The tumor is small, and the prostate is small, so I'm a good candidate. And he said it's one and done vs. two treatments for HDR.

I frankly think another reason for the change after the first visit (and I've seen with others here) is that at MSK the team of ROs doing prostate take a look each others; patients and advise. So I'm thinking Zelefsky likely advised as well. I've connected with someone who in fact has a similar profile to mine and just finished LDR with Zelefsky. I've not seen your thoughts on LDR v. HDR and wondered what you thought.

My RO, Shasha, has done thousands of LDR and HDR treatments and SBRT. Interestingly, he's not a huge promoter of spaceoar, particularly for LDR, though he's happy to do it. He said that the way he does LDR he's not concerned about the issue and doesn't think it's necessary. Though again, he's happy to do it. I bring this up because it resonated with something you'd said about both the necessity of spaceoar and the skill of the RO,

[Tall_Allen in reply to NYC_talker]

If you have a master, like Zelefsky, doing LDR brachy, I think it's every bit as good as SBRT or HDR brachytherapy, as long as the risk of extracapsular extension is low. They are all excellent choices in his hands. Just make sure that there will be a confirmational CT scan within 30 days.

As you know I'm not a big fan of SpaceOAR. It is oversold to patients and often given by doctors who make some extra money by injecting the gel. But like any invasive procedure, there are risks attached to it, and it is very expensive (even if covered).

[NYC_talker in reply to Tall_Allen]

Thanks, Allen. You're always a great resource. Appreciate it.

[timotur]

Congrats on catching this early. I was 3+4 , but was Stage 3b before I caught it with +LN and +SV, and had HDR-Brachy/IMRT/18mosADT. Since you have no ECE or SV involvement, one option would be mono-HDR-Brachy with no ADT, or possibly for 6-months. At a PSA of around 5, you should be ok with no ADT most likely. You may think about a PSMA scan to see if there's any LN involvement, but there's probably not a case for it with negative ECE.

[NYC_talker in reply to timotur]

Thanks Tim -- turns out that, yes, he's now advising mono (no ADT, all inside the capsule small tumor). And he leans more toward LDR than HDR if I go with brachy.

[ADTMan]

The brachytherapy treatment at MSK is an afternoon procedure done once. There is no discomfort and the only side effect I had was from the anesthesia. I think what MSK is doing is instead of doing brachytherapy twice, it is done once and the remainder of the necessary radiation is SBRT. Because I was a higher grade, I had 25 IMRT treatments and am on ADT for 2 years. I think the only side effect you may have is increased urination at night. You don't want this coming back. I would follow my doctors advice.

[NYC_talker in reply to ADTMan]

Thanks. And glad my doc downgraded the treatment to mono therapy. But I would do whatever is best coming from a doctor I trust.

[cesces]

"HDR brachy followed a month later by 5 sessions of SBRT. "

Sounds reasonable to me

[cybertreated2019]

You have done the right work to consider your options. My numbers were similar to yours almost four years ago at age 62. Diagnosis of favorable intermediate PC. Spent nearly a year looking at options. I had 5 sessions of SBRT over 10 days in Jan 2019. SE during treatment were urinary and bowel urgency but quickly passed. It was a good choice so far. PSA still dropping, no ED or incontinence. Pee a little more often.

[NYC_talker in reply to cybertreated2019]

This now conforms with my doc's new treatment advice. Monotherapy -- LDR brachy or SBRT. I'll take my time to decide, and speak with others. But glad to have this input. thanks.

[NYC_talker]

Thanks for the replies. One somewhat odd but pertinent bit of information to add: In my RO's office visit notes, which were posted well over a week after the visit and which I've now combed through again, he states that he offered "definitive radiation treatment" with "choice" of HDR brachy "or" SBRT. And he states that I was provided with written brochures of "both options." (I was indeed provided with material on both.) This is not what I remember from the visit -- and I was not alone at the visit -- which was his offering combo therapy in two parts, one month apart.

Perhaps two of us misunderstood the doctor, and/or he was unclear. Or perhaps he re-thought it as he formally wrote his visit notes in the days following. My urologist simply told me in an email that he agreed with the RO's plan, though we didn't actually discuss the plan. So I'll definitely get clarification next week when I meet with my RO.

[Bigm789]

TPLA FLA laser ablation , could treat focally , Elestra laser.

[NYC_talker]

Hi all. An update: My RO at MSK, after seeing the MRI (which I'd not done before our first visit), as well as the MSK analysis of my pathology, now says mono therapy is all that is needed: Either brachy (and he leans, now, more toward LDR than HDR) or SBRT.

So that is my decision now, though I am also getting a second opinion at NYU.