Treatment decision: LDR brachy at MSK

[NYC_talker]

Hi all.

Many thanks to folks here for helping to inform my decision. I'm going to have LDR brachytherapy -- seed implants -- as monotherapy at MSKCC, a place where brachytherapy was pioneered. Scheduled for next month.

Some background summary from earlier: PSA went up to 5.74 (8/21) from 5.3 (2/21). 12 core biopsy in 9/21: GS 3+4. 4 of 12 cores positive, all on the left side, peripheral zone.

2 were GS 6 & 2 were GS 3+4=7. One of those 7 cores had carcinoma in 67% per my urologist's lab's biopsy report (which was downgraded by MSK's analysis of the pathology, along with a few other aspects). Bone scan clear, and so is CT scan.

During my first consultation, based solely on the first lab's pathology report, my RO at MSK was thinking a combo might be necessary and was talking about HDR brachy and 5 SBRT.

At second consultation, after MSK's analysis of the pathology and after an MRI (showing 1 lesion at 1 cm -- and no ECE, no seminal vesicle or lymph nodes), and I assume after consultation with others there, he said combo was overkill and monotherapy is the way to go, as some of you suggested here back when I first posted.

All three monotherapies that were discussed -- LDR, HDR and SBRT -- are equal in terms of excellent outcomes, as he explained. He said LDR, of which he's performed thousands (in addition to thousands of HDR and SBRT), might be a preferable option for me because it's one and done -- an hour in which they implant the seeds while you're under, and that's that. (HDR would require two treatments as a monotherapy).

That appealed to me. I spoke to other docs about other options, and spoke with men who'd had LDR (at MSK) with my RO and others. It requires great expertise, but I know I'm in good hands at MSK and with my RO. One trade off might be more intense urinary issues short-term, but I've been okay in that department now -- another quality that makes you a better candidate for LDR going in -- so hoping it won't be so bad.

I thought I'd chronicle it here because LDR as monotherapy has been in decline and there aren't a lot of recent experiences relayed here.

It's not in decline because it's less effective -- far from it. Rather, as a monotherapy it can only be utilized for low risk or favorable intermediate risk. With the rise in AS, and with the rise of other options like HDR and SBRT, less LDR has been performed. Some centers even stopped doing it, as it requires highly trained ROs and their numbers started to decline, too, among younger doctors.

It seems there might be a revival of LDR, however, particularly as studies show great outcomes utilizing it for brachy boost for more advanced PCa.

LDR monotherapy also isn't an option if there's any ECE or if the prostate is too large. But I fit the bill. So I'm scheduled for right after the new year and will let you know how it goes.

Any thoughts, advice and experiences from you all are welcome.

[Tall_Allen]

Zelefsky is indeed a world master. The reason for the decline is mostly because it's reimbursed so poorly and it takes a lot of practice to do well. I've heard a few get cocky and don't do the CT scan within 30 days.

[Schwah in reply to Tall_Allen]

Funny you say that. When I was considering treatments I went to Loma linda to learn about proton therapy. They pushed it very very hard. Almost obnoxiously so that it felt cult like. When we met with the dr there (this was 11 years ago), my wife told him we were confused and asked him what he’d do “if it was his fathers or brother”. To our shock he said, “I’d use the seeds. But it’s hard to find guys who do that cause it’s the lowest reimbursement from Medicare .” That’s when our eyes were opened to the fact that much of the medical community is driven by profit. Not that they don’t want to help you but they want you to choose them or they get nothing out of you.

Schwah

[Tall_Allen in reply to Schwah]

I had a similar experience with Loma Linda 11 years ago. They hounded me with phone calls and emails. I agree, it is cult-like. I chuckle when patients ask doctors what they would advise if it were his father (and they do it all the time). Maybe his father beat him every night? Ever hear of Oedipus? What the doctor SHOULD have said is this: "What information can I give you that you need to make this decision?"

But I have found that few doctors at large teaching hospitals are driven by profits. They could make a LOT more in private practice. They usually are true believers of the therapies they advocate.

[Schwah in reply to Tall_Allen]

I agree with that too. I’ve dealt with at least 4 different doctors at UCLA and they’ve all been honest, helpful , caring and responsive.

Schwah

[esperandrich]

Bit different than you since I am gleason 4 + 4 with two out twelve cores. No evidence of spread but still high risk. 65 years old.

So I went for 25 sessions of proton therapy, ADT for at least one year (six months so far) and LDR at UC San Diego.

Five weeks out from LDR. Had the procedure done in the early morning and was having lunch at the beach at noon. Took it easy for two days and didn't do much physical for week but was able to go back to my desk job in two days. Been taking Flomax since the day of the procedure.

First two weeks no problems but then for two days had some pain when going and had to strain and had to go at least four times a night for two days. Other than that no real problems. Started drinking more water during the day and that seemed to help. Drank less liquid afer 7 p.m. and that seemed to help.

As of today not sure I need the Flomax. Everything is fine. Still going two to three times night but it feels normal. No pain or strain when going. Meeting with the Dr. this week to see if I can go off of the Flomax.

Everybody is different but it wasn't bad at all for me.

,

[maley2711 in reply to esperandrich]

I think stopping the Flowmax will be a big test? Hope great results. MY prostate 80+/- 10 cc(depends who measures and with what images), so I've read probably too large for brachy? That brachy boost certainly has outstanding "cure" rates. Did you have whole pelvic radiation...part of standard brachy boost protocol. The ADT is what is spooking me..evryone says weights to ward off SEs, and no do weights!! Looking for isometric s equivalnet in effectiveness?

[esperandrich in reply to maley2711]

Yes I had whole pelvic. ADT is Lupron. I walk or ride a bike or play golf five days a week and only lift 20 pound dumbbells three days a week and that works for me. Also, stretching every other day. Heard others do yoga instead of stretching.

SEs are 8 to 10 "hot flashes, flushes or whatever you want to call them a day and no libido. Everybody is different though.

Stopping Flomax will be the big test and if it doesn't work I can start it again.

[NYC_talker in reply to esperandrich]

Thanks, good to hear it went well for you.

[conbio in reply to esperandrich]

Nice to hear. I'm 3 months into ADT and anticipate my EBRT early 2022 followed by LDR brachy later. Sounds like you are doing pretty well. O yea, getting hot, hot, hot. 😁

[esperandrich in reply to conbio]

makes sure you find out whether you need whole pelvic lymph nodes treatment. Saw the post from Diatom and I am glad I did but everybody is different even though we all three have the gleason 8 or 9 scores.

[NYC_talker in reply to esperandrich]

It's encouraging to read that you only had two days of issues beginning two weeks after LDR. How are things now? I'm calculating you're about nine weeks out from LDR.

[Cooolone]

Seems you have done your research, and have educated yourself on the possible treatments for your particular diagnosis. Only question I have is if you have had your biopsy and scans receive a 2nd opinion? Especially because the of the low amount of G7. I'm not in any way questioning MSK as they're top notch in my book. Disclaimer is I'm currently a patient there so the opinion is weighted, lol.

Just mentioning it so there's an objective opinion included that's not involved with the treatment choice. John Hopkins is a good choice for the 2nd opinion. Otherwise MSK is and has experienced and practiced Oncologist to perform what you are discussing. You won't do much better than there.

Best Regards

[NYC_talker]

Thanks Coool. Actually, MSK was the second opinion on all. The pathology was originally done by my urologist's lab (he's not MSK-affiliated -- he's with Mount Sinai) after he did the biopsy in his office. And MSK analysis had slight but pertinent differences in their analysis. NYU-Langone did my bone scan and CT scan . MSK then analyzed those scans too. No important difference, but I would say their analysis of those scans was more meticulously done -- more detail.

[CarverD]

I chose the HDR route over LDR because of the time I spend with my small grandchildren whom I would never have been able to keep out of my lap. I had mine done (10/2020) through Wilmot Cancer Institute, UR Medicine and have been extremely pleased with the outcome. Both LDR and HDR are in decline for the reasons you stated as well as that the hospitals don't make a lot of $$$ as compared to other modalities. It is a total shame as they both provide exception results as mono therapy for intermediate favorable PCa. Like MSK, UR Medicine pioneered HDR-BT in Upstate NY so I am sure your outcomes will be as good as mine have been. Good luck and God bless!

[ADTMan]

I don't mean to be a downer, but a 12 core random biopsy samples about, what, 1% of the prostate? What if the needle that found the 3+4 was moved a little and then its 4+4? My PSA was 29 and I had to fight to even get them to do an MRI before they did the biopsy. Did you get a Decipher score? I know there is a fear of overtreatment but you have cancer, i.e., Gleason 4 of an unknown quantity. If you are older than 70 I can see the reason for the monotherapy, but if your are older I may want to rethink it. Either way, you can rely on your doctor who is a world expert.

[conbio]

best of luck, sounds like a good plan

[NYC_talker]

Today's the day. Heading in for my LDR brachy at MSKCC. Will write a post on it in coming days. Thanks again to everyone here for their help.